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Original article
Preliminary study of the effects of Tai Chi and Qigong
medical exercise on indicators of metabolic
syndrome and glycaemic control in adults with raised
blood glucose levels
X Liu,1 Y D Miller,2 N W Burton,1 W J Brown1
1
School of Human Movement
Studies, The University of
Queensland, Australia; 2 School
of Psychology, The University of
Queensland, Australia
Correspondence to:
Dr X Liu, School of Human
Movement Studies, The
University of Queensland, St
Lucia, Brisbane, QLD 4072,
Australia; [email protected]
Accepted 22 January 2008
Published Online First ???
ABSTRACT
Objectives: To evaluate the feasibility, acceptability and
effects of a Tai Chi and Qigong medical exercise
programme that aimed to improve indicators of metabolic
syndrome and glycaemic control in adults with raised
blood glucose levels.
Design, setting, and participants: A single-group prepost trial of 11 participants (3 men and 8 women; age
42–65 years) with raised blood glucose levels conducted
from August to November 2005 at a university in
Australia.
Invervention: Participants attended Tai Chi and Qigong
exercise training for 1–1.5 h 3 times per week for
12 weeks and were encouraged to practise the exercises
at home.
Main outcome measures: Indicators of metabolic
syndrome (body mass index, waist circumference, blood
pressure, fasting blood glucose, triglycerides, HDLcholesterol) and glucose control (HbA1c, fasting insulin
and insulin resistance).
Results: There was good adherence and high acceptability for the group-based programme. Significant
improvements were seen in four of the seven indicators of
metabolic syndrome including body mass index (mean
difference 21.05 (95% CI 21.48 to 20.63), p,0.001),
waist circumference (22.80 cm (95% CI 24.97 to
20.62), p,0.05) and both systolic (211.64 mm Hg
(95% CI 219.46 to 23.51), p,0.01) and diastolic blood
pressure (29.73 mm Hg (95% CI 213.58 to 25.88),
p,0.001). There were also small improvements in HbA1c
(20.32% (95% CI 20.49% to 20.15%), p,0.01), fasting
insulin (29.93 pmol/l (95% CI 219.93 to 0.07),
p = 0.051) and insulin resistance (20.53 (95% CI 20.97
to 20.09), p,0.05).
Conclusions: The programme was shown to be feasible
and acceptable and the findings suggest that it may be
helpful for the control of indicators of metabolic syndrome
and glycaemic control. Larger controlled studies are
needed to confirm these promising results.
economic costs, management of metabolic syndrome is of paramount importance to public
health.
Previous studies have shown that physical
activity plays an integral role in preventing the
progression to type 2 diabetes in people who
already have pre-diabetes as well as in managing
type 2 diabetes.6–8 Many individuals, however, are
unable or unwilling to participate in conventional
types of physical activity such as strength training
and gym-based exercises which have been shown
to be beneficial in the control of diabetes.6 Tai Chi
and Qigong are the two most popular Chinese
medical exercises worldwide. Tai Chi has been
shown to have similar energy expenditure to other
moderate intensity activities such as walking at a
speed of 6 km/h,9 and to have both physiological
and psychological benefits.10 These Chinese exercises may be easier to learn than gym-based
exercises and do not require any complicated or
expensive equipment. Thus, Tai Chi and Qigong
may provide an alternative form of physical
activity for mid-age and older people with raised
blood glucose levels who may be fearful of injury
and additional perceived negative consequences of
other forms of exercise.11
There is now growing evidence to suggest that
Tai Chi and Qigong may improve indices of
glycaemic control in people with diabetes12 but,
to date, no studies have focused specifically on the
effects of Chinese medical exercises on metabolic
syndrome. A specially designed exercise programme based on Tai Chi and Qigong was therefore developed and a pilot study was conducted to
evaluate the feasibility and acceptability of the
programme and its effects on indicators of metabolic syndrome and glycaemic control in adults
with raised blood glucose levels.
