Effect of conventional medical treatment plus Qigong exercise on type 2 diabetes mellitus in Chinese patients:A Meta-analysis

INTRODUCTION

The type 2 diabetes mellitus(T2DM),is a metabolic disorder,which is characterized by high blood glucose.1The progression and development of T2DM result from insulin deficiency of both secretion and action.The T2DM is associated with multiple factors such as genetic and environmental influence.2At present,T2DM has become a healthy burden,globally.3Notably,it is predicted that the incidence of T2DM will increase to 3 million in 2025.4

Many contributions have been made to explore the effective therapy for T2DM.5-7Currently,the therapeutic managements for T2DM include mainly medication and lifestyle interventions.Medication is the most common therapy among patients with T2DM.Although there are evidence that medication decreased the mortality of diabetes patients,8a series of complications may be induced by long-term intake of medicine.9Lifestyle intervention associated with proper diet and exercise have showed advantage in decreasing blood sugars of patients,10which is becoming increasingly popular among patients all over the world.

Qigong,original from China,has been identified to be effective for various diseases.11,12Qigong exercise is widely recognized to have potential in health improvement not only in China but also in Western countries.13Many attentions have been focused on the effect of Qigong on T2DM treatment.Some investigations have suggested that Qigong have benefits in blood glucose control of patients with diabetes.14However,the evidence of the therapeutic effect on diabetes is insufficient.In this paper,we performed Meta-analysis to systematically review the effects of conventional medical treatment plus Qigong exercise in T2DM patients who administrated with traditional medicine and aimed to provide an objective perspective to evaluate the effect of Qigong on T2DM treatment.

METHODS

Search strategy for studies

The studies reported from January 1980 to January 2017 were reviewed,which concerned the association between Qigong and the type 2 diabetes.Literatures were searched from electronic literature databases including PubMed,Medline,Embase,China National Knowledge Infrastructure Database,Wanfang and China Science and Technology Journal Database.We used various combinations of search terms which contained of Qigong or chikung or qi-gong and diabetes(mellitus)or type 2 diabetes(mellitus)or DM or T2DM.

The search strategy in PubMed was that:

18 Liu ZH,Ding YL,Xiu LC,et al.A Meta-analysis of the association between TNF-α -308G＞A polymorphism and type 2 diabetes mellitus in Han Chinese population.PLos One 2013;8(3):e59421.

2#"type 2 diabetes"[All Fields];

3#"T2DM"[All Fields];

4#"qigong"[MeSH Terms];

5#"qigong"[All Fields];

6#"Ch'i Kung"[All Fields];

7#"chikung"[All Fields];

8#"qi-gong"[All Fields];

Corvis ST 3次测量结果重复测量方差分析显示总体差异无统计学意义（F=0.86，P=0.428），由Bonferroni矫正结果显示第1次测量与第2次测量的差值为（0.295±1.222）μm（P=1.000）；第1次测量与第3次测量的差值为（-1.136±1.121）μm（P=0.940）；第2次测量与第3次测量差值为（-1.432±1.118）μm（P=0.620），两两测量差异均无统计学意义。

9#"diabetes mellitus,type 2"[MeSH Terms]OR"type 2 diabetes"[All Fields]OR T2DM"[All Fields];

某日经过一家普通餐厅，便有心进去进餐。当他走进洗手间时，发现一张老旧却别致的桌子上放着一瓶鲜艳盛开的花，洗手间内干净整洁，一尘不染。他发现很多人洗手后会主动把台子擦干净。老板刚好进来，他便对老板说：“这花真漂亮！”老板得意地说：“知道吗？我在此摆鲜花已十余年了，你绝对想不到它为我省去多少清洁工作。”

10#"qigong"[MeSH Terms]OR"qigong"[All Fields]

OR"Ch'i Kung"[All Fields]OR"chikung"[All Fields]

通过对HAUNI公司6500 kg/h KLD-2Z两段式滚筒烘丝机两种加工模式启动状态和收尾状态的控制模式进行优化，烘丝出口含水率≤10.5%的干头干尾烟丝量明显降低。烘丝机在两区同温控制模式下的平均干头干尾量由原来的63.51 kg/批下降至35.91 kg/批，降幅达到43.46%；在筒壁温度前高后低控制模式下的平均干头干尾量由原来的52.50 kg/批下降至30.73 kg/批，降幅达到41.47%。优化后，有效降低了烟丝消耗，进一步稳定了卷烟产品质量。

11#"qi-gong"[All Fields]AND"diabetes mellitus,type 2"[MeSH Terms]OR"type 2 diabetes"[All Fields]OR"T2DM"[All Fields].

