Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) FROM PMTCT TO A MORE COMPREHENSIVE AIDS RESPONSE FOR WOMEN: A MUCH-NEEDED SHIFT CYNTHIA EYAKUZE, DEBRA A. JONES, ANN M. STARRS AND NAOMI SORKIN Keywords PMTCT, ABSTRACT Half of the 33.2 million people living with HIV today are women. Yet, responses to the epidemic are not adequately meeting the needs of wom
Complementary and alternative medicine
for the treatment of type 2 diabetes
Richard Nahas MD CCFP Matthew Moher
the most prevalent and fastest grow-ing diseases in Canada, responsible OBJECTIVE To review clinical evidence supporting complementary and
for expenditures of 9 billion dollars per alternative medicine interventions for improving glycemic control in type 2 diabetes mellitus.
year.1 Family physicians play a central role in the management of diabetes. Although QUALITY OF EVIDENCE MEDLINE and EMBASE were searched from January
1966 to August 2008 using the term type 2 diabetes in combination with each of the following terms for specific therapies selected by the authors: they do not necessarily provide real-world cinnamon, fenugreek, gymnema, green tea, fibre, momordica, chromium, and benefits. In the recent ACCORD (Action to vanadium. Only human clinical trials were selected for review.
Control Cardiovascular Risk in Diabetes)2 MAIN MESSAGE Chromium reduced glycosylated hemoglobin (HbA ) and
fasting blood glucose (FBG) levels in a large meta-analysis. Gymnema sylvestre Vascular Disease: Preterax and Diamicron reduced HbA levels in 2 smal open-label trials. Cinnamon improved FBG but its MR Controlled Evaluation)3 trials, intensive effects on HbA are unknown. Bitter melon had no effect in 2 smal trials. Fibre glycemic control had minimal effect on clin- had no consistent effect on HbA or FBG in 12 smal trials. Green tea reduced ical cardiovascular outcomes. In fact, in a FBG levels in 1 of 3 smal trials. Fenugreek reduced FBG in 1 of 3 smal trials. Va- recent meta-analysis, combination therapy nadium reduced FBG in smal , uncontrol ed trials. There were no trials evaluating microvascular or macrovascular complications or other clinical end points.
the risk of a composite end point of car- CONCLUSION Chromium, and possibly gymnema, appears to improve gly-
diovascular events and mortality (relative cemic control. Fibre, green tea, and fenugreek have other benefits but there risk 1.43, 95% confidence interval [CI] 1.10 is little evidence that they substantially improve glycemic control. Further to 1.85).4 The use of thiazolidinediones has research on bitter melon and cinnamon is warranted. There is no comple- recently been called into question because mentary and alternative medicine research addressing microvascular or they increase cardiovascular risk and frac- Résumé
using complementary and alternative medi- OBJECTIF Faire le point sur les données cliniques en faveur d’interventions
cine (CAM) therapies,6 often without con- de médecine complémentaire et alternative pour améliorer le contrôle de la sulting or even informing their FPs. It is glycémie dans le diabète de type 2.
QUALITÉ DES PREUVES On a consulté MEDLINE et EMBASE entre janvier 1966
their CAM use and provide evidence-based et août 2008 à l’aide du terme type 2 diabetes en combinaison avec chacun des information about the safety and efficacy of termes suivants pour des traitements spécifiques, choisis par les auteurs : cinna- mon, fenugreek, gymnema, green tea, fibre, momordica, chromium et vanadium. Here we provide a brief review of the evi- Seuls les essais cliniques humains ont été retenus pour cette étude.
PRINCIPAL MESSAGE Le chrome a réduit l’hémoglobine glycosylée (HbA )
therapies commonly used to treat type 2 DM.
et la glycémie à jeun (GÀJ) dans une grande méta-analyse. Le gymnema sylvestre a réduit les niveaux d’ HbA dans 2 petits essais sans insu. La can- Quality of evidence
nelle a amélioré la GÀJ, mais on ignore ses effets sur l’ HbA . La margose n’a eu aucun effet dans 2 petits essais. Les fibres ont eu des effets variables sur le HbA ou sur la GÀJ dans 12 petits essais. Le thé vert a abaissé la GÀJ dans 1 essai sur 3. Le fenugrec a diminué la GÀJ dans un essai sur 3. Le vanadium a key words were type 2 diabetes in combi- réduit la GÀJ dans des petits essais non contrôlés. Aucun essai n’a évalué les nation with each of cinnamon, fenugreek, complications micro ou macro-vasculaires, ou d’autres issues cliniques.
gymnema, green tea, fibre, momordica, chro- CONCLUSION Le chrome et possiblement le gymnema sylvestre semblent
mium, and vanadium. These interventions améliorer le contrôle de la glycémie. Les fibres, le thé vert et le fenugrec ont d’autres effets bénéfiques, mais il y a peu de données indiquant qu’ils améliorent le contrôle de la glycémie. La margose et la cannelle mériteraient This article has been peer reviewed.
d’autres études. Il n’existe aucune recherche en médecine complémentaire et Cet article a fait l’objet d’une révision par des pairs.
alternative sur les issues cliniques micro ou macro-vasculaires.
