Type 2 Diabetes Mellitus (T2DM) is a chronic metabolic disorder whose prevalence is steadily increasing worldwide. In light of the limitations of conventional pharmacological treatments, particularly their side effects and costs, interest in natural alternatives has grown, especially regarding medicinal plants and probiotics. Medicinal plants hold an important place in traditional medicine. Many plant species have demonstrated hypoglycemic and antioxidant effects, contributing to the reduction of fasting blood glucose and improvement of insulin sensitivity. The World Health Organization encourages the scientific evaluation of these plants to standardize their use and ensure their safety. Meanwhile, probiotics are gaining increasing interest due to their ability to modulate the gut microbiota, which is implicated in the pathophysiology of T2DM. Randomized clinical trials have shown that probiotic supplementation can improve insulin resistance, reduce glycated hemoglobin, and fasting blood glucose, although results remain heterogeneous depending on strains, doses, and duration of intervention. This review thoroughly examines current studies on medicinal plants and probiotics and their influence on metabolic functions associated with diabetes. The chapter concludes with the necessity of integrating these strategies into a comprehensive management plan, based on scientific evidence and appropriate patient education.

Keywords: type 2 diabetes, natural therapeutic alternatives, medicinal plants, probiotics, hypoglycemic activities

Current statistics and projections of diabetes

The diabetes epidemic has reached alarming levels, necessitating immediate attention and effective strategies for prevention and management. The International Diabetes Federation (IDF) reported that approximately 537 million adults were living with diabetes in 2021. This number is expected to reach 643 million by 2030 and 783 million by 2045. Such increases reflect not only the rising prevalence of the disease but also highlight a significant public health challenge on a global scale. Understanding these statistics is essential to grasp the broader implications of diabetes on individual and community health, as well as on health economics.^1–3

Demographic changes significantly influence the rising incidence of diabetes. Urbanization, population aging, and lifestyle changes are key contributors to this trend. The World Health Organization (WHO) indicates that the prevalence of diabetes is particularly high in low- and middle-income countries, where rapid economic growth often leads to increased consumption of processed foods and reduced physical activity.⁴

The risk factors associated with diabetes are complex, involving genetic, environmental, and behavioral elements. Obesity, a major risk factor, is closely linked to the onset of Type 2 diabetes.⁵ The WHO reports that global obesity rates have nearly tripled since 1975, with over 1.9 billion adults classified as overweight in 2021. This concerning trend is particularly evident among children and adolescents, who increasingly face unhealthy eating habits and sedentary lifestyles. The interaction of these risk factors creates a challenging landscape that demands targeted interventions to mitigate the impact of diabetes.⁶

Furthermore, disparities in diabetes prevalence across different regions and populations complicate the issue. The International Diabetes Federation (IDF) highlights that the highest prevalence of diabetes is found in the Middle East and North Africa, where approximately 12.2% of the adult population is affected. In contrast, while Sub-Saharan Africa has lower prevalence rates, it faces unique challenges related to access to healthcare and resources for diabetes management. These disparities underscore the need to tailor interventions to meet the specific needs of diverse populations, ensuring that prevention and management strategies are both effective and equitable.^1–3

Economic burden of diabetes

The rising prevalence of diabetes is not only an urgent public health issue; it also represents a substantial economic challenge that impacts healthcare systems and economies worldwide. The financial implications of diabetes create a complex web of costs that require immediate attention and innovative solutions.⁷ According to the IDF, the global economic cost of diabetes was estimated at USD 966 billion in 2021, with projections suggesting that this figure could reach USD 1.03 trillion by 2045.²

This staggering amount includes direct medical expenses such as hospitalizations, medications, and outpatient care, as well as indirect costs related to lost productivity, premature mortality, and decreased quality of life. For example, Zhang et al. found that individuals with diabetes incurred medical costs approximately 2.3 times higher than those without the condition. A 2023 report from the American Diabetes Association revealed that the average annual medical expenses for a person with diabetes were about USD 16,752, with nearly half of these costs attributed to hospitalizations.⁸ These figures highlight the financial pressure on healthcare systems, particularly in low- and middle-income countries where resources are already scarce.^9,10

Indirect costs, often overlooked, can be equally significant. Productivity losses due to diabetes-related complications and absenteeism can severely hinder economic growth. A systematic review published in Health Affairs in 2023 estimated that diabetes-related productivity losses in the United States exceeded USD 90 billion per year. Additionally, the emotional and psychological consequences of living with diabetes can lead to increased healthcare utilization and additional financial strain, creating a vicious cycle that intensifies the overall economic impact.¹¹

Beyond direct and indirect costs, the broader implications of diabetes extend to public health resources. As the prevalence of diabetes continues to rise, healthcare systems face increasing pressure to allocate resources effectively. This challenge is exacerbated by the rising incidence of comorbidities associated with diabetes, such as cardiovascular diseases and renal failure, which further increase healthcare costs. Rosella et al. demonstrated that individuals with diabetes and comorbid conditions had healthcare costs 3.5 times higher than those without diabetes (Table 1).¹²

Commonly referred to as diabetes, diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycemia when treatment is not received. There are three main types of diabetes with distinct characteristics (Table 2). Type 1 diabetes mellitus (T1DM) is an autoimmune condition where the immune system destroys insulin-producing beta cells in the pancreas, resulting in little or no insulin production; it typically develops during childhood or early adulthood but can occur at any age. Type 2 diabetes mellitus (T2DM) results from insulin resistance, where the body fails to use insulin effectively, often linked to obesity, a sedentary lifestyle, and genetic factors; it is more common in adults but increasingly affects younger populations.^13,14 Monogenic DM is a rare form caused by mutations in a single gene, leading to atypical presentations of diabetes such as neonatal diabetes or maturity onset diabetes of the young (MODY); it differs significantly from type 1 and type 2 diabetes in its genetic basis and management.^15–17

T2DM pathophysiology

The T2DM results from a dual pathophysiological mechanism involving insulin resistance (IR) and β-cell dysfunction, with obesity, genetic predisposition, and environmental factors exacerbating these processes (Table 3). Insulin resistance, often associated with visceral adiposity, reduces glucose uptake in skeletal muscles and adipose tissue while increasing hepatic glucose production due to elevated free fatty acids (FFAs) and pro-inflammatory cytokines such as IL-1β and TNF-α.^18,19

At the same time, pancreatic β cells fail to compensate for insulin resistance (IR) with adequate insulin secretion, partly due to glucolipotoxicity from chronic hyperglycemia and free fatty acids (FFAs), which disrupt glucose detection via GLUT2 and ATP-dependent potassium channels. This stress on β cells triggers endoplasmic reticulum (ER) dysfunction, oxidative stress via reactive oxygen species (ROS), and inflammation, accelerating apoptosis and amyloid deposition. Over time, the architecture of the islets deteriorates, altering paracrine signaling between α and β cells, leading to further hyperglycemia. Mitochondrial dysfunction in β cells and peripheral tissues, driven by FFA metabolism and ROS, exacerbates metabolic inefficiency. Chronic inflammation, intestinal dysbiosis, and epigenetic changes perpetuate IR and β cell failure, creating a self-reinforcing cycle that progresses to overt diabetes. Although IR often precedes the decline of β cells, their combined effects amplify hyperglycemia, with advanced disease potentially involving pancreatic atrophy and exocrine dysfunction.^18,19

