The Continuum Center for Health & Healing

Research on Diabetes

Below are brief summaries of relevant research on Diabetes. To find more information about an article, click on the title of the article.

• Overview of the Integrative Approach
• Causes and Risk Factors
• Related Health Conditions
• Psychological Factors: Anxiety, Apathy, Depression and Distress
• Treatments
• Acupuncture and East Asian Medicine
• Exercise/Movement
• Healing Arts/Creativity
• Manual Medicine: Massage, Chiropractic, Craniosacral therapy
• Mind-body: Biofeedback, Relaxation/Meditation
• Nutrition, Herbs, Dietary Supplements
• Therapies for Psychological Health
• Age-specific: children, young adults, older adults
• Gender specific: diabetes in men and women
• Environmental influences

Overviews of the Integrative Approach

Nahas R and Moher M. Complementary and alternative medicine for the treatment of type 2 diabetes. Canadian Family Physician. 55(6):591-6, 2009.
Chromium and possibly gymnema appear to improve glycemic control. Fiber, green tea, and fenugreek have other benefits but there is little evidence that they substantially improve glycemic control. Further research on bitter melon and cinnamon is warranted.

Kligler B, Lynch D. An integrative approach to the management of type 2 diabetes mellitus. Alternative Therapies in Health & Medicine. 2003; 9(6):24-32.
The role of medication, diet, exercise, mind-body approaches, and herbal and nutritional supplements in managing diabetes is discussed.

Gillies CL, Abrams KR, Lambert PC, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ. 2007; 334(7588):299.
In this review, the use of diet, exercise, medication and herbal medicine was shown to reduce the rate of progression to type-2 diabetes in people with impaired glucose tolerance. Lifestyle interventions were as effective as drug treatment.

Kligler B. The role of the optimal healing environment in the care of patients with diabetes mellitus type II. Journal of Alternative & Complementary Medicine. 2004; 10 Suppl 1:S223-9.
The evidence for and against a variety of interventions for type-2 diabetes is discussed including nutritional, herbal, mind-body and exercise strategies.

Toobert DJ, Glasgow RE, Strycker LA, et al. Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes. International Journal of Behavioral Nutrition and Physical Activity. 2007; 4:1.
Women with type-2 diabetes who did the Mediterranean Lifestyle Program showed significant improvements in diet, physical activity, stress management, smoking cessation, social support, and quality of life at 12 and 14 months.

Causes and Risk Factors

Depression

Knol MJ, Twisk JW, Beekman AT, et al. Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis. Diabetologia. 2006; 49(5):837-45.
Depressed adults have a 37% increased risk of developing type-2 diabetes.

Ethnicity

Shai I, Jiang R, Manson JE, et al. Ethnicity, obesity, and risk of type 2 diabetes in women: a 20-year follow-up study. Diabetes Care. 2006; 29(7):1585-90.
The risk of diabetes is significantly higher among Asians, Hispanics, and blacks. Weight gain is particularly harmful for Asians. For each 5-kg weight gain the risk of diabetes was increased by 84% for Asians, 44% for Hispanics, 38% for blacks, and 37% for whites.

Vitale C, Marazzi G, Volterrani M, et al. Metabolic syndrome. Minerva Medica. 2006; 97(3):219-29.
Metabolic syndrome includes insulin resistance, abdominal obesity, elevated blood lipids and blood pressure, and inflammation. It greatly increases the risk of developing cardiovascular disease and type-2 diabetes.

Hypertension

Stratton IM, Cull CA, Adler AI, et al. Additive effects of glycaemia and blood pressure exposure on risk of complications in type 2 diabetes: a prospective observational study (UKPDS 75). Diabetologia. 2006; 49(8):1761-9.
Risk of complications in type-2 diabetes is associated with hyperglycemia and hypertension. Intensive treatment of both these risk factors is needed to minimize complications.

Inflammation

Zozulinska D, Wierusz-Wysocka B. Type 2 diabetes mellitus as inflammatory disease. Diabetes Research in Clinical Practice. 2006; 74(2 Suppl):S12-6. Studies confirm the role of inflammation in the development of type-2 diabetes and its vascular complications. Diet, lack of exercise, smoking and stress cause and intensify chronic inflammation. Weight loss, exercise, and treatment with ACE inhibitors, statins, aspirin and glitazones (a drug for type-2 diabetes) all have an anti-inflammatory effect.

Magnesium Levels

Everett CJ, King DE. Serum magnesium and the development of diabetes. Nutrition. 2006; 22(6):679.
This study followed 9,784 people 25 to 74 years old. Results showed that low serum magnesium is associated with the development of diabetes.

Obesity

Daousi C, Casson IF, Gill GV, et al. Prevalence of obesity in type 2 diabetes in secondary care: association with cardiovascular risk factors. Postgraduate Medical Journal. 2006; 2(966):280-4.
In patients with type-1 diabetes, 55.3% were overweight, 16.6% were obese and 0.4% were morbidly obese. In patients with type-2 diabetes, 86% were overweight, 52% were obese, and 8.1% were morbidly obese. Obesity was associated with significantly worse cardiovascular risk factors in these patients.

Meisinger C, Doring A, Thorand B, et al. Body fat distribution and risk of type 2 diabetes in the general population: are there differences between men and women? The MONICA/KORA Augsburg cohort study. American Journal of Clinical Nutrition. 2006; 84(3):483-9.
People with a high body mass index combined with a high waist circumference and a high waist-hip ratio had the highest risk of diabetes. Overall fat and abdominal fat were strongly related to the development of type-2 diabetes.

