Nutrition 29 (2013) 11921196

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Nutrition
journal homepage: www.nutritionjrnl.com

Review

Effect of short-term administration of cinnamon on blood pressure in patients

with prediabetes and type 2 diabetes
Rajadurai Akilen Ph.D. a, *, Zeller Pimlott M.Sc. b, Amalia Tsiami Ph.D. b, Nicola Robinson Ph.D. c
a

Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
Faculty of Health and Human Science, University of West London, Brentford, London, UK
c
Faculty of Health and Social Care, London South Bank University, London, UK
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 4 December 2012
Accepted 6 March 2013

Objective: The aim of this study was to systematically review and evaluate the effect of short-term
administration of cinnamon on blood pressure regulation in patients with prediabetes and type 2
diabetes by performing a meta-analysis of randomized, placebo-controlled clinical trials.
Methods: Medical literature for randomized controlled trials (RCTs) of the effect of cinnamon on
blood pressure was systematically searched; three original articles published between January
2000 and September 2012 were identied from the MEDLINE database and a hand search of the
reference lists of the articles obtained through MEDLINE. The search terms included cinnamon or
blood pressure or systolic blood pressure (SBP) or diastolic blood pressure (DBP) or diabetes. A random
effects model was used to calculate weighted mean difference and 95% condence intervals (CI).
Results: The pooled estimate of the effect of cinnamon intake on SBP and DBP demonstrated that
the use of cinnamon signicantly decreased SBP and DBP by 5.39 mm Hg (95% CI, 6.89 to 3.89)
and 2.6 mm Hg (95% CI, 4.53 to 0.66) respectively.
Conclusion: Consumption of cinnamon (short term) is associated with a notable reduction in
SBP and DBP. Although cinnamon shows hopeful effects on BP-lowering potential, it would be
premature to recommend cinnamon for BP control because of the limited number of studies
available. Thus, undoubtedly a long-term, adequately powered RCT involving a larger number of
patients is needed to appraise the clinical potential of cinnamon on BP control among patients with
type 2 diabetes mellitus.
2013 Elsevier Inc. All rights reserved.

Keywords:
Blood pressure
Diabetes
Cinnamon
Blood glucose
Randomized control trials

Introduction
A number of medicinal plants have a history of traditional
use in treating raised blood sugar levels and cardiovascular
risk factors. One such compound that has recently been the
subject of intense research is cinnamon, a compound Generally
Regarded As Safe (GRAS) status by the FDA. Cinnamon offers
a great potential as a dietary strategy to improve glycemic control
because it contains doubly linked type-A polyphenol compounds.
Food manufacturers need incentives to incorporate cinnamon into
their products and specically want to know what claims can be
made on their packaging if they incorporate cinnamon ingredients. Data on the blood glucoselowering potential of cinnamon
are promising, but limited in that there are only three human

The authors declare that they have no conict of interests.

* Corresponding author. Tel.: (001)-416-928-3700; fax: (001)-416-978-5882.
E-mail address: rakilen22@hotmail.com (R. Akilen).
0899-9007/$ - see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nut.2013.03.007

intervention trials looking at the effect of cinnamon on blood

pressure (BP) lowering effect of cinnamon.
Insulin resistance might be encouraged by activation of the
reninangiotensinaldosterone system and is associated with
increased free radical formation. Occurring in cardiovascular,
muscle, and liver tissue, local insulin resistance appears to
contribute to the development of endothelial dysfunction and
hypertension. Diminished insulin sensitivity is related to the
signs and symptoms of the metabolic syndrome including increased BP, visceral obesity, fasting plasma glucose (FPG), lowdensity lipoprotein, and decreased high-density lipoprotein [1].
Macrovascular problems are more common than microvascular
issues; up to 80% of patients with type 2 diabetes mellitus (T2DM)
will develop or die of macrovascular disease (MVD) [2], and the
cost linked with MVD is an order of magnitude greater than that
associated with microvascular disease [3]. Some observational
evidence suggests that the level of glycemia is a risk factor for
MVD [4]; however, experimental studies to date have not clearly
shown a causal relationship between improved glycemic control

R. Akilen et al. / Nutrition 29 (2013) 11921196

and reductions in serious cardiovascular outcomes and BP [3].