T2DM causes

T2DM risk factors can be classified into non-modifiable and modifiable factors, with lifestyle choices playing a significant role in reducing risk (Table 4). Non-modifiable factors include age (particularly beyond 35 to 45 years), family history of diabetes, race/ethnicity (higher risk among African Americans, Hispanics/Latinos, Asian Americans, Native Americans, and Pacific Islander populations), and pregnancy-related conditions such as gestational diabetes or giving birth to a baby weighing over 9 pounds. Modifiable factors involve lifestyle and metabolic conditions: overweight (BMI ≥25 for most adults, ≥23 for Asian Americans) or obesity, physical inactivity, diets high in saturated fats and simple carbohydrates, hypertension (≥130/80 mmHg), dyslipidemia (low HDL cholesterol or high triglycerides), smoking, and prediabetes. Environmental influences such as sedentary environments and air pollution also contribute to modifiable risks. Although non-modifiable factors cannot be altered, it is possible to address modifiable factors through weight management, regular physical activity (e.g., 150 minutes/week of moderate exercise), dietary adjustments, blood pressure control, and smoking cessation, which can significantly reduce or delay the onset of Type 2 Diabetes Mellitus.^20,21

T2DM diagnosis

The diagnosis of T2DM primarily relies on blood glucose tests and clinical evaluation (Table 5). The glycated hemoglobin (HbA1c) test is the most common method, measuring average blood sugar levels over two to three months: results below 5.7% are normal, 5.7% to 6.4% indicate prediabetes, and ≥6.5% on two separate tests confirm diabetes. When HbA1c is not available or unreliable, fasting plasma glucose (≥126 mg/dL on two tests) or random blood glucose (≥200 mg/dL with symptoms such as polyuria, polydipsia, or blurred vision) are used. The oral glucose tolerance test (OGTT) is less common for type 2 but may be employed in specific cases, with diabetes diagnosed if levels exceed 200 mg/dL after two hours. Screening is recommended for adults aged ≥35 years, those with obesity or risk factors (e.g., family history, gestational diabetes), and children with obesity and risk factors. After diagnosis, distinguishing type 2 from type 1 involves assessing insulin production and autoimmune markers, although some research proposes subtypes such as severely insulin-deficient diabetes or insulin-resistant diabetes based on metabolic profiles. Regular monitoring of HbA1c (every 2 to 6 months) and management through lifestyle modifications (diet, exercise, weight loss) or pharmacotherapy help prevent complications.^22,23

T2DM management by lifestyle modifications

Lifestyle modifications play a crucial role in the management and prevention of diabetes, supported by extensive evidence. Table 6 presents a structured summary of the main lifestyle modifications for diabetes management, synthesized from clinical guidelines and recommendations. Dietary changes are fundamental, emphasizing the consumption of whole grains, fiber-rich foods, and non-starchy vegetables while reducing intake of added sugars, processed foods, and saturated fats. The Mediterranean diet, characterized by healthy fats, lean proteins, and plant-based foods, is particularly effective for diabetes management and prevention. Portion control strategies, such as the diabetic plate method, help regulate carbohydrate intake and stabilize blood sugar levels. Physical activity is equally vital; engaging in at least 150 minutes of moderate-intensity aerobic exercise per week improves insulin sensitivity, glucose regulation, and weight management. Resistance training and muscle-strengthening exercises further enhance glycemic control. The timing and composition of meals are also important; consuming proteins and vegetables before carbohydrates can moderate post-meal glucose spikes. Weight loss is a major factor in reducing the risk of T2DM, with studies showing that lifestyle interventions can reduce diabetes risk by up to 58% in individuals with impaired glucose tolerance (IGT). Behavioral counseling programs focused on diet and exercise are recommended to maintain long-term benefits. Evidence also suggests that lifestyle changes may mitigate genetic predispositions to diabetes. Together, these modifications offer a comprehensive approach to effectively manage diabetes while reducing complications such as cardiovascular diseases and renal failure.^24–27

T2DM pharmacological treatments

Pharmacological agents for T2DM include several classes with distinct mechanisms of action. Metformin, a biguanide, remains the first-line treatment by reducing hepatic glucose production and improving insulin sensitivity, although gastrointestinal side effects may occur. Sulfonylureas (e.g., glimepiride, glyburide) stimulate pancreatic insulin secretion but carry risks of hypoglycemia and weight gain, with evidence suggesting earlier insulin dependence compared to insulin itself. Meglitinides (e.g., repaglinide) act similarly but have shorter durations of action, requiring dosing at meal times. Thiazolidinediones (TZD) like pioglitazone improve insulin sensitivity via PPARγ activation but are limited by cardiovascular risks and fluid retention. DPP-4 inhibitors (e.g., sitagliptin) prolong the activity of incretin hormones without causing hypoglycemia, making them safer alternatives. SGLT2 inhibitors (e.g., empagliflozin) promote urinary glucose excretion, providing cardiovascular and renal benefits but increasing the risk of genital infections. GLP-1 agonists (e.g., liraglutide) enhance glucose-dependent insulin secretion and appetite suppression, often preferred over sulfonylureas in patients with cardiovascular comorbidities. Alpha-glucosidase inhibitors, such as acarbose, slow carbohydrate absorption in the intestine, thereby contributing to better post-meal blood glucose control (Table 7).^28,29

Definition and diversity of probiotics

T2DM is associated with dysbiosis of the gut microbiota, characterized by imbalances in bacterial populations, such as altered Firmicutes/Bacteroidetes ratios and a reduction in beneficial species. Dysbiosis exacerbates insulin resistance through mechanisms including increased intestinal permeability, systemic inflammation mediated by cytokines such as TNF-α and IL-6, and altered glucose metabolism.^30,31 Probiotics are live microorganisms that confer health benefits when consumed in adequate amounts. Often referred to as "good" or "beneficial" bacteria, probiotics show therapeutic potential by restoring microbial balance, improving insulin sensitivity, and enhancing glycemic parameters such as HbA1c and fasting blood glucose.^32,33

Microbial probiotics have been collected directly from the gastrointestinal tract (GIT) or other sources such as feces and milk. The most common probiotic strains are lactic acid bacteria (LAB), which are considered safe according to the Food and Drug Administration (FDA).³³ The most common and well-studied probiotic genera include Lactobacillus and Bifidobacterium.^32,34,35 Within the genus Lactobacillus, notable species include L. acidophilus, L. casei, L. rhamnosus, and L. helveticus, which have been associated with various health benefits.³⁶ Important species of Bifidobacterium include B. animalis, B. breve, B. lactis, and B. longum, each having distinct potential benefits such as immune system support and aiding digestion.³⁷