Sleep

Knutson KL, Ryden AM, Mander BA, et al. Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus. Archives of Internal Medicine. 2006; 166:1768-1774.
Poor sleep and too little sleep were significant predictors of HbA1c, a key marker of glycemic control. Improving sleep duration and sleep quality may help improve glucose control. Stress

Lloyd CE, Dyer PH, Lancashire RJ, et al. Association between stress and glycemic control in adults with type 1 (insulin-dependent) diabetes. Diabetes Care. 1999; 22(8): 1278-83.
In this study, recent severe stressors were associated with poorer glycemic control while positive life events were associated with improved glycemic control.

Abraham NG, Brunner EJ, Eriksson JW, Robertson RP. Metabolic syndrome: psychosocial, neuroendocrine and classical risk factors in Type 2 diabetes. Annals of the New York Academy of Sciences. 2007; 113:256-75.
Stress plays a role in the development of the metabolic syndrome, including chronic work stress.

Related Health Conditions

Cardiovascular Disease

Hobbs FD. Reducing cardiovascular risk in diabetes: beyond glycemic and blood pressure control. International Journal of Cardiology. 2006; 110(2):137-45.
In addition to high blood sugar and hypertension, high triglycerides, high LDL and low HDL are important risk factors in patients with diabetes. Lipid-lowering therapy substantially reduces the risk of cardiovascular disease in people with diabetes.

Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. New England Journal of Medicine. 2005; 353(25):2643-53.
Intensive diabetes therapy to keep blood sugar levels as close to normal as possible slows the onset and progression of eye, kidney and nerve diseases in type-1 diabetes and reduces the risk of myocardial infarction or stroke by 57%.

Depression

Kinder LS, Carnethon MR, Palaniappan LP. Depression and the metabolic syndrome in young adults: findings from the third national health and nutrition examination study. Psychosomatic Medicine. 2004; 66:316-322.
Women, but not men, with a history of depression were twice as likely to have the metabolic syndrome.

Lustman PJ, Clouse RE. Depression in diabetic patients: the relationship between mood and glycemic control. Journal of Diabetes Complications. 2005; 19(20); 113-22.
Diabetes doubles the risk of depression and leads to poorer blood sugar control and difficulty sticking to medication and diet regimens. Cognitive behavior therapy and antidepressant medication improved glycemic control in some studies.

Diabetic Neuropathy

Blomeier H, Jameson JL. Modifiable vascular risk factors are associated with diabetic neuropathy in type 1 diabetes. Postgraduate Medicine. 2005; 117(4):7.
Intensive management of glucose control reduces the risk of neuropathy in patients with type-1 diabetes. Other risk facts include high LDL, total cholesterol and triglycerides, hypertension, cardiovascular disease and smoking.

Cayley WE Jr. Antidepressants for the treatment of neuropathic pain. American Family Physician. 2006; 73(11):1933-4.
Tricyclic antidepressants, particularly amitryptyline, are effective in treating diabetic neuropathy. Caution should be used in older adults and people with cardiovascular disease, glaucoma or autonomic neuropathy because of possible adverse effects.

Rathur HM, Boulton AJ. Recent advances in the diagnosis and management of diabetic neuropathy. Journal of Bone & Joint Surgery - British Volume. 2005; 87(12):1605-10.
The basics of diabetic neuropathy are discussed including treatment of symptoms by antidepressants, anticonvulsants, anti-arrhythmics and other medications as well as through control of hyperglycemia

Vinik A. CLINICAL REVIEW: Use of antiepileptic drugs in the treatment of chronic painful diabetic neuropathy. Journal of Clinical Endocrinology & Metabolism. 2005; 90(8):4936-45.
Strategies for controlling pain in diabetic neuropathy include tricyclic anti-depressants, capsaicin, clonidine, acupuncture, and electrical stimulation. Antiepileptic drugs have been shown to be especially effective for neuropathic pain.

Kidney function

Barnett A. Prevention of loss of renal function over time in patients with diabetic nephropathy. American Journal of Medicine. 2006; 119(5 Suppl 1):S40-7.
The DETAIL study directly compared telmisartan and enalapril in 250 patients with hypertension, type-2 diabetes and early-stage nephropathy. Over 5 years, no patient went into end-stage renal disease or required dialysis, and cardiac events were extremely low.

McCullough PA, Bakris GL, Owen WF Jr, et al. Slowing the progression of diabetic nephropathy and its cardiovascular consequences. American Heart Journal. 2004; 148(2):243-51.
Current therapies for diabetic nephropathy focus on lowering blood pressure to a target of 130/80 mm Hg or lower. Control of hyperglycemia and cholesterol, smoking cessation, exercise, and weight loss are all important.

Panic Episodes

Ludman E, Katon W, Russo J, et al. Panic episodes among patients with diabetes. General Hospital Psychiatry. 2006; 28(6):475-81.
There is a strong link between panic episodes and increased complications from diabetes. In this study panic episodes were associated with a higher Hb(A1c), increased diabetic complications, and greater disability.

Vascular complications

Havas S, Donner T. Tight control of type 1 diabetes: recommendations for patients. American Family Physician. 2006; 74(6):971-8.
Good control of blood sugar and cardiovascular risk factors such as hypertension and high cholesterol can substantially reduce the development of vascular complications from type-1 diabetes.

Psychological Factors: Anxiety, Apathy, Depression

Anxiety

Wild D, von Maltzahn R, Brohan E, et al. A critical review of the literature on fear of hypoglycemia in diabetes: Implications for diabetes management and patient education. Patient Education & Counseling. 2007:68(1):10-5.
Significant anxiety and fear of hypoglycemia may have a significant negative effect on diabetes management, metabolic control and health outcomes. There is evidence that blood glucose (BG) awareness training and cognitive behavioral therapy can reduce levels of fear and improve disease management.