METHODS
Participants and study design
Diabetes is becoming an increasingly prevalent
health problem throughout the world. In 2000
there were 170 million people with diabetes
worldwide, a number which is expected to rise to
over 360 million by 2030.1 The constellation of risk
factors known as ‘‘metabolic syndrome’’2 (see box
1) has been shown to be highly predictive of the
development of diabetes and other health problems.3–5 Given the dramatically increasing prevalence of diabetes and the associated premature
mortality, disability, complications and social and
Br Copyright
J Sports Med 2008;0:1–5.
Articledoi:10.1136/bjsm.2007.045476
author (or their employer)
A single group pre-post trial was performed with
outcome measures assessed immediately before
and after a 12-week Tai Chi and Qigong programme. Participants were recruited using a range
of methods including letters of invitation to
members of Diabetes Australia Queensland, referral from general practitioners (GPs) and public
advertisements in the local print media. The
eligibility and exclusion criteria are shown in
table 1. From 32 initial respondents, 11 obtained
clearance to participate in the programme from
2008. Produced by BMJ Publishing Group Ltd under licence.
1
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Box 1 Definition of metabolic syndrome
Metabolic syndrome is defined as central obesity* + two of the
following:
c Raised blood pressure: systolic >130 mm Hg or diastolic
85 mm Hg or treatment of previously diagnosed hypertension
c Raised plasma glucose: fasting plasma glucose >5.6 mmol/l
or previously diagnosed type 2 diabetes
c Raised triglycerides: >1.7 mmol/l or specific treatment for
this lipid abnormality
c Reduced HDL-cholesterol: ,1.03 mmol/l (men), ,1.29 mmol/
l (women) or specific treatment for this lipid abnormality.
*Central obesity is defined as:
c Europids: waist circumference >94 cm (men), 80 cm
(women)
c South Asians: waist circumference >90 cm (men), 80 cm
(women)
c Chinese: waist circumference >90 cm (men), 80 cm
(women)
c Japanese: waist circumference >85 cm (men), 90 cm
(women)
If body mass index is .30 kg/m2 then central obesity can be
assumed and waist circumference does not need to be measured.
Source: International Diabetes Federation.2
Table 1
Eligibility and exclusion criteria for participation in the study
Eligibility criteria
Exclusion criteria
N Cleared by GP to attend the programme
N Evidence of raised fasting blood
glucose (.5.6 mmol/l) in the last
month
N BMI >25 kg/m2 and ,40 kg/m2
N Between 30 and 64 years of age
N Willing and able to regularly attend the
programme for three sessions/week
over 12 weeks (Monday, Wednesday
and Friday evenings for 1–1.5 h per
session) at the university campus
N Have a DVD/video player and telephone
at home
N Contraindications for physical activity
N Taking diabetes medication
N Currently pregnant, within 3 months postpartum, or anticipating pregnancy during
the course of the intervention
N Physically active (currently doing physical
activity regularly at least three times a
week)
N Inability to complete the data collection
forms or follow the programme
instructions
assayed, at the same time, on completion of the intervention.
Blood glucose, triglycerides and HDL-cholesterol were measured
on a Cobas Autoanalyser using a Thermotrace Kit (Thermo
Electron, Noble Park, Victoria, Australia). Serum insulin was
determined using an enzyme-linked immunosorbent assay
(ELISA) kit (DRG Diagnostics, Marburg, Germany). Insulin
resistance was calculated using the homeostasis model assessment (HOMA) index formula:15 insulin resistance = fasting
blood glucose (mmol/l) 6 fasting insulin (mU/ml )/22.5.
Questionnaire
their GP and attended baseline assessment. Most were already
meeting the Australia national physical activity guidelines.13
Given the low number of eligible volunteers, the exclusion
criterion of being physically active was relaxed and all 11 agreed
to participate in the study.