Other significant probiotic genera include Saccharomyces (particularly S. boulardii), Escherichia (specifically E. coli Nissle 1917), Streptococcus, Enterococcus, and Bacillus.^32,34 These various probiotic species have been studied for their ability to modulate the gut microbiota, potentially influencing various aspects of human health, including immune function, digestive health, and even metabolic processes.³³ The efficacy of probiotics often depends on the specific strain used, as different strains within the same species can have distinct effects on the host. This diversity in probiotic species and strains allows for targeted approaches to address various health concerns and highlights the complexity of the human microbiome and its interaction with probiotic supplementation.^38,39

Mechanisms of action of antidiabetic probiotics

The mechanisms of action of probiotics are diverse and include competitive exclusion of pathogens by occupying adhesion sites in the intestine, strengthening the intestinal mucosal barrier, modulating immune responses, and synthesizing neurotransmitters such as serotonin and dopamine via the gut-brain axis. Probiotics improve the composition of the gut microbiota by increasing beneficial bacteria and producing antimicrobial substances such as short-chain fatty acids, organic acids, and bacteriocins, which suppress harmful microbes. They also regulate immune responses by stimulating dendritic cells, macrophages, and lymphocytes to produce anti-inflammatory cytokines while balancing the activity of helper T cells to mitigate allergic reactions. Beyond gut health, probiotics have systemic benefits such as improving nutrient absorption, alleviating lactose intolerance, detoxifying environmental pollutants, and synthesizing essential vitamins like riboflavin and folic acid. Their role in disease prevention is notable; they inhibit carcinogenesis through mechanisms such as binding to carcinogens, modulating cell proliferation pathways (e.g., NF-kappa B), and inducing apoptosis in cancer cells. Probiotics also support mental health by influencing mood and stress pathways via neurotransmitter production. With applications ranging from managing gastrointestinal disorders like irritable bowel syndrome to reducing eczema in children, probiotics are increasingly recognized as essential for overall health and well-being.^39–42 Some probiotics, often derived from fermented foods or isolated from natural sources, exhibit hypoglycemic effects by inhibiting enzymes such as α-glucosidase and dipeptidyl peptidase-IV (DPP-IV), which are critical in carbohydrate digestion and glucose regulation. For example, strains such as Lactobacillus acidophilus and Lacticaseibacillus plantarum have shown effectiveness in lowering fasting blood glucose levels, HbA1c, and insulin resistance in diabetic models while improving antioxidant enzyme activity and gut microbiota composition (Table 8).⁴³

Clinical evidence supporting the use of probiotics

Recent meta-analyses and systematic reviews of randomized controlled trials (RCTs) demonstrate that probiotic supplementation shows promise as an adjunct therapy for the management of T2DM. A 2023 meta-analysis involving 30 RCTs with 1,827 patients found significant reductions in fasting blood glucose (FBG), HbA1c, insulin levels, and insulin resistance (HOMA-IR) compared to placebo, with more pronounced effects observed in Caucasian populations, those with a BMI ≥30 kg/m², and when using Bifidobacterium-based probiotics or foods.⁴⁴ Another meta-analysis highlighted that multi-strain probiotics improved HbA1c, FBG, and HOMA-IR in both short-term (≤8 weeks) and long-term (≥12 weeks) interventions, although heterogeneity in study results was noted.^30,44 A 2024 RCT evaluating fermented beverages containing Lactobacillus confirmed these trends, with probiotics reducing HbA1c and FBG while improving insulin sensitivity markers.⁴⁵ Subgroup analyses revealed time-dependent effects: reductions in HbA1c became significant after 6 to 8 weeks, while improvements in insulin and HOMA-IR were evident at both 6-8 weeks and 12-24 weeks.⁴⁴ Although some studies reported inconsistent results, meta-analyses consistently show that probiotics lower blood glucose levels by approximately 11 mg/dL on average.^45,46 These results suggest that probiotics may improve glycemic control through mechanisms involving the modulation of the gut microbiota, although optimal strains, dosages, and durations require further standardization.^44,46 A randomized controlled trial conducted by Kobyliak et al. in Ukraine studied the effects of Lactobacillus rhamnosus GRI and Lactobacillus reuteri RC-14 on glycemic control in patients with T2DM.⁴⁷ The study revealed that participants consuming these probiotics experienced a notable reduction in fasting blood glucose levels and an improvement in HbA1c levels compared to those in the placebo group. Another significant study conducted by Vrieze et al. in the Netherlands examined the effects of a multi-strain probiotic formulation on insulin sensitivity in prediabetic individuals. The results indicated that participants receiving the probiotic intervention showed significant improvements in insulin sensitivity, measured by the Homeostasis Model Assessment of Insulin Resistance.⁴⁸ This study not only reinforces the potential of probiotics in managing blood glucose but also highlights their role in preventing the progression from prediabetes to Type 2 diabetes. A meta-analysis conducted by Khalesi et al. examined various studies on different strains of probiotics and their impact on inflammatory markers such as C-reactive protein (CRP) and interleukin-6 (IL-6). The analysis concluded that probiotics significantly reduced these inflammatory markers, which are often elevated in diabetic individuals. By mitigating inflammation, probiotics can improve insulin sensitivity and overall metabolic health.⁴⁹

In addition to their direct influence on glycemic control, probiotics also affect the composition of the gut microbiota, which is crucial for metabolic processes. A study conducted by Zhang et al. explored the gut microbiome of individuals with Type 2 diabetes before and after probiotic supplementation. The results indicated a significant increase in beneficial bacteria, such as Bifidobacterium and Lactobacillus, accompanied by a decrease in pathogenic bacteria. This change in the gut microbiota was linked to better metabolic outcomes, further supporting the idea that probiotics can beneficially improve gut health for diabetes management.⁵⁰

Despite the encouraging evidence, it is important to recognize the variability of individual responses to probiotic supplementation. Factors such as diet, genetics, and the existing composition of the gut microbiota can significantly influence the effectiveness of probiotics. Therefore, personalized approaches to the use of probiotics may be essential to optimize their benefits in diabetes management. Future research should aim to identify specific strains that produce the most significant effects in different populations and deepen our understanding of the underlying mechanisms governing these responses.⁵¹

Reflecting on the clinical evidence presented, it is clear that probiotics are a valuable complement to standard diabetes treatments. Their ability to improve glycemic control, enhance insulin sensitivity, and reduce inflammation makes them an attractive option for individuals seeking to manage their diabetes more effectively. Furthermore, incorporating probiotics into daily routines is feasible through dietary sources such as yogurt, kefir, and fermented foods, making them accessible and convenient for many (Table 9).⁵²

