THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 15, Number 6, 2009, pp. 627632

Mary Ann Liebert, Inc.
DOI: 10.1089=acm.2008.0330

Adhering to a Tai Chi Program to Improve Glucose Control

and Quality of Life for Individuals with Type 2 Diabetes

Rhayun Song, R.N., Ph.D.,1 Sukhee Ahn, R.N., Ph.D.,1 Beverly L. Roberts, R.N., Ph.D., F.A.A.N.,2
Eun Ok Lee, R.N., D.N.S.,3 and You Hern Ahn, M.D., Ph.D.4

Abstract

Purpose: This study was to examine the effects of adherence to a 6-month tai chi exercise program on glucose
control, diabetic self-care activities, and quality of life among individuals with type 2 diabetes.
Method: The data from a quasi-experimental study at multisite health-promotion centers in Korea with pretest
and 3- and 6-month post-test measures were used. Ninety-nine (99) adults diagnosed with type 2 diabetes and
HbA1c 6.0 or higher were included in the analysis. The tai chi intervention consisted of 19 movements from Yang
and Sun styles provided twice a week for 6 months. Sixty-two (62) subjects completed both pretest and post-test
measures. To achieve the desired outcomes, subjects needed to complete 80% of the sessions of the tai chi
program, and 31 subjects who met this criteria were compared to those who did not (n 31). Outcome measures
included glucose control (fasting blood sugar, HbA1c), diabetic self-care activities, and quality of life (36-Item
Short Form Health Survey, version 2).
Results: Using repeated measure analysis of variance for baseline, 3 months, and 6 months, the adherent group
had greater decline in fasting glucose (interaction effect F 5.60, df 2, p < 0.05) and HbA1c (interaction effect
F 4.15, df 2, p < 0.05) than the nonadherers. The adherent group performed significantly more diabetic self-
care activities (interaction effect F 5.13, df 2, p < 0.05), and had better quality of life in mental component
summary, social functioning, mental health, and vitality as compared to the nonadherent group. The significant
differences in quality of life remained after adjusting for self-care activities except for mental health, which was
no longer significant.
Conclusion: For those with type 2 diabetes, tai chi could be an alternative exercise intervention to increase
glucose control, diabetic self-care activities, and quality of life. Whether tai chi can reduce or prevent diabetic
complications requires further study.

Introduction most problematic and underused therapies in diabetes man-

agement.2

R educing morbidity and mortality and improving

quality of life for people with diabetes is a major public
health objective. Scientists who conducted the Diabetes Pre-
vention Program study found that people can reduce the oc-
currence of diabetes and its complications by losing weight
(5%7% of their weight), eating a healthy diet (low fat,
lower calorie), and increasing their physical activity.1 Of the
self-care behaviors affecting glucose control and prevention
of diabetes complications, regular exercise is one of the
Brisk walking has been proposed as a low-cost exercise for
individuals with type 2 diabetes.3 However, brisk walking
involves mainly endurance exercise activities that do not
involve resistance for strength, and often requires safe places
to walk and good weather. The combination of endurance
and resistance exercise with moderate intensity is considered
more suitable for type 2 diabetic patients to improve func-
tional performance capacity while lowering cardiovascu-
lar challenge,4 and walking does not address any of these.

1
College of Nursing, Chungnam National University, Daegon, Korea.
2
College of Nursing, University of Florida, Gainesville, FL.
3
College of Nursing, Seoul National University, Seoul, Korea.
4
College of Medicine, Hanyang University, Seoul, Korea.