Vol 55: JUNE • JUIN 2009 Canadian Family Physician • Le Médecin de famille canadien 591
Clinical Review Complementary and alternative medicine
literature reviews and clinical experience. Results were is contact dermatitis from volatile oils. Safety in preg- screened by one author to include clinical trials, system- atic reviews, and meta-analyses. Only human clinical Overall, there is moderate evidence that cinnamon lowers blood glucose levels. Its effect on HbA appears negligible, but long-term studies are required to prop- Main findings
Relevant findings for each search term are briefly sum-marized in Table 1 and are detailed as follows: Chromium. Chromium is an essential trace element with many sites of action, including carbohydrate and Cinnamon. True cinnamon (Cinnamomum verum) is lipid metabolism. Trivalent chromium is a constituent a small evergreen tree, the bark of which is a common of a complex known as the “glucose tolerance factor,”15 culinary spice. Most cinnamon sold in the United States and chromium deficiency causes reversible insulin resis- and Canada is actually derived from C aromaticum or C cassia, sometimes called “Chinese cinnamon” to dis- A meta-analysis identified 41 trials (N = 1198) that tinguish it from C verum. Cinnamon has been used for evaluated the effects of various chromium formula- thousands of years to treat diabetes and other condi- tions at doses of 200 to 1000 µg daily for 2 to 26 weeks. tions. The aqueous extract appears to activate the insu- Of these, 14 trials (n = 431) evaluated patients with lin receptor by multiple mechanisms, and also increases type 2 DM and baseline HbA levels of 7.0% to 10.2%. Chromium picolinate and brewer’s yeast at doses of 200 A recent meta-analysis identified 5 trials (N = 282) that to 1000 µg for 6 to 26 weeks reduced HbA levels by an evaluated C cassia at 1 to 6 g daily for 40 days to 4 average of 0.6% (95% CI -0.9% to -0.2%) and FBG levels months.11 One trial was not randomized, while another by an average of 1 mmol/L (95% CI -1.4 to -0.5).19 These trial investigated adolescents with type 1 diabetes. The findings are limited by the fact that more than half the other 3 randomized controlled trials (RCTs) involved studies included were of poor quality and used different 196 patients. In one, 60 patients with poorly controlled formulations and doses of chromium in populations that diabetes were given 1, 3, or 6 g of C cassia for 40 days. might have had very different amounts of chromium in Fasting blood glucose (FBG) levels decreased by 18% their diet. No significant adverse effects were reported in to 29%, but chromium-reduced glycosylated hemoglo- bin (HbA ) levels were not investigated.12 In a second The meta-analysis included 2 RCTs that evaluated trial, 79 well-controlled diabetes patients received 3 g of combination therapy using 600 µg chromium pico- C cassia daily for 4 months. More moderate reductions linate and 2 mg biotin. Biotin is a B vitamin that has in FBG levels (average 10.3% vs 3.4% in placebo group, enhanced chromium absorption in animal studies. P = .046) were noted, but HbA levels were unchanged.13 One 3-month trial in 447 patients with diabetes (mean In the third trial, 43 patients with diabetes with an aver- baseline HbA level 8.6%) noted an HbA level reduc- age HbA measurement of 7.1% were treated with 1 g tion of 0.54% (P = .03) overall, and an impressive 1.76% daily for 3 months. No change was reported in FBG or reduction among patients with baseline HbA levels above 10% (P = .0001).20 In the second trial, 36 patients No significant adverse effects were reported in the with diabetes were treated for 1 month; no reduction in reviewed trials. The only reported risk of cinnamon use Table 1. Summary of evidence supporting complementary and alternative medicine therapies for
type 2 diabetes mellitus
BoDy oF evIDeNCe
HbA and FBG level reduction in meta-analysis FBG level reduction in uncontrolled trials HbA level reduction (non-significant) in 1 of 3 trials FBG level reduction in 6 of 12 trials FBG level reduction in 1 of 3 trials Other benefits No benefit to HbA or FBG levels in 2 small trials FBG level reduction in 1 of 3 trials Other benefits HbA —glycosylated hemoglobin A , FBG—fasting blood glucose.
592 Canadian Family Physician • Le Médecin de famille canadien Vol 55: JUNE • JUIN 2009
Complementary and alternative medicine Clinical Review
There is strong evidence that 200 to 1000 µg of chro- the freshly collected leaves. The numerous health ben- mium picolinate daily improves glycemic control. Based efits of tea consumption are attributed to polyphe- on its safety and potential cost-effectiveness, a definitive nol catechins, particularly epigallocatechin gallate.45,46 clinical trial is urgently needed. Biotin might enhance its These compounds have improved insulin sensitivity and effects, but this combination requires further study.
