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Reactive hypoglycemia

Related Terms

Anorexia nervosa, aspirin, blood glucose, blood sugar, carbohydrate, convulsions, encephalopathy, fasting hypoglycemia, fructose, galactose, gastric bypass surgery, glucagon, glucose, glycogen, hormone, hyperinsulinemia, insulinomas, low blood sugar, paresis, post-absorptive, postprandial, reactive hypoglycemia, sepsis, sulfa antibiotic.

Background

Hypoglycemia, also called low blood sugar, occurs when the blood glucose (blood sugar) level drops too low to provide enough energy for the body's activities. In adults or children older than 10 years, hypoglycemia is uncommon except as a side effect of diabetes treatment, but it can result from other medications or diseases, hormone or enzyme deficiencies, or tumors.

Two types of hypoglycemia can occur in individuals who do not have diabetes: reactive (postprandial, or after meals) and fasting (post-absorptive). Reactive hypoglycemia is not usually related to any underlying disease; fasting hypoglycemia often is related to an underlying disease. Reactive hypoglycemia describes recurrent episodes of hypoglycemia occurring two to four hours after a high carbohydrate meal (or taking glucose by mouth). Reactive hypoglycemia is due to an excessive insulin release triggered by the carbohydrate meal that continues past the digestion and disposal of the glucose derived from the meal.

Normally, the body makes insulin when it is needed. Right after meals, the body produces enough insulin to process the blood sugar from that meal, moving it out of the blood and into the cells. Between meals, the level of insulin drops before it drives blood sugar levels too low.

If there is not enough insulin to let glucose enter the cells, too much glucose remains in the blood. This can cause symptoms of diabetes, including fatigue, frequent urination, thirst, and a risk of ketoacidosis (a dangerous condition with warning signs that include rapid deep breathing and sweet-smelling breath. Hypoglycemia can occur if the individual has more insulin than usual, has eaten too little food, or has been extra active (exercise helps insulin work more efficiently).

Many conditions besides diabetes may lead to low blood sugar levels in individuals who do not have diabetes. For instance, some types of cancer, critical illnesses (such as kidney, heart, or liver failure), and some medications (such as aspirin and sulfa antibiotics) may lead to hypoglycemia. Individuals who drink excessive amounts of alcohol without food may develop hypoglycemia. Individuals with anorexia nervosa or those who do not eat enough food may develop hypoglycemia. Tumors of the pancreas may stimulate the pancreas to release too much insulin, which may then lead to hypoglycemia.

Common symptoms include confusion, abnormal behavior, impaired vision (such as blurred or double vision), irregular heartbeat, tremors, anxiety, sweating, and hunger. In rare cases, patients may develop seizures or lose consciousness.

Treatment of hypoglycemia involves short-term steps to increase the individual's blood sugar level. It also involves long-term steps to identify and treat the underlying cause of hypoglycemia. Individuals with hypoglycemia will first receive treatment to reduce symptoms. They may receive glucose tablets or eat foods high in sugar (such as candy) to increase blood sugar levels. In severe cases, individuals may require intravenous glucose or an injection of the glucagon hormone.

Once initial symptoms are treated, healthcare providers will work with the individual to determine the underlying cause of symptoms. Treating the underlying cause reduces the chances of hypoglycemia occurring in the future. If a tumor in the pancreas is causing symptoms, individuals may need to have it surgically removed. If a medication is causing the condition, an alternative drug or dose may be recommended.

Medications, including some used to treat diabetes, are the most common cause of hypoglycemia.

Signs and symptoms

Symptoms of hypoglycemia include: hunger; nervousness and shakiness; perspiration; dizziness or light-headedness; sleepiness; confusion; difficulty speaking; and feeling anxious or weak. Other symptoms include agitation, increased heart rate, flushing, blurred vision, and loss of consciousness.

Hypoglycemia can also occur while the individual is sleeping. The individual may cry out or have nightmares, have pajamas or sheets damp from perspiration, or feel tired, irritable, or confused upon waking.

Diagnosis

Blood glucose can be easily measured by blood testing in a doctor's office. Home test kits are also available for rapid glucose measurement. These home test kits are designed for use by diabetics to monitor and regulate their blood glucose at home while taking insulin or oral glucose-lowering agents. Doctors first measure the level of sugar in the blood. A low sugar level in the blood found at the time an individual is experiencing typical symptoms of hypoglycemia confirms the diagnosis.

The blood glucose levels in healthy individuals fluctuate depending greatly on the duration of fasting. The normal range is 70-120 milligrams/deciliter (mg/dl) after an overnight (12 hours) fast. In healthy men, the blood glucose can drop to 55 milligrams/deciliter (mg/dl) after 24 hours of fasting and to 48 milligrams/deciliter (mg/dl) after 72 hours of fasting. In healthy women, glucose levels can be as low as 35 milligrams/deciliter (mg/dl) after only 24 hours of fasting. These lower levels are not healthy and should be avoided.

Healthcare providers use a method called Whipple's triad to diagnose hypoglycemia. First, healthcare providers will evaluate the patient's signs and symptoms during a physical examination. In some cases, a healthcare provider may have the individual fast for 24 hours before the exam. Next, the healthcare provider will take a sample of the individual's blood to determine how much sugar is present. The last step needed to confirm a diagnosis is evaluating the patient's symptoms after blood sugar levels are raised. Individuals with hypoglycemia will experience no symptoms once their blood sugar levels are increased.

Complications

Short-term risks of hypoglycemia include the dangerous situations that can arise while an individual is hypoglycemic, whether at home or work (such as driving or operating machinery). In addition, prolonged coma is sometimes associated with neurological symptoms such as paresis (partial paralysis), convulsions, and encephalopathy (disease of the brain). The potential long-term complications of severe hypoglycemia are mild intellectual impairment and permanent neurologic damage, such as partial paralysis. Glucose is required by brain cells for energy, and a lack of glucose, such as during hypoglycemia, can result in brain damage.

Treatment

If the blood glucose is 70 milligrams/deciliter (mg/dl) or lower when checked, one of these "quick fix" foods should be used right away to raise the blood glucose, including: 2-3 glucose tablets; 1/2 cup (four ounces) of any fruit juice that contains sugar (orange juice is a good choice) ; 1/2 cup (four ounces) of a regular (not diet) soft drink; 1 cup (8 ounces) of milk; 5-6 pieces of hard candy; or 1-2 teaspoons of sugar or honey. The symptoms of hypoglycemia may be relieved within minutes after consuming one of the above.

Healthcare professionals recommend checking the blood glucose levels every 15 minutes. If it is still too low, repeat quick fix food dose until the blood glucose is at least 70 milligrams/deciliter. Then, if it will be an hour or more before the next meal, have a snack. The snack may consist of foods such as peanut butter (unless allergic to peanuts), cheese, crackers, or tuna fish or egg salad on wheat bread.

