Maturitas 80 (2015) 1423

Contents lists available at ScienceDirect

Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Review

A systematic review and meta-analysis of tai chi for treating

type 2 diabetes
Myeong Soo Lee a, , Ji Hee Jun a , Hyun-Ja Lim b , Hyun-Suk Lim c
a
Medical Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
b
Department of Nursing, Chodang University, Muan, South Korea
c
Department of Nursing, Howon University, Kunsan, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this review was to update and critically evaluate the evidence from randomised clinical trials
Received 19 September 2014 (RCTs) of tai chi for patients with type 2 diabetes mellitus (T2DM). Twelve databases were searched
Accepted 20 September 2014 by August 2014. Fifteen RCTs met all of the inclusion criteria. One RCT compared the effects of tai chi
with sham exercise and failed to show the effectiveness of tai chi on fasting blood glucose (FBG), or
Keywords: HbA1c. The other four RCTs tested the effects of tai chi compared with various types of exercise and the
Type 2 diabetes
meta-analysis failed to show an FBG-lowering effect. Five RCTs compared the effects of tai chi with an
Tai chi
anti-diabetic medication and the meta-analysis showed favourable effects of tai chi on FBG. One RCT
Fasting blood glucose
Complementary medicine
showed the positive effects of tai chi plus standard care on HbA1c and FBG compared with standard care
alone. Four RCTs compared the effects of tai chi to no treatment and the meta-analysis failed to show
the positive effects of tai chi on HbA1c. Three RCTs reported superior effects of tai chi on quality of life.
In conclusion, the existing trial evidence is not convincing enough to suggest that tai chi is effective for
managing patients with T2DM.
2014 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1. Criteria for considering studies for this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1.1. Type of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1.2. Type of participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1.3. Type of interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1.4. Type of outcome measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2. Search methods for the identication of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2.1. Electronic searches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2.2. Other sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2.3. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2.4. Data collection and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.3. Data extraction and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.4. Assessment of bias risk in the included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.5. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.1. Study description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2. Risk of bias assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.3. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Corresponding author at: Korea Institute of Oriental Medicine, Daejeon 305-811, South Korea. Tel.: +82 042 868 9266; fax: +82 042 863 9299.
E-mail addresses: drmslee@gmail.com, mslee@kiom.re.kr (M.S. Lee).

http://dx.doi.org/10.1016/j.maturitas.2014.09.008
0378-5122/ 2014 Elsevier Ireland Ltd. All rights reserved.
 M.S. Lee et al. / Maturitas 80 (2015) 1423 15

3.3.1. Tai chi vs. exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

3.3.2. Tai chi vs. standard anti-diabetic medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.3.3. Tai chi plus standard diabetic care vs. standard diabetic care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.3.4. Tai chi vs. no-treatment or wait list . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.4. Adverse effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1. Introduction 2. Methods

