Research in Nursing & Health

Efficacy of Five-Element
Gymnastics in Glucose and Lipid
Control in Taiwanese Patients With
Type 2 Diabetes
Chiu-Ling Huang,1* Yen-Kuang Tai,2** Yi-Hsin Yang,3y Ruey-Hsia Wang4z

1
Department of Nursing, Yuan’s General Hospital, Kaohsiung, Taiwan
2
Division of Endocrinology and Metabolism, Department of Internal Medicine, Yuan’s General Hospital, Kaohsiung, Taiwan
3
Department of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
4
College of Nursing, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan
Accepted 19 March 2012

Abstract: The purpose of this quasi-experimental study was to determine

the efficacy of Five-Element Gymnastics (FEG) in controlling glycosylated
hemoglobin (HbA1C), total cholesterol (TC), high-density lipoprotein
cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and
triglycerides (TG) at the 8th and the 16th weeks of intervention for patients
with type 2 diabetes in Taiwan. FEG consolidates several traditional
Chinese exercises including Qigong, Xiang Gong, and martial arts with
gymnastics. The experimental group (n ¼ 31) practiced FEG at home for
16 weeks. The control group (n ¼ 35) maintained usual activities. FEG
was associated with decrease of HbA1C, TG, and LDL-C levels at the
8th week and continuous decrease of HbA1C through the 16th week. FEG
could be an exercise choice for patients with type 2 diabetes. ß 2012 Wiley
Periodicals, Inc. Res Nurs Health

Keywords: diabetes mellitus; five-element gymnastics; glucose; lipidemia

According to a report from the International
Diabetes Federation (IDF), 3.8 million people
worldwide die from diabetes-related diseases
every year (IDF, 2010). It is projected that
internationally 380 million patients will have
diabetes in 2025 (Chan et al., 2009). The World
Health Organization has declared diabetes to be
the most severe chronic disease of the 21st
century (World Health Organization, 2010). In
Taiwan, the population with diabetes has been
increasing rapidly with a prevalence rate of
9.2%, affecting two million people (Department
of Health, Executive Yuan, Republic of China
[DHEY-RC], 2009). Diabetes is the fifth leading
cause of death in Taiwan (DHEY-RC, 2010),
posing a significant threat to the health of the
Taiwanese population.
Type 2 diabetes can cause high levels of
glycosylated hemoglobin (HbA1c), triglyceride
(TG), total cholesterol (TC), and low-density

This project was supported by the Yuan’s General Hospital, Taiwan (RG09-006).
Correspondence to Ruey-Hsia Wang
*Diabetes Nurse Educator.
**Chief.
y
Associate Professor.
z
Professor.
Published online in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/nur.21480

ß 2012 Wiley Periodicals, Inc.