reduced β-cell damage in animal and in vitro studies.47-53 Although caffeine initially impairs glucose metabolism, Vanadium. Vanadium is a poorly understood trace long-term exposure stimulates lipolysis, increases basal element that is ubiquitous in nature and believed to energy expenditure, and mobilizes muscle glycogen.54,55 have many functions in human physiology. In vitro and Prospective and retrospective population studies sug- animal studies have demonstrated its insulinomimetic gest that green tea consumption reduces the risk of type effects mediated by inhibition of phosphotyrosine phos- 2 DM by up to 48%.56,57 Surprisingly, only 1 small RCT phatase enzymes that affect the insulin receptor.22-24 (N = 49) has evaluated green tea in the context of dia- A recent meta-analysis identified 5 uncontrolled trials betes. In this study, patients with baseline HbA levels (N = 48) in which 50 to 300 mg of vanadium was admin- of 6.5% to 9.1% were randomized to receive either an istered for 3 to 6 weeks.25 Vanadyl sulfate was used in extract containing green tea catechins and black tea 4 trials and sodium metavanadate was used in 1 trial. theaflavins or placebo for 3 months. No improvements All 5 trials reported reductions in FBG levels, but these in HbA levels were seen and FBG values were not were of short duration; none of the trials included con- measured.58 Side effects included a generalized rash in 1 trols. Commonly reported side effects included gastroin- testinal upset, bloating, and nausea.
Three open-label trials (N = 141) of 1 to 2 months’ There is insufficient evidence to support the use of duration reported no changes in HbA values.59-61 vanadium in the treatment of type 2 DM.
Investigators in one trial administered 1.5 L of oolong (partly oxidized) tea to 20 patients for 4 weeks and Fibre. Dietary fibre is recognized as an important part reported a 30% decrease in FBG levels (P < .001).44 of a healthy diet. Soluble and insoluble fibre have posi- There is little evidence to support the use of green tea tive effects on cardiovascular risk factors,26 intestinal for glycemic control. Epidemiologic data suggest large disorders,27 and certain cancers.28-30 Cohort studies sug- potential benefits, but further research is warranted. gest that consumption of cereal fibre and whole grains is Green tea consumption should still be recommended for inversely related to type 2 DM incidence.31 its other potential health benefits.
We identified 12 small RCTs (N = 345) that evaluated the effect of fibre in diabetes patients.32-43 Many differ- Bitter melon. Bitter melon (Momordica charantia) is ent kinds of fibre were used, including wheat, guar, beet, a tropical vine that produces fruit that is used to treat soy, corn, agar, glucomannan, psyllium, and mixtures. diabetes in many traditional cultures, including Indian Daily doses of 2 to 50 g were administered for 3 to 20 Ayurvedic medicine. Several of its active ingredients, weeks. In 3 trials of 12 to 20 weeks’ duration, only 1 including charantin, vicine, and polypeptide-p,62-64 are found an improvement in HbA levels: in this trial of 76 believed to stimulate insulin secretion and alter hepatic patients with well-controlled diabetes, a non-significant decrease from 6.6% to 6.1% was seen in those who con- Two RCTs have evaluated the effects of bitter melon sumed agar containing 4.5 g fibre daily for 12 weeks. Six in patients with type 2 DM. In one RCT, 40 patients with of the 12 RCTs reported reductions in FBG; the other 6 baseline HbA values of 7% to 9% were given either RCTs reported no change in this outcome. Most of the 3 g of fruit and seed extract or placebo. After 3 months, studies also reported improvements in other risk factors, there was no change in HbA or FBG values.68 The other particularly those related to cholesterol levels. Some trial, in which 51 patients consumed either 6 g of fruit trials reported gastrointestinal side effects, including and seed extract or placebo for 1 month, also reported bloating, diarrhea, and abdominal pain.44 no effect on HbA or FBG values.69 No side effects were There is little evidence that dietary fibre improves gly- cemic control. Existing trials are limited by the hetero- There is no evidence to support the use of bit- geneity of fibre formulations and the variation in doses ter melon. It should be noted that stimulating insulin and duration of treatment. Evidence of a short-term release is probably less desirable than improving insu- hypoglycemic effect in diabetes patients is conflicting. lin sensitivity. Bitter melon’s widespread traditional use Nonetheless, fibre can be recommended based on its merits further study, particularly in patients originating salutary effect on other cardiovascular risk factors.
from cultures with a long history of traditional use.
Green tea. Green and black tea both originate from the Fenugreek. Fenugreek (Trigonella foenum-graecum) leaves of the Camellia sinensis plant. Green tea is heated has been cultivated and used medicinally and ceremoni- to inactivate the enzymes that would otherwise oxidize ally for thousands of years in Asian and Mediterranean Vol 55: JUNE • JUIN 2009 Canadian Family Physician • Le Médecin de famille canadien 593
Clinical Review Complementary and alternative medicine
cultures. Its leaves and seeds are used to treat diabetes EDITOR’S KEY POINTS
in Ayurvedic and other traditional medical systems. The • Chromium (200 to 1000 µg per day) is the only most studied active ingredient is 4-hydroxyisoleucine, complementary and alternative medicine interven- which increases pancreatic insulin secretion and inhibits tion with level 1 evidence to support its use in dia- sucrose α-D-glucosidase and α-amylase.70-72 Additionally, betes management, but a large-scale clinical trial is fenugreek seeds are used to lower cholesterol, as sapo- genins in the seeds increase biliary secretion73-80; they • Small studies indicate that Gymnema sylvestre improves HbA levels. Larger studies are required to Three small short-term RCTs (N = 50) have evaluated fenugreek in patients with type 2 DM. In one trial, 25 • Cinnamon probably lowers blood glucose levels, but patients consumed 1 g of seed extract or placebo for its effects on HbA levels are unknown.