627
628
Despite well-recognized health benefits of exercise, the long-
term adherence to exercise has been shown to range between
30% and 50%.5 Adherence is low for persons with diabetes
because of high costs, lack of motivation, or lack of places to
exercise.
Tai chi is a beneficial alternative form of exercise in diabetes
management, and its low intensity may make it applicable to
those who would not engage in more strenuous exercise. Tai
chi is an ancient Chinese martial art that combines deep dia-
phragmatic breathing and relaxation with slow, gentle, and
circular movements.6,7 Tai chi consists of both endurance and
resistance exercises with qigong breathing while maintaining
low stances with constant weight transfers. Tai chi is a mod-
erately intense aerobic exercise8 and is considered equivalent
to the amount of aerobic exercise intensity recommended for
type 2 diabetes.9 Among various styles of tai chi, Yang style or
more vigorous forms are considered to be suitable for im-
proving glucose control and cardiovascular function in indi-
viduals with type 2 diabetes.9,10 Unlike traditional exercise,
tai chi requires no special facility or expensive equipment
and can be performed either individually or in groups
that improve accessibility and exercise compliance for this
population.11
With only a few clinical trials of tai chi in type 2 diabetes,
evidence supporting the practice of tai chi in diabetes man-
agement is currently not convincing, based on a systematic
review.12 A casecontrol study implementing Chen style
tai chi for 12 weeks has been effective in decreasing HbA1c
in patients with type 2 diabetes compared to their age-
matched controls.13 On the other hand, a randomized clinical
trial with less vigorous forms of tai chi style revealed no
significant changes in glucose control after 16 weeks.9 A lon-
gitudinal randomized controlled study compared a stan-
dardized Yang style tai chi to control groups also found no
significant changes in blood glucose and HbA1c in the tai chi
group.14,15
Several things may partially explain the nonsignificant
findings in prior studies: baseline effects due to the subjects
being normoglycemic at the pretest14 and utilization of less
intense form of tai chi without considering exercise compli-
ance.9,15 Exercise adherence should be considered in evalu-
ating the program effectiveness because the frequency of
exercise contributes to the size of its effects.15,16 A multisite
intervention study conducted in persons with type 2 diabetes
at health-promotion centers in Korea also found that the
intervention effects in glucose control varied according to the
attendance rates of the tai chi sessions.17
Hence, a secondary data analysis of a large-scale inter-
vention study17 was used to examine the effects of adherence
to tai chi sessions on glucose control, diabetic self-care ac-
tivities, and quality of life among persons with type 2 dia-
betes. Since the performance of self-care activities could
affect glucose control and quality of life in this population,
the effects of tai chi will be examined after statistically con-
trolling for self-care activities.
Methods
Design and sample
The data for this analysis were from a quasi-experimental
multisite intervention study.17 Subjects who registered at six
health promotion centers in Korea were recruited, and the
SONG ET AL.
inclusion and exclusion criteria was described previously.17
The inclusion criteria for the secondary data analysis was (1)
being diagnosed with type 2 diabetes according to the cri-
teria by Korean Diabetes Association18 for at least 12 months,
and (2) HbA1c 6.0 or higher at baseline.
Of the 148 subjects in a large-scale study, 99 adults with
type 2 diabetes met the inclusion criteria, and 62 completed
both pretest and post-test measures at 3 months and at 6
months. Based on the recommendation of the American
College of Sports Medicine (ACSM) that 80% of exercise at-
tendance is required for significant outcomes to be found,16
subjects were categorized as adherent (n 31) if they par-
ticipated in more than 38 sessions or as nonadherent (n 31)
if they participated in less than 80% of the sessions.
Tai chi intervention
The tai chi program consisted of 19 movements from Yang
and Sun styles. Qigong breathing with open and closing
hands (Sun style tai chi) and stepping forward and back-
ward with weight transference (Yang style tai chi) were in-
cluded.19 Each session commenced with warm-up exercise to
prepare body and mind, and concluded with cool-down
exercise to release muscle tension and stiffness.
The combined forms of tai chi required metabolic equiv-
alents (METs) 3 to 5.12 The 1-hour sessions of tai chi were
provided twice a week for 6 months, and subjects were en-
couraged to practice at home for 20 minutes at least 3 times a
week to meet the recommended dose of exercise.16 Prior to
implementing the tai chi program, certified tai chi instructors
were trained at a series of workshops to ensure that each site
uniformly provided a standardized tai chi program. A vid-
eotape of Tai Chi for Diabetes program19 was used to ensure
consistency in the intervention provided. An individual ex-
ercise contract along with daily exercise log and weekly
phone contacts were utilized to increase attendance and the
frequency of home exercise for the subjects.
Measures
Glucose control. Glucose control was measured by
fasting blood sugar that reflects current glucose control and
HbA1c that reflects average glucose during the previous 3
months.20 This allowed the effects of tai chi to be evaluated
during the last 3 months of the intervention at a time when
the greatest effects of tai chi are expected. The blood samples
were sent to the same medical laboratory to ensure the
consistent analysis and reduce errors in measurements.
Diabetes self-care activities. The diabetes self-activity
scale was developed based on the items of the diabetes self-
efficacy scale21 to assess frequency in performing self-care
activities. The items included diabetic diet, medication, glu-
cose management, exercise, and hospital visit. The scale con-
sisted of 7 items rated on a 4-point scale from 1 (never do) to 4
(always do). The ratings were summed and divided by the
number of items for an item mean, with higher scores re-
flecting more frequently performed diabetes self-care activi-
ties. Cronbachs as for the scale was 0.79 for the current study.
Quality of life. The quality of life was measured by the
Korean version of 36-Item Short Form Health Survey version
2 (SF-36v2), assessing eight dimensions of quality of life
TAI CHI FOR GLUCOSE CONTROL 629