Hypertension is extremely common in patients with T2DM,
affecting up to 60% of the population [3].
In 1990, it was reported that compounds found in cinnamon
(cinnamon cassia) have insulin-potentiating properties and may
be involved in the alleviation of the signs and symptoms of
diabetes and cardiovascular disease (CVD) related to insulin
resistance [1,5]. Naturally occurring compounds that have been
shown to improve insulin sensitivity include polyphenols found
in cinnamon [1]. The potential glucose-lowering effect and
pharmacologic mechanisms of cinnamon have been identied in
in vitro and in vivo animal studies [6]. Cao et al [7] reported that
puried cinnamon extracts and cinnamon polyphenols increased
insulin receptor b proteins and glucose transporter (GLUT4)
proteins. These proteins are involved in the insulin signalling
transduction pathways that function in insulin receptor substrate
activation and insulin-regulated glucose transportation, respectively [7]. Aqueous extracts and polyphenol compounds of
cinnamon have been shown, in an in vitro assay to potentiate
insulin activity more than 20-fold, higher than any other
compound tested at comparable dilutions [8]. Our research
group previously demonstrated the detailed cellular mechanism
of cinnamon [6].
Cinnamon extracts are reported to favorably inuence
the insulin system [811]. Based on the possible relationship
between insulin metabolism and BP regulation, we hypothesize
that cinnamon may be able to improve glycemic control
(by improving insulin sensitivity) and decrease BP in patients
with T2DM. In 2010, we reported that cinnamon has blood glucoselowering and BP-lowering potential and may be able to
bring about the easing of signs and symptoms of diabetes and
CVD [6]. In the present study, we systematically reviewed and
evaluated the effect of short-term administration of cinnamon
on BP regulation in patients with prediabetes and T2DM by
performing a meta-analysis of randomized, placebo-controlled
clinical trials.
Material and methods
We searched the medical literature for randomized controlled trials (RCTs) of
the effect of cinnamon on BP; three original articles published between January
2000 and September 2012 were identied from the MEDLINE database and
a hand search of the reference lists of the articles obtained through MEDLINE. The
search terms included cinnamon OR blood pressure OR systolic blood pressure
(SBP) OR diastolic blood pressure (DBP) OR diabetes. We limited the search to RCTs
conducted in humans and published in the English language. Studies were
selected for analysis if they met the following criteria:
1. They were controlled and had either randomized crossover or parallel
design.
2. They provided the dose of cinnamon.
3. They provided baseline SBP and DBP so that changes in both for each study
could be calculated.
A ow diagram of the selection of the included RCTs is shown in Figure 1. The
MEDLINE search identied 93 studies. After the exclusion of 90 studies, 3 RCTs
met our strict inclusion criteria. For each of the studies meeting the inclusion
criteria, data on study design, population, sample size, number of dropouts,
intervention type, dose, and duration of trial were extracted for further analysis.
Study quality was also independently assessed according to the criteria for
quality assessment for RCTs developed by Delphi consensus [12]. The nine criteria
were treatment allocation [randomized 1 point], similarity of groups at baseline with respect to the most important prognostic indicators [1 point], eligibility
criteria [specied 1 point], blinding [treatment allocation blinded 1 point,
outcome assessment blinded 1 point, care provided blinded 1 point, and
patients blinded 1 point], measures of variability presented for blood pressure
measurements [yes 1 point], and intention-to-treat [yes 1 point; studies with
no dropouts received 1 point for this criterion]. Thus, the highest score a trial
could get was 9 points [12,13].