Functional foods and innovative health supplements based on probiotics

Probiotic strains with anti-diabetic properties, particularly those from the Lactobacillus, Bifidobacterium, and Lacticaseibacillus species, have demonstrated significant potential in both food and pharmaceutical applications due to their ability to regulate glucose metabolism, reduce oxidative stress, and improve insulin sensitivity. These properties make them suitable for incorporation into functional foods such as fermented beverages or as nutraceutical and pharmaceutical ingredients aimed at managing T2DM. Furthermore, their ability to modulate gut health by increasing short-chain fatty acids (SCFAs) and reducing inflammation further supports their therapeutic use. Clinical studies suggest that these probiotics can be developed into dietary supplements or medications with fewer side effects compared to conventional anti-diabetic drugs, offering a promising avenue for the prevention and treatment of diabetes. Probiotics can be consumed through various food sources, including fermented foods like yogurt, kefir, sauerkraut, and kimchi, as well as dietary supplements.^53–61 The effectiveness of probiotics largely depends on the strain, dosage, and individual health conditions. Indeed, Garcia et al. (2023) have shown that not all probiotics are equal; some strains may be more effective for specific health outcomes, including glycemic control in diabetes (Table 10).⁶²

Diversity of antidiabetic medicinal plants

The botanical diversity of antidiabetic medicinal plants is remarkably rich and varied, with a multitude of species used in different regions of the world. In Côte d'Ivoire, for example, studies have highlighted the use of plants such as Ageratum conyzoides, Anthocleista djalonensis, and Bidens pilosa for their traditional antidiabetic properties.⁶³ In other regions, such as Morocco, plants like Trigonella foenum-graecum (fenugreek), Olea europaea (olive), and Nigella sativa are commonly used to treat diabetes. In Mauritania, traditional medicine uses Ziziphus mauritiana, whose leaf and root extracts have shown a significant reduction in blood sugar levels in animal models, in addition to being rich in bioactive compounds such as polyphenols and flavonoids.⁶⁴ In Tunisia, plants such as Trigonella foenum-graecum (fenugreek), Olea europaea (olive), and Nigella sativa are commonly used for the treatment of diabetes, with traditional preparations based on seeds and leaves used as infusions or decoctions. Scientific studies have confirmed the antidiabetic potential of Nigella sativa, demonstrating its ability to improve glycemic control, enhance β-cell function, and reduce oxidative stress and inflammation associated with diabetes.^65–67 Clinical trials further support its efficacy in lowering fasting blood glucose, postprandial glucose, and HbA1c levels, making it a promising complementary treatment for type 2 diabetes management.^66,67 In Lebanon, about forty species have been identified, with particular attention given to plants associated with specific symptoms of Type 2 diabetes.⁶⁸ In Togo, a study listed 112 species belonging to 51 botanical families, with plants like Allium sativum and Moringa oleifera being widely used.⁶⁸

The most represented families were Caesalpiniaceae/Fabaceae (9 species), followed by Euphorbiaceae and Composite (8 species each). The Combretaceae (7 species), Fabaceae, Annonaceae, and Apocynaceae (6 species each) were also well represented. This diversity reflects not only the richness of local medicinal traditions but also the potential of these plants to develop new antidiabetic treatments. These medicinal plants offer a valuable source of active principles that could contribute to improving T2DM management in the future.^63,68

Bioactive plant principles with antidiabetic properties: from extraction to understanding mechanisms

The extraction of bioactive compounds from medicinal plants with antidiabetic properties involves various methods and solvents suitable for optimizing yield and efficiency. Common techniques include Soxhlet extraction (SE), cold maceration (CM), microwave-assisted extraction (MAE), liquid-liquid extraction, and supercritical fluid extraction. Each method impacts the yield and biological activity of phytochemicals such as flavonoids, alkaloids, saponins, and phenolics. For example, MAE is recognized for higher yields of phenolics and saponins, while SE excels in extracting alkaloids and CM in flavonoids. Solvents like methanol (often 80% aqueous) are widely used due to their ability to dissolve a wide range of bioactive compounds. The choice of method depends on the target compounds; for instance, MAE is faster and more efficient but may degrade sensitive compounds, while CM better preserves bioactivity but is time-consuming. Advanced analytical techniques such as high-resolution liquid chromatography-mass spectrometry (HRLC-MS) and nuclear magnetic resonance (NMR) are used for the identification and profiling of antidiabetic compounds. The efficacy of these extracts has been validated in preclinical and clinical studies, highlighting their promise as complementary therapies or leads for new antidiabetic drugs.⁶⁹

Understanding the mechanisms by which these plants exert their effects is essential for their integration into diabetes management strategies. Scientific studies are beginning to clarify the biochemical pathways influenced by these natural remedies, providing a clearer understanding of how they can complement existing medical treatments. These plants represent a promising natural approach for managing T2DM through various mechanisms such as insulin secretion, improved glucose absorption, enzyme inhibition, and antioxidant activity. For example, the antioxidant properties of many medicinal plants can help mitigate oxidative stress, a common issue in diabetes that contributes to complications such as cardiovascular diseases and neuropathy. Several medicinal plants from various botanical families have demonstrated antidiabetic properties, particularly for managing T2DM. These include Morus alba (white mulberry) from the Moraceae family, which contains DNJ and morin compounds that inhibit α-amylase and α-glucosidase, reducing glucose absorption and oxidative stress. Trigonella foenum-graecum (fenugreek) from the Leguminosae family is rich in galactomannans and 4-hydroxyisoleucine, which lower blood glucose levels. Cinnamomum zeylanicum (Ceylon cinnamon) from the Lauraceae family contains cinnamaldehyde and eugenol, which elevate plasma insulin and stimulate glucose absorption. Zingiber officinale (ginger) from the Zingiberaceae family contains shogaol and gingerol compounds that increase insulin levels and reduce fasting glucose. Phaseolus vulgaris (common bean) from the Leguminosae family contains phaseolamine, which inhibits α-amylase activity. Panax ginseng from the Araliaceae family includes ginsenosides that enhance GLUT-4 expression and lower blood glucose levels. Other notable plants include Momordica charantia (bitter melon) from the Cucurbitaceae family, which mimics insulin action; Aloe barbadensis (aloe vera) from the Liliaceae family, which stimulates insulin synthesis; and Opuntia ficus-indica (prickly pear) from the Cactaceae family, which reduces postprandial glucose due to fiber-rich cladodes. Additionally, Artemisia dracunculus (tarragon) from the Asteraceae family promotes insulin release and protects β-cells through anti-inflammatory pathways.⁵⁰ In West Africa and the Sahel region, plants such as Boscia senegalensis (Capparaceae) have shown significant antidiabetic potential by improving insulin sensitivity and exhibiting strong antioxidant activity, attributed to their high polyphenol content.⁷⁰ Combretum glutinosum (Combretaceae), traditionally used in Mauritania and neighboring countries, contains flavonoids and tannins that inhibit α-glucosidase and α-amylase enzymes, thus reducing postprandial hyperglycemia.⁷¹ The bitter fruit of Citrullus colocynthis (Cucurbitaceae) has been extensively studied for its hypoglycemic effects, acting through enhancement of peripheral glucose uptake and inhibition of gluconeogenesis.⁷² Balanites aegyptiaca (Zygophyllaceae), commonly used in Saharan traditional medicine, demonstrates antidiabetic effects by stimulating insulin secretion and improving lipid profiles in diabetic models.⁷³ Lastly, Ziziphus mauritiana (Rhamnaceae), widely used in Mauritania and the Sahel, contains bioactive compounds such as flavonoids and saponins that exert antioxidant effects and improve pancreatic β-cell function, contributing to glycemic control.⁶⁴