Similarly,this search strategy was performed in the other database.

Selection of studies and quality assessment

We adopted blinding method to select the eligible studies and set strict inclusion and exclusion criteria.Quality assessment of the candidate studies were performed according to Cochrane risk of bias tool which is also recommended for assessing bias risk of trials.15

既然他们来到我的身边会让我如此惧怕，我也就极有可能选择逃避了。特别是那个黑旋风李逵，我一定要远离他，越远越好。如此，我不就成了那个好龙的叶公吗？

Studies were eligible for Meta-analysis should meet following criteria:(a)the study was designed to research the T2DM patients,who were randomly divided into two groups,including experimental group(treated with not only conventional medical treatment but also Qigong exercise)and control group(treated with conventional medical treatment and diet control or other exercise,not Qigong);(b)the diagnostic criteria for type 2 diabetes of World Health Organization(WHO)in 1999 was used to diagnose T2DM;16(c)the mean and conventional deviation data of fasting blood-glucose(FBG),2-hplasmaglucose(2hPG),hemoglobinAlc(HbAlc),triglyceride(TG),total cholesterol(TC),high-density lipoprotein(HDL)and low density lipoprotein(LDL)were provided or could derive from the literature data;(d)the study type was randomized controlled trials(RCT);(e)studies were excluded if they were abstracts,reviewers,letters,comments and other non-theoretical of studies.The Physiotherapy Evidence Database(PEDro)score was used to evaluate the quality of included studies.

Data extraction

Two investigators independently screened literatures and extracted data from all eligible studies according to a pre-designed form.For each eligible study,the following data were extracted:the first author,year of publication,location,sample size in different groups,age and gender of participants,data for FBG,2hPG,HbAlc,TG,TC,HDL and LDL in different groups.After the above data extraction,they exchanged the audit abstract table,and discussion was conducted to resolve the disagreement.

Statistical analysis

RevMan 5.2(Nordic Cochrane Centre,Copenhagen,Denmark)and Stata 11.0 software(Stata Corp.,College Station,TX,USA)were used to analysis data in this Meta-analysis.Measurement data were denoted as mean±standard deviation,and the nominal data were denoted as percentages.Primary outcomes were blood glucose,including FBG,2hPG,and HbAc1.Blood lipid indexes were defined as secondary outcomes,in clud-ing TG,TC,HDL and LDL.Standardized mean difference(SMD)and their 95%confidence interval(CI)were calculated for evaluating the effect of Qigong on patients with T2DM.Cochran's χ2test(Qtest)was used to examine heterogeneity among studies in the Meta-analysis for FBG,2hPG,HbAc1,TG,TC,HDL and LDL.17In addition,α=0.05 was chosen,ifP≤0.05,I2≥50%,that indicated a significant heterogeneity.When significant heterogeneity was found,the random effect model was used to pool the data.Otherwise,the fixed effect model was used.Different withP＜0.05 was considered as significant.The publication bias was evaluated by Egger's test.18Sensitivity analysis was performed by the leave-one-out procedure to estimate the effect of a single study on the overall pooledSMDvalue.18

RESULTS

Search results

After initial search,there were a total of 334 candidate literatures and only 11 studies19-29met the inclusion criteria(Figure 1).The general features of the included studies were list in Table 1.Totally,834 patients with T2DM(418 cases in experimental group and 416 cases in control group)were enrolled.In Cochrane risk of bias tool,selection bias,attrition bias,reporting bias and other bias were not obvious.Taken together,the overall bias was low for all the enrolled studies(Figure 2).

The sensitivity analysis suggested that omitting one study did not affect the pooledSMDvalue.The data by Meta-analysis of our study was proven to be stable and reliable.

Similarly,there were significant heterogeneity in the data of TG,HDL,TC and LDL,therefore,the random effects model were used to pool the data(Table 2).The pooled data of TG and HDL was －1.05(－1.67,－0.43)(Figure 4A),0.69(0.19,1.19)(Figure 4B)(P＜0.05,Figure 4A-B),which suggested blood lipid indexes were significantly associated with Qigong.The pooled data of TC and LDL was － 0.42(－ 1.12,0.28)(Figure 4C)and －0.26(－0.69,0.18)(Figure 4D),respectively.However,there were no significant effects of Qigong on TC and LDL(P＞0.05,Figure 4C-D).

Publication bias

Publication bias of FBG was tested by Egger's test(t=0.6791,P=0.5324,Table 2),which revealed that there was no publication bias among the eligible studies.