2 months with no change in FBG levels.81 In a small • Bitter melon has a long history of traditional use, crossover study, 10 patients added 25 g of defatted seed but preliminary evidence suggests its benefits might powder to 1 meal or ate the meal without the powder for 15 days. Several measures of glucose metabolism • Vanadium is poorly understood, has potential were all unchanged.82 A third trial, which used a higher adverse side effects, and should probably be avoided.
dose (100 g) of defatted seed powder in 15 patients for • Green tea, fenugreek, and fibre can be recom- 10 days, did report improvements in FBG values.83 None mended on account of their other health benefits, of the trials investigated HbA levels. No adverse effects but evidence that they improve glycemic control is There is very limited evidence to support the use of fenugreek in diabetes management. High doses of seed POINTS DE REPèRE DU RÉDACTEUR
powder might be effective but require further study and • La seule substance en médecine complémentaire are likely impractical for most patients. Its widespread et alternative dont l’usage dans le traitement du traditional use and its reported lipid-lowering benefits diabète s’appuie sur des preuves de niveau 1 est le chrome (200 à 1000 μg/d), mais il faudra un essai clinique à grande échelle pour confirmer ces Gymnema. Gymnema sylvestre is also known as gur- mar (sugar destroyer) in Hindi. The leaves of this plant • Certaines petites études indiquent que le gymnema are used in Ayurvedic medicine to treat diabetes, choles- sylvestre améliore les niveaux de HbA . Ces résultats terol, and obesity.84 Gymnemic acid, a mixture of many prometteurs devront être confirmés par de plus different saponins, is believed to be the active fraction, although a clear mechanism of action is yet to be been • La cannelle abaisse probablement le glucose sanguin, Two small open-label trials have yielded promising • La margose est d’usage traditionnel depuis long- results. In the first trial, 22 patients with type 2 DM were temps, mais des données préliminaires suggèrent given either 200 mg of an ethanolic extract daily or que ses avantages pourraient être limités.
their usual treatment for 18 to 20 months. Significant • Les effets du vanadium sont mal connus; il pourrait improvements in FBG and HbA levels (P < .001 for avoir des effets indésirables et on devrait vraisem- both) were noted in the test group.86 The other trial was uncontrolled, but reported that 3 months of treatment • Le thé vert, le fenugrec et les fibres peuvent with 800 mg daily of a similar extract reduced FBG lev- être recommandés à cause de leurs autres effets els by 11% and HbA levels by 0.6% in a mixed popula- bénéfiques sur la santé, mais les preuves qu’ils tion of 65 patients with type 1 and type 2 diabetes.87 No améliorent le contrôle de la glycémie sont limitées adverse effects were reported in either trial.
Preliminary evidence of any benefit is probably insuf- ficient to support the widespread use of G sylvestre for diabetes management at this time. The significant involve HbA measurements and should be of at least improvements in HbA levels definitely warrant further 4 months’ duration. Most of these trials were of insuf- study as well as judicious use in selected patients.
ficient duration to evaluate this outcome. None of the research examined has addressed the potential effect Conclusion
of CAM interventions on cardiovascular outcomes. This Changes in HbA values are most often used to evalu- is important because better glycemic control might not ate hypoglycemic effects. It is important to consider that always lead to real-world clinical benefits. It is also the life span of a red blood cell is 120 days. Therefore, important because some interventions can improve studies investigating diabetes management should 594 Canadian Family Physician • Le Médecin de famille canadien Vol 55: JUNE • JUIN 2009
Complementary and alternative medicine Clinical Review
Overall, there is a paucity of research evaluating overweight to obese patients with type 2 diabetes. Diabetes Metab Res Rev 2008;24(1):41-51.
CAM therapies that are commonly used to treat type 2 21. Geohas J, Daly A, Juturu V, Finch M, Komorowski JR. Chromium picolinate DM. This should be a high priority for CAM researchers and biotin combination reduces atherogenic index of plasma in patients with type 2 diabetes mellitus: a placebo-controlled, double-blinded, randomized clinical trial. Am J Med Sci 2007;333(3):145-53.
22. O’Connell BS. Selected vitamins and minerals in the management of diabe- Dr Nahas is a Lecturer in the Department of Family Medicine at the University tes. Diabetes Spectrum 2001;14(3):133-48. Available from: http://spectrum.
of Ottawa and Medical Director of the Seekers Centre for Integrative Medicine diabetesjournals.org/cgi/reprint/14/3/133.pdf. Accessed 2009 Apr 17.
in Ottawa, Ont. Mr Moher is a fourth-year medical student at the University of 23. Verma S, Cam MC, McNeill JH. Nutritional factors that can favorably influ- ence the glucose/insulin system: vanadium. J Am Coll Nutr 1998;17(1):11-8.