Apathy

Depression

Eren I, Erdi O, Sahin M. The effect of depression on quality of life of patients with type II diabetes mellitus. Depression & Anxiety. 2008:25(2):98-106.
It has been reported that depression in patients with diabetes causes further decline in their quality of life. In this study, physical and psychological health, social relationships, and quality of life were significantly lower in depressed patients with Type 2 diabetes than in the non-depressed group.

Psychological Distress

Helgeson VS, Snyder PR, Escobar O, et al. Comparison of adolescents with and without diabetes on indices of psychosocial functioning for three years. Journal of Pediatric Psychology. 2007:32(7):794-806.
Diabetes is not associated with psychological distress from early to middle adolescence, but may be associated with later social difficulties and eating disturbances. Depression and anxiety increased in females but not in males.

Hislop AL, Fegan PG, Schlaeppi MJ, et al. Prevalence and associations of psychological distress in young adults with Type 1 diabetes. Diabetic Medicine. 2008:25(1):91-6.
Approximately one-third of young adults with Type 1 diabetes experience psychological distress, which is associated with poorer glycemic control.

Treatments

Acupuncture & East Asian Medicine, Ayurveda

Abuaisha BB, Costanzi JB, and Boulton AJ. Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: A long-term study. Diabetes Research & Clinical Practice. 1998; 39 (2): 115-21.
77% of patients with diabetes and chronic peripheral neuropathy who were treated with acupuncture over a 10 week period showed significant improvement in symptoms. After 4 months to one year, 67% were able to stop or significantly reduce their medications.

Elder C. Ayurveda for diabetes mellitus: a review of the biomedical literature. Alternative Therapies in Health & Medicine. 2004; 10(1):44-50.
Ayurveda is the traditional healthcare system of India. Studies suggest the effectiveness of Ayurvedic approaches including herbs, diet, yoga and meditation in managing diabetes, although more research is needed.

Liu JP, Zhang M, Wang WY, et al. Chinese herbal medicines for type 2 diabetes mellitus. Cochrane Database of Systematic Reviews. 2004; (3):CD003642.
Sixty-nine different Chinese herbal medicines are included in this review. In 29 trials of herbal medicines used with hypoglycemic drugs, 15 different herbal preparations showed added benefit over hypoglycemic drugs alone. Two herbal therapies combined with diet and behavior change showed better hypoglycemic effects than diet and behavior change alone. More high quality research is needed.

Shekelle PG, Hardy M, Morton SC, et al. Are Ayurvedic herbs for diabetes effective? Journal of Family Practice. 2005; 54(10):876-86.
Sixty-two studies were included in this review. Evidence suggests that the herbs C indica, holy basil, fenugreek, and G sylvestre and the herbal formulas Ayush-82 and D-400 have a glucose-lowering effect and deserve further study.

Vuksan V, Sung MK, Sievenpiper JL, et al. Korean red ginseng (Panax ginseng) improves glucose and insulin regulation in well-controlled, type 2 diabetes: Results of a randomized, double-blind, placebo-controlled study of efficacy and safety. Nutrition, Metabolism and Cardiovascular Diseases. 2008; 18(1): 46-56.
The anti-diabetic effectiveness and safety of 12 weeks of Korean red ginseng was assessed. Although there was no change in the HbA(1c), good glycemic control was maintained and glucose and insulin regulation was improved in people with well-controlled type-2 diabetes.

Exercise/Movement

Anderssen SA, Carroll S, Urdal P, Holme I. Combined diet and exercise intervention reverses the metabolic syndrome in middle-aged males: results from the Oslo Diet and Exercise Study. Scandinavian Journal of Medicine & Science in Sports. 2007; 17(6): 687-95.
Combining diet and exercise was significantly more effective than diet or exercise alone in the treatment of metabolic syndrome.

Cauza E, Hanusch-Enserer U, Strasser B, et al. The metabolic effects of long term exercise in Type 2 Diabetes patients. Wien Med Wochenschr. 2006; 156(17-18):515-9.
Glycemic control improved, HbA1C values fell, and there were significant decreases in total cholesterol, LDL-cholesterol and triglycerides in active patients who exercised over the long term.

Gregg EW, Gerzoff RB, Casperson CJ, et al. Relationship of walking to mortality among US adults with diabetes. Archives of Internal Medicine. 2003;163:11440-7.
Compared with inactive people, those who walked at least 2 hours a week had a 39% lower mortality rate from any cause and a 34% lower mortality rate from heart disease. Mortality rates were lowest for people who walked 3 to 4 hours per week.

Innes KE, Bourguignon C, Taylor AG. Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with yoga: a systematic review. Journal of the American Board of Family Practice. 2005;18(6):491-519.
Results from this review of 70 studies on yoga and cardiovascular disease indicate beneficial changes in glucose tolerance and insulin sensitivity, lipid profiles, blood pressure, and coagulation profiles.

Kristal AR, Littman AJ, Benitez D, White E. Yoga practice is associated with attenuated weight gain in healthy, middle-aged men and women. Alternative Therapies in Health & Medicine. 2005; 11(4):28-33.
Yoga practice for four or more years was associated with a 3.1-lb lower weight gain in normal-weight participants and an 18.5-lb lower weight gain in overweight participants.