An estimated 285 million people (between the ages of 20 2.1. Criteria for considering studies for this review
years and 79 years) have diabetes worldwide [1] and 85% have
type 2 diabetes mellitus (T2DM) [1]. A healthy diet and regu- 2.1.1. Type of studies
lar physical activity are recommended to prevent the likelihood All of the prospective randomised clinical trials (RCTs) were
or the occurrence of diabetes and to reduce the severity of included in the study. Non-RCTs, observational studies, case series,
diabetes [2]. Currently, there is no cure for T2DM, and many and case reports were excluded. Dissertations and abstracts were
patients seek help from complementary and alternative thera- included. No restrictions of time or language were imposed.
pies to alleviate or resolve their problems. One recent analysis of
a national survey in the US showed that the severity and dura- 2.1.2. Type of participants
tion of T2DM positively correlated with the usages of CAM [3]. All adults, aged 18 years or older, of either gender who had
Another review suggested emerging evidence of positive nd- T2DM, regardless of the origin of disease, were included in the
ings with natural products and mind-body therapies on glycaemic study.
parameters in T2DM [4]. Tai chi and qigong, which are one type
of mind-body therapies, are frequently used by patients with 2.1.3. Type of interventions
DM. Trials investigating any style of tai chi were included in the
Tai chi includes elements of relaxation, deep and regulated study. We included the trials in which participants received tai chi
breathing techniques, and slow movements [5]. Tai chi is occa- alone or received tai chi combined with other treatments. The trials
sionally recommended for patients with DM [6]. There are three with designs that did not permit an evaluation of the effectiveness
systematic reviews of tai chi relative to DM [79]. One review of the test intervention (e.g., using a treatment of unproven efcacy
included 2 randomised clinical trials (RCTs) and 3 controlled clinical in the control group or comparing two different types of qigong)
trials (CCTs) compared with several types of controls [8]. Although were excluded.
outdated, this review suggested that supporting evidence for the
2.1.4. Type of outcome measures
practice of tai chi for patients with type 2 DM is scarce and uncon-
vincing. The same group updated this topic and included 8 RCTs
Primary outcomes:
and 2 CCTs [7]. This review also failed to show the effects of tai
chi for patients with type 2 DM. Recently, another review pub- - Glycaemic control (measured by HbA1c and fasting blood glucose
lished in 2013 was based on the 4 RCTs (the same 3 RCTs with (FBG)).
a previous review and 1 new RCT), 2 new CCTs and 3 new UOS,
and the conclusion was consistent with the results of other studies Secondary outcomes:
[9]. Although this meta-analysis maintained rigorous methodology,
it had several major aws. The authors did not consider hetero- - Quality of life.
geneity of the included trials when they pooled the results of the - Adverse events.
studies used in their meta-analysis. There is clinical heterogeneity
2.2. Search methods for the identication of studies
according to the type of control intervention. None of the meta-
analysis results of the four randomised controlled trials (RCTs), 2.2.1. Electronic searches
according to the type of control intervention, avoided heterogene- Databases searched from their respective inceptions through
ity. Therefore, it was not possible to statistically pool the data. August 2014 included PubMed, AMED, EMBASE, The Cochrane
Various types of control intervention, for example, conventional Library, 5 Korean Medical Databases (Korean Studies Information,
exercise, wait-list, or no treatment, were compared with tai chi. DBPIA, Korea Institute of Science and Technology Information,
Second, the authors pooled the results regardless of their design Research Information Sharing Service, and KoreaMed), and 3 Chi-
(two non-RCTs and three uncontrolled trials), which raised the like- nese Medical Databases (China National Knowledge Infrastructure:
lihood of biased results. Additionally, the review did not consider CNKI, Wangfang, and VIP).
the methods quality when they pooled the data, which may intro-
duce an interpretation bias during the evaluation of the review 2.2.2. Other sources
results. Hence, the meta-analysis results are incorrect, although Studies were obtained from the following sources:
the conclusion does not change when we consider all of the
limitations. - The reference lists of all relevant articles;
Therefore, the aim of this article was to update, complete and - Hand searching of department les; and
critically evaluate the evidence from RCTs of tai chi as a treatment - Unpublished conference proceedings relevant to depression, if
modality for patients with type 2 DM. available.
16 M.S. Lee et al. / Maturitas 80 (2015) 1423
2.2.3. Search strategy
The search was conducted in Korean, Chinese, and English using
the following terms:
- (tai chi OR taiji OR tai chi chuan) AND (diabetes OR diabetic OR
insulin).
These strategies were modied for use with other databases.
2.2.4. Data collection and analysis
2.2.4.1. Selection of studies. All of the titles and abstracts of stud-
ies retrieved from the electronic searches were reviewed by two
authors (J.H. Jun and H.J. Lim), who selected relevant articles by title
and abstract. The hard copies of each publication were reviewed by
three independent authors to determine their eligibility for inclu-
sion in the study based on the inclusion criteria (J.H. Jun, H.J. Lim and
H.S. Lim). Disagreements were resolved through discussion among
the three authors (J.H. Jun, H.J. Lim, and H.S. Lim) and an arbiter (M.S.
Lee). We contacted the authors of the included studies for clarica-