24. Pandey SK, Anand-Srivastava MB, Srivastava AK. Vanadyl Dr Nahas and Mr Moher contributed to the literature review, selection and sulfate-stimulated glycogen synthesis is associated with activation of review of studies, and preparation of the manuscript for publication.
phosphatidylinositol 3-kinase and is independent of insulin receptor tyrosine phosphorylation. Biochemistry 1998;37(19):7006-14.
25. Smith DM, Pickering RM, Lewith GT. A systematic review of vanadium oral supplements for glycaemic control in type 2 diabetes mellitus. QJM Correspondence
Dr R. Nahas, Medical Director, Seekers Centre for Integrative Medicine, 6 26. Galisteo M, Duarte J, Zarzuelo A. Effects of dietary fibers on disturbances Deakin St, Ottawa, ON K2E 1B3; e-mail firstname.lastname@example.org clustered in the metabolic syndrome. J Nutr Biochem 2008;19(2):71-84. Epub 2007 Jul 6.
27. Marlett JA, McBurney MI, Slavin JL; American Dietetic Association. Position 1. Health Canada. It’s your health. Type 2 diabetes. Ottawa, ON: Health Canada; of the American Dietetic Association: health implications of dietary fiber. J 2004. Available from: www.hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/ Am Diet Assoc 2002;102(7):993-1000.
diabete-eng.php. Accessed 2009 Apr 17.
28. Cummings JH, Bingham SA, Heaton KW, Eastwood MA. Fecal weight, colon 2. Action to Control Cardiovascular Risk in Diabetes Study Group; Gerstein HC, cancer risk and dietary intake of nonstarch polysaccharides (dietary fiber). Miller ME, Byington RP, Goff DC Jr, Bigger JT, et al. Effects of intensive glu- Gastroenterology 1992;103(6):1783-9.
cose lowering in type 2 diabetes. N Engl J Med 2008;358(24):2545-59. Epub 29. Howe GR, Benito E, Castelleto R, Cornée J, Estève J, Gallagher RP, et al. Dietary intake of fiber and decreased risk of cancers of the colon and rectum: 3. ADVANCE Collaborative Group; Patel A, MacMahon S, Chalmers J, Neal evidence from the combined analysis of 13 case–control studies. J Natl Cancer B, Billot L, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358(24):2560-72. Epub 2008 30. Prentice RL. Future possibilities in the prevention of breast cancer: fat and fiber and breast cancer research. Breast Cancer Res 2000;2(4):268-76. Epub 4. Rao AD, Kuhadiya N, Reynolds K, Fonseca VA. Is the combination of sulfo- nylureas and metformin associated with an increased cardiovascular disease 31. Murakami K, Okubo H, Sasaki S. Effect of dietary factors on incidence of or all-cause mortality? A meta-analysis of observational studies. Diabetes type 2 diabetes: a systematic review of cohort studies. J Nutri Sci Vitaminol Care 2008;31(8):1672-8. Epub 2008 May 5.
5. Lipscombe LL. Thiazolidinediones: do harms outweigh benefits? CMAJ 32. Beattie VA, Edwards CA, Hosker JP, Cullen DR, Ward JD, Read NW. Does adding fibre to a low energy, high carbohydrate, low fat diet confer any ben- 6. McFarland B, Bigelow D, Zani B, Newsom J, Kaplan M. Complementary and efit to the management of newly diagnosed overweight type II diabetics? Br alternative medicine use in Canada and the United States. Am J Public Health Med J (Clin Res Ed) 1988;296(6630):1147-9.
33. Vuksan V, Jenkins DJ, Spadafora P, Sievenpiper JL, Owen R, Vidgen E, et 7. Imparl-Radosevich J, Deas S, Polansky MM, Baedke DA, Ingebritsen TS, al. Konjac-mannan (glucomannan) improves glycemia and other associated Anderson RA, et al. Regulation of PTP-1 and insulin receptor kinase by frac- risk factors for coronary heart disease in type 2 diabetes. A randomized con- tions from cinnamon: implications for cinnamon regulation of insulin signal- trolled metabolic trial. Diabetes Care 1999;22(6):913-9.
ing. Horm Res 1998;50(3):177-82.
34. Rodríguez-Morán M, Guerrero-Romero F, Lazcano-Burciaga G. Lipid- and 8. Jarvill-Taylor KJ, Anderson RA, Graves DJ. A hydroxychalcone derived from glucose-lowering efficacy of Plantago Psyllium in type II diabetes. J Diabetes cinnamon functions as a mimetic for insulin in 3T3-L1 adipocytes. J Am Coll Complications 1998;12(5):273-8.
35. Mahalko JR, Sandstead HH, Johnson LK, Inman LF, Milne DB, Warner RC, 9. Qin B, Nagasaki M, Ren M, Bajotto G, Oshida Y, Sato Y. Cinnamon extract et al. Effect of consuming fiber from corn bran, soy hulls, or apple powder (traditional herb) potentiates in vivo insulin-regulated glucose utilization via on glucose tolerance and plasma lipids in type 2 diabetes. Am J Clin Nutr enhancing insulin signaling in rats. Diabetes Res Clin Pract 2003;62(3):139-48.