Table 1. Demographic Characteristics at the Baseline Measure by Groups (N 62)

Adherent (n 31) Nonadherent (n 31)

Characteristics Frequency (%) Frequency (%) w2 p

Gender 1.65 0.34

Female 23 (74.2) 27 (87.1)
Male 8 (25.8) 4 (12.9)
Education 5.42 0.06
6 years or less 10 (32.2) 18 (58.1)
712 years 14 (45.2) 11 (35.5)
13 years or more 7 (22.6) 2 (6.5)
Economic status 2.67 0.26
Middle or high 26 (83.9) 22 (71.0)
Low 5 (16.1) 9 (29.0)
Marital status 0.47 0.73
Married 27 (87.1) 25 (80.6)
Widowed=other 4 (12.9) 6 (19.4)
Admission history 1.25 0.40
No 20 (64.5) 24 (77.4)
Yes 11 (35.5) 7 (22.6)
Smoking 0.40 0.38
Never smoked 25 (80.6) 26 (86.7)
Quit (<1 year) or smoking 6 (19.4) 4 (13.3)
Chronic diseasea
Arthritis 13 (41.9) 9 (29.0) 1.12 0.42
Hypertension 19 (61.3) 23 (74.2) 1.18 0.42
Others 3 (9.7) 5 (16.1) 0.57 0.71
a
Multiple choices on chronic disease other than diabetes.

along with physical and mental component summary scores.
Each dimension was scored with weighted items as 100
points, representing higher scores for higher quality of life.
The psychometrics of the Korean version of SF-36 was re-
ported for discriminant validity and reliability coefficient of
0.85.22 For the present study, Cronbachs as for subscale
ranges were 0.750.85.
Results
Description of subjects
Mean age of the subjects was 64 years old (standard de-
viation [SD] 8.02) and their mean scores of body mass in-
dex were 25.8 (SD 3.6) for the adherent group and 24.4
(SD 2.57) with no significant group differences. Most of
them were female (80%), married (84%), and not currently
employed (85%). The majority of the subjects had less than
high school education (<12 years), and reported their so-
cioeconomic status as middle level (76%). Besides type 2
diabetes, subjects had hypertension (68%) and arthritis (35%).
The adherent group (n 31) and nonadherent group (n 31)
had similar demographic characteristics (Table 1). The
adherent group attended a mean of 89.45 (SD 4.20) tai chi
sessions while the nonadherent group attended 21.77
(SD 23.19).
Effects of adhering to tai chi
Using repeated measure analysis of variance, the inter-
action effects were significant for serum glucose (F 7.76,
df 2, p 0.001), and in HbA1c (F 5.20, df 2, p 0.01). months. These results are similar to those found in a 12-week
Specifically, the group who adhered to 80% of tai chi ses-
sions had better glucose control from baseline to 6 months
than those who were not adherent. Similarly, the adherent
group engaged in more diabetic self-care activities at 6
months (F 5.13, df 2, p 0.009). Since frequency of self-
care activities may affect glucose control, the effects of ad-
hering to tai chi were examined controlling for these self-care
activities. The significant effects on serum glucose and
HbA1c did not substantially change and remain significant
after adjusting for the self-care activities (Table 2).
Also, the adherent group had significantly improved
quality of life in the mental component summary of the SF-
36, social functioning, mental health, and vitality as com-
pared to the nonadherent group. No significant differences
were found in other components of quality of life (Table 3).
When controlling for self-care activities, the effects for ad-
herent remained unchanged except for mental health, which
become nonsignificant.
Discussion
In this study, participating in 80% or more sessions of a 6-
month tai chi program significantly improved glucose con-
trol in individuals with type 2 diabetes (0.5% of HbA1c), and
the effects remained even when controlling for self-care ac-
tivities. Those subjects who adhered to 80% or more of the
tai chi sessions also had greater quality of life in most di-
mensions than the nonadherent subjects.
Aerobic, resistance, or combined exercise has been found
to have small to moderate beneficial effects on glucose con-
trol in type 2 diabetic patients.23 In this study, the adherent
group had a 0.5% improvement in HbA1c from baseline to 6
program of Chen style tai chi 3 times a week in persons with
type 2 diabetes when compared to age-matched controls,13
630 SONG ET AL.