Malhotra V, Singh S, Tandon OP, et al. Effect of Yoga asanas on nerve conduction in type 2 diabetes. Indian Journal of Physiology & Pharmacology. 2002;46(3):298-306.
Twenty patients with type-2 diabetes performed yoga postures for 30-40 minutes a day for 40 days. Nerve function improved in the yoga group.

Sigal R, Kenny GP, Boule NG, et al. Effects of aerobic training, resistance training, or both on glycemic control in Type 2 diabetes. Annals of Internal Medicine. 2007; 146: 357-369.
Combining aerobic exercise and strength training doubled the improvement in blood sugar control over either exercise alone. The combined exercise group averaged a full percentage point drop in their A1C levels.

Singh S, Malhotra V, Singh KP, et al. Role of yoga in modifying certain cardiovascular functions in type 2 diabetic patients. Journal of the Association of Physicians of India. 2004; 52:203-6.
Patients did yoga exercise 30-40 min a day for 40 days. There was a significant decrease in fasting and after meal blood sugar levels, HbA1C levels, pulse rate and blood pressure after the yoga regimen.

Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. Canadian Medical Association Journal. 2006;174(6):801-9.
Regular physical activity helps prevent cardiovascular disease, diabetes, cancer, hypertension, obesity, depression and osteoporosis. Further increases in physical activity lead to additional improvements in health status.

Yeh SH, Chunag H, Lin LW, et al. Tai chi chuan exercise decreases A1C levels along with increase of regulatory T-cells and decrease of cytotoxic T-call population in type 2 diabetic patients. Diabetes Care. 2007; 30(3):716-8.
Type-2 diabetes is associated with chronic inflammation. Regular tai chi exercise can increase certain immune cells, which correlate with decreased levels of A1C in patients with type-2 diabetes.

Mind-Body Practices

Attari A, Sartippour M, Amini M, and Haghighi S. Effect of stress management training on glycemic control in patients with type 1 diabetes. Diabetes Research & Clinical Practice. 2006; 73(1):23-8.
Results show a significant benefit of stress management training on glycemic control in patients with type 1 diabetes. Patients showed improved ways of coping and their HbA1C dropped on average from 11.7 before training to 8.5 after training.

Fiero PL, Galper DI, Cox DJ, et al. Thermal biofeedback and lower extremity blood flow in adults with diabetes: is neuropathy a limiting factor? Applied Psychophysiology & Biofeedback. 2003; 29(3): 193-203.
Patients with diabetes who have mild-to-moderate neuropathy can increase blood flow to the extremities with thermal biofeedback.

Galper DI, Taylor AG, Cox DJ. Current status of mind-body interventions for vascular complications of diabetes. Family & Community Health. 2003; 26(1):34-40.
Impaired peripheral blood flow causes leg and foot pain. Thermal biofeedback, alone or with other mind-body techniques, improved peripheral circulation, pain, neuropathy, ulcer healing, walking, and quality of life.

McGinnis RA, McGrady A, Cox SA, Grower-Dowling KA. Biofeedback-assisted relaxation in type 2 diabetes. Diabetes Care. 2005; 28(9):2145-9.
Biofeedback and relaxation were associated with significant decreases in average blood glucose, A1C and muscle tension. After three months, glucose and A1C levels remained lower and patients had less depression and anxiety.

Rice BI. Mind-Body Interventions. Diabetes Spectrum. 2001; 14:213-217.
This article covers the research on biofeedback/relaxation, hypnosis and yoga in the management of diabetes and related symptoms. Click on "Begin Automatic Download" to view full article.

Rice BI, Kalker AJ, Schindler JV, Dixon RM. Effect of biofeedback-assisted relaxation training on foot ulcer healing. Journal of the American Podiatric Medical Association. 2001; 91:132-141.
When medical care was combined with biofeedback-assisted relaxation training to increase blood flow to the legs and feet in 32 patients with chronic non-healing foot ulcers, 14 out of 16 ulcers (87.5%) healed, as compared with 7 out of 16 ulcers (43.8%) in the control group.

Rice BI, Schindler JV. Effect of thermal biofeedback-assisted relaxation training on blood circulation in the lower extremities of a population with diabetes. Diabetes Care. 1992; 15(7):853-8.
Significant increase in blood circulation in the lower extremities in people with diabetes was found with relaxation training/thermal biofeedback.

Nutrition/Herbs/Supplements

Wycherley TP, Noakes M, Clifton PM, et al. A High Protein Diet With Resistance Exercise Training Improves Weight Loss And Body Composition in Overweight And Obese Patients With Type 2 Diabetes. Diabetes Care. 2010.
The effects of two low-fat low-calorie diets with different carbohydrate/protein ratios, with and without resistance training, were evaluated in overweight patients with type 2 diabetes. Over 16 weeks, an energy restricted high protein diet combined with resistance training lead to greater weight loss and more favorable changes in body composition. All treatments had similar improvements in glycemic control and cardiovascular disease risk markers.

Sartore G, Reitano R, Barison A, et al. The effects of psyllium on lipoproteins in type II diabetic patients. European Journal of Clinical Nutrition. 63(10):1269-71, 2009.
The effect of two months of psyllium on metabolic control and blood fats in 40 patients with type II diabetes was studied. Body mass index, waist circumference, HbA1c and fasting plasma glucose levels significantly decreased in the psyllium group and the group treated with dietary measures alone. However, triglycerides (a known risk factor for cardiovascular disease) were significantly lower in the psyllium group.