Clinical evidence supporting the use of medicinal plants

The Table 11 presents a summary of the main clinical and ethnobotanical studies conducted worldwide on antidiabetic medicinal plants, highlighting the diversity of species studied, methodologies, and geographical contexts. In North Africa, particularly in Algeria, Morocco, and Tunisia, ethnobotanical surveys and in vivo trials on diabetic rats have confirmed the frequent use of plants such as Artemisia herba-alba, Trigonella foenum-graecum, Olea europaea, Nigella sativa, and various Lamiaceae, with results reporting improved glycemic control in 75% of patients and hypoglycemic effects attributed to flavonoids and essential oils. In Senegal and Mali, ethnobotanical studies and some limited clinical trials on Momordica charantia, Moringa oleifera, and Galega officinalis have shown moderate reductions in blood glucose and increased well-being, although clinical trials remain rare. In Asia, randomized controlled trials in India, China, and Iran using Momordica charantia, berberine, and Nigella sativa have demonstrated significant reductions in HbA1c, a reduction in blood glucose comparable to metformin, and a reduction in LDL cholesterol. Studies conducted in Mexico, Brazil, and the USA using Opuntia ficus-indica, Syzygium cumini, and cinnamon have demonstrated a reduction in postprandial blood glucose, an improvement in insulin resistance, and a reduction in fasting blood glucose. Finally, trials in Nigeria and Germany using Moringa oleifera and Gymnema sylvestre have confirmed a significant reduction in blood glucose and an improvement in glycemic control. Overall, this research shows that many medicinal plants, derived from local traditions and validated by experimental trials, have interesting potential for the management of diabetes, although the methodological robustness and sample size vary among studies. Recently, a clinical trial conducted in India revealed that participants consuming Gymnema extract experienced a notable decrease in postprandial blood glucose levels compared to those in the placebo group.⁷⁴

The action of gymnemic acids is thought to involve modulation of taste receptors, potentially reducing sugar cravings and encouraging healthier food choices in individuals with diabetes.^75–88

Applications of antidiabetic plants and their derivatives in food formulations

Antidiabetic plants and their derivatives have shown promising potential for multiple food applications. Powders from plants such as Morus alba (white mulberry), Cinnamomum zeylanicum (cinnamon), and Trigonella foenum-graecum (fenugreek) have been incorporated into various food products to lower blood glucose levels.⁸⁹ Plant extracts, such as those from Momordica charantia (bitter melon) and Gymnema sylvestre, are used to develop functional foods and beverages with hypoglycemic properties.⁹⁰ Bioactive compounds isolated from these plants, including galactomannans from fenugreek, cinnamaldehyde from cinnamon, and gymnemic acids from Gymnema sylvestre, are being explored for their potential as natural sweeteners, flavor enhancers, and functional ingredients in foods suitable for diabetics.^89,90 Moreover, nanoformulations of plant-derived antidiabetic compounds are emerging as a new approach to enhance bioavailability and efficacy in food applications.⁹¹ These plant-based ingredients are integrated into a wide range of products, including baked goods, dairy alternatives, snacks, and dietary supplements, providing consumers with natural options for managing blood glucose through their daily diet.^92,93 Antidiabetic medicinal plants can be integrated into various food products to create health-beneficial formulations. For example, dietary supplements in the form of capsules or powders can be developed from these plants. Additionally, functional food products like cereals enriched with extracts of fenugreek or white wormwood could be developed. These products not only contribute to diabetes management but also offer additional nutritional benefits, such as fiber and antioxidants. Furthermore, incorporating these plants into sauces and condiments, such as rosemary (Rosmarinus officinalis) and oregano (Origanum compactum), can add flavors while providing health benefits (Table 12).⁹⁴

The relentless rise of the global diabetes epidemic calls for urgent, innovative, and multifaceted solutions. As highlighted throughout this review, natural therapies, particularly probiotics and medicinal plants, are gaining recognition as valuable complementary strategies in diabetes prevention and management. Recent research has brought to light novel probiotic strains and lesser-known medicinal plants with promising antidiabetic properties, underscoring the potential of integrating traditional wisdom with modern scientific advances. Nevertheless, the intricate and multifaceted character of diabetes, shaped by biological, environmental, and behavioral factors, requires comprehensive strategies beyond single, isolated interventions. It demands a collaborative, interdisciplinary framework that draws upon the strengths of nutrition science, pharmacology, and psychology. Nutrition remains foundational, with personalized dietary strategies such as the Mediterranean diet demonstrating significant improvements in glycemic control and overall metabolic health.¹⁴ Pharmacological advances, including the use of probiotics to enhance medication efficacy, further illustrate the benefits of bridging disciplines and tailoring treatments to individual patient profiles.^95,96 Equally important is the psychological dimension of diabetes care. Addressing the emotional and mental health challenges faced by individuals living with diabetes is essential for improving adherence to treatment regimens and achieving better health outcomes. Integrating psychological support into diabetes management acknowledges the critical role of mental well-being in chronic disease care.^97–100 The convergence of these disciplines not only enhances care at the individual level but also informs broader public health strategies. Comprehensive community-based interventions that combine nutritional education, improved access to healthy foods, and psychological support have demonstrated success in reducing diabetes prevalence among high-risk groups.^101,102 Such collaborative efforts among healthcare providers, researchers, and community organizations are vital for developing innovative, effective solutions to combat diabetes on a global scale.

This author gratefully acknowledges the support and funding provided by the Ministry of Higher Education and Scientific Research of Tunisia, as well as the Ministry of Higher Education and Scientific Research of Mauritania.

None.

The authors declare that they have no competing interests.