Table 2. Group Comparisons on Glucose Control and Diabetic Self-Care Activities at Pretest,
3 Months, and 6 Months (N 62)

Pretest 3 months 6 months

M (SD) M (SD) M (SD) Source F p

Glucose
Adherent 151.70 (61.81) 124.00 (26.21) 127.86 (31.70) Group 2.49 0.11
Nonadherent 144.22 (46.74) 145.09 (50.56) 166.26 (72.23) Time 4.87 0.01
Group*time 5.60 0.006
HbA1C
Adherent 7.31 (1.12) 6.87 (0.78) 6.83 (0.59) Group 1.01 0.32
Nonadherent 7.19 (1.18) 7.24 (1.20) 7.31 (1.23) Time 2.58 0.08
Group*time 4.15 0.02
Diabetic self care activities
Adherent 3.21 (0.57) 3.42 (0.44) 3.43 (0.44) Group 2.70 0.10
Nonadherent 3.33 (0.42) 3.15 (0.47) 3.10 (0.55) Time 0.06 0.94
Group*time 5.13 0.009

M, mean; SD, standard deviation.

Table 3. Group Comparisons on Quality of Life at Pretest, 3 Months, and 6 Months (N 62)

Pretest 3 months 6 months

Quality of life M (SD) M (SD) M (SD) Source F p

Physical component summary

Adherent 43.12 (7.79) 43.41 (8.01) 44.08 (8.17) Group 0.09 0.75
Nonadherent 43.13 (9.07) 42.87 (7.85) 42.86 (10.73) Time 0.07 0.92
Group*time 0.18 0.83
Mental component summary
Adherent 37.61 (11.13) 40.87 (9.84) 46.27 (9.52) Group 0.45 0.50
Nonadherent 39.67 (12.17) 39.38 (12.50) 40.80 (11.23) Time 7.78 0.001
Group*time 4.39 0.01
Physical functioning
Adherent 46.17 (6.36) 46.91 (5.88) 48.88 (6.82) Group 1.35 0.24
Nonadherent 44.20 (8.24) 43.38 (8.55) 44.33 (10.02) Time 1.17 0.31
Group*time 0.85 0.43
Social functioning
Adherent 38.90 (7.73) 42.42 (7.11) 46.11 (7.38) Group 0.30 0.58
Nonadherent 41.54 (10.48) 41.19 (10.32) 41.35 (11.00) Time 6.07 0.004
Group*time 6.16 0.004
Rolephysical
Adherent 34.73 (15.99) 37.76 (13.67) 37.26 (14.96) Group 0.12 0.73
Nonadherent 35.68 (16.60) 35.68 (14.76) 35.36 (15.67) Time 0.25 0.77
Group*time 0.29 0.74
Roleemotional
Adherent 32.30 (20.81) 37.82 (19.29) 42.33 (17.83) Group 0.91 0.34
Nonadherent 32.80 (21.57) 33.30 (22.29) 34.81 (21.45) Time 2.16 0.11
Group*time 0.98 0.37
Mental health
Adherent 41.77 (9.24) 43.15 (7.97) 46.64 (7.56) Group 1.15 0.28
Nonadherent 41.55 (9.55) 41.19 (9.36) 42.21 (8.90) Time 10.07 <0.001
Group*time 4.46 0.01
Vitality
Adherent 44.55 (9.79) 44.23 (5.96) 49.87 (8.42) Group 0.89 0.34
Nonadherent 48.66 (8.66) 46.81 (9.98) 46.66 (9.62) Time 7.39 0.001
Group*time 3.73 0.02
Bodily pain
Adherent 43.85 (8.89) 45.35 (8.89) 46.44 (8.03) Group 0.34 0.56
Nonadherent 44.25 (9.24) 43.98 (9.27) 44.25 (8.64) Time 0.61 0.54
Group*time 0.64 0.53
General health
Adherent 37.66 (9.18) 36.98 (9.59) 41.69 (7.76) Group 0.20 0.66
Nonadherent 39.00 (10.75) 39.96 (11.60) 40.25 (9.32) Time 3.77 0.02
Group*time 2.13 0.12

M, mean; SD, standard deviation.