Sensitivity analysis

A total of 11 studies have reported the effect of Qigong on T2DM.In order to investigate the association between Qigong and T2DM,the blood sugar indexes as primary outcomes and blood lipid indexes as secondary outcomes were both evaluated.Meta-analysis indicated that there was significant heterogeneity in the data of FBG and 2hPG,therefore,the random effects model(Dersimonian-Laird method)was used to pool the data.The pooledSMDs of FBG and 2hPG were－0.70(－0.93,－0.47)(Figure3A)and －0.66(－1.11,－0.21)(Figure 3B).However,there was no heterogeneity in the data of HbA1c,so the fixed effect model was performed on this data.The pooledSMDof HbA1c was－0.73(－0.96,－0.50)(Figure 3C).The pooled data suggested Qigong significantly associated with the levels of FBG,2hPG,HbA1c in patients with T2DM(P＜0.05,Figure 3,Table 2).

Figure 1 Flow chart of the study selection process

Figure 2 Risk of bias assessed by Cochrane risk of bias tool A:risk of bias graph;B:risk of bias summary.

DISCUSSION

Lifestyle intervention is increasingly prevalent among patients with T2DM.Qigong exercise as a traditional Chinese medicine has been practiced for thousands of years.The benefit of Qigong for diabetes management has been under debate for many years.30-36In order to explore the relatively reliable and stable conclusion,we carried out Meta-analysis for comprehensive assessment of published literatures associated with the effect of Qigong on T2DM.We found that additional Qigong significantly reduced the levels of blood sugar glucose in T2DM patients with conventional medical treatment.As for blood lipid index,Qigong was significantly associated with levels of TG and HDL,while no significant association was found between Qigong and TC and LDL.These results indicated that Qigong is a good addition to conventional medical treatment for T2DM patients.

Results indicated that there were heterogeneities among included studies in the data of FBG,2hPG,HbA1c,TG,TC,HDL and LDL.In this paper,all the patients with T2DM were Han Chinese.For Chinese Han population,they live in a vast country and geographical and cultural differences may contribute to genetic heterogeneity.In this work,the patients with T2DM involved in 4 eligible studies were from the north of China,while others were from south China.

People from the two regions have differences in diet,living environment,customs and culture.All these factors may lead to population stratification.Additional source of heterogeneity across individual studies might include different Qigong intervention(6 studies used Ba Duan Jin exercise.One study used Ma Wang Dui Dao Yin movements and 2 studies used Qigong therapy without mentioning specific method).Although Ba Duan Jin and Ma Wang Dui Dao Yin belong to fitness Qigong,the breath dispatching was different from each other.Thus,the selection might affect the conclusion to some extent.Other factors contributing to heterogeneity may be age,gender and limited cases.Unfortunately,the confounding factors were not further analyzed due to the limited literatures included in our work.

Figure 3 Forest plots of Qigong effect on the levels of blood glucose indexes

A:fasting blood-glucose;B:2-hplasmaglucose;C:hemoglobin Alc.

Our results suggests that conventional medical treatment plus Qigong exercise show significant effect on the level of FBG,2hPG,HbA1c,TG,HDL in T2DM patients with conventional medical treatment.The similar results have also been demonstrated by the study by Leeet al,36who suggest favorable effects of Qigong on HbA1c,2hPG,insulin sensitivity,and blood viscosity with 7 out of 9 studies conducted in China.The control of blood glucose may result from the contribution of Qigong to muscle movement and stress-reduction.13The compromised health-related quality of life and poor psychological health may increase the risk of patients suffering from diabetes.37,38After Qigong intervention,patients with T2DM had significant improvements on mental health,general health,vitality and stress releasing.39As for TC and LDL,our results showed that there was no statistical significance between the levels in the patients with Qigong and those without.While previous studies showed that Qigong intervention also showed positive association with TC13and LDL level.20The inconsistent conclusion may result from heterogeneity across the individual studies,the differences in region and race of patients and other factors such as age,lifestyle and body mass index of patients also showed effect on the results of our study.

(3)对钢轨进行打磨。波磨出现后，会反过来激化和加剧轮对黏滑振动，促进波磨进一步发展，波深越大则波磨发展越快，构成恶性循环。钢轨打磨中断了这种恶性循环的发展过程，减缓了波磨发展速率。

Although Qigong has potential beneficial effects on T2DM,methodological complexity make it difficult to draw firm conclusions about effective constituent for T2DM improvement.Qigong is traditionally viewed as a practice to cultivate and balanceQior what has been translated as"life energy".The enrolled 2 studies in the Meta-analysis compared the effect of Ba Duan Jin with exercises such as walking,jogging,and fast walking,and suggest Ba Duan Jin show better improvement on T2DM.21,27In addition,a previous study put forward that Qigong can improve glucose Metabolism by the benefits of relaxation response.40Moreover,a systematic review and Meta-analysis of psychological therapies to assess their effectiveness in improving glycaemic control in T2DM demonstrated that no improvement were found in blood glucose concentration among people who receive psychological therapies.41Thus,we suggest Qigong combining breath,mind for health,meditation,and martial arts training performed more effective on T2DM than simple exercises might fromQicultivation.Nevertheless,the precise reason for T2DM improvement is need for further experiment to explore the outcomes of the studies from relaxation or from the physical movement or from the authenticQicultivation.