1193

Meta-analysis
The summary results of each clinical trial and selected characteristics of the
study were tabulated for analysis. The estimate of the principle effect was dened
as the mean difference (net change in mm Hg) between the change in SBP and
DBP among the participants ingesting cinnamon powder or extract (post-intervention value minus baseline value) and that among the participants ingesting
the control diet. The mean change in each study end point from baseline was
treated as a continuous variable, and the weighted mean difference was calculated as the difference between the mean value in the treatment and control
groups. A random effects model was used to calculate weighted mean difference
and 95% condence intervals (CI). Statistical heterogeneity was addressed using
the I2 statistic. Statistics were performed using Review Manager (version 5.1).

Results
Baseline characteristics of the three studies that met the
selection criteria are shown in Table 1. Overall, 139 participants
were included in the meta-analysis. All studies used a parallel,
randomized design. The participants initial SBPs and DBPs are
shown in Table 1. Two studies used cinnamon powder and one
study used extract (Table 1). The doses of cinnamon ranged from
500 mg to 2.4 g/d and all three RCTs had the same length of
12 wk of study duration. All three RCTs included middle-aged
men and women: The mean age in the individual studies
ranged from 45.6 to 64.4 y. Total calorie intake was reported in
two RCTs (Table 1), and all RCTs reported similar weight/body
mass index (BMI) changes for participants ingesting the intervention or control treatments.
The effect of cinnamon on SBP and DBP at baseline and postintervention is shown in Table 2. Two RCTs showed signicant
reduction in SBP [6,14], and one study showed marginally
signicant reduction in SBP [15]. In contrast, two RCTs did not
show any signicant reduction in DBP [14,15], however, one
study showed signicant reduction in DBP [6].
The pooled estimate of the effect of cinnamon intake on SBP
and DBP is shown in Table 3. Overall, the use of cinnamon
signicantly decreased SBP and DBP by 5.39 mm Hg (95% CI,
6.89 to 3.89) and 2.6 mm Hg (95% CI, 4.53 to 0.66),
respectively. Evaluation of the funnel plot (data not shown) could
not rule out publication bias for any analysis. After conducting
subgroup and sensitivity analysis, it was found that the exclusion
of an RCT conducted with patients with prediabetes [14], or
evaluating the effect of cinnamon on patients with T2DM separately [6,15], did not signicantly change the meta-analysis
results (Table 3).

Discussion
The present meta-analysis is the rst quantitative review
of RCTs yielding information about the effect of cinnamon on
BP. The meta-analysis showed that the intake of cinnamon was
associated with a signicant decrease in SBP (5.39 mm Hg) and
DBP (2.6 mm Hg). The results of meta-analysis depend on the
studies included. In the present review, we used a broad initial
search to prevent any possible publication bias. Additionally, we
selected studies on the basis of their outcome by dening
inclusion/exclusion criteria. The use of these criteria led to three
eligible RCTs. The number of studies is not large, but the Delphi
method scores (Table 1) ensured that the trials had a high
internal validity and were reasonably comparable. Age, BMI, and
body weight were similar across all participants, and therefore
less likely to be heterogeneous factors contributing to contrasting results. Differences in research methodologies included
variations in baseline SBP and DBP, concurrent use of diabetes

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R. Akilen et al. / Nutrition 29 (2013) 11921196

Potentially relevant studies identified and screened (n = 93)

Studies excluded (n = 75):

No cinnamon intervention, no diabetes/blood pressure
intervention, no patient group, co-intervention with other
ingredients, no control or intervention group, no description
or trial, duplicates, animal (in vivo) trials, and not published
in English language

Studies retrieved for more detail evaluation (n = 18):

Studies excluded (n = 15):

RCTs of cinnamon and type 2 diabetes (n = 7)
RCTs of cinnamon and type 1 diabetes (n = 1)
RCTs of cinnamon and healthy individuals (n = 5)
RCTs of cinnamon and prediabetes (n = 1)
RCTs of cinnamon and polycystic ovary syndrome (n = 1)

Studies included in Meta analysis (n = 3):