Mozaffari-Khosravi H, Jalali-Khanabadi BA, Afkhami-Ardekani M, et al. The effects of sour tea (Hibiscus sabdariffa) on hypertension in patients with type II diabetes. Journal of Human Hypertension. 23(1):48-54, 2009.
In this study of sixty patients with type II diabetes and mild hypertension participants drank either sour tea (hibiscus sabdariffa) or black tea two times a day for one month. Drinking sour tea had positive effects on blood pressure and supports the findings of anti-hpertensive effects of sour tea seen in other studies.

Al-Achi A. Herbs that affect blood glucose levels. Women's Health in Primary Care. 2005; 8(7):325-330. Green tea helps reduce the amount of glucose absorbed in the intestines. Ginseng lowers blood sugar levels by decreasing glucose production in the liver or increasing glucose use by tissues. Garlic and onion have a glucose-lowering effect. Bitter melon enhances glucose use by the liver and reduces insulin resistance. Always tell your physician about your use of herbal medicines to avoid interactions with diabetes medications and undesirable effects on blood sugar levels.

Bhathena SJ, Velasquez MT. Beneficial role of dietary phytoestrogens in obesity and diabetes. American Journal of Clinical Nutrition. 2002; 76(6):1191-201. Studies suggest that soy protein and flaxseed improve glucose control and insulin resistance. Soy protein also appears to moderate hyperglycemia and reduce body weight and high lipid and insulin blood levels.

Barbagallo M, Dominiquez LJ. Magnesium metabolism in type 2 diabetes mellitus, metabolic syndrome and insulin resistance. Archives of Biochemistry and Biophysics. 2007; 458(1);40-7. Type-2 diabetes is characterized by magnesium depletion which worsens insulin resistance. Benefits of magnesium supplementation in patients with diabetes have been found in most clinical studies.

Browning LM, Jebb SA. Nutritional influences on inflammation and type 2 diabetes risk. Diabetes Technology & Therapeutics. 2006; 8(1):45-54. Inflammation plays a clear role in the development of type-2 diabetes. Omega-3 fatty acids, whole grains, low glycemic index foods and antioxidant vitamins help to decrease inflammation. An "anti-inflammatory" strategy to tackle type-2 diabetes includes a healthy weight, reducing saturated fat, and increasing complex carbohydrates, fruits and vegetables.

Bonnefont-Rousselot D. The role of antioxidant micronutrients in the prevention of diabetic complications. Treatments in Endocrinology. 2004;3(1):41-52. This article reviews the use of minerals (vanadium, chromium, magnesium, zinc, selenium, copper) and vitamins (vitamin E, vitamin C, coenzyme Q, nicotinamide, riboflavin, lipoic acid, and flavonoids) in reducing oxidative stress and preventing diabetic complications.

Burani J, Longo PJ. Low-glycemic index carbohydrates: an effective behavioral change for glycemic control and weight management in patients with type 1 and 2 diabetes. Diabetes Educator. 2006; 32(10:78-88. In this study, a low glycemic diet reduced HbA1c by 19% and decreased BMI by 8%. This diet is recognized by the Canadian Diabetes Association, Diabetes UK and the Dietitians of Australia for blood sugar control and weight management. Glycemic index is a measure of how fast carbohydrates (including fruit) are converted in the body to glucose.

Halat KM, Dennehy CE. Botanicals and dietary supplements in diabetic peripheral neuropathy. Journal of the American Board of Family Practice. 2003;16(1):47-57. Studies show that evening primrose oil, alpha-lipoic acid and capsaicin improve symptoms of neuropathy without affecting glucose control. It is important to be aware of the possibility of potential drug interactions and side effects.

Kennedy RL, Chokkalingam K, Farshchi HR. Nutrition in patients with Type 2 diabetes: are low-carbohydrate diets effective, safe or desirable? Diabetic Medicine. 2005;22(7):821-32. Although many controversies remain, there is now mounting evidence that low-carbohydrate, high-protein diets can lead to effective weight loss and may be useful for patients with diabetes.

Lovejoy JC. The impact of nuts on diabetes and diabetes risk. Current Diabetes Reports. 2005; 5(5):379-84. Studies show that people who regularly eat nuts have reduced risk for cardiovascular disease and diabetes. Nuts appear to have a neutral effect on glucose and insulin, and a beneficial effect on lipid profile.

Riccardi G, Capaldo B, Vaccaro O. Functional foods in the management of obesity and type 2 diabetes. Current Opinion in Clinical Nutrition & Metabolic Care. 2005; 8(6):630-5. For prevention of type-2 diabetes, several types of foods have been identified (low saturated fat products, vegetables, fruit, whole grain foods, and low glycemic index starchy foods).

Shapiro K, Gong WC. Natural products used for diabetes. Journal of the American Pharmaceutical Association. 2002; 42(2):217-26. Commonly used natural products for diabetes include nopal (prickly pear cactus), fenugreek, karela (bitter melon), gymnema, ginseng, tronadora, chromium, and alpha-lipoic acid. Available evidence suggests that several natural products in common use can lower blood glucose in patients with diabetes.

Schroder H. Protective mechanisms of the Mediterranean diet in obesity and type 2 diabetes. Journal of Nutritional Biochemistry. 2007; 18(3): 149-60. The Mediterranean diet is based on high consumption of vegetables and fresh fruits and the use of olive oil as the main source of fat. Studies show that this type of diet protects against weight gain and the development of type 2 diabetes.

Yeh GY, Eisenberg DM, Kaptchuk TJ, Phillips RS. Systematic review of herbs and dietary supplements for glycemic control in diabetes. Diabetes Care. 2003; 26(4):1277-94. This extensive review of herbs and supplements to improve glucose control showed positive results in 76% of the studies with few adverse effects. The best evidence was for Coccinia indica and American ginseng. Chromium is the most widely studied supplement. Gymnema sylvestre, Aloe vera, vanadium, Momordica charantia, and nopal also show early positive results.