Intervention
In addition to their usual care, participants attended three Tai
Chi/Qigong training classes per week for 12 weeks under the
guidance of a Tai Chi/Qigong instructor. Participants also
received a video/DVD demonstrating the exercises and were
encouraged to practise the movements at home on days when
they did not attend the group sessions. The exercise was KaiMai
Tai Chi/Qigong style at low to moderate intensity.14 Each
session lasted 1–1.5 h with 28 min warm up, 30 min practice
and 6–28 min cool down. The intensity of the exercise during
each session varied among participants according to individual
health and fitness levels. The duration of the classes was
progressively increased from 1 h to 1.5 h throughout the
12 weeks of the programme.
Measures
Following informed consent, all participants completed the
baseline assessment up to 1 week prior to the start of the
intervention. Each assessment was conducted at the university
by a research assistant and required participants to provide a
fasting venous blood sample, complete a questionnaire and
undergo physical measures. Baseline assessment procedures
were replicated at the end of the 12-week intervention period.
Haematological measures
A fasting blood sample was collected from the antecubital vein
at least 48 h after exercise for analysis of HbA1c, triglycerides,
HDL-cholesterol, plasma glucose and serum insulin. HbA1c was
measured immediately using a DCA 2000+ Analyzer (Bayer
Corporation, Elkhart, Indiana, USA). Baseline and post-intervention plasma and serum samples were stored at 280uC until
2
The questionnaire included questions about age, sex, country of
birth, family of diabetes, language spoken at home and physical
activity. Physical activity was assessed using a 1-week recall
questionnaire adapted from the Active Australia Survey.13 The
items have demonstrated acceptable test-retest reliability.16
At post-intervention, open-ended questions were added to
assess the acceptability and feasibility of the Tai Chi/Qigong
programme. Items asked about perceived benefits of and barriers
to participating in the programme, comments on the DVD/
video provided for at-home practice and intentions for physical
activity after the intervention.
Physical measures
Waist circumference, height and weight were measured using
standard protocols.17 Body mass index (BMI) was calculated as
weight (kg) divided by height squared (m2). Resting blood
pressure was measured using a portable mercury sphygmomanometer (ALPK2, Japan) following standard protocols.18
Adherence, acceptability and feasibility
Records of attendance at the group sessions and reasons for
non-attendance were recorded by the exercise instructor at each
class. Participants were asked to keep a diary to monitor their
at-home practice during the intervention.
Statistical analyses
Statistical analyses were conducted using the Statistical Package
for Social Sciences (SPSS) Version 15.0 software. Means and
standard deviations (SD) were calculated for normally distributed continuous variables. Differences between baseline and
post-intervention measures were analysed using paired t tests;
confidence intervals (95% CI) were calculated to describe mean
differences. As physical activity was not normally distributed,
medians and interquartile ranges were calculated to compare
baseline and post-intervention values. McNemar’s x2 test was
conducted to examine within-participant change in metabolic
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syndrome. Unless otherwise noted, significance was set at an
alpha level of 0.05.
RESULTS
Participant characteristics
Eleven participants (three men, eight women, age 42–65 years)
participated in this pilot study. Only four were born in Australia
but all except one spoke English at home. Five had fasting blood
glucose levels indicative of elevated blood glucose (5.8–
6.4 mmol/l) and six had levels >7 mmol/l (7–8.7 mmol/l).
BMI levels ranged from 18.5 to 36.4 kg/m2. Seven participants
met the criteria for diagnosis with metabolic syndrome
according to the International Diabetes Federation definition
of metabolic syndrome (shown in box 1).2 Eight participants
reported a family history of diabetes and nine met the current
Australian public health guidelines for physical activity
(>150 min of moderate physical activity per week) at baseline.13
Adherence, acceptability and feasibility
Adherence to the programme was very good with 11 participants retained during the 12-week programme. On average,
participants attended 92% of the group classes with absence
attributed to competing family or work commitments.
Compliance with the ‘‘at home’’ sessions was also very good
with participants completing 78% of the recommended ‘‘at
home’’ training sessions.