If taking insulin or a diabetes medication that can cause hypoglycemia, healthcare professionals recommend to always carry one of the quick-fix foods. Wearing a medical identification bracelet or necklace is also a recommended.

Individuals who are known to be at risk of severe episodes of hypoglycemia may keep prescribed glucagon on hand for emergencies. Glucagon administration stimulates the liver to release large amounts of sugar. If glucagon is given by injection, it generally restores blood sugar to an adequate level within five to 15 minutes.

In severe hypoglycemia, diagnosed by a medical professional, the individual may need hospitalization. Severe low blood sugars are treated with intravenous (into the veins or IV) glucose solutions to maintain the blood sugar at normal levels.

It is important to treat hypoglycemia quickly because hypoglycemia can get worse and the individual can loose consciousness. If consciousness is lost, immediate medical treatment is necessary, such as an injection of glucagon or emergency room treatment.

If blood-sugar levels are so low in an individual that unconsciousness or inability to swallow develops, emergency medical treatment is needed. This is called insulin shock. An injection of glucose solution or the hormone glucagon will be given immediately.

If glucagon is not available, the individual should be taken to the nearest emergency room for treatment. If the individual passes out from hypoglycemia, other people should never inject insulin, never give the individual food or fluids, and never put their hands in the individual's mouth. They may inject glucagon and call for emergency help (911).

For long-term management, dietary modifications may be necessary to deliver glucose to the body more evenly throughout the day thereby preventing further hypoglycemic attacks. Small, frequent meals with complex carbohydrates, fiber, and fat are recommended. The avoidance of simple sugars, alcohol, and fruit juice are dietary modifications that may also be recommended by healthcare professionals. Eating meals at regular intervals and balancing extra exercise with extra food is recommended. Physical exercise can also help the body maintain a healthy blood sugar level. Talking with a doctor about an exercise program is important.

Surgery is required to treat a pancreatic tumor (insulinoma) that causes hypoglycemia. This sometimes involves removing most of the pancreas. In cases where surgery is not an option, chemotherapy may be used to destroy cancerous cells. Insulin-producing tumors should be removed surgically. However, because these tumors are small and difficult to locate, a specialist should perform the surgery.

For more information on diabetes treatment, see the diabetes condition monograph.

Integrative therapies

Note: Integrative therapies listed below are used for blood sugar regulation conditions, including diabetes, hyperglycemia, and hypoglycemia. Patients with hypoglycemia or low blood sugar should not take herbs or supplements known to lower blood sugar or herbs or supplements used in the treatment of diabetes. Patients should consult with their health care provider before using integrative therapies for any blood sugar regulation condition.

Strong scientific evidence:

Alpha-lipoic acid: Many studies have shown that ALA may improve blood sugar levels among patients with type 2 diabetes. Higher-quality studies are needed to provide more definitive answers in the future.

Avoid if allergic to ALA. Use cautiously with diabetes and thyroid diseases. Avoid with thiamine deficiency or alcoholism. Avoid if pregnant or breastfeeding.

Good scientific evidence:

Beta-glucan: Beta-glucan is a soluble fiber derived from the cell walls of algae, bacteria, fungi, yeast, and plants. It is commonly used for its cholesterol-lowering effects. There are several human trials supporting the use of beta-glucan for glycemic (blood sugar) control in patients with diabetes. Although early evidence is promising, additional study is needed before a firm recommendation can be made.

Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously with AIDS or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.

Chromium: Chromium has been studied in the treatment of hypoglycemia (low blood sugar). More research is needed in this area.

Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.

Ginseng: Several studies report a blood sugar-lowering effect of American ginseng (Panax quinquefolium) in individuals with type 2 diabetes and hyperglycemia. Future research is needed to evaluate long-term efficacy of American ginseng compared to standard oral hypoglycemic drugs.

Ginseng may increase the effects of blood sugar lowering medications, including insulin. Avoid ginseng with a known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

Gymnema: Preliminary human research reports that gymnema (Gymnema sylvestre) may be beneficial in patients with type 1 diabetes mellitus or type 2 diabetes mellitus. Further studies of dosing, safety, and effectiveness are needed before a strong recommendation can be made.

Gymnema may increase the effects of blood sugar lowering medications, including insulin. Gymnema may alter the ability to detect sweet tastes. Avoid if allergic or sensitive to plants in the Asclepiadaceae (milkweed) family. Use cautiously with prescription drugs that may lower blood sugar levels. Dosing adjustments may be necessary.

Stevia: Stevia (Stevia rebaudiana) has been widely used for diabetes in South America and animal studies have had promising results. Studies report decreases in plasma glucose when stevia was taken in normal volunteers, but conclusive evidence of effectiveness when used for diabetes or hyperglycemia is currently lacking. Additional study is needed in this area.

Stevia may increase the effects of blood sugar-lowering medications, including insulin. Avoid if allergic or hypersensitive to the daisy family (Asteraceae/Compositae) including plants like ragweed, chrysanthemums, marigolds, and many other herbs. Use cautiously with hypotension (high blood pressure), hypocalcemia (calcium deficiency), and hypoglycemia (low blood sugar). Avoid with impaired kidney function or other kidney diseases. Avoid if pregnant or breastfeeding.

Unclear or conflicting scientific evidence:

Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Today it is widely used throughout the world and is one of the main pillars of Chinese medicine. Although preliminary results are promising, there is a lack of well-designed studies to determine the effect of acupuncture on diabetes.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, or with agents that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary diseases (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Alfalfa: A small number of animal studies report reductions in blood sugar levels following ingestion of alfalfa (Medicago sativa). Human data are limited, and it remains unclear if alfalfa can aid in the control of sugar in patients with diabetes or hyperglycemia.

Avoid if allergic to alfalfa, clover, or grass. Avoid with a history of lupus. Avoid before any surgery/dental/diagnostic procedures that may have a risk of bleeding, and avoid use immediately after these procedures. Use cautiously with stroke, hormone conditions (breast tenderness, breast cancer, ovarian cancer, menstrual problems), diabetes, hypoglycemia, thyroid disease, gout, blood clots, seizures, liver disease, or kidney disease. Use cautiously with blood sugar-altering medications, aspirin or any aspirin products, ibuprofen, and blood-thinners (like warfarin). Use cautiously if operating heavy machinery or driving. Alfalfa may be contaminated with dangerous bacteria (like E. coli, Salmonella, Listeria). Avoid if pregnant or breastfeeding.

Aloe: Transparent gel from the pulp of the meaty leaves of Aloe vera has been used topically for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Dried latex from the inner lining of the leaf has traditionally been used as an oral laxative. Although some preliminary research for using aloe in type 2 diabetes is positive, study results are mixed. More research is needed to explore the effectiveness and safety of aloe in diabetics.

Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Avoid applying to open, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools, hepatitis, a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.

Amylase inhibitors: Amylase inhibitors have been shown to decrease levels of blood glucose. Large, well-designed studies are needed before a firm recommendation can be made for patients with diabetes.