2 RESEARCH IN NURSING & HEALTH
lipoprotein cholesterol lipid (LDL-C), and low
levels of high-density lipoprotein cholesterol
lipid (HDL-C). Exercise can effectively control
HbA1c and lipid levels for patients with
diabetes (Church et al., 2010; Kelley & Kelley,
2007; Snowling & Hopkins, 2006). A moderate
form of exercise, Five-Element Gymnastics
(FEG), which incorporates traditional Chinese
exercise including Qigong, Xiang Gong, and
martial arts with gymnastics, has been suggested
to Taiwanese patients with type 2 diabetes as an
exercise choice (M. H. Chen & Cheng, 2010;
C. M. Cheng, 1997). However, the efficacy of
FEG in glycemic and lipid control for patients
with type 2 diabetes has not been tested. The
purpose of this study was to assess the efficacy
of FEG in the control of glycemic and lipid
levels in Taiwanese adults with type 2 patients.
Effective glycemic control can lower the risk
of developing diabetes-related complications
(American Diabetes Association [ADA], 2012).
HbA1C is an important indicator for glycemic
control in patients with type 2 diabetes and
generally should be lower than 7.0% (ADA,
2012). TC, LDL-C, and TG are important risk
factors for cardiovascular disease (Ganong,
2001). High LDL-C concentrations also have
been associated with an increased incidence of
coronary heart disease (LaRosa et al., 1990). In
contrast, HDL-C is important in protecting
against cardiovascular disease; low HDL-C is
associated with increased risk of myocardial
infarction (Gordon, Castelli, Hjortland, Kannel,
& Dawber, 1977). Thus, improving glycemic
and lipid control is important for patients with
type 2 diabetes.
Exercise is an important part of diabetes self-
management. Performing at least 150 min/week
of moderate-intensity aerobic physical activity
(50–70% maximum heart rate) is recommended
for people with diabetes (ADA, 2012). Structured
aerobic exercise interventions of at least 8 weeks
duration have been shown to lower HbA1C in
patients with type 2 diabetes (Boulé, Haddad,
Kenny, Wells, & Sigal, 2001). However, even
mild or moderate exercise is encouraged
because of ease of adoption and maintenance
(Colberg et al., 2010). According to the report
of the Third National Health and Nutrition
Examination Survey, 31% of patients with
type 2 diabetes do not exercise regularly, and
another 38% do not achieve the recommended
amount of exercise (Nelson, Reiber, & Boyko,
2002). Lack of adequate settings, the necessity
of going to a gymnasium for exercise, or boring
single movement routines all have been shown
Research in Nursing & Health
to negatively affect the motivation for exercise
in Taiwanese patients with type 2 diabetes
(Chao, Lian, Yu, & Yvonne, 2007; Liou, 2008).
The Chinese ancient yin-yang scholars creat-
ed a theory of health, the five-element (Wú
Xı́ng) theory. They believed that our universe
consists of five basic elements: metal, wood,
water, fire, and earth, which represent the
organs of lung, liver, kidney, heart, and spleen,
respectively. Health depends on a balance in
relationships among these five elements, each of
which has its Yin and Yang sides. In Chinese
culture, a balance between Yin and Yang
and harmonic interactions among the five
elements are both believed to be necessary for
physiological and psychological well-being
(M. H. Chen & Cheng, 2010).
The ancient Chinese developed traditional
Chinese exercises, such as Qigong, Xiang
Gong, and martial arts, to fight against diseases
and aging by improving Five-Element balance
(Yeh & Chen, 2004). The Qi in Qigong means
to breathe, Gong means to train, so Qigong
means breathing training. Qigong has been shown
to improve function of the musculoskeletal and
central nervous systems (Y. M. Chen, 2008).
Qigong training for patients with type 2 diabetes
has been shown to significantly decrease
HbA1C levels (Tsujiuchi et al., 2002). A
systematic review also found that Qigong
improved insulin sensitivity (Lee, Chen, Choi,
& Ernst, 2009). Xiang Gong, another of the
Chinese traditional exercises, has been shown to
improve endocrine and renal functions (C. M.
Cheng, 1997); however, the effect of Xiang
Gong on HbA1C and lipid levels is not known.
Tai Chi Chuan has been shown to enhance
cardiovascular and circulatory functions (S. C.
Chen, Ueng, Lee, Sun, & Lee, 2010), and
significantly decrease HbA1C and TG levels in
patients with diabetes (S. H. Yeh et al., 2007;
Zhang & Fu, 2008). Because Tai Chi Chuan is a
kind of martial art, other martial arts also may
have effects on HbA1C and lipid levels.
Because FEG combines Qigong, Xiang Gong,