Participants reported both physical and psychological benefits
from the programme. Perceived physical benefits included
improvements in energy levels, physical well-being, sleeping
patterns, bladder function, flexibility and endurance, blood
circulation in the legs, breathing, muscle tone, immunity, pain
reduction, a reduced need for other therapies and fewer food
cravings. Reported psychological benefits included improved
mood, confidence, self-esteem and coping; less stress; improved
training motivation; and positive changes in life perspective and
family harmony.
Owing to a lack of energy and physical strength before
participating in the programme, some participants experienced
initial transient musculoskeletal soreness but this subsided as
the programme continued. Some participants reported preexisting physical problems which required some of the exercises
to be modified. Improvements in some of these problems were
reported during the exercise programme.
All participants reported that the DVD/video was useful for
their learning and training, with comments indicating that it
enhanced motivation and assisted with memorising the movements. All participants indicated that they would like to
continue with this Tai Chi/Qigong programme.
Changes in indicators of metabolic syndrome and glycaemic
control
Mean changes in indicators of metabolic syndrome and glycaemic
control from baseline to post-intervention are shown in table 2.
There were significant improvements in body weight (mean
difference 22.96 cm (95% CI 24.13 to 21.79), p,0.001) in four
of the seven indicators of metabolic syndrome (BMI, waist
circumference, systolic and diastolic blood pressure) and in the
three additional indicators of glycaemic control (HbA1c, insulin
and insulin resistance). There were no significant changes in the
three remaining indicators of metabolic syndrome (fasting blood
glucose, triglycerides and HDL-cholesterol), but downward trends
in the three haematological measures were observed. Although
the McNemar x2 test did not find a statistically significant
difference in the percentage of participants with metabolic
syndrome from pre- to post-intervention, the proportion with
metabolic syndrome decreased from 64% to 36%.
DISCUSSION
This 12-week Tai Chi/Qigong intervention resulted in significant improvements in four indicators of metabolic syndrome
(BMI, waist circumference, systolic and diastolic blood pressure)
in a small group of 11 participants. Although most of the
participants reported some difficulties with the exercises at the
beginning of the programme, this did not influence class
attendance or adherence to at-home practice recommendations.
These physical difficulties subsided with progression of the
programme, a pattern that is commonly recognised in physical
activity training. Participants indicated that they were able to
follow the instructor’s directions and the exercises were
considered acceptable. Although some participants reported
difficulty making time to attend the class three times each week
(mainly due to family or work commitments), the average
attendance at group sessions suggests that the majority were
able to overcome barriers to attendance. Moreover, none of the
participants dropped out of the programme and all were
available for final assessment after 12 weeks.
Although the majority of participants in this study were
meeting the Australian physical activity guidelines before
commencing the programme, this did not control their risk
factors for metabolic syndrome. As there was no evidence of any
Table 2 Changes in weight and indicators of metabolic syndrome and glycaemic control (N = 11)
Measures
Weight (kg)
Indicators of metabolic syndrome:
BMI (kg/m2)
Waist circumference (cm)
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Fasting blood glucose (mmol/l)
Triglycerides (mmol/l)
HDL-cholesterol (mmol/l)
Indicators of glycaemic control:
HbA1c (%)
Fasting blood insulin (pmol/l)
Insulin resistance (HOMA units)
Baseline
Mean (SD)
Post-intervention
Mean (SD)
Difference
Mean (SD)
95% CI of mean difference
p Value
(paired t test)
76.38 (20.91)
73.42 (20.11)
22.96 (1.75)
24.13 to 21.79
0.000
27.83 (5.28)
93.16 (13.48)
129.73 (13.76)
84.55 (7.58)
6.89 (0.87)
1.73 (0.76)
1.64 (0.19)
26.78 (4.98)
90.36 (13.50)
118.09 (9.65)
74.82 (5.21)
6.61 (0.48)
1.52 (0.66)
1.58 (0.27)
21.05 (0.63)
22.80 (3.24)
211.64 (11.64)
29.73 (5.73)
20.28 (0.63)
20.21 (0.39)
20.06 (0.16)
21.48 to 20.63
24.97 to 20.62
219.46 to 23.51
213.58 to 25.88
20.71 to 0.14
20.48 to 0.05
20.17 to 0.05
0.000
0.017
0.008
0.000
0.168
0.102
0.224
5.59 (0.31)
58.69 (20.00)
2.61 (0.98)
5.27 (0.39)
43.75 (25.00)
2.08 (1.12)
20.32 (0.26)
29.93 (14.86)
20.53 (0.65)
20.49 to 20.15
219.93 to 0.07
20.97 to 20.09
0.002
0.051
0.023
BMI, body mass index.