TAI CHI FOR GLUCOSE CONTROL
and in another study of weekly 2-hour qigong breathing with
relaxation exercise.6 The size of these changes in HbA1c in
this study and previous ones are significant because a 0.4%
change in HbA1c may decrease microvascular complications
and diabetes-related deaths.24 Although a randomized con-
trolled study with Yang style tai chi had no significant
changes in blood glucose and HbA1c, insulin sensitivity was
significantly greater in the tai chi and resistance groups than
the control group.14
Inconsistencies in the findings of this study and previous
ones using tai chi may be accounted for by differences in the
length of the programs and metabolic intensity.14,15 The av-
erage length and the number of tai chi exercise sessions
varied greatly among studies, resulting in unequal doses of
tai chi exercise across the studies. In addition, the intensity of
the tai chi may also have been different across studies. For
example, the exercise intensity of Yang or Sun style of tai chi
could vary according to the forms selected, ranging from 2.5
(mild stretching: i.e., open and close hands) to 4.0 (general
tai chi forms: i.e., moving with bending knees) METs.25 The
present study utilized both basic and advanced movements
from Yang and Sun style so as to provide both flexible
movements with qigong breathing (Sun style) and graceful yet
solid movements with constant weight transfers (i.e., stroking
birds tail in Yang style) to enhance microcirculation.19
According to the American Diabetes Association, persons
with diabetes should have no more than 2 consecutive days
without physical activity to improve glucose control and
reduce the risk of cardiovascular disease.26 Although the
tai chi program in the present study was held twice a week,
subjects were encouraged to practice at home at least 3 times
a week. In spite of individual exercise contracts, daily exer-
cise log, and weekly phone contacts, only half of the subjects
attended more than 80% of supervised exercise sessions
during the 6-month study period.
In the present study, regular practice of tai chi for 6
months improved some dimensions of quality of life that
included the mental component summary, social function-
ing, vitality, and mental health subscales of the SF-36. These
findings suggest that practicing tai chi may be more bene-
ficial to the mental dimensions of quality of life than the
physical components. In a cross-sectional study with a senior
population, tai chi practitioners reported significantly higher
quality of life on most subscales of the SF-36 even after
controlling for demographic variables,27 and greater quality
of life was significantly related to greater number of years
and frequency of practicing tai chi.28 Similar findings were
found in a study with older adults practicing tai chi for 3
times a week for 6 months,29 and in a study of Chinese
women practicing 10 weeks of tai chi.30
The findings of the present study should be interpreted
with caution. The subjects were recruited from persons reg-
istered at health-promotion centers, and they may have en-
gaged in more self-care activities than persons in the general
population with type 2 diabetes. In addition, those who at-
tended less than 80% of tai chi program over 6 months may
have had other reasons for not performing self-care activities
or having lower quality of life that were not captured in the
present study. Although attendance in the 2 times a week
supervised sessions of tai chi was tracked, the home practice
was not assessed. Further study is required to have a true