Amylase inhibitors are generally considered safe. Avoid if allergic or sensitive to amylase inhibitors, wheat, or legumes. Use cautiously with diabetes or hypoglycemia or if taking agents that lower blood sugar. Use cautiously with digestive, kidney, or liver problems. Use cautiously if pregnant or breastfeeding.

Arabinogalactan: Arabinogalactan's effects on blood sugar and insulin levels have been studied. In people without diabetes, it has not been shown to affect these levels. Additional research is needed for patients with hyperglycemia.

Avoid if allergic or sensitive to arabinogalactan or larch. People who are exposed to arabinogalactan or larch dust may have irritation of the eyes, lungs, or skin. Use cautiously in people with diabetes, digestive problems, or immune system disorders, and in people who consume a diet that is high in fiber or low in galactose. Arabinogalactan should not be used during pregnancy or breastfeeding.

Arabinoxylan: Altering the outer shell of rice bran using enzymes from Hyphomycetes mycelia mushroom extract produces the compound arabinoxylan. The product called MGN-3 (or BioBran? in Japan) is a complex containing arabinoxylan as a major component. Although preliminary research is positive, there is currently a lack of scientific evidence investigating the role of arabinoxylan in patients with type 2 diabetes. More study is needed.

Use cautiously if elderly or with kidney dysfunction. Use cautiously with diabetes. Avoid if pregnant or breastfeeding. Users of MGN-3 should be aware of other constituents (cornstarch, dextrin, tricalcium phosphate, silicon dioxide). Patients with allergies to other constituents should not take MGN-3.

Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. Early studies in humans suggest that arginine supplements may decrease the severity of type 1 or type 2 diabetes. Large, well-designed studies are needed to understand this relationship.

Avoid if allergic to arginine, with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin?) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control blood sugar levels.

Ashwagandha: Based on early study, ashwagandha (Withania somnifera) may decrease blood sugar levels in patients with type 2 diabetes. Additional evidence is required.

Avoid if allergic or hypersensitive to ashwagandha products or any of their ingredients. Dermatitis has been reported.There are few reports of adverse effects associated with ashwagandha, but there are few human trials using ashwagandha, and most do not report the doses or standardization/preparation used.Avoid with peptic ulcer disease. Ashwagandha may cause abortion based on anecdotal reports. Avoid if pregnant or breastfeeding.

Astragalus: Although there is experimental evidence that astragalus (Astragalus membranaceus) alone, and in combination with hypoglycemic medication, has significant hypoglycemic properties, available clinical studies have been poorly designed and results inadequately presented. The clinical data suggest that astragalus-containing herbal remedies plus conventional therapy (oral hypoglycemics) in the treatment of non-insulin dependent diabetes mellitus (NIDDM) are more effective than conventional oral hypoglycemics alone. More research is required in this area.

Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, transplants, or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.

Atkin's diet: The Atkins diet proposes that, in order to lose weight, one should adopt an eating style that radically departs from the U.S. Food and Drug Administration's (FDA) food pyramid. It proposes the elimination of most carbohydrates as a source of energy; in the place of carbohydrates, the diet advocates the significantly increased consumption of fats, including trans fats and hydrogenated oils. Carbohydrate-restricted diets have been shown to have positive effects on serum insulin in both diabetics and non-diabetics and insulin requirements in diabetics. Preliminary evidence suggests that following the Atkins Diet? may result in improvements in metabolic parameters in patients with diabetes. Furthermore, a decrease in HbA1c and medication requirements were noted in type 2 diabetics. Long term safety studies are still required in this field, as well as additional well-designed clinical trials.

Avoid with severe kidney disease, renal disorders. Avoid if using growth hormone. Use cautiously with mood disorders, such as depression, schizophrenia, or bipolar disorder, as well as individuals using medications for these purposes. Use cautiously in athletes due to potential for muscle cramps, negative feelings towards exercise, fatigue, and hypoglycemia. Use cautiously with osteoporosis, gout, diabetes, menstrual disorders, gastrointestinal disorders, celiac disease, skin conditions, epilepsy, and cardiovascular disease. Use cautiously in malnourished individuals, vegetarians, or individuals with absorption concerns. Use cautiously if taking diuretics, medications that alter cholesterol, medications that alter blood sugar, medications for seizures, steroids, or NSAIDS. Use cautiously in anemic individuals, individuals with thyroid concerns, and in individuals with previous history of stroke or heart attack. Avoid if pregnant or breastfeeding.

Ayurveda: Several studies have been conducted with various Ayurvedic treatments for diabetes, with mixed or modest results. The traditional antidiabetic remedy Coccinia indica may help improve glucose tolerance in adult-onset diabetes. An herbal tea containing Salacia reticulata (Kothala Himbutu tea) may improve glycemic control and reduce the need for Glibenclamide treatment in patients with type II diabetes mellitus. Drinking an aqueous suspension of the vegetable pulp from the herb Momordica charantia, a bitter vegetable popularly known as Karolla, may reduce serum glucose levels in people with moderate non-insulin dependent diabetes. A traditional Ayurvedic formula called Pancreas Tonic, taken in a powder capsule form, may bring intermediate term glucose control in type II diabetic patients with elevated HbA(1c) levels. The Ayurvedic herb Vijayasar (Pterocarpus marsupium), also called Bijaka, Pitasara, or Pitashalaka, may help modulate blood glucose levels in newly diagnosed or untreated non-insulin dependent diabetes mellitus. In all the above remedies, better-designed trials are needed to more clearly determine safety and effectiveness.

Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.

Banaba: Banaba (Lagerstroemia speciosa) is a medicinal plant that grows in India, Southeast Asia, and the Philippines. Preliminary research investigating the effects of banaba on diabetes reports promising results. However, additional research is necessary before a firm conclusion can be made.

Banaba is generally considered to be safe when taken orally for 15 days for the treatment of type 2 diabetes. Caution should be exercised in patients with known allergy/hypersensitivity to banaba, its constituents or any members of the Lythraceae family. Use cautiously in patients with diabetes since banaba may lower blood sugar. Avoid if pregnant or breastfeeding.

Barley: Barley (Hordeum vulgare) is a cereal used as a staple food in many countries. It is commonly used as an ingredient in baked products and soup in Europe and the United States. Barley malt is used to make beer and as a natural sweetener called malt sugar or barley jelly sugar. Preliminary evidence suggests that barley meal may improve glucose tolerance and hyperglycemia. This is believed to be due to fermentation of undigested carbohydrates in barley, which decreases hepatic glucose production by up to 30%. Barley products have been shown to have lower glycemic index compared to wheat or rice. Better research is necessary before a firm conclusion can be drawn.

Avoid if allergic or hypersensitive to barley flour or beer. Barley appears to be well tolerated in non-allergic, healthy adults in recommended doses for short periods of time, as a cereal or in the form of beer. Use cautiously with diabetes, asthma or arrhythmia (irregular heartbeat). Contamination of barley with fungus has occurred. Traditionally, women have been advised against eating large amounts of barley sprouts during pregnancy. Infants fed with a formula containing barley water, whole milk, and corn syrup have developed malnutrition and anemia, possibly due to vitamin deficiencies.