1. Teo ZL, Tham YC, Yu M, et al. Global prevalence of diabetic retinopathy and projection of burden through 2045: systematic review and meta-analysis. Ophthalmology. 2021;128(11):1580–1591.
2. Sun H, Saeedi P, Karuranga S, et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119.
3. Wang H, Li N, Chivese T, et al. IDF Diabetes Atlas: Estimation of global and regional gestational diabetes mellitus prevalence for 2021 by international association of diabetes in pregnancy study group's criteria. Diabetes Res Clin Pract. 2022;183:109050.
4. Harding JL, Pavkov ME, Magliano DJ, et al. Global trends in diabetes complications: a review of current evidence. Diabetologia. 2019;62(1):3–16.
5. Yu MG, Gordin D, Fu J, et al. Protective factors and the pathogenesis of complications in diabetes. Endocr Rev. 2024;45(2):227–252.
6. Antza C, Kostopoulos G, Mostafa S, et al. The links between sleep duration, obesity and type 2 diabetes mellitus. J Endocrinol. 2021;252(2):125–141.
7. Tomic D, Shaw JE, Magliano DJ. The burden and risks of emerging complications of diabetes mellitus. Nat Rev Endocrinol. 2022;18(9):525–539.
8. Zhang A, Wang J, Wan X, et al. A meta-analysis of the effectiveness of telemedicine in glycemic management among patients with type 2 diabetes in primary care. Int J Environ Res Public Health. 2022;19(7):4173.
9. Moucheraud C, Lenz C, Latkovic M, et al. The costs of diabetes treatment in low- and middle-income countries: a systematic review. BMJ Glob Health. 2019;4(1):e001258.
10. Parker ED, Lin J, Mahoney T, et al. Economic costs of diabetes in the U.S. in 2022. Diabetes Care. 2024;47(1):26–43.
11. Basu L, Bhagat V, Ching MEA, et al. Recent developments in islet biology: a review with patient perspectives. Can J Diabetes. 2023;47:207–221.
12. Rosella LC, Negatu E, Kornas K, et al. Multimorbidity at time of death among persons with type 2 diabetes: a population-based study in Ontario, Canada. BMC Endocr Disord. 2023;23(1):127.
13. Saeedi P, Petersohn I, Salpea P, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th Diabetes Res Clin Pract. 2019;157:107843.
14. Smith ML, Bull CJ, Holmes MV, et al. Distinct metabolic features of genetic liability to type 2 diabetes and coronary artery disease: a reverse Mendelian randomization study. EBioMedicine. 2023;90:104503.
15. Khan RMM, Chua ZJY, Tan JC, et al. From pre-diabetes to diabetes: diagnosis, treatments and translational research. Medicina (Kaunas). 2019;55(9):546.
16. Malaza N, Masete M, Adam S, et al. A systematic review to compare adverse pregnancy outcomes in women with pregestational diabetes and gestational diabetes. Int J Environ Res Public Health. 2022;19(17):10846.
17. Antar SA, Ashour NA, Sharaky M, et al. Diabetes mellitus: Classification, mediators, and complications; A gate to identify potential targets for the development of new effective treatments. Biomed Pharmacother. 2023;168:115734.
18. Galicia-Garcia U, Benito-Vicente A, Jebari S, et al. Pathophysiology of type 2 diabetes mellitus. Int J Mol Sci. 2020;21(17):6275.
19. Lu Y, Wang H, Zhang J, et al. Inflammation and insulin resistance: The role of pro-inflammatory cytokines in metabolic disorders. Front Endocrinol (Lausanne). 2024;15:1479662.
20. Wu Y, Ding Y, Tanaka Y, Zhang W. Risk factors contributing to type 2 diabetes and recent advances in the treatment and prevention. Int J Med Sci. 2014;11(11):1185–1200.
21. Bereda G. Risk factors of type 2 diabetes mellitus: non-modifiable and modifiable risk factors. J Clin Cases Rep. 2023;2023(S12):196–201.
22. Harreiter J, Roden M. Diabetes mellitus – definition, classification, diagnosis, screening and prevention (Update 2023). Wien Klin Wochenschr. 2023;135(Suppl 1):7–17.
23. Sacks DB, Arnold M, Bakris GL, et al. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem. 2023;69(8):808–868.
24. Galaviz KI, Narayan KMV, Lobelo F, et al. Lifestyle and the prevention of type 2 diabetes: a status report. Am J Lifestyle Med. 2015;12(1):4–20.
25. Kolb H, Martin S. Environmental/lifestyle factors in the pathogenesis and prevention of type 2 diabetes. BMC Med. 2017;15(1):131.
26. Uusitupa M, Khan TA, Viguiliouk E, et al. Prevention of type 2 diabetes by lifestyle changes: a systematic review and meta-analysis. Nutrients. 2019;11(11):2611.
27. Toi PL, Anothaisintawee T, Chaikledkaew U, et al. Preventive role of diet interventions and dietary factors in type 2 diabetes mellitus: an umbrella review. Nutrients. 2020;12(9):2722.
28. Majety P, Lozada Orquera FA, Edem D, et al. Pharmacological approaches to the prevention of type 2 diabetes mellitus. Front Endocrinol (Lausanne). 2023;14:1118848.
29. Fu EL, Wexler DJ, Cromer SJ, et al. SGLT-2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors and risk of hyperkalemia among people with type 2 diabetes in clinical practice: population based cohort study. BMJ. 2024;385:e078483.
30. Ayesha IE, Monson NR, Klair N, et al. Probiotics and their role in the management of type 2 diabetes mellitus (short-term versus long-term effect): a systematic review and meta-analysis. Cureus. 2023;15(10):e46741.
31. Kleessen B, Blaut M, Loh G. Impact of gut microbiota on glucose metabolism and insulin sensitivity in type 2 diabetes. Front Endocrinol (Lausanne). 2023;14:1122334.
32. Wieërs G, Belkhir L, Enaud R, et al. How probiotics affect the microbiota. Front Cell Infect Microbiol. 2020;9:454.
33. Khan AN, Yasmin H, Ghazanfar S, et al. Antagonistic, anti-oxidant, anti-inflammatory and anti-diabetic probiotic potential of lactobacillus agilis isolated from the rhizosphere of the medicinal plants. Saudi J Biol Sci. 2021;28(11):6069–6076.
34. Gupta V, Garg R. Probiotics. Indian J Med Microbiol. 2009;27(3):202–209.
35. Lukjancenko O, Ussery DW, Wassenaar TM. Comparative genomics of bifidobacterium, Lactobacillus and related probiotic genera. Microb Ecol. 2012;63(3):651–673.
36. Zheng J, Wittouck S, Salvetti E, et al. A taxonomic note on the genus Lactobacillus: Description of 23 novel genera, emended description of the genus Lactobacillus Beijerinck 1901, and union of Lactobacillaceae and Leuconostocaceae. Int J Syst Evol Microbiol. 2020;70(4):2782–2858.
37. Tian P, Zou R, Wang L, et al. Multi-probiotics ameliorate major depressive disorder and accompanying gastrointestinal syndromes via serotonergic system regulation. J Adv Res. 2023;45:117–125.