tion if necessary. The details of the study selection are shown in a
PRISMA ow chart (Fig. 1). One reviewer (J.H. Jun) searched Chinese
databases and identied and extracted related studies.
2.3. Data extraction and management
Study selection, data extraction and assessment of methodologi-
cal quality were independently performed by two reviewers (J.H.
Jun and H.J. Lim). All of the articles were read by three indepen-
dent reviewers (J.H. Jun, H.J. Lim, and H.S. Lim), and the data from
the articles were validated and extracted according to pre-dened
criteria.
2.4. Assessment of bias risk in the included studies
According to the guidelines of the Cochrane Handbook of Sys-
tematic Reviews of Interventions, the risk of bias will be assessed
to evaluate the methodological quality of the included studies
[10]. The following domains will be evaluated for methodologi-
cal quality: sequence generation, allocation concealment, blinding
of participants and outcome assessors, incomplete outcome data
and selective outcome reporting. The evaluated domains will be
assessed as Low, High or Uncertain according to the criteria
of the Cochrane guidelines.
2.5. Data synthesis
The post-treatment value of FBG was used to assess the dif-
ferences between the intervention groups and the control groups.
Weighted mean differences (WMD) and 95% condence intervals
(CI) were calculated using the Cochrane Collaborations software
(Review Manager (RevMan) Version 5.0 for Windows). We then
pooled the data across studies using a random effects model. The
chi-squared test and the Higginss I2 test were used to assess het-
erogeneity.
3. Results
3.1. Study description
We identied 558 published articles, of which 543 publications
had to be excluded (Fig. 1). Fifteen RCTs met our inclusion crite-
ria, and their key data are summarised in Table 1 [1125]. Three
articles referred to one trial that reported different outcome meas-
ures (we counted it as one RCT) [11,26,27]. Eleven of the included
RCTs were conducted in China [1214,1620,2224], two RCTs
originated from Australia [11,25], one RCT originated from Taiwan
[11,25] and the other RCT was conducted in Thailand [21]. All of
the RCTs had a parallel group design. The sample sizes ranged
from 41 to 117. A simplied tai chi style was used in ve RCTs
[12,13,18,22,23], Yang-style tai chi was used in one trial [21], Chen-
style was used in one trial [15], Sun and Yang-style was used in
two trials [11,25], Lin-style was used in one trial [21], Da Yuan Jiang
Tang-style was used in one study [16], and four trials did not report
the tai chi style used [17,19,20,24]. All of the RCTs had a parallel
group design. The number of tai chi sessions ranged from approx-
imately 24336. The number of supervised interventions ranged
from two to seven sessions weekly, with a duration of 3060 min
per session.
3.2. Risk of bias assessment
Because tai chi is for the most part self-administered, designing
an RCT with a credible placebo-control is challenging. The majority
of the studies had a high risk of bias from blinding, sequence gen-
eration or allocation concealment (Fig. 2A and B). Only three RCTs
reported sequence generation methods [11,15,23], other 12 RCTs
did not do so. One RCT employed sham exercise as the control and
archived patient blinding, whereas the other 14 RCTs failed to do so
because of the tai chi characteristics. Only one RCT adopted an allo-
cation concealment method [11], whereas the other 14 RCTs failed
to do so. Two trials used assessor blinding [11,21]. Three articles
referred to one trial that reported different outcome measures and
was open to high selective reporting bias.
3.3. Outcomes
3.3.1. Tai chi vs. exercise
Five RCTs tested the effects of tai chi compared with gentle exer-
cise, walking, dancing and conventional exercise [1115]. Three
RCTs failed to show the effects of tai chi on HbA1c and the meta-
analysis also failed to do so (n = 148; WMD, 0.00; 95% CI, 0.31
to 0.31; P = 0.98; heterogeneity: 2 = 0.22, P = 0.64, I2 = 0%) (Fig. 3A)
[11,14,15]. One RCT reported favourable effects of tai chi on FBG
[13], whereas the other four RCTs failed to do so [11,12,14,15]. The
meta-analysis failed to show favourable effects of tai chi on FBG
(n = 212; WMD, 0.03 mmol/L; 95% CI, 0.49 to 0.42; P = 0.88; het-
erogeneity: 2 = 4.88, P = 0.18, I2 = 39%) (Fig. 3B). One RCT failed to
report favourable effects of tai chi on the QoL compared with gentle
exercise [11].
3.3.2. Tai chi vs. standard anti-diabetic medications
Five RCTs assessed the effectiveness of tai chi on QoL and FBG,
and HbA1c compared with standard care, including anti-diabetic
medications [1620]. One RCT reported favourable effects of tai
chi on FBG [13], whereas the other four RCTs failed to do so
[11,12,14,15]. The meta-analysis failed to show favourable effects
of tai chi on FBG. Two RCTs failed to suggest a signicant difference
of HbA1c between tai chi and anti-diabetic medications [16,18],
whereas one RCT showed the positive results of tai chi [18]. The
meta-analysis failed to show favourable effects of tai chi on HbA1c
(n = 127; WMD, 0.54; 95% CI, 1.23 to 0.15; P = 0.13; hetero-
geneity: 2 = 2.32, P = 0.32, I2 = 14%) (Fig. 3C) [16,18,19]. Two RCTs
suggested favourable effects of tai chi on FBG compared with anti-
diabetic medications [16,17], whereas the other three RCTs failed
to do so [1820]. The meta-analysis showed favourable effects
of tai chi on FBG (n = 188; WMD, 1.57; 95% CI, 2.34 to 0.80;
P < 0.0001; heterogeneity: 2 = 3.00, P = 0.39, I2 = 0%) (Fig. 3B).
3.3.3. Tai chi plus standard diabetic care vs. standard diabetic
care
One RCT showed positive effects of tai chi on HbA1c and FBG
compared with standard diabetic care without medication [21].
Table 1
Summary of randomised controlled clinical studies of tai chi for type 2 diabetes.