Beet: Limited available study has evaluated the effect of beets on secretion of gastric hormones in patients with type 2 diabetes following meals. Additional research is needed.

Use cautiously in patients with a known allergy or hypersensitivity to any part of the beet plant, including the beetroot, beet leaves, beet sugar, or beet fiber, or any other members of the Chenopodiaceae family. Avoid feeding beets and other high-nitrate vegetables to infants under three months of age, as advised by the American Academy of Pediatrics, due to high nitrate content and the risk of nitrate poisoning.

Berberine: Berberine is a bitter-tasting, yellow, plant alkaloid with a long history of medicinal use in Chinese and Ayurvedic medicine. Berberine is present in the roots, rhizomes, and stem bark of various plants including goldenseal (Hydrastis canadensis). Historically, berberine has been suggested to aid in glycemic regulation. However, the safety and effectiveness of berberine for type 2 diabetes remains unclear. More research is needed in this area.

Avoid if allergic or hypersensitive to berberine, to plants that contain berberine (Hydrastis canadensis (goldenseal), Coptis chinensis (coptis or goldenthread), Berberis aquifolium (Oregon grape), Berberis vulgaris (barberry), and Berberis aristata (tree turmeric)), or to members of the Berberidaceae family. Avoid in newborns due to potential for increase in free bilirubin, jaundice, and development of kernicterus. Use cautiously with cardiovascular disease, gastrointestinal disorders, hematologic disorders, leucopenia, kidney disease, liver disease, respiratory disorders, cancer, hypertyraminemia, diabetes, or hypotension. Use cautiously in children due to lack of safety information. Use cautiously in individuals with high exposure to sunlight or artificial light. Use cautiously for longer than eight weeks due to theoretical changes in bacterial gut flora. Use cautiously if taking anticoagulants, antihypertensives, sedatives, anti-inflammatories, medications metabolized by CYP P450 3A4 including cyclosporin, or any prescription medications. Avoid if pregnant or breastfeeding.

Bilberry: Bilberry (Vaccinium myrtillus), a close relative of blueberry, has a long history of medicinal use. Bilberry has been used traditionally in the treatment of diabetes mellitus, and animal research suggests that bilberry leaf extract may lower blood sugar levels. Human research is needed in this area.

Avoid if allergic to plants in the Ericaceae family or to anthocyanosides (a component of bilberry). Avoid with a history of low blood pressure, heart disease, bleeding, diabetes, blood clots, or stroke. Avoid if pregnant or breastfeeding. Stop use before surgeries or dental or diagnostic procedures involving blood tests.

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

Avoid if hypersensitive to constituents of biotin supplements.

Bitter melon: Bitter melon (Momordica charantia) has traditionally been used as a remedy for lowering blood glucose in patients with diabetes mellitus. Preliminary study has indicated that bitter melon may decrease serum glucose levels. However, because safety and efficacy have not been established, bitter melon should be avoided by diabetics except under the strict supervision of a qualified healthcare professional, including a pharmacist, with careful monitoring of serum blood sugars.

Bitter melon may increase the effects of blood sugar lowering medications, including insulin. Avoid if allergic or hypersensitive to bitter melon or members of the Curcurbitaceae (gourd or melon) family, including Persian melon, honeydew, casaba, muskmelon, and cantaloupe. Avoid ingestion of bitter melon seeds or outer rind, due to toxic lectins. Avoid if pregnant or breastfeeding.

Black tea: Black tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Black tea may lower blood sugar levels. In early study, a combination of black tea and green tea extract did not lower blood sugar levels in patients with type 2 diabetes. However, black tea alone did lower blood sugar and increased insulin levels in healthy patients. Additional research with black tea alone in diabetic patients is needed.

Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported after caffeine ingestion. Use cautiously with diabetes. Use cautiously if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. If breastfeeding mothers consume black tea, it may lead to anemia, decreased iron metabolism, and irritability in their infants.

Burdock: Animal research and initial human studies suggest possible blood sugar-lowering effects of burdock (Arctium lappa) root or fruit. However, the available human research has not been well designed, and further study in patients with diabetes is needed.

Avoid with known allergy to burdock, its constituents, or members of the Asteraceae/Compositae family, including ragweed, chrysanthemums, marigolds, and daisies. Use cautiously with allergies or intolerance to pectin, diabetes, glucose intolerance, electrolyte imbalances, or dehydration. Use cautiously if taking antidiabetic agents, diuretics, or blood thinners. Avoid if pregnant or breastfeeding.

Chromium: Chromium has been studied for sugar abnormalities in patients with types 1 and 2 diabetes mellitus, as well as at-risk populations. Some studies suggest that taking chromium by mouth may lower blood sugar levels, whereas other studies show no effects. Better studies are needed to provide more definitive answers.

Chrysanthemum: Based on early study, the chrysanthemum product jiangtangkang may be beneficial for patients with non-insulin dependent diabetes. However, results are mixed and additional studies are needed before a firm recommendation can be made.

Avoid if allergic or hypersensitive to chrysanthemum, its constituents, or members of the Asteraceae/Compositae family, such as dandelion, goldenrod, ragweed, sunflower, and daisies. Use cautiously if taking medication for gout, cancer, or HIV. Use cautiously with compromised immune systems or if taking immunomodulators. Avoid with photosensitivity or if taking photosensitizers. Avoid large acute or chronic doses of ingested pyrethrin. Avoid pyrethrin with compromised liver function, epilepsy, or asthma. Avoid ocular exposure to pyrethrin. Avoid if pregnant or breastfeeding.

Cinnamon: Several human studies support the use of cinnamon (Cinnamomum spp.) in type 2 diabetes. More research on the proposed health benefits of cinnamon supplementation is warranted.

Avoid if allergic or hypersensitive to cinnamon, its constituents, members of the Lauraceae family, or Balsam of Peru. Use cautiously if prone to atopic reactions or if taking cytochrome P450 metabolized agents, anticoagulants (blood thinners), insulin or blood sugar-altering medications, antibiotics, or cardiovascular agents. Avoid if pregnant or breastfeeding.

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

Avoid if allergic to chamomile, feverfew, honey, yarrow, or any related plants such as aster, daisies, sunflower, chrysanthemum, mugwort, ragweed, or ragwort. Use cautiously with diabetes or bleeding disorders, gastroesophageal reflux disease (GERD), kidney or liver diseases, or a history of stroke or electrolyte disorders. Potassium blood levels should be monitored. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Devil's club: The hypoglycemic (blood sugar-lowering) effect is one of many reported uses for devil's club (Oplopanax horridus), which had a traditional use in diabetes and continues to be used for this condition. Although early evidence looks promising, additional high-quality trials are needed to make a firm recommendation.

