Treatment of diabetes , history, diet, major difficulties especially in treating Americans and the future of insulin therapy. We will have a history review from Paleolithic times to the present, with review of diet. We will look at my personal challenges in treating diabetes in Americans, and we will then review the history of insulin discovery, the pharmacodynamics of present day insulins, and the present investigations in newer quicker insulins and longer acting insulins. Pragmatic approach to the treatment of diabetes, what are the difficulties in treating Americans, and the past, present and future of insulin therapy. Carbohydrates are a relatively new feature in our diet and were unusual in the hunter gatherer diet. Limiting carbohydrates have significant benefit in treating diabetes. America is a melting pot and the diversity in metabolisms, mental health and habits make it especially challenging to treat diabetes. Major improvements have been made in the treatment with insulin including quick acting insulin which soon will be even quicker, mixtures of insulin and GLP-1s and soon to be weekly insulin.