10. Cao H, Polansky MM, Anderson RA. Cinnamon extract and polyphenols 36. Maeda H, Yamamoto R, Hirao K, Tochikubo O. Effects of agar (kanten) affect the expression of tristetraprolin, insulin receptor, and glucose trans- diet on obese patients with impaired glucose tolerance and type 2 diabetes. porter 4 in mouse 3T3-L1 adipocytes. Arch Biochem Biophys 2007;459(2):214- Diabetes Obes Metab 2005;7(1):40-6.
37. Karlander S, Armyr I, Efendic S. Metabolic effects and clinical value of beet 11. Baker WL, Gutierrez-Williams G, White CM, Kluger J, Coleman CI. Effect fibre treatment in NIDDM patients. Diabetes Res Clin Pract 1991;11(2):65-71.
of cinnamon on glucose control and lipid parameters. Diabetes Care 38. Cho SH, Kim TH, Lee NH, Son HS, Cho IJ, Ha TY. Effects of Cassia tora fibre supplement on serum lipids in Korean diabetic patients. J Med Food 12. Khan A, Safdar M, Ali Khan MM, Khattak KN, Anderson RA. Cinnamon improves glucose and lipids of people with type 2 diabetes. Diabetes Care 39. Jenkins DJ, Kendall CW, Augustin LS, Martini MC, Axelsen M, Faulkner D, et al. Effect of wheat bran on glycemic control and risk factors for cardiovascu- 13. Mang B, Wolters M, Schmitt B, Kelb K, Lichtinghagen R, Stichtenoth DO, et lar disease in type 2 diabetes. Diabetes Care 2002;25(9):1522-8.
al. Effects of a cinnamon extract on plasma glucose, HbA, and serum lipids 40. Karlström B, Vessby B, Asp NG, Boberg M, Gustafsson IB, Lithell H, et al. in diabetes mellitus type 2. Eur J Clin Invest 2006;36(5):340-4.
Effects of an increased content of cereal fibre in the diet of type 2 14. Blevins SM, Leyva MJ, Brown J, Wright J, Scofield RH, Aston CE. Effect of (non-insulin-dependent) diabetic patients. Diabetologia 1984;26(4):272-7.
cinnamon on glucose and lipid levels in non insulin-dependent type 2 diabe- 41. Hollenbeck CB, Coulston AM, Reaven GM. To what extent does increased dietary tes. Diabetes Care 2007;30(9):2236-7. Epub 2007 Jun 11.
fiber improve glucose and lipid metabolism in patients with noninsulin-dependent 15. Schwarz K, Mertz W. Chromium (III) and the glucose tolerance factor. Arch diabetes mellitus (NIDDM)? Am J Clin Nutr 1986;43(1):16-24.
Biochem Biophys 1959;85:292-5.
42. Lu ZX, Walker KZ, Muir JG, O’Dea K. Arabinoxylan fibre improves metabolic 16. Jeejeebhoy KN, Chu RC, Marliss EB, Greenberg GR, Bruce-Robertson A. control in people with type II diabetes. Eur J Clin Nutr 2004;58(4):621-8.
Chromium deficiency, glucose intolerance, and neuropathy reversed by chro- 43. Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy S, Brinkley LJ. mium supplementation, in a patient receiving long-term total parenteral Beneficial effects of high dietary fiber intake in patients with type 2 diabetes nutrition. Am J Clin Nutr 1977;30(4):531-8.
mellitus. N Engl J Med 2000;342(19):1392-8.
17. Brown RO, Forloines-Lynn S, Cross RE, Heizer WD. Chromium deficiency 44. Chuang LM, Jou TS, Yang WS, Wu HP, Huang SH, Tai TY, et al. Therapeutic after long-term total parenteral nutrition. Dig Dis Sci 1986;31(6):661-4.
effect of guar gum in patients with non-insulin-dependent diabetes mellitus. J 18. Freund H, Atamian S, Fischer JE. Chromium deficiency during total paren- Formos Med Assoc 1992;91(1):15-9.
teral nutrition. JAMA 1979;241(5):496-8.
45. Higdon JV, Frei B. Tea catechins and polyphenols: health effects, metabo- 19. Balk EM, Tatsioni A, Lichtenstein AH, Lau J, Pittas AG. Effect of chromium lism, and antioxidant functions. Crit Rev Food Sci Nutr 2003;43(1):89-143.
supplementation on glucose metabolism and lipids: a systematic review of 46. Nagle DG, Ferreira D, Zhou YD. Epigallocatechin-3-gallate (EGCG): chemi- randomized controlled trials. Diabetes Care 2007;30(8):2154-63. Epub 2007 cal and biomedical perspectives. Phytochemistry 2006;67(17):1849-55. Epub 20. Albarracin CA, Fuqua BC, Evans JL, Goldfine ID. Chromium picolinate and 47. Anderson RA, Polansky MM. Tea enhances insulin activity. J Agric Food biotin combination improves glucose metabolism in treated, uncontrolled Vol 55: JUNE • JUIN 2009 Canadian Family Physician • Le Médecin de famille canadien 595
Clinical Review Complementary and alternative medicine
48. Gomes A, Vedasiromoni JR, Das M, Sharma RM, Ganguly DK. Antihyperglycemic 68. Dans AM, Villarruz MV, Jimeno CA, Javelosa MA, Chua J, Bautista R, et effect of black tea (Camellia sinensis) in rat. J Ethnopharmacol 1995;45(3):223-6.