RCTs of cinnamon, type 2 diabetes, and blood pressure (n = 2)
RCTs of cinnamon, prediabetes, and blood pressure (n = 1)
Fig. 1. Flow diagram showing the process of, and reasons for, the selection and exclusion of studies for this meta-analysis. RCT, randomized controlled trial.

and antihypertensive medications, and the type and dose of

cinnamon used as treatment.
One possible explanation for the signicant changes in BP is
that the RCTs included in this meta-analysis contained participants with higher normal baseline SBP or DBP. The results
demonstrate that the majority of the patients had elevated or
upper normal BP levels, but not hypertension. According to the
current guidelines recommended for the treatment of diabetes,
normal or near normal BP with a SBP of < 130 mm Hg and DBP
of < 80 mm Hg should be achieved [16]. This suggests that
in patients with well-controlled blood pressure at baseline
(SBP < 130 mm Hg or DBP < 80 mm Hg), the effects of cinnamon
on SBP or DBP may be minimal. This might be why the Wainstein
et al study [15] did not demonstrate a signicant reduction

in DBP in the cinnamon group. Therefore, we suspect that it is

most likely that the therapeutic dose of cinnamon may depend
on the participants baseline BP rather than there being a significant dose-dependent effect. However, Ziegenfuss et al [14],
report an 3.8% SBP reduction in participants with a mean baseline SBP of 133 mm Hg, ingesting 500 mg cinnamon extract
(equivalent to 10 g of cinnamon) daily for 12 wk, illustrating that
a higher cinnamon dose can bring about a signicant reduction
in SBP. In contrast, Wainstein et al [15], report a borderline SBP
reduction (P 0.06) in patients with a higher mean baseline SBP
of 141 mm Hg ingesting 1.2 g/d of cinnamon for 12 wk, showing
that even a lower dose of cinnamon can bring about a marginally
signicant reduction in SBP in patients with higher SBP at
baseline.

Table 1
Baseline characteristics of the study population
Characteristics

N
Sex
Age (y)
SBP (mmHg)
DBP (mmHg)
Weight (kg)
BMI (kgm2)
Waist circumference (cm)
Total calorie intake (kcal/d)
Carbohydrate (%)
Fats (%)
Protein (%)
Subjects
Dose of cinnamon
Duration of trial
Delphi criteria score*

Wainstein et al, 2011

Akilen et al, 2010

Cinnamon

Cinnamon

Placebo

29
30
14 M, 14 F
21 M, 9 F
61.7  6.3
64.4  15.4
140.8  14
130.7  12
78.6  9.5
75  9.3
85.1  15.1
88.8  21.2
29.8  4.3
30.9  6.9
107.3  12.8
110.1  16.3

Type 2 diabetes
1.22.4 g/d (powder)
12 wk
7

Ziegenuss et al, 2006

Placebo

30
28
11 M, 9 F
15 M, 13 F
54.9  10.1
54.4  12.5
133  8.6
134  10.9
85  6.45
87  8.82
87.6  17.5
87.5  20.2
33.4  4.2
32.1  8.3
106.4  11.9
105.1  13.4
1836  270
1844  228
43  12
46  13
33  10
33  9
23  7
20  11
Type 2 diabetes
2 g/d (powder)
12 wk
8

Cinnamon

Placebo

12
10
8 M, 4 F
3 M, 7 F
46.3  8.8
45.6  11.1
133  14
133  22
83  6
86  14
93.1  18.1
89.3  30.6
32.3  5.7
34.4  12.6
NA
NA
1741  551
1706  427
47.7  12.2
47  6.9
38.1  6.6
38.3  5.8
13.9  3.2
14.6  2.7
Prediabetes & metabolic syndrome
500 mg/d (extract)
12 wk
7

N, total number of subjects; M, males; F, females; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure
Results show the baseline characteristics of the study population
* Maximum Delphi score 9.