Figure 4 Forest plots of Qigong effect on the level of blood lipid indexes

A:triglyceride;B:high-density lipoprotein;C:total cholesterol;D:low density lipoprotein.

There are some limitation should be mentioned in the Meta-analysis.First,although overall bias was not obvious,high performance bias and detection bias were found among the studies.Second,the enrolled population was all form China,and the conclusion obtained from the Meta-analysis might be suitable for Chinese population.

In conclusion,this study indicates that Qigong intervention is an effective additional treatment on T2DM in Chinese patients when used together with the conventional medical treatment.However,more studies should be conducted to verify the stability of these findings.

水稻二化螟属鳞翅目螟蛾科，又名钻心虫、蛀秆虫。二化螟寄主范围广泛，可危害水稻、小麦、玉米、油菜等作物。对水稻产量影响严重，是水稻的主要害虫。水稻从分蘖期到乳熟期均可受害，形成不同的受害状。以幼虫钻稻茎为害，发病先期枯心，既而死穗，后期秕粒增加。严重影响了水稻的产量和品质。因此，有效做好水稻二化螟的防治对促进水稻丰产丰收具有重要意义。严重的能造成绝产。

二语学习者在习得一个语块后就能在语义上进行替换，创造出无数新鲜的内容，使语言具备产出性，也能够促进词汇深度知识的习得。构式语法理论不仅有助于教师创新教学模式，也有利于学生自主性学习模式的养成，提高军事英语词汇学习的质量，使他们能够产出更准确、更地道、更丰富的目的语语言。当然，我们也应该清醒地认识到，无论是语法教学法、词汇教学法、交际教学法还是任务型教学法，都有各自的优缺点，是可以取长补短、综合利用的。笔者日后还将进行更深入、更全面的研究，找到构式语法理论与其他教学法的最佳切合点，更有效地提高学生的军事英语应用能力。

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采用自制调查表,对患儿家属对治疗的满意度进行调查,量表总分0~100分,≥80为满意,60~79分为一般满意,<60分为不满意。

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孤石局部露头型是指孤石上部仅有小部分出露于坡表(如图5所示)，孤石下部绝大部分仍然埋入周边残积土层中，孤石的埋入量大于80%。由于孤石大部分埋入边坡中，孤石的下部支撑物不明，与局部埋入型不同的是孤石出露表面部分非常少，对其整体估计更为困难。但，此类孤石一般比较稳定，发生失稳情况较少。

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9月12日，据驻民政部纪检监察组消息：中国福利彩票发行管理中心原主任王素英涉嫌严重违纪违法，目前正接受纪律审查和监察调查。

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马飚，中国作协会员，攀钢员工，研究生学历。在《诗刊》《星星》《诗探索》《文学自由谈》《诗潮》及各类选本发表诗歌1000余首，2015年获《星星》诗刊全国大奖赛一等奖。

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OR"qi-gong"[All Fields];

1.3 园林绿化企业的档案管理，具备比较特殊的动态性。由于园林绿化企业的施工对象，是各个片区的树木花木等，这些动态的植物在生长的过程当中，往往也会面临着各种特殊的状况，不同的特殊状况对植物所产生的影响不同，有些植物在种植的过程当中出现病死或者是虫害等状况，需要进行及时的养护或者更换。园林绿化企业的管理与施工的对象是不断变化的，所以园林绿化的档案也应该随时进行补充，这是企业在档案管理过程里面面对的一个比较特殊的情况。

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在花鸟题材的选择上不仅仅可以从传统的造型中获取灵感，还可以从西方花鸟系列的作品中寻找新的方向。让传统与现代充分融合交汇，突破对已有花鸟题材的认知的限制，尽可能地展现更加多元化的粉彩花鸟的艺术魅力。

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40 Tsujiuchi T,Kumano H,Yoshiuchi K,et al.The effect of Qigong relaxation exercise on the control of type 2 diabetes mellitus A randomized controlled trial.Diabetes care 2002;25(1):241-242.

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