control (no tai chi) group to confirm the intervention effect.
631
Conclusions
In conclusion, a combined forms of Yang and Sun style
tai chi was effective in reducing blood glucose and HbA1c
and improving most of the mental dimensions of quality of
life when it was practiced regularly over 6 months. Tai chi
combines physical exercise with meditation, based on the
balancing qi flow.31 The effects of tai chi on diabetic control
may have been associated with the aerobic exercise compo-
nents of tai chi, but qigong relaxation exercise may also had
an effect on glucose control as was found in other studies.6,32
Whether beneficial effects of tai chi are from the exercise
component or the qigong relaxation component of tai chi
need to be further investigated. The clinical implications of
the changes in HbA1c found in the present study and others
suggest that tai chi may reduce the complications and mor-
tality associated with diabetes. However, longitudinal stud-
ies over several years are required to determine the effects of
tai chi on these clinically important outcomes.
Disclosure Statement
The authors state that no competing financial interests
exist.
References
1. Task Force on Community Preventive Services. Re-
commendations for healthcare system and self-management
education interventions to reduce morbidity and mortality
from diabetes. Am J Prev Med 2002;22(4 suppl):1014.
2. Kavookjian J, Elswick BM, Whetsel T. Interventions for
being active among individuals with diabetes: A systematic
review of the literature. Diabetes Educ 2007;33:962988.
3. Praet SF, van Rooij ES, Wijtvliet A, et al. Brisk walking
compared with an individualised medical fitness programme
for patients with type 2 diabetes: A randomised controlled
trial. Diabetologia 2008;51:736746.
4. Praet SF, van Loon LJ. Exercise: The brittle cornerstone of
type 2 diabetes treatment. Diabetologia 2008;51:398401.
5. Howteerakul N, Suwannapong N, Rittichu C, Rawdaree P.
Adherence to regimens and glycemic control of patients
with type 2 diabetes attending a tertiary hospital clinic. Asia
Pac J Public Health 2007;19:4349.
6. Tsujiuchi T, Kumano H, Yoshiuchi K, et al. The effect of qi-
gong relaxation exercise on the control of type 2 diabetes
mellitus: A randomized controlled trial. Diabetes Care 2002;
25:241242.
7. Yeh SH, Chuang H, Lin LW, et al. Tai chi chuan exercise
decreases A1C levels along with increase of regulatory T-
cells and decrease of cytotoxic T-cell population in type 2
diabetic patients. Diabetes Care 2007;30:716718.
8. Zhuo D, Shephard RJ, Plyley MJ, Davis GM. Cardior-
espiratory and metabolic responses during Tai Chi Chuan
exercise. Can J Appl Sport Sci 1984;9:710.
9. Tsang T, Orr R, Lam P, et al. Effects of tai chi on glucose
homeostasis and insulin sensitivity in older adults with
type 2 diabetes: A randomised double-blind sham-exercise-
controlled trial. Age Ageing 2008;37:6471.
10. Wang C, Collet JP, Lau J. The effect of tai chi on health
outcomes in patients with chronic conditions: A systematic
review. Arch Intern Med 2004;164:493501.
11. Taylor-Piliae RE. Tai chi as an adjunct to cardiac reha-
bilitation exercise training. J Cardiopulm Rehabil 2003;23:
9096.
632
12. Lee MS, Pittler MH, Kim MS, Ernst E. Tai chi for type 2
diabetes: A systematic review. Diabet Med 2008;25:240241.
13. Yeh SH, Chuang H, Lin LW, et al. Regular tai chi chuan ex-
ercise improves T cell helper function of type 2 DM patients
with an increase in T-bet transcription factor and IL-12 pro-
duction. Br J Sports Med 2008; April 2;e-pub ahead of print.