First author (yr) Sample size (M/F) Intervention group Type of tai chi Control group Main outcomes Intergroup Authors Comments
[Ref] Country Duration of disease (regimen) (regimen) differences conclusion
(yr)

Tsang (2008) [11] 38 (8/30) T2DM Tai chi (55 min, 12 movements Sham exercise (1) HbA1c (1)(4) NS . . .did not improve Double-blind
Australia (10.64) twice weekly for 16 (Sun and (gentle (2) FBG glucose randomised
weeks, n = 17) Yang-style) callisthenics, n.r. (3) QoL homeostasis. . . placebo-controlled
twice weekly for 16 trial
weeks, n = 20) No adverse events
(+)
Kan (2004) [12] 48 (25/23) T2DM Tai chi (60 min, 24 movements Walking or running FBG NS . . .improve Adverse events
China (3<) every day for 12 (simplied version) (60 min every day glycaemic were not described
weeks, n = 26) for 12 weeks, control. . . ()
n = 22)
Wang (2003) [13] 16 (n.r.) T2DM (2<) Tai chi (60 min, 24 movements Walking or running FBG P < 0.05 . . .improve Adverse events
China every day for 12 (simplied version) (60 min every day metabolic were not described
weeks, n = 10) for 12 weeks, n = 6) disorder. . . ()
Wang (2009a) [14] 54 (30/24) T2DM Tai chi (3050 min, n.r. (Yang style) Dancing exercise (1) HbA1c (1) NS . . .tai chi Adverse events
China (8.32) every day for 24 (3050 min every (2) FBG (2) NS and. . .dancing were not described
weeks, n = 28) day for 24 weeks, exercise can reduce ()