and martial arts with gymnastics, practicing
FEG may improve interactions among the lung,
liver, kidney, heart, and spleen elements, as
suggested by the five-element theory. FEG
includes three phases: (a) a warm up (1 minute);
abdominal breathing is emphasized in this
stage; (b) the main course (13 minutes), which
is composed of 18 styles. Each style has three
sections of four sets of eight beats. Expiration
and inspiration, repeated movements from
extremities to whole body, left–right, up–down,
 EFFICACY OF FEG IN GLUCOSE AND LIPID CONTROL/ HUANG ET AL.
and front-rear activities are emphasized in this
stage. The third phase is (c) a cool down
(1 minute), in which counter-like breathing is
emphasized to relax the muscles. A complete
cycle of FEG takes 15 minutes to practice.
Stretching activities are emphasized during
warm-up and cool-down stages, whereas aerobic
activities are emphasized in the main course
stage. Thus, FEG has both aerobic and stretching
effects. The intensity of Chinese traditional
exercises is mild to moderate (Zhang & Fu,
2008). FEG is designed to be of moderate
intensity, is attractive because it combines
different types of Chinese traditional exercises,
and is safe for people to practice at home.
Glycemic and lipid control is affected by a
number of personal characteristics that may
interact with the effects of exercise intervention.
These include demographic characteristics
(gender, age, educational level, marital status,
employed status), disease characteristics
(complications, treatment methods, duration of
disease), life styles behaviors (smoking, alcohol
use, usual patterns of exercise intensity and
frequency), and body mass index (BMI;
Julienne et al., 2010; Leonard & Yvonne, 2006;
Zeinab et al., 2010). Therefore, the influence of
these factors on glycemic and lipid control must
be considered when assessing the efficacy of
FEG. The purpose of this study was to examine
the efficacy of FEG on glycemic and lipid con-
trol of Taiwanese patients with type 2 diabetes
at the 8th and 16th weeks of intervention,
controlling for relevant personal characteristics.
We hypothesized that FEG would be associated
with a decrease in HbA1C, TC, and LDL-C,
and an increase in HDL from baseline to the 8th
week and 16th week of intervention.
Methods
Design
A quasi-experimental, untreated control group
design was used. The study was conducted from
October 2009 through March 2010. Patients
with type 2 diabetes were recruited from the
endocrinology clinic of one regional hospital in
Southern Taiwan. In order to avoid contamina-
tion between experimental and control groups,
patients visiting Monday clinic were randomly
selected into the experimental group; patients
visiting Wednesday clinic were randomly selected
into the control group. The experimental group
Research in Nursing & Health
3
practiced FEG for 16 weeks, and the control
group was asked to maintain their usual daily
activities. HbA1C and lipid levels were
measured at baseline, the 8th week, and the
16th week of intervention.
Participants
Sample size was determined based on an a level
of .05, power was .80, and effect size for
HbA1C of .70 (Tsujiuchi et al., 2002).
The required minimum sample size was 32
participants for each group. Estimating an attri-
tion rate of 20%, this required 38 participants
for each group. Thus, 76 participants were
recruited.
Patients just diagnosed with type 2 diabetes
may still be adjusting their medication, which
may confound the effect of exercise on HbA1C
and lipid levels. Patients who have had diabetes
for >10 years may have complications that
increase the risk of exercising (American
College of Sports Medicine, [ACSM], 2006).
Patients with HbA1C levels more than 10% are
more likely to induce ketosis when exercising
(Ronald, Glen, David, Carmen, & Russel,
2006). Considering the above factors, the
inclusion criteria were set as: (a) diagnosed as
type 2 diabetes for 1–10 years; (b) aged
between 30 and 70 years; (c) had taken oral
diabetic medication or insulin therapy for at
least 6 months; (d) most recent HbAlc level
was between 7.5% and 10%; (e) were free of
physical, hearing, and visual impairment; and
(f) were able to communicate in Mandarin
Chinese, Taiwanese, or Hakka. To prevent the
confounding effect of medications on HbA1C
and lipid profiles, participants who changed
their diabetes medication during the intervention
were excluded from analysis. The final sample
size was 30 in the experimental group, 35 in the
control group.
The flow of recruitment, intervention, and
measurement is shown in Figure 1. Retention