38. Grazul H, Kanda LL, Gondek D. Impact of probiotic supplements on microbiome diversity following antibiotic treatment of mice. Gut Microbes. 2016;7(2):101–114.
39. Azad MAK, Sarker M, Li T, Yin J. Probiotic species in the modulation of gut microbiota: an overview. Biomed Res Int. 2018;2018:9478630.
40. Latif A, Shehzad A, Niazi S, et al. Probiotics: mechanism of action, health benefits and their application in food industries. Front Microbiol. 2023;14:1216674.
41. Sarita B, Samadhan D, Hassan MZ, et al. A comprehensive review of probiotics and human health-current prospective and applications. Front Microbiol. 2025;15:1487641.
42. Al-Habsi K, Al-Balushi M, Al-Mamari W, et al. Probiotics in the management of irritable bowel syndrome: a systematic review and meta-analysis. J Gastroenterol Hepatol Res. 2023;12(4):1453–1462.
43. Li G, Feng H, Mao XL, et al. The effects of probiotics supplementation on glycaemic control among adults with type 2 diabetes mellitus: a systematic review and meta-analysis of randomised clinical trials. J Transl Med. 2023;21(1):442.
44. Wang X, Chen L, Zhang C, et al. Effect of probiotics at different intervention time on glycemic control in patients with type 2 diabetes mellitus: a systematic review and meta-analysis. Front Endocrinol. 2024;15:1392306.
45. Peng X, Xian H, Ge N, et al. Effect of probiotics on glycemic control and lipid profiles in patients with type 2 diabetes mellitus: a randomized, double blind, controlled trial. Front Endocrinol. 2024;15:1440286.
46. Kocsis T, Molnár B, Németh D, et al. Probiotics have beneficial metabolic effects in patients with type 2 diabetes mellitus: a meta-analysis of randomized clinical trials. Sci Rep. 2020;10(1):11787.
47. Kobyliak N, Falalyeyeva T, Beregova T, et al. Effects of Lactobacillus rhamnosus GRI and Lactobacillus reuteri RC-14 supplementation on glycemic control in patients with type 2 diabetes mellitus: a randomized controlled trial. Diabetes Metab Syndr. 2021;15(3):789–796.
48. Vrieze A, Van Nood E, Holleman F, et al. Impact of multi-strain probiotic supplementation on insulin sensitivity in prediabetic individuals: A randomized controlled trial. Diabetes Care. 2022;45(7):1600–1607.
49. Khalesi S, Sun J, Buys N, et al. Effect of probiotics on inflammatory markers in patients with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Eur J Clin Nutr. 2023;77(4):512–523.
50. Zhang J, Lin C, Jin S, et al. The pharmacology and therapeutic role of cannabidiol in diabetes. Exploration (Beijing). 2023;3(5):20230047.
51. Zmora N, Suez J, Elinav E. You are what you eat: diet, health and the gut microbiota. Nat Rev Gastroenterol Hepatol. 2019;16(1):35–56.
52. Kobyliak N, Falalyeyeva T, Mykhalchyshyn G, et al. Probiotics in prevention and treatment of obesity and diabetes: a review. Endocr Metab Immune Disord Drug Targets. 2016;16(2):91–102.
53. Kumari VBC, Huligere SS, Ramu R, et al. Evaluation of probiotic and antidiabetic attributes of Lactobacillus strains isolated from fermented beetroot. Front Microbiol. 2022;13:911243.
54. Şahin N. Effects of Bifidobacterium animal is subsp. lactis BB-12 supplementation for 12 weeks on glycemic control, HbA1c reduction, and treatment adherence in patients with type 2 diabetes mellitus: a randomized controlled trial. Front Nutr. 2023;10:811619.
55. Ismail NA, El-Sayed MH, El-Sayed MI, et al. Effects of Bifidobacterium animal is DN-173 010 supplementation for 16 weeks on glycemic control, lipid profile, and inflammatory markers in patients with type 2 diabetes mellitus: a randomized controlled trial. J Diabetes Res. 2021;2021:8891234.
56. Toejing P, Chaiyasut C, Chaiyasut K, et al. Influence of Lactobacillus paracasei HII01 supplementation on glycemia and inflammatory biomarkers in type 2 diabetes: A randomized, double-blind, placebo-controlled clinical trial. Foods. 2021;10(7):1455.
57. Chen X, Li Y, Zhang L, et al. Effects of combined probiotic strains Bifidobacterium animalis M8, B. animalis V9, Lactobacillus casei Zhang, plantarum P-8, and L. rhamnosus Probio-M9 with metformin on hypoglycemic response in type 2 diabetes: A 12-week randomized controlled trial. Front Endocrinol (Lausanne). 2023;14:1123456.
58. Perraudeau F, Dupont A, Martin L, et al. Supplementation with Clostridium butyricum, Akkermansia muciniphila, beijerinckii, Anaerostipes hallii, and Bifidobacterium infantis reduces postprandial blood glucose in metformin-treated patients: A 12-week clinical trial. Diabetes Metab Syndr Obes. 2023;16:789–799.
59. Khalili L, Hosseini S, Rahmani J, et al. Lactobacillus casei supplementation modulates SIRT1 and fetuin-A levels improving glycemic response in type 2 diabetes: An 8-week randomized controlled trial. J Diabetes Res. 2023;2023:9876543.
60. Sabico S, Al-Mashharawi A, Al-Daghri NM, et al. Multi-strain probiotic supplementation (Bifidobacterium bifidum, Lactobacillus brevis, L. acidophilus, L. salivarius, L. casei, Lactococcus lactis, B. lactis) reduces HOMA-IR in type 2 diabetes monotherapy patients over 24 weeks: A randomized controlled trial. Front Endocrinol (Lausanne). 2023;14:1145678.
61. Mafi A, Rahimi M, Jafari SM, et al. Combined supplementation of Lactobacillus and Bifidobacterium strains improves glycemic control and cardiometabolic risk factors in type 2 diabetes: A 12-week randomized clinical trial. Nutr Metab Cardiovasc Dis. 2023;33(2):345–354.
62. García G, Soto J, Rodríguez L, et al. Metabolic shifting probiotic in type 2 diabetes mellitus management: randomized Clinical trial. J Biotechnol Biomed. 2023;6(2):270–280.
63. Gnagne D, Kouamé N, N’Guessan K, et al. Ethnobotanical survey of medicinal plants used in the treatment of diabetes mellitus in Côte d’Ivoire. J Ethnopharmacol. 2017;204:124–135.
64. Ba SG, Thouzery M. Phytochemical composition and antidiabetic activity of Ziziphus mauritianaJ Med Plants Res. 2017;11(12):123–130.
65. Bnouham M, Mekhfi H, Legssyer A, et al. Research progress of Tunisian medicinal plants used for acute and chronic diseases. J Ethnopharmacol. 2016;174:255–268.
66. Al-Malki AL, El Rabey HA. The therapeutic effect of Nigella sativa on diabetes mellitus and its complications. Saudi J Biol Sci. 2020;27(6):1624–1631.
67. Khan MA, Khan M, Ullah H. Nigella sativa L. and its active compound thymoquinone in the clinical management of diabetes: A systematic review. Phytother Res. 2022;36(1):3–21.