R. Akilen et al. / Nutrition 29 (2013) 11921196

1195

Table 2
Effect of cinnamon on systolic and diastolic blood pressure
Study

Variable

Cinnamon

Placebo

Baseline

Post
Intervention

Baseline

Post
Intervention

137.1  14.7
75.9  10.4

130.7  12
75  9.3

132.7  10.3
73.7  7.0

Wainsein et al, 2011

[C 29, P 30]

SBP
DBP

140  14
78.6  9.5

Akilen et al, 2010

[C 30, P 28]
Ziegenfuss et al, 2006
[C 12, P 10]

SBP
DBP
SBP
DBP

133
8.5
133
83






8.6
6.45
14
6

129
81
128
84






7.9
5.80
18
9

134
87
133
83






10.9
8.82
22
14

135
86
142
86






9.2
8.08
20
12

Results

0.06
0.68

<0.001
<0.001
<0.001
<0.32

SBP values decreased in the cinnamon group and

increased in the placebo group This difference of SBP
was only marginally signicant. No signicant changes
were observed in DBP.
SBP and DBP signicantly (P < 0.05) reduced after
12 weeks in the cinnamon group compared to placebo.
Subjects in the cinnamon group showed a signicant
reduction (P < 0.05) in SBP compared to placebo. No
signicant changes were observed in DBP.

C, cinnamon; P, placebo; SBP, systolic blood pressure; DBP, diastolic blood pressure
All results are reported in mmHg. Data presented as mean SD. P values show the changes (baseline versus post intervention) between cinnamon and placebo groups

Furthermore, the pooled results of our meta-analysis also

suggested that there is a close association between glycemic
indicators (FPG or haemoglobin [Hb]A1c) and SBP or DBP levels.
For instance, Ziegenfuss et al [14] and Akilen et al [6] showed
a signicant reduction in SBP or DBP followed by a signicant
reduction in glycemic indicators (FPG or HbA1c). In contrast,
Wainstein et al [15] did not demonstrate a signicant reduction
in either BP or glycemic indicators. As a result, we would suggest
that the BP-lowering potential of cinnamon may be closely
related to the blood glucoselowering potential of cinnamon.
However, well-dened adequately powered RCTs are of paramount importance to prove this assumption in the future.
Rodent studies have found that addition of dietary cinnamon
consistently reduced SBP levels [17]. However, the detailed
mechanism of cinnamon on BP in humans needs to be studied
further. Dietary factors generally accepted to enhance insulin
sensitivity such as soluble bers, chromium, and vanadium are
associated with lower BP [17]. In corroboration of the relationship between glucose/insulin metabolism and BP regulation,
exercise and certain drugs, such as metformin, which augment
insulin sensitivity, are also recognized to lower BP [17]. This
suggests that perturbed glucose/insulin metabolism may be
directly or indirectly involved, at least to some extent, in some
forms of hypertension. Furthermore, recent meta-analysis also
demonstrated that cinnamon intake lowers FPG [18,19]. We have
already demonstrated the effect of cinnamon and its cellular
mechanism on blood glucose and BP regulation in patients with
T2DM [6,20]. In a recent review, Qin et al [21] conrmed that
cinnamon and components of cinnamon have been shown to
have benecial effects on virtually all of the factors associated
with metabolic syndrome, including insulin sensitivity, glucose,
lipids, antioxidants, inammation, BP, and body weight.
Oxidative stress plays a major role in the pathogenesis and
progression of diabetes and CVD [22]. Furthermore, functional
foods with an antioxidant effect have been reported to repress
oxidative stress [22], and positively associated with BP-lowering