Therapies for Psychological Health

Hains AA, Davies WH, Parton E, et al. A stress management intervention for adolescents with type 1 diabetes. Diabetes Educator. 2000;26(3):417-24.
A stress management program using both cognitive-restructuring and problem-solving strategies helped adolescents with diabetes cope with stress.

Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet. 2004; 363:1589-1597.
Studies that evaluated counseling, cognitive behavior therapy, and psychodynamic therapy showed improvements in long-term glycemic control and psychological distress.

Kanner S, Hamrin V, Grey M. Depression in adolescents with diabetes. Prevalence and interventions for depression in youth with type 1 diabetes. Journal of Child & Adolescent Psychiatric Nursing. 2003;16(1):15-24.
Young people with type-1 diabetes have much higher rates of depression than the general population. Serotonin reuptake inhibitors (an anti-depressant medication), cognitive behavioral treatment, interpersonal therapy, improving family communication and problem-solving skills, and diabetes education may help to decrease their depression.

van der Ven NC, Hogenelst MH, Tromp-Wever AM, et al. Short-term effects of cognitive behavioural group training (CBGT) in adult Type 1 diabetes patients in prolonged poor glycaemic control. A randomized controlled trial. Diabetes Medicine. 2005; 22(11):1619-23.
In this study of 107 patients with type-1 diabetes and poor glycemic control, cognitive behavioral group training improved feelings of effectiveness, diabetes-related distress and mood at 3 months' follow-up, but not glycemic control.

Bradshaw BG, Richardson GE, Kumpfer K, et al. Determining the efficacy of a resiliency training approach in adults with type 2 diabetes. Diabetes Educator. 2007;33(4):650-9.
People with diabetes who had resiliency training reported learning positive ways of coping with stress, knowing enough about themselves to make right diabetes choices, having fun in life, eating healthier, and increasing physical activity.

Age Specific

Children

Lalla E, Cheng B, Lal S, et al. Diabetes mellitus promotes periodontal destruction in children. Journal of Clinical Periodontology. 2007; 34(4):294-8.
The association between diabetes and periodontal attachment and bone loss is well established. In this study children with diabetes had increased gingival inflammation and attachment loss, an early association between diabetes and periodontal disease. Addressing periodontal needs should be the standard of care for children with diabetes.

Nathan BM, Moran A. Metabolic complications of obesity in childhood and adolescence: more than just diabetes. Current Opinion in Endocrinology, Diabetes and Obesity. 2008;15(1):21-9.
Metabolic complications of obesity (insulin resistance, hypertension and high cholesterol) during childhood increase the risk for type-2 diabetes and early cardiovascular disease. Other serious disorders associated with obesity and insulin resistance include polycystic ovary disease and fatty liver disease.

Owen CG, Martin RM, Whincup PH, et al. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. American Journal of Clinical Nutrition. 2006;84(5):1043-54.
This systematic review of 23 studies showed that infants who were breastfed had a lower risk of type-2 diabetes than those who were formula fed.

Schwab KO, Doerfer J, Krebs A, et al. Early atherosclerosis in childhood type 1 diabetes: role of raised systolic blood pressure in the absence of dyslipidaemia. European Journal of Pediatrics. 2007; 166(6):541-8.
In children with well-controlled type-1 diabetes, systolic blood pressure may be more important than high cholesterol in the early development of atherosclerosis.

Taylor JS, Kacmar JE, Nothnagle M, Lawrence RA. A systematic review of the literature associating breastfeeding with type 2 diabetes and gestational diabetes. Journal of the American College of Nutrition. 2005; 24(5):320-6.
Having been breastfed for at least two months may lower the risk of diabetes in both children and mothers.

Adolescents/Young Adults

Dovey-Pearce G, Doherty Y, May C. The influence of diabetes upon adolescent and young adult development: A qualitative study. British Journal of Health Psychology. 2007; 12(Pt 1):75-91.
This study on the influence of diabetes on psychosocial development in teens and young adults found that peer support buffered negative effects, especially if young people control the disclosure of their diabetes. A key challenge is coming to terms with risk and mortality.

Gunczler P, Lanes R, Soros A, et al. Coronary artery calcification, serum lipids, lipoproteins, and peripheral inflammatory markers in adolescents and young adults with type 1 diabetes. Journal of Pediatrics. 2006; 149(3):320-3.
Teens and young adults with type-1 diabetes are at high risk of developing microvascular and macrovascular artery disease, as risk factors such as high cholesterol and triglycerides and pro-inflammatory markers were already present in a significant percentage of patients studied.

Houston TK, Person SD, Pletcher MJ, et al. Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. BMJ. 2006; 332(7549):1064-9.
Findings support a role of both active and passive smoking in the development of glucose intolerance in young adults.

Pacaud D, Crawford S, Stephure DK, et al. Effect of type 1 diabetes on psychosocial maturation in young adults. Journal of Adolescent Health. 2007; 40(1):29-35.
Young adults with type-1 diabetes showed no delay in maturity in terms of responsibility and independence, social maturity, number of social contacts and feelings of control.

Petitti DB, Imperatore G, Palla SL, et al. Serum Lipids and Glucose Control: The SEARCH for Diabetes in Youth Study. Archives of Pediatric & Adolescent Medicine. 2007; 162(20:159-65.
Blood sugar control and lipid levels are both associated with type-1 and type-2 diabetes in young people.