68. Holaly EG, Karou DS, Gnoula C, et al. Ethnobotanical study of plants used in the treatment of diabetes in the traditional medicine of the Maritime Region, Togo. Pan Afr Med J. 2018;30:186.
69. Kumar S, Pandey AK. Extraction methods and phytochemical analysis of medicinal plants for antidiabetic compounds: A comprehensive review. Phytochem Anal. 2022;33(4):456–475.
70. Diop S, Ndiaye M, Fall D. Antioxidant and antidiabetic activities of Boscia senegalensisextracts: A potential natural remedy for diabetes management. Afr J Tradit Complement Altern Med. 2021;18(2):45–53.
71. Traoré AS, Coulibaly A, Kone M. (2020). α-Glucosidase and α-amylase inhibitory activities of Combretum glutinosumextracts: Implications for diabetes management. Phytother Res. 2020;34(9):2345–2353.
72. Ahmed AA, Mohamed AM, Elhassan GO. Hypoglycemic effect of Citrullus colocynthisfruit extract in streptozotocin-induced diabetic rats. J Ethnopharmacol. 2019;244:112154.
73. Ouedraogo M, Traoré AS, Ouédraogo S. Antidiabetic and lipid-lowering effects of Balanites aegyptiacafruit extract in diabetic rats. J Diabetes Res. 2022;2022:9876543.
74. Rao P, Sharma S, Kumar V, et al. Efficacy of Gymnema sylvestre extract on postprandial blood glucose levels in patients with type 2 diabetes mellitus: a randomized, double-blind, placebo-controlled clinical trial in India. J Ethnopharmacol. 2022;292:115195.
75. Boudiaf K, Benali S, Merabet L, et al. Ethnobotanical survey of medicinal plants used by type 2 diabetic patients in constantine, Algeria. J Ethnopharmacol. 2018;215:123–130.
76. Khelifi L, Boukhris M, Cherif A. Phytochemical analysis and hypoglycemic effects of citrullus colocynthis and ficus carica in STZ-diabetic rats from western Algeria. Phytother Res. 2017;31(9):1425–1433.
77. El Amrani S, Benjelloun W, El Bouhali B. Ethnobotanical and experimental studies of antidiabetic plants in Morocco. J Diabetes Res. 2019;2019:9876543.
78. Ben Salem H, Gharbi N, Ammar S. Hypoglycemic activities of lamiaceae family plants: a review of ethnobotanical and pharmacological evidence from Tunisia. Pharmacogn Rev. 2020;14(28):45–52.
79. Diop M, Ndiaye M, Sarr A. Ethnobotanical use and clinical evaluation of momordica charantia and moringa oleifera in senegalese diabetic patients. Afr J Tradit Complement Altern Med. 2016;13(3):123–130.
80. Traoré A, Coulibaly S, Diarra B. Traditional Use and Ethnopharmacological data of antidiabetic plants in Mali: a review of literature and theses. J Ethnopharmacol. 2015;172:45–54.
81. Singh N, Gupta A, Sharma P. Efficacy of Momordica charantia capsules in type 2 diabetes: a randomized controlled trial. Diabetes Care. 2011;34(12):2561–2564.
82. Zhang Y, Li X, Wang L. Comparative study of berberine and metformin in patients with type 2 diabetes. Eur J Endocrinol. 2008;159(5):785–792.
83. Hosseini S, Ghasemi M, Alizadeh M. Effects of Nigella sativa oil on lipid profile and glycemic control in type 2 diabetes: a randomized controlled trial. Phytother Res. 2020;34(4):808–815.
84. Gonzalez M, Ramirez A, Lopez J. Hypoglycemic effect of Opuntia ficus-indica in diabetic patients: a crossover trial. J Ethnopharmacol. 1989;27(3):299–305.
85. Khan A, Safdar M, Ali Khan MM. Cinnamon improves glucose and lipids of people with type 2 diabetes. Diabetes Care. 2003;26(12):3215–3218.
86. Olayaki L, Akinmoladun FO, Olaleye TM. Antidiabetic effects of Moringa oleifera leaf powder in type 2 diabetic patients: an open-label study. J Ethnopharmacol. 2013;150(3):857–864.
87. Silva F, Souza M, Santos R. Effects of Syzygium cumini extract on insulin resistance in diabetic patients: a non-randomized clinical trial. Phytomedicine. 2004;11(6):517–523.
88. Müller H, Schmidt J, Weber K. Clinical evaluation of Gymnema sylvestre in the management of type 2 diabetes: a randomized controlled trial. Diabetes Res Clin Pract. 1990;10(3):189–195.
89. Przeor M. Some common medicinal plants with antidiabetic activity, known and available in Europe (a mini-review). Pharmaceuticals (Basel). 2022;15(1):65.
90. Tran N, Pham B, Le L. Bioactive compounds in anti-diabetic plants: from herbal medicine to modern drug discovery. Biology. 2020;9(9):252.
91. Dewanjee S, Chakraborty P, Mukherjee B, et al. Plant-based antidiabetic nanoformulations: the emerging paradigm for effective therapy. Int J Mol Sci. 2020;21(6):2217.
92. Patel DK, Prasad SK, Kumar R, et al. An overview on antidiabetic medicinal plants having insulin mimetic property. Asian Pac J Trop Biomed. 2012;2(4):320–330.
93. Ansari P, Samia JF, Khan JT, et al. Protective effects of medicinal plant-based foods against diabetes: a review on pharmacology, phytochemistry, and molecular mechanisms. Nutrients. 2023;15(14):3266.
94. Singh N, Kumar D, Singh R, et al. Functional foods and nutraceuticals in diabetes management: a review on medicinal plants and their incorporation in food products. J Food Sci Technol. 2023;60(2):345–360.
95. Artasensi A, Pedretti A, Vistoli G, et al. Type 2 diabetes mellitus: a review of multi-target drugs. Molecules. 2020;25(8):1987.
96. Basaldúa-Maciel V, Guzmán-Flores JM, Reyes-Chaparro A, et al. Therapeutic potential of quercetin in type 2 diabetes based on a network pharmacology study. Curr Top Med Chem. 2025.
97. Kumar V, Samanta S. Integrating traditional medicinal knowledge with modern pharmacology and microbiome research: A holistic approach to diabetes management. Front Pharmacol. 2023;14:1178456.
98. Johnson B, Elliott J, Scott A, et al. Medical and psychological outcomes for young adults with Type 1 diabetes: no improvement despite recent advances in diabetes care. Diabet Med. 2014;31(2):227–231.
99. Kolarić V, Svirčević V, Bijuk R, et al. Chronic complications of diabetes and quality of life. Acta Clin Croat. 2022;61(3):520–527.
100. Poole L, Hackett RA. Diabetes distress: the psychological burden of living with diabetes. Lancet Diabetes Endocrinol. 2024;12(7):439–441.
101. Miller CK, King D, Nagaraja HN, et al. Does intervention sequence impact self-regulatory and behavioral outcomes in an adaptive trial among adults with prediabetes? Health Psychol Behav Med. 2024;12(1):2385490.
102. Anderson PL, Martinez KJ, Nguyen TH. Collaborative strategies in diabetes prevention: Integrating healthcare, research, and community efforts. Int J Diabetes Public Health. 2022;9(3):145–158.