M.S. Lee et al. / Maturitas 80 (2015) 1423

n = 26) blood glucose. . .
Chen (2010) [15] 117 (63/54) obese Tai chi (60 min, 3 Brief form of tai chi Conventional (1) HbA1c (1), (2) NS . . .is efcient and Adverse events
Taiwan patients with times weekly for 99-form (Chen exercise (aerobic (2) FBG safe. . . were mentioned in
T2DM (8.5/7.8) 12 weeks, n = 62) style) exercise plus the discussion (+)
home-based No details were
exercise, 60 min, 3 reported
times weekly for
12 weeks, n = 55)
Yan (2004) [16] 18 (10/8) T2DM Tai chi (3060 min Da Yuan Jiang Tang Standard diabetes (1) HbA1c (1) NS . . .improve Adverse events
China (3.0/2.9) twice daily for 24 style care (n.r. in detail, (2) FBG (2) P < 0.01 glycaemic were not described
weeks, n = 10) plus n = 8) control. . . ()
standard diabetes
care
Li (2013) [17] China 60 (36/24) Old Tai chi (45 min n.r. Standard diabetes FBG P < 0.05 . . .improve Adverse events
patients with once daily for 8 care (anti-diabetic glycaemic were not described
T2DM (3 weeks, n = 30) plus medication, n.r. in control. . . ()
months-10 yr) standard diabetes detail, n = 30)
care
Wang (2004) [18] 57 (27/30) Old Tai chi (1520 min n.r. (simplied Standard diabetes (1) HbA1c (1) P < 0.05 . . .improve Adverse events
China patients with once daily for 12 version) care (n.r., n = 28) (2) FBG (2) NS glycaemic were not described
T2DM (2.7/2.8) weeks, n = 29) plus control. . . ()
running and
walking
Wei (2012) [19] 52 (30/22) T2DM Tai chi ball (60 min 36 movements Standard diabetes (1) HbA1c (1), (2) NS . . .improve Adverse events
China (0.53) once daily for 12 (n.r.) care (antidiabetic (2) FBG glycaemic were not described
weeks, n = 26) medication, n.r. in control. . . ()
detail, n = 26)
Xiao (2010) [20] 48 (28/20) T2DM (A) Tai chi (60 min 24 movements (C) Standard FBG NS . . .effect on Adverse events
China (6.8) once daily for 24 (n.r.) diabetes care preventing and were not described
weeks, n = 12) (conventional curing DM. . . ()
(B) Tai chi plus medication, not
herbal injection detail reported,
(n = 12)a n = 12)
(D) Herbal
injection (n = 12)a

17
 18
Table 1 (Continued)

First author (yr) Sample size (M/F) Intervention group Type of tai chi Control group Main outcomes Intergroup Authors Comments
[Ref] Country Duration of disease (regimen) (regimen) differences conclusion
(yr)

Youngwanichsetha 69 postpartum Tai chi (50 min, 3 18 movements (Lin Standard diabetes (1) HbA1c (1) P = 0.04 . . .improved No medication
(2013) [21] women with T2DM sessions weekly at Houshengs style) care (n = 33) (2) FBG (2) P = 0.02 glycaemic No adverse events
Thailand (2.47/2.78) hospital and 5 control. . . (+)
times weekly at (+)
home for 12 weeks,
plus standard

M.S. Lee et al. / Maturitas 80 (2015) 1423

diabetes care,
n = 34)
Wang (2009b) [22] 64 (52/46) old Tai chi (4560 min 24 movements No treatment QoL P < 0.05 . . .improve both Adverse events
China patients with every day for 24 (simplied version) (n = 30) physical and were not described
T2DM (1<) weeks, n = 34) mental health ()
QoL. . .
Wu (2010) [23] 40 (15/25) T2DM Tai chi (60 min 3 24 movements No treatment (1) HbA1c (1) P < 0.05 . . .improve Adverse events
China (1.35/1.36) times weekly for (simplied version) (n = 20) (2) QoL (2) P < 0.05 glycaemic were not described
24 weeks, n = 20) control. . . ()
Zhang (2008) [24] 20 women with Tai chi (60 min 5 n.r. No treatment FBG NS . . .improve No adverse events
China T2DM (4.4) ADA times weekly for (n = 10) glycaemic (+)
14 weeks, n = 10) control. . .
Lam (2008) [25] 53 (24/29) T2DM Tai chi (60 min 20movements (Sun Wait-list (n = 25) (1) HbA1c (1) NS . . .no. . . First
Australia (for at least 6 twice weekly for 12 and Yang style) (2) QoL (2) Physical health, improvement in community-based
months) weeks, n = 28) P = 0.04; social metabolic RCT
functioning, control. . . Control
P = 0.024; general improvements in participants were
health, P = 0.044 physical and social allowed to
functioning continue their
usual exercise.
n.r. for medication
usage