Zhao W, Chen Y, Lin M, Sigal RJ. Association between diabetes and depression: Sex and age differences. Public Health. 2006; 120(8):696-704.
Diabetes is significantly associated with depression, particularly in young adult women aged 20-39 years. The association was not significant in men.

Older Adults

Beulens JW, Stolk RP, van der Schouw YT, et al. Alcohol consumption and risk of type 2 diabetes among older women. Diabetes Care. 2005; 28(12):2933-8. This multicenter study found a decreased risk of type-2 diabetes with moderate alcohol consumption in older women.

Bond GE, Burr R, Wolf FM, et al. The effects of a web-based intervention on the physical outcomes associated with diabetes among adults age 60 and older: a randomized trial. Diabetes Technology & Therapeutics. 2007; 9(1):52-9. The effects of a 6-month web-based intervention plus usual care on older adults with diabetes was tested. There were significant reductions in A1C, weight, and cholesterol levels and significant improvement in HDL levels at 6-month follow-up.

Brandon LJ, Gaasch DA, Boyette LW, Lloyd AM. Effects of long-term resistive training on mobility and strength in older adults with diabetes. Journals of Gerontology Series A-Biological Sciences & Medical Sciences. 2003; 58(8):740-5. The effect of strength training in older diabetic patients was studied. Strength increased 31.4% after the first 6 months of training and mobility improved.

Chyun DA, Melkus GD, Katten DM, et al. The association of psychological factors, physical activity, neuropathy, and quality of life in type 2 diabetes. Biological Research for Nursing. 2006; 7(4):279-88. Neuropathy, physical inactivity, higher body mass index, and anxiety and depression are associated with poorer quality of life and are common in older adults with type-2 diabetes.

Daly RM, Dunstan DW, Owen N, et al. Does high-intensity resistance training maintain bone mass during moderate weight loss in older overweight adults with type 2 diabetes? Osteoporosis International. 2005;16(12):1703-12. Results indicated that weight loss should be combined with progressive resistance training.

Decoster VA, George L. An empowerment approach for elders living with diabetes: a pilot study of a community-based self-help group - The Diabetes Club. Educational Gerontology. 2005; 31(9):699- 713. Findings showed significant improvements in diabetes self-efficacy, self-care behaviors, and reduction of A1C.

Engel L, Lindner H. Impact of using a pedometer on time spent walking in older adults with type 2 diabetes. Diabetes Educator. 2006; 32(1):98-107. The use of a pedometer helped previously sedentary older adults with type-2 diabetes meet their physical activity target levels. Significant reductions in waist circumference and weight were achieved and cardiovascular fitness improved significantly.

Ibanez J, Izquierdo M, Arguelles I, et al. Twice-weekly progressive resistance training decreases abdominal fat and improves insulin sensitivity in older men with type 2 diabetes. Diabetes Care. 2005;28(3):662-7. Two progressive resistance training sessions per week, even without a weight loss diet, significantly improved insulin sensitivity and fasting blood sugar and decreased abdominal fat in older men with type-2 diabetes.

Miller, CK, Edwards L, Kissling G, et al. Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: Results from a randomized controlled trial. Preventive Medicine. 2002; 34(2): 252-9. In this study older adults who received nutrition education had greater improvements in fasting glucose, A1C and total cholesterol.

Smith TC, Wingard DL, Smith B, et al. Walking decreased risk of cardiovascular disease mortality in older adults with diabetes. Journal of Clinical Epidemiology. 2007; 60(3):309-17. Adults with diabetes who walked a mile or more per day were half as likely to die from all causes combined and less than one-fifth as likely to die from cardiovascular disease.

Williams JW Jr, Katon W, Lin EHB, et al. Improving patient care. The effectiveness of depression care management on diabetes-related outcomes in older patients. Annals of Internal Medicine. 2004;140(12): 1015-24. Older patients with diabetes who received health education, problem-solving training or support for anti-depressant medication had less severe depression, improved function and exercised more. Emotional and physical health improved, especially in those who did not have good glycemic control.

Zhang X, Norris SL, Gregg EW, Beckles G. Social support and mortality among older persons with diabetes. Diabetes Educator. 2007; 33(2):273-81. Social support was significantly related to physical and mental health in older people with diabetes.

Gender Specific

Women

Colhoun H. Coronary heart disease in women: why the disproportionate risk? Current Diabetes Reports. 2006; 6(1):22-8.
Women with type-1 or type-2 diabetes have a much greater risk of heart disease than men with diabetes. The usual heart protective effect that women have before menopause does not apply in women with diabetes and risk factors need to be controlled at an early age.

Janghorbani M, Feskanich D, Willett WC, Hu F. Prospective study of diabetes and risk of hip fracture: the Nurses' Health Study. Diabetes Care. 2006; 29(7):1573-8.
Both type-1 and type-2 diabetes are associated with an increased risk of hip fracture, increasing the need for fracture-prevention strategies.

LeMone P. The physical effects of diabetes on sexuality in women. Diabetes Educator. 1996; 22(4):361-6.
The physical effects of diabetes on sexuality in women with type-1 or type-2 diabetes were studied. Women reported fatigue, changes in blood glucose control around menstruation, vaginitis, decreased sexual desire, decreased vaginal lubrication, and increased time to reach orgasm.

Ren J. Cardiac health and diabetes mellitus in women: problems and prospects. Minerva Cardioangiologica. 2006; 54(3):289-309.
Heart disease shows a 5-fold increase in women with diabetes.