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change in duration of physical activity from pre- to postprogramme, the improvement in risk factors observed here is
likely to be attributable to participation in this specific Tai Chi/
Qigong programme which probably replaced the participants’
pre-programme activities.
The changes in body weight and waist circumference were
consistent with results reported by Dunstan et al following a 3month high-intensity progressive resistance training programme
plus dietary intervention in people with diabetes.6 In contrast,
Castaneda et al7 reported that body weight remained stable in
both their high-intensity progressive resistance training group
and a control group at 4 months, and Mourier et al19 reported no
significant change in waist circumference after a 10-week
aerobic training programme for people with diabetes. No
previous Tai Chi/Qigong studies have reported significant
changes in body weight or BMI.20–22
The significant reductions in adiposity variables in the
current study are noteworthy because central obesity is integral
to the definition and development of metabolic syndrome2 and
diabetes.2 23–25 While the mechanisms responsible for these
changes in BMI and waist circumference cannot be directly
determined from the data collected in this study, it is possible
that the moderate-intensity Tai Chi/Qigong exercise may have
been at an optimal intensity for fat metabolism.26
The significant reductions in both systolic and diastolic blood
pressure in this study confirm the findings of previous Tai Chi
intervention studies,27–29 and a review of 30 Qigong studies by
Mayer et al30 which concluded that practising Qigong may have a
positive effect on hypertension. Given that there is, on average, a
reduction of 2 mm Hg in systolic pressure per kg of weight lost,31
the reduction in blood pressure observed here was greater than
might be expected from the average weight reduction of 3 kg. In
contrast with the reduction observed here, Dustan et al6 did not
find any changes in systolic or diastolic blood pressure after
3 months of resistance training in people with diabetes.
Although there were no statistically significant changes in
fasting blood glucose or insulin, the average reduction in fasting
insulin of almost 10 pmol/l produced a significant improvement
in insulin resistance after this 12-week programme. In contrast,
both Dunstan et al6 and Castaneda et al7 reported that fasting
blood glucose and insulin levels remained unchanged during
their resistance training interventions, so that insulin resistance
did not change. The mean change in insulin resistance reported
here (0.53) was similar to that reported in the SLIM study32
(0.72) after 1 year of a combined exercise and diet intervention.
According to the World Health Organization, insulin resistance
is integral to the definition and development of metabolic
syndrome.33 It is also recognised as a strong predictor of
What is already known on this topic
c
c
c
4
Several large randomised controlled trials have shown that
lifestyle interventions can play a role in the prevention and
management of metabolic syndrome and in improvement of
glycaemic control, most of which have involved both exercise
and dietary change.
Preliminary evidence suggests that traditional Chinese medical
exercises (Tai Chi and Qigong) may be helpful in the
management of diabetes.
There have been no studies of the effect of Tai Chi or Qigong
on the constellation of risk factors that comprise the metabolic
syndrome.
What this study adds
c
c
This pilot study provides the first evidence on the feasibility,
acceptability and effects of a Tai Chi and Qigong medical
exercise programme for improving indicators of metabolic
syndrome and glycaemic control. The study provides valuable
data on which sample size calculations for future controlled
studies can be based.