Avoid if allergic or hypersensitive to devil's club, its related species or other member of the ginseng (Araliaceae) family. The spines on the stems and leaves may cause an allergic reaction of the skin. Use cautiously with drugs for diabetes. Avoid if pregnant or breastfeeding.

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

Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

Fenugreek: Fenugreek (Trigonella foenum-graecum) has been found to lower serum glucose levels both acutely and chronically. Although promising, these data cannot be considered definitive, and at this time there is insufficient evidence to recommend either for or against fenugreek for either type 1 diabetes or type 2 diabetes.

Avoid if allergic to fenugreek or chickpeas. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously with asthma, diabetes, or a history of ulcers or stroke. Avoid if pregnant. Children should not take doses larger than what is commonly found in foods.

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

Avoid if allergic/hypersensitive to Fig or members of the Moraceae family. Use cautiously if allergic to kiwi fruit, papaya, avocado, pineapple, and banana. Use cautiously with bleeding disorders and sensitive skin. Use cautiously if pregnant or breastfeeding. Excessive sunlight or ultraviolet light exposure should be avoided while using products that contain fig leaf.

Flaxseed: Human studies on the effect of flaxseed (Linum usitatissimum) on blood sugar levels report mixed results. Flaxseed cannot be recommended as a treatment for hyperglycemia or diabetes at this time.

Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil, or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed with a history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Use cautiously with history of a bleeding disorder or with drugs that cause bleeding risk (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil?), high triglyceride levels, diabetes, mania, seizures, or asthma. Avoid if pregnant or breastfeeding. Avoid with prostate cancer, breast cancer, uterine cancer or endometriosis. Avoid ingestion of immature flaxseed pods.

Glucosamine: Early research suggests that glucosamine does not improve blood sugar control, lipid levels, or apolipoprotein levels in patients with diabetes. Additional research is needed.

Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine/chondroitin products and asthma. Use caution with diabetes or history of bleeding disorders. Avoid if pregnant or breastfeeding.

Green tea: Green tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Green tea has a long history of use, dating back to China approximately 5,000 years ago. Green tea, black tea, and oolong tea are all derived from the same plant. More studies are required to determine if green tea and polyphenols have any therapeutic benefit for diabetes prevention or treatment.

Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.

Holy basil: Holy basil (Ocimum sanctum) may have blood sugar-lowering effects and may be useful as an adjunct to dietary therapy and drug treatment in mild to moderate diabetes mellitus. It is unknown whether common culinary basil (Ocimum basilicum) would have similar effects. More research is warranted.

Avoid if allergic or hypersensitive to Ocimum sanctum, the Lamiaceae family, or any of the components of holy basil. Use cautiously with diabetes, sensitive skin or bleeding disorders. Avoid if pregnant or breastfeeding.

Honey: Early evidence suggests that honey may help lower blood sugar levels in patients with type 2 diabetes mellitus. Additional study is warranted.

Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe in the recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.

Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Although hydrotherapy is used by healthcare practitioners for diabetes mellitus support, there is insufficient research in this area.

Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.

Jackfruit: Jackfruit (Artocarpus heterophyllus), which refers to both a species of tree and its fruit, is native to southwestern India and Sri Lanka. Jackfruit was reportedly cultivated for food as early as the 6th Century B.C. in India. Jackfruit leaves may improve high blood sugar or glucose intolerance. However, there is little available research in this area. Additional study is needed.

Avoid if allergic or hypersensitive to jackfruit (Artocarpus heterophyllus), its constituents, or members of the Moraceae family. Use cautiously with birch pollen allergies, coagulation disorders, and diabetes. Use cautiously if taking anticoagulants, using immunosuppression therapy, or with transplanted tissues. Use cautiously in patients attempting to become pregnant. Avoid if pregnant or breastfeeding.

Kudzu: Preliminary evidence suggests puerarin, a constituent of kudzu (Pueraraia lobata), may improve insulin resistance in patients with diabetes. Additional study is needed before a firm conclusion can be made.

Use caution with anticoagulants/anti-platelet and blood pressure lowering agents, hormones, antiarrhythmics, benzodiazepines, bisphosphonates, diabetes medications, drugs that are metabolized by the liver's cytochrome P450 enzymes, mecamylamine, neurologic agents, and methotrexate. Well designed studies on the long-term effects of kudzu are currently unavailable. Avoid if allergic or hypersensitive to Pueraria lobata or members of the Fabaceae/Leguminosae family. Avoid if pregnant or breastfeeding.

L-Carnitine: It has been suggested that L-carnitine under constant infusion may increase insulin sensitivity in patients with type 2 diabetes mellitus and enhance glucose oxidation. Carnitine may also decrease fasting blood glucose and Lp(a). Additional study is needed before a firm recommendation can be made.

Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

Lutein: Lutein is found in high levels in foods such as green vegetables, egg yolk, kiwi fruit, grapes, orange juice, zucchini, squash, and corn. For some commercially available supplements, lutein is extracted from marigold petals. Currently, there is insufficient available evidence to recommend for or against the use of lutein for diabetes mellitus. Preliminary evidence is conflicting.

Avoid if allergic or hypersensitive to lutein or zeaxanthin. Use cautiously if at risk for cardiovascular disease or cancer. Avoid if pregnant or breastfeeding.

Maitake: Maitake is the Japanese name for the edible fungus Grifola frondosa, which is characterized by a large fruiting body and overlapping caps. Maitake has been used traditionally both as a food and for medicinal purposes. In animal studies, maitake extracts are reported to lower blood sugar levels. However, little is known about the effect of maitake on blood sugar and diabetes in humans.

Maitake has not been studied thoroughly in humans, and its effects are not well known. Because it has been used historically as a food, it is thought that low doses may be safe. Avoid if allergic or hypersensitive to Grifola frondosa (maitake) or its constituents. Use cautiously with low blood pressure, diabetes, or low blood sugar. Use cautiously if taking blood pressure medications, antidiabetic agents, immunostimulants, immunosuppressants, or interferons. Avoid if pregnant or breastfeeding.

Massage: There is early evidence suggesting that parental massage of children with diabetes may benefit blood sugar levels and symptom levels. There is also some evidence suggesting that self-massage of injection sites may increase insulin absorption.

Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin?). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

Milk thistle: A small number of studies suggest possible improvements of blood sugar control using milk thistle (Silybum marianum) supplementation in cirrhotic patients with diabetes mellitus. More research is needed.

Avoid if allergic to plants in the aster family (Compositea, Asteraceae), daisies, artichoke, common thistle, or kiwi. Use cautiously with diabetes. Avoid if pregnant or breastfeeding.

Myrcia: Myrcia is a medium-sized shrub that grows in drier regions of the Amazon and other parts of Brazil. In Brazil, the common name pedra hume ca? refers to three species of myrcia plants that are used interchangeably: Myrcia salicifolia, Myrcia uniflorus, and Myrcia sphaerocarpa. Myrcia has been used traditionally by indigenous tribes in the rainforest to treat diabetes. Human study has not confirmed a blood sugar-lowering benefit in patients with type 2 diabetes. More research is warranted.