* These studies were reported from one trial. n.r., not reported; NS, not signicant; FBG, fasting blood glucose; HbA1c, glycosylated haemoglobin; RCT, randomised clinical trial; (+), mentioned in text; (), not mentioned in text.
a
We excluded these groups from the analysis because they are in the excluded criteria.
 M.S. Lee et al. / Maturitas 80 (2015) 1423
Fig. 1. Flowchart of trial selection process. UOS, uncontrolled observational study; CCT, controlled clinical trial; RCT, randomised clinical trial.
3.3.4. Tai chi vs. no-treatment or wait list
Four RCTs compared the effects of tai chi to no treatment or wait-
list on FBG, HbA1c, and QoL [2225]. One RCT showed favourable
effects of tai chi on HbA1c [23], whereas the other RCT failed to do
so [25] (Fig. 3E). One RCT failed to show any changes in FBG [24].
Three RCTs reported superior effects of tai chi on QoL compared
with no-treatment or wait-list controls [22,23,25].
3.4. Adverse effects
Four RCTs assessed adverse effects [11,15,21,24], whereas 11
RCTs did not. Three of 4 RCTs reported no adverse effects [11,21,24],
whereas the other RCT [15] only mentioned in previous studies and
this current pilot study, very few adverse reactions or injuries were
reported.
4. Discussion
This systematic review identied few RCTs regarding tai chi for
treating patients with T2DM. Collectively, these trials do not refute
the notion that tai chi has some potential benet for managing
patients with T2DM. The evidence is, however, by no means com-
pelling. We found that tai chi was compared with several control
interventions, including (sham) gentle exercise, walking, running,
19
dancing, wait-list or no treatment. Whether the fact that no dif-
ferential effects emerged compared to other exercises may reect
equivalent effects on glycaemic control with several types of exer-
cise treatments is unclear [1115]. However, one of these RCTs
suggested that tai chi is not superior to sham gentle exercise for
glycaemic control [11]. Additional research is therefore required
to clarify this issue. Compared to no treatment, the effects of tai
chi observed in patients with T2DM and in subjective QoL may
suggest effectiveness compared against the natural course of the
disease; however, there is little information concerning specic
effects [2225]. Additionally, the evidence from RCTs that com-
pared tai chi with conventional anti-diabetic medications seems
to be mixed [1620]. The favourable effects of tai chi in reducing
FBG were shown, whereas the effects of tai chi on HbA1c were not
positive. One RCT showed that tai chi as an adjunctive treatment
had favourable effects on HbA1c and FBG [21]. Overall, our ndings
provide insufcient evidence that tai chi is benecial for treating
patients with T2DM compared with several controls.
Our review aimed to update and complete the evidence by
adding recent RCTs concerning the effectiveness of tai chi for man-
aging patients with T2DM. Compared to 3 previous reviews [79],
we identied 8 new RCTs [1623] with comprehensive searches
and successfully updated the therapeutic evidence. The results of
our review are similar to the other 3 reviews that failed to show
effects of tai chi for managing patients with T2DM [79]. However,
20 M.S. Lee et al. / Maturitas 80 (2015) 1423

Fig. 2. (A) Risk of bias summary: review authors judgements about each risk of bias item for each included study; (B) risk of bias graph: review authors judgements about
each risk of bias item presented as percentages across all included studies.
 M.S. Lee et al. / Maturitas 80 (2015) 1423 21