al. The effect of Momordica charantia capsule preparation on glycemic 49. Broadhurst CL, Polansky MM, Anderson RA. Insulin-like biological activity control in type 2 diabetes mellitus needs further studies. J Clin Epidemiol of culinary and medicinal plant aqueous extracts in vitro. J Agric Food Chem 69. John AJ, Cherian R, Subhash HS, Cherian AM. Evaluation of the efficacy of 50. Wu LY, Juan CC, Hwang LS, Hsu YP, Ho PH, Ho LT. Green tea supplementation bitter gourd (momordica charantia) as an oral hypoglycemic agent—a ran- ameliorates insulin resistance and increases glucose transporter IV content in domized controlled clinical trial. Indian J Physiol Pharmacol 2003;47(3):363-5.
a fructose-fed rat model. Eur J Nutr 2004;43(2):116-24. Epub 2004 Jan 6.
70. Sauvaire Y, Petit P, Broca C, Manteghetti M, Baissac Y, Fernandez-Alvarez 51. Waltner-Law ME, Wang XL, Law BK, Hall RK, Nawano M, Granner DK. Epigallocatechin gallate, a constituent of green tea, represses hepatic glucose J, et al. 4-Hydroxyisoleucine: a novel amino acid potentiator of insulin secre- production. J Biol Chem 2002;277(38):34933-40. Epub 2002 Jul 12.
tion. Diabetes 1998;47(2):206-10.
52. Sabu MC, Smitha K, Kuttan R. Anti-diabetic activity of green tea polyphe- 71. Ajabnoor MA, Tilmisany AK. Effect of Trigonella foenum graceum on nols and their role in reducing oxidative stress in experimental diabetes. J blood glucose levels in normal and alloxan-diabetic mice. J Ethnopharmacol Ethnopharmacol 2002;83(1-2):109-16.
53. Wolfram S, Raederstorff D, Preller M, Wang Y, Teixeira SR, Riegger C, et 72. Amin R, Abdul-Ghani AS, Suleiman MS. Effect of Trigonella feonum graecum al. Epigallocatechin gallate supplementation alleviates diabetes in rodents. J on intestinal absorption. Proc. Of the 47th Annual Meeting of the American Diabetes Assocation (Indianapolis U.S.A.). Diabetes 1987;36(Suppl 1):211a.
54. Lane JD, Barkauskas CE, Surwit RS, Feinglos MN. Caffeine impairs glucose 73. Stark A, Madar Z. The effect of an ethanol extract derived from fenugreek metabolism in type 2 diabetes. Diabetes Care 2004;27(8):2047-8.
(Trigonella foenum-graecum) on bile acid absorption and cholesterol levels 55. Robinson LE, Savani S, Battram DS, McLaren DH, Sathasivam P, Graham TE. in rats. Br J Nutr 1993;69(1):277-87.
Caffeine ingestion before an oral glucose tolerance test impairs blood glucose 74. Petit P, Sauvaire Y, Ponsin G, Manteghetti M, Fave A, Ribes G. Effects of a management in men with type 2 diabetes. J Nutr 2004;134(10):2528-33.
fenugreek seed extract on feeding behaviour in the rat: metabolic-endocrine 56. Iso H, Date C, Wakai K, Fukui M, Tamakoshi A; JACC Study Group. The rela- correlates. Pharmacol Biochem Behav 1993;45(2):369-74.
tionship between green tea and total caffeine intake and risk for self-reported type 2 diabetes among Japanese adults. Ann Intern Med 2006;144(8):554-62.
75. Al-Habori M, Al-Aghbari AM, Al-Mamary M. Effects of fenugreek seeds 57. Polychronopoulos E, Zeimbekis A, Kastorini CM, Papairakleous N, Vlachou I, and its extracts on plasma lipid profile: a study on rabbits. Phytother Res Bountziouka V, et al. Effects of black and green tea consumption on blood glu- cose levels in non-obese elderly men and women from Mediterranean Islands 76. Al-Habori M, Raman A. Antidiabetic and hypocholesterolaemic effects of (MEDIS epidemiological study). Eur J Nutr 2008;47(1):10-6. Epub 2008 Jan 18.
fenugreek. Phytother Res 1998;12(4):233-42.
58. Mackenzie T, Leary L, Brooks WB. The effect of an extract of green and 77. Valette G, Sauvaire Y, Baccou JC, Ribes G. Hypocholesterolaemic effect of black tea on glucose control in adults with type 2 diabetes mellitus: double- fenugreek seeds in dogs. Atherosclerosis 1984;50(1):105-11.
blind randomized study. Metabolism 2007;56(10):1340-4.