Avoid if allergic/hypersensitive to myrcia or members of the myrtle family (Myrtaceae). Use cautiously with diabetes, low blood sugar (hypoglycemia), high blood pressure (hypertension) and overactive thyroid (hyperthyroidism). Avoid with gastrointestinal disorders or obstructions. Avoid if pregnant or breastfeeding.

Niacin: Niacinamide has been shown to exert a protective effect on pancreatic cell function in animal studies. Further research is warranted to better determine effects in patients with type 1 diabetes and type 2 diabetes.

Avoid if allergic to niacin or niacinamide. Avoid with history of liver disease or dysfunction, irregular heartbeats (arrhythmia), heart disease, blood clotting, bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout or diabetes. Avoid if pregnant or breastfeeding.

Nopal: Traditionally, nopal, or prickly pear, has been used as both a food and medicine. Animal studies have shown that nopal may reduce blood glucose levels in patients with diabetes. However, the quality of available studies is low and more research needs to be performed.

Avoid if allergic/hypersensitive to nopal (Opuntia spp.), any of its constituents, or members of the Cactaceae family. Use cautiously if taking medications that alter blood sugar, cholesterol, or blood pressure. Use cautiously with thyroid dysfunction, rhinitis (runny or congested nose), or asthma. Avoid with immunosuppression or impaired liver function. Avoid if pregnant or breastfeeding. The nopal plant should be handled cautiously, as it is covered in long sharp spines and shorter soft-appearing barbs of glochids, which may be painful and difficult to remove once they are imbedded in the skin. It is recommended that oral doses of dried nopal be taken with at least eight ounces (250mL) of water.

Onion: Limited available clinical study found that fresh onion (Allium cepa) significantly decreased serum glucose levels in patients with diabetes. More research is needed in this area.

Avoid if allergic or hypersensitive to onion (Allium cepa), its constituents, or members of the Lilaceae family. Use cautiously with hematologic (blood) disorders, diabetes, hypoglycemia (low blood sugar), and hypotension (low blood pressure). Use cautiously if taking anticoagulants or antiplatelets (blood thinners). Avoid in medicinal doses if pregnant or breastfeeding.

Psychotherapy: Psychotherapy may improve blood sugar control in patients with type 1 diabetes mellitus or type 2 diabetes mellitus. More studies are needed.

Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression.

Psyllium: Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata. Psyllium contains a high level of soluble dietary fiber and is the chief ingredient in many commonly used bulk laxatives, including products such as Metamucil?. Several studies have examined the administration of psyllium with meals or just prior to meals in order to measure effects on hyperglycemia (high blood sugar levels). Better evidence is necessary before a firm conclusion can be drawn.

Psyllium-containing products may delay gastric emptying time and reduce absorption of some drugs. It is advised that drugs be taken at separate administration times from psyllium to minimize potential interactions (for example, one hour before or a few hours after taking psyllium). Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantains (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Avoid in individuals with repeated or prolonged psyllium exposure who have not manifested allergic or hypersensitive symptoms. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.

Pycnogenol?: Pycnogenol? is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster spp. atlantica), which is grown in coastal south-west France. Supplementation of Pycnogenol? with conventional treatment for type 2 diabetes may lower glucose levels and improve endothelial function. Further research is needed.

Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia, or bleeding disorders. Use cautiously if taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.

Qi gong: There is some evidence that patients with diabetes may benefit from Qi gong. However, more research is needed.

Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders.

Red clover: Red clover (Trifolium praetense) has been studied in patients with type 2 diabetes to determine potential benefits in diabetic complications such as high blood pressure and narrowing of the arteries and veins. Further research is needed.

Red clover is not recommended during pregnancy and breastfeeding due to its estrogen-like activity. Avoid if allergic to red clover or other isoflavones. Use cautiously with hormone replacement therapy (HRT) or birth control pills. Use cautiously with history of a bleeding disorder, breast cancer, or endometrial caner. Use cautiously with drugs that thin the blood. Avoid if pregnant or breastfeeding.

Red yeast rice: Red yeast rice is the product of yeast (Monascuspurpureus) grown on rice, and is served as a dietary staple in some Asian countries. Early human evidence suggests the potential for benefits in patients with diabetes. Additional study is needed.

There is limited evidence about the side effects of red yeast. Mild headache and abdominal discomfort may occur. Side effects may be similar to those for the prescription drug lovastatin (Mevacor?). Heartburn, gas, bloating, muscle pain or damage, dizziness, asthma, and kidney problems are possible. People with liver disease should not use red yeast products. Avoid if allergic or hypersensitive to red yeast. Use cautiously with bleeding disorders. Avoid if pregnant or breastfeeding.

Reflexology: Reflexology may help manage type 2 diabetes in some patients. More clinical trials are necessary to determine whether reflexology is an effective treatment for this indication.

Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

Reishi mushroom: Reishi mushroom (Ganoderma lucidum), also known as ling zhi in China, grows wild on decaying logs and tree stumps. Based on animal studies that demonstrated the blood sugar and lipid-lowering activities of Ganoderma lucidum (ling zhi, reishi mushroom), a clinical study was conducted to evaluate the effect of Ganopoly? versus placebo in diabetic patients. The treatment of Ganopoly? slightly decreased the levels of plasma glucose and glycosylated hemoglobin and improved other markers for type 2 diabetes mellitus. Long-term studies with larger sample size are needed to evaluate the efficacy and safety of Ganopoly? in treating diabetic patients.

Reishi may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin?). Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of its family. Avoid if pregnant or breastfeeding.

Safflower: Lipid (fat) abnormalities are commonly associated with type 2 diabetes mellitus, and complications of atherosclerotic disease are frequently associated with diabetes. Safflower (Carthamus tinctorius) oil may negatively affect glucose metabolism due to the extra intake of energy or fat, but these effects may be less pronounced than with use fish oil. Additional research is needed in this area.

Avoid if allergic/hypersensitive to safflower, Carthamus tinctorius, safflower oil, daisies, ragweed, chrysanthemums, marigolds or any related constituents. Use parenteral safflower oil emulsions cautiously in newborns. Use cautiously if taking anticoagulants (blood thinners) or anti-platelet drugs, immunodepressants, or pentobarbital. Use cautiously with diabetes, hypotension, inadequate liver function, hypercoagulability, and skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.

Seaweed: Fucus vesiculosus is a brown seaweed that grows on the northern coasts of the Atlantic and Pacific oceans and the North and Baltic seas. Its name is sometimes used for Ascophyllum nodosum,which is another brown seaweed that grows alongside Fucus vesiculosus. These species are often included in kelp preparations along with other types of seaweed. Based on animal research, extracts of bladderwrack may be of benefit for hyperglycemia. However, reliable human studies are currently lacking.