The major strengths were the innovative intervention (based
on a unique programme of Kai Mai-style Tai Chi and Qigong
developed specifically for diabetes control) and the inclusion of
a range of outcome indicators. Given the lack of a control
group and small sample size, the results must be viewed as
cautiously optimistic.
diabetes, cardiovascular disease and stroke.3–5 The reduction of
0.53 units in insulin resistance in this study may therefore be
clinically meaningful and partly attributable to improvements
in central obesity and adipocyte insulin resistance.23
There was a small but statistically significant reduction in
HbA1c of 0.3% (p,0.01) after 12 weeks in the current study.
Although this effect was greater than that reported by Tessier et
al34 (0.2%) following a 16-week walking, cycling and weight
training intervention study, the clinical significance of this
finding is unclear. Dunstan et al6 have suggested that an
improvement in HbA1c of 0.6% (which was observed after
3 months of resistance training) does have clinical significance.
However, that study involved a combination of high-intensity
resistance training and a healthy eating plan, so the unique
effect of the exercise programme could not be ascertained. The
low initial mean HbA1c level (5.6%) of the study sample and
the relatively short-term intervention of the current study may
partially explain the small change in HbA1c.
Importantly, three of the seven participants (43%) who had
metabolic syndrome at pre-intervention no longer met the
diagnostic criterion for metabolic syndrome at post-intervention.
Clearly, the small sample size does not allow us to show any
statistical significance but the findings add support to the notion
that this kind of exercise may have a role to play in controlling or
even perhaps reversing metabolic syndrome in some people.
CONCLUSION
This Tai Chi and Qigong exercise programme was acceptable to
participants. The 12-week trial of its effects was feasible and we
found significant improvements in four indicators of metabolic
syndrome and three additional measures of glycaemic control in
adults with raised blood glucose levels. These findings provide
grounds for cautious optimism about a role for Tai Chi and
Qigong medical exercise in managing metabolic syndrome and
improving glycaemic control.
Acknowledgements: The authors thank Diabetes Australia Queensland for their
assistance with recruitment and the technical staff who assisted with screening and
measurement (Natalie Stroble and Cecilia Shing). The Tai Chi and Qigong programme was
developed by XL. The authors also thank the participants for their commitment to this
study.
Funding: This research project was funded by a grant from the Diabetes Australia
Research Trust. XL was supported by a University of Queensland scholarship. YDM and
NWB were supported by NHMRC capacity building (Owen, Brown, Bauman and Trost
#252977) and program (Owen, Bauman and Brown #301200) grants in physical activity
and health at the School of Human Movement Studies, University of Queensland.
Competing interests: None.
Ethics approval: The study was approved by the Human Research Ethics Committee at
the University of Queensland.
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A preliminary study of the effects of Tai Chi
and Qigong medical exercise on indicators of
metabolic syndrome and glycaemic control in
adults with elevated blood glucose.
Liu Xin, Yvette D Miller, Nicola W Burton and Wendy J Brown
Br J Sports Med published online April 2, 2008
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Short report
Retraction
X Liu, Y D Miller, N W Burton, et al. Preliminary study of the effects of Tai Chi and Qigong
medical exercise on indicators of metabolic syndrome and glycaemic control in adults with
raised blood glucose levels. Br J Sports Med 2009;43:840–844 doi:10.1136/bjsm.2007.045476.
This article has been updated and replaced by X Liu, Y D Miller, N W Burton, et al. A preliminary study of the effects of Tai Chi and Qigong medical exercise on indicators of metabolic syndrome, glycaemic control, health related quality of life, and psychological health
in adults with elevated blood glucose Br J Sports Med Published Online First 16 October 2008
doi:10.1136/bjsm.2008.051144.
The publisher is withdrawing this article with the agreement of the corresponding author.
Br J Sports Med 2010;44:608. doi:10.1136/bjsm.2007.045476retract
608