potential. Hyperglycemia causes the auto-oxidation of glucose,

glycation of proteins, and the activation of polyol metabolism;
cinnamon has been reported to improve the antioxidant status of
patients with metabolic syndrome [23]. Previous studies also
demonstrated that plasma melondialdehyde levels were reduced
by an aqueous extract of cinnamon, indicating decreased lipid
peroxidation [23]. This could be linked with BP regulation.
According to Wainstein et al [15], it has been proposed that
cinnamon may exert its benecial effects via activation of
peroxisome proliferator-activator receptors and inhibition of
advanced glycation end-product formation. Several phenolic
compounds found in cinnamon such as catechin, epicatechin,
procyanidin B2, and phenol polymers, showed signicant inhibitory effects on the formation of advanced glycation end
products [21]. Cinnamon also has been shown to reduce both
glucose and SBP in rodent studies [17]. Moreover, cinnamon
could be included with low-carbohydrate ketogenic diets (LCKD)
to improve glycemia and BP, as LCKD showed positive effects on
HbA1c, body weight, waist circumference, serum triglycerides,
and glycemic control in participants with T2DM [24]. However,
patients with diabetes on a combination of ketogenic and
cinnamon diet should be under strict medical supervision
because of its higher blood glucoselowering potential.
Most importantly, not all clinical trials have shown positive
effects of cinnamon on glycemic and BP regulation, and the type
and amount of cinnamon, as well as the type of individual and
the type of medication taken concurrently, are likely to affect the
response to cinnamon [21]. One of the key limitations of this
meta-analysis is that it is based on a small number of RCTs.
Consequently, our meta-analysis may be underpowered to detect
statistically signicant difference in many end points. Therefore,
the small number of clinical trials and low population numbers
do not allow a denitive conclusion to be drawn regarding the
efcacy of cinnamon as a treatment for hypertension, and may
raise expectations in terms of potential usefulness of cinnamon
in BP control, which seem unjustied given the limited evidence

Table 3
Pooled estimate of the effect of cinnamon intake on systolic and diastolic blood pressure
Variable

SBP
DBP

Base case (type 2 and prediabetes)

Type 2 diabetes only

WMD, xed 95% CI

(net change)

Test of
heterogeneity P

WMD, xed 95% CI

(net change)

Test of
heterogeneity P

5.39 [6.89, 3.89]

2.6 [4.53, 0.06]

3 (139)
3 (139)

7.04
2.63

<0.00001
0.008

0.07
0.74

5.02 [6.55, 3.49]

2.64 [4.63, 0.64]

2 (117)
2 (117)

6.43
2.59

<0.00001
0.01

0.92
0.45

N, number of trials (number of subjects); Z, test for overall effort; SBP, systolic blood pressure; DBP, diastolic blood pressure; WMD, weighted mean difference; xed,
xed effect model
All results are reported in mmHg as weighted mean difference (95% CI) using a random effects model

1196

R. Akilen et al. / Nutrition 29 (2013) 11921196

to date. We have already observed many promising results in the

eld of nutritional supplements and cardiometabolic health,
which however has been rarely supported by large, properly
designed clinical trials. Therefore, there is a need to use caution
in the interpretation of promising ndings from very limited trial
evidence, as in this context. Nevertheless, we hope to revisit this
question in the future when there is more research data and
enough power available to prove the long-term tolerability and
efcacy of cinnamon on BP control.
Conclusion
In summary, this meta-analysis of three RCTs indicates that
the consumption of cinnamon (short term) is associated with
notable reduction of SBP and DBP in patients with prediabetes
and T2DM. We believe that the possible reductions in SBP and
DBP were strongly related to the patients baseline elevated BP
levels and signicant reduction in glycemic indicators (FPG or
HbA1c). However, the precise relationship between BP regulation
and the effect of cinnamon in humans remains unclear and to
be established in future studies. Although cinnamon shows
hopeful effects on BP-lowering potential, it would be premature
to recommend cinnamon for BP control, and this may raise
expectations in terms of potential utility of cinnamon supplementation in BP regulation, which seem unjustied given the
limited evidence to date. Given the limited number of studies
available, undoubtedly, a long-term, adequately powered, clinical RCT involving a larger number of patients is needed to
appraise the clinical potential of cinnamon on BP control among
patients with prediabetes and T2DM.
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