Evidence-Based Complementary and Alternative Medicine
Volume 2018 (2018), Article ID 8182938, 8 pages
The Effects of Qigong on Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis
1College of Physical Education, Shandong Normal University, Jinan 250014, China
2College of Physical Education, Shandong University, Jinan 250011, China
Academic Editor: Ching-Liang Hsieh
Copyright © 2018 Ding Meng et al.. That is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. The objective of this study was to investigate the effects of Qigong on type 2 diabetes mellitus (DM) with the orderly review and meta-analysis. Methods. All prospective, randomized, controlled clinical trials published in English or Chinese and involving the usage of Qigong by individuals with DM were searched in seven electronic databases in their respective beginning to June 2016. The meta-analysis was ran using the Revman 5.2. The quality of the included trials was assessed using the Jadad score scale. Two researchers independently completed the addition, information extraction, and quality evaluation. Outcomes. Twenty-one trials with 1326 patients fulfilled the inclusion criteria and were reviewed. The meta-analysis demonstrated that, compared with no exercise, the Qigong had significant effects on fasting blood sugar (MD = −0.99, 95% CI (−1.23, 0.75), ), HbA1c (MD = −0.84, 95% CI (−1.02, −0.65), ), and postprandial blood sugar (MD = −1.55, 95% CI (−2.19, −0.91), ). Conclusion. The Qigong training may improve the blood sugar condition of the type 2 DM patients and has favorable impacts on the management of type 2 DM. However, future study with greater quality still has to be conducted to address the ramifications of Qigong on type 2 DM.
Diabetes mellitus is a chronic disease caused by inherited and/or acquired deficiency in production of insulin from the pancreas or from the ineffectiveness of the insulin produced. The first WHO Global report on diabetes suggested that the most-to-date amount of adults living with diabetes is 422 millions, which has almost quadrupled since 1980. This dramatic rise is largely because of the prevalence of type 2 diabetes and factors driving it contain overweight and obesity. The Report on the Position of Nutrition and Chronic Diseases of Chinese residents (2015) suggested that the prevalence of diabetes has been 9.7% among adults aged more than 18 years, which markedly improved 2.6 percent in a decade .
Modern medical research indicates that enhancing lifestyle can efficiently restrain and prevent the occurrence of diabetes and its complications. The Diabetes Diagnosis and Therapy Guideline issued by the American Diabetes Association in 2009 stated that exercise prescription is an important treatment on enhancing lifestyle, and efficient exercise may prevent and manage the occurrence of type 2 diabetes. Moderate-to-vigorous intensity of aerobic exercise and moderate resistance training may reduce blood sugar and dyslipidemia indicators in patients with type 2 diabetes . Cardiovascular exercise may improve the correlation between the visceral fat area and HbA1c in middle-aged and older obese patients with type 2 diabetes, as well as enhancing their lipid metabolism, body composition, and cardiopulmonary function, to be able to effectively control blood sugar levels  and reduce the incidence of middle-aged and older obese patients with type 2 diabetes. In summary, exercise has been demonstrated to be an important prescription to help fight diabetes.
Qigong, a traditional fitness system that originates from early China, combines body movement, mediation guidance, respiratory regulation, and so on. The combination of those elements achieves the effect of physical and psychological adjustment [4, 5]. Furthermore, Qigong may be effective at helping preserve neuroendocrine equilibrium and blood sugar control. Specifically, numerous orderly review studies have been conducted to investigate the effects of Baduanjin on diabetes. Yang et al.’s  research included seven clinical trials of Baduanjin on diabetes. The study suggested that the Baduanjin intervention could effectively decrease the fasting blood glucose, HbA1c, and blood lipid levels in patients with diabetes. Yu et al.’s  research included ten clinical trials of Baduanjin on diabetes. The results showed that the Baduanjin exercise could regulate blood sugar and blood lipid in diabetes patients. Fengkun  concluded that Baduanjin exercise could decrease blood sugar and blood lipid levels in patients with diabetes through a systematic review which comprised eight trials.
However, there were several insufficient aspects of the previous systematic reviews. First, the existing study included fewer study objects and particularly lack of applicable English literatures. Secondly, existing research only included Baduanjin Qigong exercise, which didn’t completely reflect the effects of Qigong on management for diabetes. Therefore, there’s a need to include more high-quality researches to further elucidate the role of Qigong in the management and treatment of diabetes.