Seaweeds may alter thyroid hormone levels. Avoid if allergic or hypersensitive to Fucus vesiculosus and iodine. Avoid with history of thyroid disease, bleeding, acne, kidney disease, blood clots, nerve disorders, high blood pressure, stroke, or diabetes. Avoid if pregnant or breastfeeding.

Soy: Several small studies have examined the effects of soy (Glycine max) supplements on blood sugar in patients with type 2 diabetes. Results are mixed, with some research reporting decreased blood glucose levels, and other trials noting no effects. Overall, research in this area is not well designed and better information is needed before the effects of soy on blood sugar can be clearly described.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy.

Spirulina: The term spirulina refers to a large number of cyanobacteria, or blue-green algae. Spirulina is a rich source of nutrients, containing up to 70% protein, B-complex vitamins, phycocyanin, chlorophyll, beta-carotene, vitamin E, and numerous minerals. Preliminary study of people with type 2 diabetes mellitus reports that spirulina may reduce fasting blood sugar levels after two months of treatment. More research is needed before a firm conclusion can be drawn.

Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, and osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or in those taking antiobesity agents or appetite suppressants; and if consuming a high-protein diet. Avoid in children and if pregnant or breastfeeding.

Tai chi: Tai chi has been suggested as a possible therapy for improving body composition and improving blood sugar regulation in diabetics. Early results are mixed, and additional study is needed. Tai chi is not recommended over current standard of care for diabetes control.

Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

Taurine: Taurine is a nonessential amino acid-like compound. Taurine is found in high abundance in the tissues of many animals, especially sea animals, and in much lower concentrations in plants, fungi, and some bacteria. It has been proposed that diabetes patients have decreased taurine levels. Currently, there is limited available evidence to support the use taurine in the treatment of type 2 diabetes mellitus.

Taurine is an amino acid and it is unlikely that there are allergies related to this constituent. However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously in patients with high cholesterol, low blood pressure, coagulation disorders, potential for mania, or epilepsy. Avoid consumption of energy drinks containing taurine, caffeine, glucuronolactone, B vitamins, and other ingredients, then consuming alcohol or exercising. Use cautiously if pregnant or breastfeeding because taurine is a natural component of breast milk.

Therapeutic touch: There is currently not enough evidence to recommend therapeutic touch as an effective treatment for diabetes. Additional research is needed in this area.

Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.

Thymus extract: Preliminary evidence in conventionally treated patients with type I diabetes suggests that a combination of azathioprine and thymostimulin increased remission. Thymostimulin alone had no effect. Additional study is needed in this area.

Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.

Vitamin D: Vitamin D is found in numerous dietary sources such as fish, eggs, fortified milk, and cod liver oil. The sun is also a significant contributor to our daily production of vitamin D and as little as 10 minutes of exposure is thought to be enough to prevent deficiencies. It has been reported that infants given calcitriol during the first year of life are less likely to develop type 1 diabetes than infants fed lesser amounts of vitamin D. Other related studies have suggested using cod liver oil as a source of vitamin D to reduce the incidence of type 1 diabetes. There is currently insufficient evidence to form a clear conclusion in this area. In recent studies, adults given vitamin D supplementation were shown to improve insulin sensitivity. Further research is needed to confirm the effects of vitamin D on type 1 diabetes and type 2 diabetes.

Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.

Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. Vitamin E has been proposed for improvement of abnormal sugar levels in diabetes mellitus. Further evidence is necessary.

Vitamin E may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin?). Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Avoid above the recommended daily level in pregnant women and breastfeeding women.

White horehound: Animal studies and early human studies suggest that white horehound (Marrubium vulgare) may lower blood sugar levels. White horehound has been used for diabetes in some countries, including Mexico. Further well-designed human trials are needed.

Avoid if allergic or hypersensitive to white horehound or any member of the Lamiaceaefamily (mint family). White horehound is generally considered safe when used to flavor foods. Use cautiously with diabetes, high/low/unstable blood pressure, high levels of sodium in the blood, irregular heartbeats or gastrointestinal diseases (like ileus, atony or obstruction). Use cautiously with diuretics (drugs that increase urine production). Avoid if pregnant or breastfeeding.

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several preliminary human studies suggest that daily yoga may improve control of blood sugar levels in people with type 2 diabetes when it is added to standard drug therapy. It is not clear if yoga is better than any other form of exercise therapy. Better research is needed.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Zinc: Diabetic patients typically have significantly lower serum zinc levels compared with healthy controls. Based on clinical study, zinc supplementation may elevate serum zinc levels and improve glycemic control in patients with diabetes. Further research is needed.

Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

Fair negative scientific evidence:

Coenzyme Q10: Preliminary evidence suggests that CoQ10 does not affect blood sugar levels in patients with type 1 or type 2 diabetes and does not alter the need for diabetes medications.

Allergy associated with Coenzyme Q10 supplements has not been reported, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix?), or blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.

Garlic: Animal studies suggest that garlic (Allium sativum) may lower blood sugar and increase the release of insulin, but studies in humans do not confirm this effect for type 2 diabetes.

Garlic may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin?). Avoid if allergic or hypersensitive to garlic or other members of the Lilaceae(lily) family (like hyacinth, tulip, onion, leek, chive). Avoid with history of bleeding problems, asthma, diabetes, low blood pressure or thyroid disorders. Stop using supplemental garlic two weeks before dental/surgical/diagnostic procedures and avoid using immediately after such procedures to avoid bleeding problems. Avoid in supplemental doses if pregnant or breastfeeding.

Niacin: Results from several clinical trials suggest that niacinamide may not be effective for type 1 diabetes mellitus prevention.

Omega-3 fatty acids: The available scientific evidence suggests that there are no significant long-term effects of fish oil in patients with diabetes. Most studies in this area are not well designed.

Caution is advised when taking omega-3 supplements, as numerous adverse effects including an increase in bleeding and drug interactions are possible. Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

Prayer: Prayer has not been shown to help prevent or treat diabetes or related health issues. Diabetes should be treated by a qualified healthcare professional using proven therapies.

Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers.

Selenium: Some studies have suggested that selenium supplementation may help with type 2 diabetes prevention by improving glucose metabolism. However, results from the Nutritional Prevention of Cancer (NPC) trial showed increased rates of type 2 diabetes in subjects taking selenium supplements. Although diabetes was not the primary focus of this study, these results indicate a potential risk of selenium supplementation that needs further examination.

Avoid if allergic or sensitive to products containing selenium. Avoid with history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

Prevention

Diet modification: It is important to choose foods low in fat and calories such as fresh fruits, vegetables, and whole grains. It is best to eliminate all refined carbohydrates (sugars and white flour) and hydrogenated oils. Limiting the amount of high-sugarbeverages, such assoft drinks and fruit punches, is also recommended by healthcare professionals.Avoid high-fat foods like full-fat dairy products, such as ice cream and butter, and high-fatmeats.Decreasing the consumption of dairy products may also help with blood sugar control. Lean poultry and fish should be eaten more often than red meat. It is best not to cook with butter, margarine, lard, and hydrogenated oils. Olive oil or vegetable oils such as safflower are recommended by healthcare professionals.