Yun S, Kabeer NH, Zhui BP, Brownson RC. Modifiable risk factors for developing diabetes among women with previous gestational diabetes. Preventing Chronic Disease. 2007; 4(1):A07.
Women who have had gestational diabetes are at high risk for developing nongestational diabetes. Risk factors include less physical activity and greater weight.

Men

Blans MC, Visseren FL, Banga JD, et al. Infection induced inflammation is associated with erectile dysfunction in men with diabetes. European Journal of Clinical Investigation. 2006; 36(7):497-502. Elevated C-reactive protein (an indication of inflammation) or elevated fibrinogen levels as well as infection with cytomegalovirus or C. pneumoniae were associated with erectile dysfunction in diabetes.

Buvat J, van Ahlen H, Schmitt H, et al. Efficacy and safety of two dosing regimens of tadalafil and patterns of sexual activity in men with diabetes mellitus and erectile dysfunction: Scheduled use vs. on-demand regimen evaluation (SURE) study in 14 European countries. Journal of Sexual Medicine. 2006; 3(3):512-20. Tadalafil 20 mg taken on demand or three times per week was found to be safe and effective in improving sexual activity in patients with diabetes and erectile dysfunction.

Church TS, LaMonte MJ, Barlow CE, Blair SN. Cardiorespiratory fitness and body mass index as predictors of cardiovascular disease mortality among men with diabetes. Archives of Internal Medicine. 2005; 165(18):2114-20. Low fitness level was associated with increased risk of cardiovascular disease mortality in normal weight, overweight, and class 1 obese men with diabetes.

Corona G, Mannucci E, Petrone L, et al. Association of hypogonadism and type II diabetes in men attending an outpatient erectile dysfunction clinic. International Journal of Impotence Research. 2006; 18(2):190-7. Patients with diabetes often have lower levels of testosterone, especially patients in their 60's. This might worsen sexual dysfunction by reducing libido and mood.

Gallacher JE, Pickering J, Elwood PC, et al. Glucoregulation has greater impact on cognitive performance than macro-vascular disease in men with type 2 diabetes: data from the Caerphilly study. European Journal of Epidemiology. 2005; 20(9):761-8. Men with diabetes showed cognitive deficits in certain areas of mental performance, reflecting the direct effect of glucose regulation on cognitive skills.

Kalter-Leibovici O, Wainstein J, Ziv A, et al. Clinical, socioeconomic, and lifestyle parameters associated with erectile dysfunction among diabetic men. Diabetes Care. 2005; 28(7):1739-44. Age, diabetes duration, current A1C level, circulatory disease, cardiovascular disease, and diuretic treatment were significantly associated with erectile dysfunction. Physical activity and alcohol intake may be protective.

Kapoor D, Goodwin E, Channer KS, Jones TH. Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with type 2 diabetes. European Journal of Endocrinology. 2006; 154(6):899-906. In this study testosterone replacement therapy reduced insulin resistance and improved glycemic control in men with low levels of testosterone and type-2 diabetes.

Kurl S, Laukkanen JA, Niskanen L, et al. Metabolic syndrome and the risk of stroke in middle-aged men. Stroke. 2006; 37(3):806-11. Men with the metabolic syndrome had twice the risk for all strokes and 2.41-fold risk for ischemic stroke.

Mallon L, Broman JE, Hetta J. High incidence of diabetes in men with sleep complaints or short sleep duration: a 12-year follow-up study of a middle-aged population. Diabetes Care. 2005: 28(11): 2762-7. Men, but not women, with new diabetes more often reported sleeping less than 5 hours per night and having difficulties falling asleep and staying asleep.

Meisinger C, Doring A, Thorand B, Lowel H. Association of cigarette smoking and tar and nicotine intake with development of type 2 diabetes mellitus in men and women from the general population: the MONICA/KORA Augsburg Cohort Study. Diabetologia. 2006; 49(8):1770-6. The number of cigarettes and the nicotine and tar consumption per day were associated with a significantly increased risk of type-2 diabetes in men but not in women in this study.

Meisinger C, Doring A, Thorand B, et al. Body fat distribution and risk of type 2 diabetes in the general population: are there differences between men and women? The MONICA/KORA Augsburg cohort study. American Journal of Clinical Nutrition. 2006; 84(3):483-9. The highest risk of diabetes was seen in men and women with a high body mass index combined with a high waist circumference and a high waist-hip ratio. Overall and abdominal fat were strongly related to the development of type-2 diabetes.

Environmental Influences

Hathout EH, Beeson WL, Ischander M, et al. Air pollution and type 1 diabetes in children. Pediatric Diabetes. 2006;7(2):81-7.
Cumulative exposure to air pollutants such as ozone and sulfate may predispose children to the development of type-1 diabetes. Early infant formula feeding and passive smoking in the household may also contribute to its onset.

Houston TK, Person SD, Pletcher MJ, et al. Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. BMJ. 2006;332(7549):1064-9.
Over 15 years, glucose intolerance was highest among smokers (21.8%), followed by never smokers with passive smoke exposure (17.2%) and previous smokers (14.4%). It was lowest for never smokers with no passive smoke exposure (11.5%). This points to the role of active and passive smoking in the development of glucose intolerance in young adulthood.

O'Neill MS, Veves A, Sarnat JA, et al. Air pollution and inflammation in type 2 diabetes: A mechanism for susceptibility. Occupational & Environmental Medicine. 2006;64(6): 373-9.
People with diabetes may be especially vulnerable to air pollution due to inflammation and changes in the lining of blood vessels. Associations were particularly strong in people not taking cholesterol lowering drugs and those with a history of smoking.