Fig. 3. Forest plot of the effects of tai chi on (A) HbA1c and (B) FBG compared with exercise; (C) HbA1c and (D) FBG compared with anti-diabetic drugs; (E) HbA1c compared
with no-treatment. FBG: fasting blood glucose.
22 M.S. Lee et al. / Maturitas 80 (2015) 1423
we have included the evidence of tai chi compared with conven-
tional medication therapies. Our review suggested some possible
positive or equivalent benets compared with conventional medi-
cation therapy or exercise.
The limitations of our systematic review in general pertain to
the potential incompleteness of the evidence reviewed. The distort-
ing effects on systematic reviews and meta-analyses arising from
publication and location biases are well documented [2830]. We
aimed to identify all RCTs on the topic with no restrictions of publi-
cation language and searched a large number of different databases.
Although we are condent that our search strategy has located all
relevant data on the subject, one can never be absolutely certain;
thus, a degree of uncertainty remains. The paucity and the often
suboptimal quality of the primary data are additional limitations.
One should note, however, that design features, such as placebo or
blinding, are difcult to incorporate in studies of tai chi and that
research funds are scarce. These factors inuence both the quality
and the quantity of research.
The majority of included trials have high or unclear risk of bias in
random sequence generation, allocation concealment and blinding.
The trials with inadequate levels of blinding are likely to show exag-
gerated treatment effects [31,32]. Only three RCTs reported random
sequence generation methods [11,15,23] and two RCTs used ade-
quate allocation concealment [11,21]. All of the other trials suffered
from a lack of adequate allocation concealment and sufcient sam-
ple size. The RCTs included in this review fail to fully control for
placebo effects because of the nature of therapy. It is therefore
impossible to tell to what extent the therapeutic response (if any)
is due to specic or non-specic effects.
Fourteen RCTs assessed glycaemic control as outcome meas-
ures [1121,2325]. Nine RCTs failed to show positive effects
[11,12,14,15,1820,24,25]. However, the original authors of seven
trials concluded that tai chi is effective for glycaemic control
from the negative results [12,14,15,1820,24]. More than half
of the authors [12,14,1820,24] from China [1214,1620,2224]
reached different conclusions from the results.
Four reviewed studies reported no adverse events related to tai
chi [11,15,21,24]. Tai chi appears to be generally safe, and seri-
ous adverse effects have not been reported. However, adverse
effects were not the focus of this review and may require additional
research.
Future RCTs examining the effects of tai chi on patients with
type 2 diabetes should adhere to the accepted standards of trial
methodology. The studies included in this review showed a num-
ber of problems that have been noted in other reviews on tai chi,
e.g., the expertise of the tai chi practitioners, the heterogeneity of tai
chi, the frequency and duration of treatment, the primary outcome
measures and statistical tests employed, and heterogeneous com-
parison groups [33,34]. Furthermore, although it is hard to blind
subjects to treatment, employing assessor blinding and allocation
concealment are important for reducing bias.
In conclusion, the evidence that tai chi might be benecial for
treating patients with DM compared with exercise treatments is
not convincing. Additionally, the evidence from RCTs, which com-
pared tai chi with conventional anti-diabetic medications, seems
to be mixed. All of the studies were burdened with a high risk of
bias. The majority of studies did not use allocation concealment and
blind assessors. Therefore, the reliability of the evidence presented
in this study is clearly limited. Additional research is required to
determine whether tai chi is benecial for treating patients with
T2DM.
Contributors
Myeong Soo Lee, Ji Hee Jun, and Hyun-Ja Lim: designed
the review, performed searches, appraised and selected trials,
extracted data, contacted authors for additional data, carried out
analysis and interpretation of the data, and drafted this report.
Hyun-Suk Lim: reviewed and critiqued on the review protocol
and this report, assisted in designing of the review.
Competing interest
None declared.
Funding
No external funding received.
Provenance and peer review
Not commissioned; externally peer reviewed.
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