2. Information and Methods
2.1. Data Sources and Search Plans
PubMed, the Cochrane Library, Embase, CNKI, Wan Fang Data, and VIP database have been used to look for randomized controlled experiments on Qigong interventions such as diabetes. The retrieval duration of these included studies was from the creation of the database into June 2016. At the exact same time, references in those comprised studies were examined, with the purpose to prevent omission. The search terms were split into two major elements: target (diabetes) recovery and intervention steps (Qigong) recovery; and also the search phrases were adjusted according to the specific database. All searches were combined with the theme and free recovery, and all recovery strategies were determined after repeatedly performing the preretrieval. These specific retrieval terms comprise Qigong, Baduanjin, Eight-section brocades, Wuqinxi, diabetes, diabetes mellitus, and DM.
2.2. Inclusion and Exclusion Criteria
Standards included randomized controlled trials, published in Chinese and English language; no limitations on age or gender of diabetic patients; experimental group taking Tai Chi or Qigong because the significant intervention in the exercise of diabetic patients; the control group which does not require any exercise or other aerobic exercises (aerobic exercise except traditional athletics including Tai Chi and Qigong: Jogging, walking, etc.) or antiresistance exercises; patients without serious DM-related complications.
Exclusion Criteria. Exclusion criteria included experimental classes that utilized voluntary grouping principles and additional nonrandomized controlled experiments; studies that didn’t contain indicators to be discussed in this study; experimental classes that utilized other main exercises excluding Qigong; patient with DM-related complications.
2.3. Trials Inclusion and Data Extraction
Trials addition and information extraction procedure had been completed by two researchers (W. C. and D. M.) independently. If there were arguments between these two researchers throughout the addition and information extraction, then a third researcher (Y. X.) will be consulted to analyze and decide whether the trials should be included or the information should be extracted. Data extraction comprises information of the primary author, publication time, printed journals, title of their trials, experimental and control group intervention steps, intervention period, the amount of experimental and control classes, and basic details like the age and gender of individuals; diabetes signs include blood sugar indicators: fasting blood glucose, glycosylated hemoglobin, and two-hour postprandial blood sugar; fasting blood sugar was the primary indicator of this study.
2.4. Trials Quality Assessment
From the information extraction procedure, the quality of included studies was evaluated using the Altered Jadad Quality Scale score, including random sequence creation and randomization concealment. Each item has a corresponding standard and score: 1–3 score, low research study; 4–7 score, high-quality study. Two raters performed the superior evaluation individually (M. D. and D. X.). Disagreements were resolved by seeking the opinion of this third rater (Y. X.).
2.5. Statistical Analysis
The meta-analysis was conducted with Review Manager 5.3 software given by the Cochrane network . The heterogeneity test X2 involving the outcome of the included studies was conducted. The heterogeneity results demonstrated that and I2 < 50% and that a fixed effect model should be used. If these heterogeneity test results demonstrated that and I2 < 50 percent, then the source of heterogeneity should be analyzed. The subgroup should be analyzed based on its heterogeneity. If there was no heterogeneity in these subgroups, a fixed effect model should be used. If there's statistical heterogeneity between subgroups, the random effects model for meta-analysis should be used. If information heterogeneity was too large within a subgroup, descriptive analysis should be used. If necessary, a sensitive evaluation should be used.
3.1. Trials Search
A total of 202 potentially relevant articles were identified by the database searches. 160 were removed as a result of duplication, and a total of 21 [10–30] reviews and insignificant articles were excluded by reading the titles and abstracts. Finally, by viewing the full text, 21 posts fulfilled the inclusion criteria and were assessed. 1 study was printed in English and ran in america. Another 20 studies were printed in Chinese and ran in China.
3.2. Inclusion Research Characteristics and Quality Tests
A total of 21 randomized controlled trials, with a total of 1,326 subjects, have been also included. The average age of those areas skyrocketed over 45.0–68.0 years, with a minimal follow-up period of six months and a maximum followup period of 12 months. The Altered Jadad score outcomes would be as follows: 15 trials were of low-quality, with a mean score of 2.7; six were of high-quality, with a mean score of 4 (Table 1).
Table 1: Characteristics and quality evaluations of the included trials.
4.1. Group Differences on Fasting Blood Glucose
4.1.1. Qigong Group versus No Exercise Group
Figure 1 shows that data obtained from 17 [10, 12–17, 19, 20, 22, 23, 25, 26, 28–31] related studies () may be combined. Using the random effect model for information combination, results demonstrated that the level of fasting blood sugar in the Qigong group was lower than that in the nonexercise group, and the difference was statistically significant (MD = −0.99, 95% CI , ).