78. Sauvaire Y, Ribes G, Baccou JC, Loubatieères-Mariani MM. Implication of 59. Ryu OH, Lee J, Lee KW, Kim HY, Seo JA, Kim SG, et al. Effects of green tea con- steroid saponins and sapogenins in the hypocholesterolemic effect of fenu- sumption on inflammation, insulin resistance and pulse wave velocity in type 2 greek. Lipids 1991;26(3):191-7.
diabetes patients. Diabetes Res Clin Pract 2006;71(3):356-8. Epub 2005 Sep 19.
79. Varshney IP, Sharma SC. Saponins and sapogenins: part XXXII. Studies on 60. Fukino Y, Shimbo M, Aoki N, Okubo T, Iso H. Randomized controlled trial Trigonella foenum-graecum Linn. seeds. J Indian Chem Soc 1966;43:564-7.
for an effect of green tea consumption on insulin resistance and inflamma- 80. Sidhu GS, Oakenfull DG. A mechanism for the hypocholesterolaemic activ- tion markers. J Nutr Sci Vitaminol (Tokyo) 2005;51(5):335-42.
ity of saponins. Br J Nutr 1986;55(3):643-9.
61. Hosoda K, Wang MF, Liao ML, Chuang CK, Iha M, Clevidence B, et al. Antihyperglycemic effect of oolong tea in type 2 diabetes. Diabetes Care 81. Gupta A, Gupta R, Lal B. Effect of Trigonella foenum-graecum (fenu- greek) seeds on glycaemic control and insulin resistance in type 2 diabetes 62. Torres WD. Momordica charantia Linn. (Family: Cucurbitaceae)—chemis- mellitus: a double blind placebo controlled study. J Assoc Physicians India try and pharmacology [review]. Las Vegas, NV: American Academy of Anti- Aging Medicine; 2004. Available from: www1.charanteausa.com/ 82. Raghuram TC, Sharma RD, Sivakumar B, Sahay BK. Effect of fenugreek bittermelonstudies/2006/07/17/momordica-charantia-linn-family- seeds on intravenous glucose disposition in non-insulin dependent diabetic cucurbitaceae. Accessed 2009 Apr 17.
patients. Phytother Res 1994;8(2):83-6.
63. Basch E, Gabardi S, Ulbricht C. Bitter melon (Momordica charantia): a 83. Sharma RD, Raghuram TC. Hypoglycaemic effect of fenugreek seeds in non- review of efficacy and safety. Am J Health Syst Pharm 2003;60(4):356-9.
insulin dependent diabetics subjects. Nutr Res 1990;10(7):731-9.
64. Baldwa VS, Bhandari CM, Pangaria A, Goyal RK. Clinical trial in patients 84. Bone K. Gymnema: a key herb in the management of diabetes. Port with diabetes mellitus of an insulin-like compound obtained from plant Townsend, WA: Townsend Letter for Doctors and Patients; 2002. Available source. Ups J Med Sci 1977;82:39-41.
from: www.townsendletter.com/Dec2002/phytotherapy1202.htm. 65. Welihinda J, Karunanayake EH, Sheriff MH, Jayasinghe KS. Effect of Momordica charantia on the glucose tolerance in maturity onset diabetes. J 85. Porchezhian E, Dobriyal RM. An overview on the advances of Gymnema Ethnopharmacol 1986;17(3):277-82. sylvestre: chemistry, pharmacology and patents. Pharmazie 2003;58(1):5-12.
66. Shibib BA, Khan LA, Rahman R. Hypoglycaemic activity of Coccinia indica and Momordica charantia in diabetic rats: depression of the hepatic 86. Baskaran K, Kizar Ahamath B, Radha Shanmugasundaram K, gluconeogenic enzymes glucose-6-phosphatase and fructose-1,6-bisphos- Shanmugasundaram ER. Antidiabetic effect of a leaf extract from phatase and elevation of both liver and red-cell shunt enzyme glucose-6- Gymnema sylvestre in non-insulin-dependent diabetes mellitus patients. J phosphate dehydrogenase. Biochem J 1993;292(Pt 1):267-70.
67. Yeh GY, Eisenberg DM, Kaptchuk TJ, Phillips RS. Systematic review of herbs 87. Joffe D. Gymnema sylvestre lowers HbA1c. Diabetes Control Newsl and dietary supplements for glycemic control in diabetes. Diabetes Care 2001;76:1. Available from: www.diabetesincontrol.com/studies/ gymnema1_2.shtml. Accessed 2009 Apr 17.
596 Canadian Family Physician • Le Médecin de famille canadien Vol 55: JUNE • JUIN 2009
Supplemento di Segnalazioni Bibliografiche Gennaio 2000 Are a i nform ativa "L'ultimo sballo" Londra rappresenta da sempre una città che fa tendenza nell’uso di nuove sostanze Negli ultimi tempi sembra che stia prendendo sempre più forza l’abitudine di assumere, insieme a droghe eccitanti come l’ecstasy o la cocaina, pillole di Viagra. L’effetto prov