14. Thomas GN, Hong AW, Tomlinson B, et al. Effects of tai chi
and resistance training on cardiovascular risk factors in el-
derly Chinese subjects: A 12-month longitudinal, random-
ized, controlled intervention study. Clin Endocrinol (Oxf )
2005;63:663669.
15. Lam P, Dennis SM, Diamond TH, Zwar N. Improving gly-
caemic and BP control in type 2 diabetes: The effectiveness
of tai chi. Aust Fam Physician 2008;37:884887.
16. Haskell WL, Lee IM, Pate RR, et al. Physical activity and
public health: Updated recommendation for adults from the
American College of Sports Medicine and the American
Heart Association. Circulation 2007;116:10811093.
17. Song R, Lee EO, Bae SC, et al. Effects of tai chi self help
program on glucose control, cardiovascular risks, and quality
of life in type 2 diabetic patients. J Muscle Joint Health 2007;
14:1325.
18. Korean Diabetes Association. The Classification and Diag-
nosis of Type II Diabetes. Online document at www.diabetes
.or.kr=clinic=faq= Accessed January 10, 2009.
19. Lam P. Tai Chi for Diabetes: Designed to Help Prevent and
Control Diabetes. Narwee, Australia: East Acton, 2001.
20. American Diabetes Association. Standards of medical care in
diabetes2008. Diabetes Care 2008;31:S12S43.
21. Stanford Patient Education Research Center. Diabetes Self-
Efficacy Scale. 2008. Online document at: http:==patient
education.stanford.edu=research=sediabetes.html Accessed
June 11, 2007.
22. Koh SB, Chang SJ, Kang MG, Cha BS, Park JK. Validity on
measurement instrument for health status assessment in
occupational workers. Korean J Prev Med 1997;30:251266.
23. Snowling NJ, Hopkins WG. Effects of different modes of
exercise training on glucose control and risk factors for
complications in type 2 diabetic patients: A meta-analysis.
Diabetes Care 2006;29:25182527.
24. Balducci S, Alessi E, Cardelli P, Cavallo S, Fallucca F, Pug-
liese G. Effects of different modes of exercise training on
SONG ET AL.
glucose control and risk factors for complications in type 2
diabetic patients: A meta-analysis. Response to Snowling
and Hopkins. Diabetes Care 2007;30:e25.
25. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium
of physical activities: An update of activity codes and
MET intensities. Med Sci Sports Exerc 2000;32(suppl):S498
S504.
26. Praet SF, van Loon LJ. Optimizing the therapeutic benefits of
exercise in type 2 diabetes. J Appl Physiol 2007;103:1113
1120.
27. Ho TJ, Liang WM, Lien CH, et al. Health-related quality of
life in the elderly practicing tai chi chuan. J Altern Com-
plement Med 2007;13:10771083.
28. Kin S, Toba K, Orimo H. Health-related quality of life
(HRQOL) in older people practicing tai chi: Comparison of
the HRQOL with the national standards for age-matched
controls. Nippon Ronen Igakkai Zasshi 2007;44:339344.
29. Lee LY, Lee DT, Woo J. Effect of tai chi on state self-esteem
and health-related quality of life in older Chinese residential
care home residents. J Clin Nurs 2007;16:15801582.
30. Ko GT, Tsang PC, Chan HC. A 10-week tai-chi program
improved the blood pressure, lipid profile and SF-36 scores
in Hong Kong Chinese women. Med Sci Monit 2006;12:
CR196CR199.
31. Adler PA, Roberts BL. The use of tai chi to improve health in
older adults. Orthop Nurs 2006;25:122126.
32. van Rooijen AJ, Rheeder P, Eales CJ, Becker PJ. Effect of
exercise versus relaxation on haemoglobin A1C in black
females with type 2 diabetes mellitus. QJM 2004;97:343
351.
Address reprint requests to:
Sukhee Ahn, R.N., Ph.D.
College of Nursing
Chungnam National University
6 Munhwa 1-dong Jung-gu
Daejeon 301747
Korea
E-mail: sukheeahn@cnu.ac.kr