Figure 1: The meta-analysis for comparing fasting blood sugar between the Qigong group and the no workout group.
4.1.2. Qigong Group versus Other Aerobic Groups
Figure 2 shows that the data got from five [10, 26–28, 31] associated studies () can be summarized. Using the random effect model for information combination, results demonstrated that there wasn’t any statistically significant difference between the Qigong group and another aerobic exercise classes (MD = −0.67, 95% CI, ,).
Figure 2: The meta-analysis for comparing the fasting blood sugar between the Qigong group and another aerobic exercise classes.
4.1.3. Qigong Group versus Antiresistance Exercise Group
Just one  study () compared the fasting blood sugar between the Qigong and also the antiresistance exercise. The random effects model was utilized to report the fasting blood sugar, and these outcomes demonstrated that the fasting blood sugar level in the Qigong group was lower than that in the antiresistance exercise category; and the difference was statistically significant (MD = −1.99, 95% CI , ).
4.2. Glycosylated Hemoglobin
4.2.1. Qigong Group versus No Exercise Group
Figure 3 shows that the information obtained from 16 [10, 12–22, 28–31] related studies () may be synthesized. Using the random effect model for information combination, these results showed that the level of HbA1c was lower than that in the control group, and the difference was statistically significant (MD = −0.84, 95% CI , ).
Figure 3: The meta-analysis for comparing the HbA1c involving the Qigong group and no exercise group.
4.2.2. Qigong Group versus Other Muscle Exercise Groups
As revealed in Figure 4, information obtained from five [10, 26–28, 31] associated studies () may be included. Using the random effect model for information combination, these results showed that the level of HbA1c of this Qigong was lower than that of another aerobic exercise group, and the difference was statistically significant (MD = −0.57, 95% CI , ).
Figure 4: The meta-analysis for comparing the HbA1c involving Qigong group and other aerobic exercise classes.
4.2.3. Qigong Group versus Antiresistance Exercise Group
The random effects model was utilized to report the HbA1c in a single  related study (), and the difference was not statistically significant between the Qigong group and the antiresistance exercise category (MD = 0.00, 95% CI , = 1.00).
4.3. Two-Hour Postprandial Blood Glucose
4.3.1. Qigong Group versus No Exercise Group
As revealed in Figure 5, the information obtained from six [12, 15, 17, 22, 24, 30] related studies () may be included. Using the random effect model for information combination, these results demonstrated that there was a statistically significant gap in the two-hour postprandial blood sugar indicator between the Qigong group and the no workout category (MD = −1.55, 95% CI , ).
Figure 5: The meta-analysis for comparing the two-hour postprandial blood sugar involving the Qigong group and no workout group.
4.3.2. Qigong Group versus Other Muscle Exercise Groups
Just one  study () reported the contrast of this two-hour postprandial blood sugar involving the Qigong and also the antiresistance exercise. The random effects model was utilized to report the two-hour postprandial blood sugar, and these outcomes demonstrated that the two-hour postprandial blood sugar level in the Qigong group was lower than that in another aerobic exercise classes; and the difference was statistically significant [MD = −0.84, 95% CI ,].
4.4. Publication Bias Evaluation
4.4.1. Publication Bias Evaluation on Comparison between Qigong and No Exercise
The fasting blood sugar for Qigong and nonexercise patients had been analyzed through link plots, which comprised 17 trials and 966 objects. These results demonstrated that the supply of included studies was asymmetric on each side of the funnel plots, suggesting that it could have novel bias in the contrast of Qigong and nonexercise.
4.4.2. Publication Bias Evaluation on Comparison between Qigong and Aerobic Exercise
The fasting blood sugar was analyzed through link plots, which comprised five studies and 389 subjects. These results demonstrated that the supply of the included studies was asymmetric on each side of the funnel plots, suggesting that it may have novel bias in the contrast of Qigong and aerobic exercise.
The objective of this study was to investigate the effects of Qigong on patients with type 2 DM using the orderly review and meta-analysis. Results suggested that Qigong had a much better effect on decreasing diabetes patients’ fasting blood glucose, HbA1c, postprandial blood sugar, and other signs, as compared with nonexercise. The outcomes of the current study were consistent with the study conducted by Fengkun , Yang et al. , Yu et al. , and so on suggesting that Qigong, as a traditional exercise, may be applied to the control of diabetic patients.