Alcohol consumption should be limited to no more than one drink per day for women,two perday for men, and none if there is difficulty controllingalcohol intake (addiction) or uncontrolled blood sugar levels.

Glucagon kit: Keeping a glucagon kit nearby in case of a low blood sugar emergency is suggested. Glucagon is an important hormone involved in carbohydrate metabolism. Produced by the pancreas, it is released when the glucose level in the blood is low (hypoglycemia), causing the liver to convert stored glycogen into glucose and release it into the bloodstream. The action of glucagon is thus opposite to that of insulin, which instructs the body's cells to take in glucose from the blood in times of satiation. An injection of glucagon will raise blood sugar levels.

Identification tags: Healthcare professionals recommend that individuals with diabetes or hypoglycemia wear a tag or bracelet identifying the condition.

Physical activity and weight control: Healthcare professionals recommend 30 minutes of moderate physical activity a day. Taking a brisk daily walk, riding a bike, or swimming laps are good exercises for individuals with diabetes and blood sugar regulation problems such as hypoglycemia. Losing weight is very important in maintaining healthy blood sugar levels by breaking down stored glycogen into glucose for release into the blood stream.

Proper glucose control: The single best thing an individual can do is to keep their blood sugar level within the suggested range every day. The only way to do this is through a combination of regular blood sugar checks (self blood glucose monitoring), a balanced diet low in simple sugars and fat and high in complex carbohydrates and fiber, and appropriate medical treatment. A nutritionist, a doctor, and others on the healthcare team will help set up appropriate diabetes treatment strategies for the individual.

Regular doctor visits: Scheduling regular health check-ups is important. However, regular checkups for blood sugar levels are not meant to replace yearly physicals or routine eye exams. Doctors will look for any diabetes-related complications, such as neuropathy, as well as screen for other medical problems. An eye care specialist will check for signs of retinal damage, cataracts, and glaucoma.

Smoking cessation: Smoking cigarettes or use of any other form of tobacco raises the risks for developing complications from diabetes, such as heart attack, stroke, nerve damage and kidney disease. Smoking damages blood vessels and contributes to heart disease, stroke, and poor circulation in the limbs. Smokers who have diabetes are three times more likely to die of cardiovascular disease than are nonsmokers who have diabetes, according to the American Diabetes Association (ADA). A doctor can help plan a strategy to stop smoking or to stop using other types of tobacco. Smoking may decrease the body's ability to regulate blood sugar levels.

Stress reduction: Chronic stress can lead to the adrenal glands releasing the stress hormone cortisol. Chronic release of cortisol can lead to health problems such as blood sugar regulation problems like hyperinsulinemia, high cholesterol levels, inflammation, poor immunity, and obesity. Stress can be controlled through integrative therapies, such as meditation, breathing, yoga, and certain herbs and vitamins. Getting plenty of rest may also help with decreasing stress and improving immunity. High blood sugar levels can weaken the immune system.

Author information

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

Bibliography

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Causes and risk factors

Glucose, a form of sugar, is an important fuel for the body. Carbohydrates are the main dietary sources of glucose. Rice, potatoes, bread, tortillas, cereal, milk, fruit, and sweets are all carbohydrate-rich foods.

After a meal, glucose molecules are absorbed into the bloodstream and carried to the cells where they are used for energy. Insulin, a hormone produced by the pancreas, helps glucose enter cells. If the individual takes in more glucose than the body needs at the time, the body stores the extra glucose in the liver and muscles in a form called glycogen. The body can use the stored glucose whenever it is needed for energy between meals. Extra glucose can also be converted to fat and stored in fat cells.

When blood glucose begins to fall, glucagon, another hormone produced by the pancreas, signals the liver to break down glycogen and release glucose, causing blood glucose levels to rise toward a normal level. If the individual has diabetes, this glucagon response to hypoglycemia may be impaired, making it harder for glucose levels to return to the normal range.

Medications: Medications, including some used to treat diabetes, are the most common cause of hypoglycemia or low blood sugar. Medications that can cause hypoglycemia include: salicylates, including aspirin, when taken in large amounts or chronically (long-term); sulfa antibiotics; pentamidine (Nebupent?), which treats a very serious kind of pneumonia; quinine, which is used to treat malaria; insulin; and anti-diabetic medications, such as metformin or Glucophage? .

If using any of these medications causes the blood glucose to drop, a doctor may advise the individual to stop using the drug or they may change the dosage.

Alcohol: Drinking, especially binge drinking, can cause hypoglycemia. During binge drinking, the body's breakdown of alcohol interferes with the liver's efforts to raise blood glucose, causing hypoglycemia. Hypoglycemia caused by excessive drinking can be very serious and even fatal. When alcohol is mixed with fruit juices (such as orange or cranberry juice) or mixers with high sugar content, hyperglycemia (high blood sugar levels) may occur.

Critical illnesses: Some illnesses, including hepatitis (inflammation of the liver), kidney failure, thyroid disorders, and brain tumors can cause hypoglycemia. Sepsis (infection occurring throughout the body), gastric bypass surgery, and starvation are other causes of hypoglycemia. In these cases, treatment targets the underlying cause.

Hormonal deficiencies: Hormonal deficiencies may cause hypoglycemia in very young children, but usually not in adults. Shortages of cortisol, growth hormone, glucagon, or epinephrine can lead to fasting hypoglycemia. Laboratory tests for hormone levels will determine a diagnosis and treatment. Hormone replacement therapy may be advised.

Tumors: Insulinomas, insulin-producing tumors, can cause hypoglycemia by raising insulin levels too high in relation to blood glucose levels. These tumors are very rare and do not normally spread to other parts of the body. Laboratory tests can pinpoint the exact cause. Treatment involves both short-term steps to correct the hypoglycemia and medical or surgical measures to remove the tumor.

Hypoglycemia in children: Children rarely develop hypoglycemia. However, children with type 1 diabetes taking insulin can develop symptoms of hypoglycemia. If hypoglycemia is present in children, other causes may include a brief intolerance to fasting, often in conjunction with an illness that disturbs regular eating patterns. Children usually outgrow hypoglycemia by age 10. Hyperinsulinemia, or the excessive production of insulin, can result in transient neonatal hypoglycemia. This is common in infants of mothers with diabetes. Persistent hyperinsulinemia in infants or children is a complex disorder that requires prompt evaluation and treatment by a specialist. Another cause of hypoglycemia in children may be enzyme deficiencies that affect carbohydrate metabolism. These deficiencies can interfere with the body's ability to process natural sugars, such as fructose and galactose, glycogen, or other metabolites. Finally, hormonal deficiencies, such as a lack of pituitary or adrenal hormones, may cause low blood sugar in children.

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