Most traditional oriental exercises like Qigong, Tai Chi, and yoga have the features of mind-body. According to the current literature, Qigong, Tai Chi, and yoga played an important role in the managing of diabetes. Three systematic reviews [32–34] printed reported that yogic practices can promote significant improvements in a number of indices of significance in type 2 DM management, including glycemic control, lipid levels, and body makeup. However, all of the reviewers said that methodological quality of their existing clinical trials was reduced, so high-quality investigations are expected to confirm and further elucidate the possible advantages of yoga applications in populations with type 2 DM. The low methodology standing of trials also exists in our current study.
Though Qigong is a type of bodily and mental exercise that originated in ancient China, which possesses the oriental culture, in the view of contemporary exercise medicine, it may be concluded that it’s a kind of light and medium intensity aerobic exercise based on the form of Qigong and workout intensity. Light and moderate intensity aerobic exercises may promote cell and tissue metabolism, induce heart blood glucose, improve the body’s use of sugar, increase target cell reactivity, improve the body’s glucose tolerance, promote HbA1c decomposition, accelerate the combo of oxygen and hemoglobin, and additional control blood sugar, thereby reducing fasting blood glucose, HbA1c, and two-hour postprandial blood sugar levels. In the current study, Qigong, as compared with other aerobic exercises, was not found to have any benefits in reducing fasting blood sugar and postprandial blood sugar. However, Qigong isn’t hard to learn, with its easy-to-learn-and-perform nature, Qigong does not require specific site and gear, both single practice and collective training are available, and many different styles of aerobic exercises don’t possess these attributes.
In addition, results of this study revealed that Qigong demonstrated better control on HbA1c than other aerobic exercise. There are a variety of advantages on raising HbA1c on human body; it may change the affinity of red blood cells into oxygen, create the tissues and cells hypoxia, and hasten the formation of cardiovascular and cerebrovascular complications; it may cause glomerular thickening and induce diabetic nephropathy. It can also cause blood lipid and blood viscosity increase. Therefore, lowering the level of HbA1c has a good control influence on the occurrence of acute complications in individuals with diabetes. 1 study  revealed that walking can decrease HbA1c levels in diabetic patients, although only walking does not. Therefore, we believed that Qigong as an exercise with the combination of meditation and movement could suppress sympathetic activation and so can improve glycemic control as neutrally mediated vasoconstriction and in the meanwhile decrease sugar delivery and uptake in skeletal muscle .
From the Western medicine perspective, the present procedure of treatment and prevention on diabetes is lifestyle management, including exercise and diet. In terms of exercise intervention for diabetes, Western medicine suggested that patients should be encouraged to engage in moderate intensity aerobic training 3–5 days per week, 30–45 minutes every day, approximately 150 minutes per week [37, 38]. Furthermore, individualized exercise plan should be supplied based on the patients’ willingness and capability. Quantification and standardization are the main characteristics and benefits of Western medicine; however, mechanical exercise plan and dull exercise fashion frequently make patients feel tired. Qigong, as a traditional exercise belongs to Chinese Tradition Medicine, isn’t as accurate as Western medicine exercise concerning the prevention and therapy on diabetes. However, Qigong emphasizes personal comprehension and cultural identification of practitioners, while Qigong is a natural combination of movement, mediation, and breathing.
There are limitations to this study that must be considered before the results can be generalized. First, because of the restriction of this searching condition, just the PubMed, the Cochrane Library, Embase, SCI, CNKI, Wan Fang Data, and Wei Pu (VIP) databases have been included in this study, and also the examined studies were bound to be omitted. Secondly, the added studies normally had significant methodology flaws; some researches didn’t explain the arbitrary allocation procedure and blindness or neglected to determine whether there were omitted studies or subjects. The Altered Jadad score in the majority of the trials was 2, which would affect the credibility of the study outcomes. Third, for added studies that had greater heterogeneity, just the random effect model was available, which could have specific confounding impacts on the outcomes. Fourth, it was likely to have novel bias in the studies that were included. Fifth, just one English printed trial was included in our current study, and most included trials have been conducted in China; hence it need stronger evidence to confirm the effects of Qigong on management of type 2 DM in non-Asian inhabitants.
Conflicts of Interest
The authors declare that they don’t have any conflicts of interest.
The work presented in this article has been supported by grant from the National Natural Science Foundation of China (71273157). The authors thank Dr. You Fu, from School of Community Health Sciences, University of Nevada, and Dr. Ryan Donald Burns, from Department of Public Health, Kinesiology, and Recreation University of Utah, for his or her help with translation.
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