rates for the experimental group were 92.1%
at the 8th week and 81.6% at the 16th week.
Retention rates for the control group were
97.4% at the 8th week and 94.7% at the 16th
week.
Intervention
The intervention was a 16-week course of
FEG. One of the researchers, a certified fitness
4 RESEARCH IN NURSING & HEALTH
FIGURE 1. Flow of recruitment, intervention
and measurement. TC, total cholesterol; TG,
triglycerides; HDL-C, high-density lipoprotein
cholesterol; LDL-C, low-density lipoprotein
cholesterol.
instructor, acted as the intervener. In the first
week, two group education sessions for the
experimental group were held in the hospital to
teach the participants the standard procedures
for practicing FEG, for recording exercise
intensity, and for preventing exercise injury.
Participants in the experimental group were
asked to practice the FEG 20 minutes per time,
twice for each day, for 16 weeks at home with
the help of an FEG DVD. To prevent complica-
tions of hypertension and heart attack during
the exercise, participants were instructed to
achieve an intensity that made them slightly
gasp with the exertion. To improve adherence to
intervention and monitor exercise intensity, we
asked participants to record the duration and
frequency of exercise and subjective perceived
intensity in an exercise log each time they
practiced FEG.
Research in Nursing & Health
Additionally, group education sessions were
held at the hospital at weeks 3, 7, 11, and 14.
Participants demonstrated their exercise at each
session so that the intervener could instruct
them if they demonstrated incorrect technique
or practice. The intervener also checked the
exercise log and encouraged participants to
continue regular practice. For participants who
were not able to join the group education
session, the intervener provided individual
instruction when they returned to the clinic.
Besides the group education, the intervener
followed up the experimental group participants
by telephone once a week. The missing rates of
each group education meeting were from 10%
to 12%. For the control group, there was no
intervention. They were provided with a DVD
and the manual for FEG after the research was
completed.
To prevent the confounding effects of diet
and medication on HbA1C and lipid profiles,
we also requested participants of both experi-
mental and control groups to maintain their
usual lifestyles and not change their medica-
tions during the study period. Physicians
maintained the same medication and dosages
for each individual participant, except for
episodic needs.
Measurement
Structured questionnaires, blood metabolic
measures, and review of medical records were
used to collect data.
Personal characteristics. Personal character-
istics included demographic characteristics,
disease characteristics, life styles behaviors, and
BMI. Demographic characteristics included
gender, age, educational level, employment
status, and marital status. Disease characteristics
were collected from medical records and included
duration of disease, medication for diabetes,
and complications (such as hypertension, hyper-
lipidemia, retinopathy, neuropathy, nephropathy,
cardiovascular disease, cerebral vascular acci-
dent, and foot ulcer) diagnosed by physicians.
Life style included smoking, alcohol use, and
exercise (duration, intensity, frequency) for
the past 3 months. Height and weight were
collected from the medical records and con-
verted to BMI (kg/m2; ACSM, 2006).
Perceived exertion. The self-report Borg
Rating of Perceived Exertion Scale (RPE; Borg,
1982) was used to evaluate the subjectively
perceived exercise intensity of participants in
 EFFICACY OF FEG IN GLUCOSE AND LIPID CONTROL/ HUANG ET AL.
the experimental group at the 4th, 8th, 12th, and
16th weeks of the intervention. Participants
were asked to rate their perceived exertion
when practicing FEG. The RPE is an ordinal
scale rated from 6 (no exertion at all) to
20 (maximal exertion), corresponding to a
maximum heart rate of 60–120 beats/minute
(Borg, 1982). Generally, a score of 9 indicates
very light, 11 indicates light, 13 indicates
somewhat hard, and 17 indicates very hard. The
higher the number participants reported, the
greater the exercise intensity. The Borg Scale
has been used in many studies, and in a
previous study in Taiwan the RPE scores were
positively correlated with heart rate and oxygen
uptake (r ¼ .56–.67; H. W. Cheng, Wang, &
Chen, 2008), providing evidence for the RPE as
a valid measure of exercise intensity.
Blood metabolic measures. HbA1C, TC,
HDL-C, LDL-C, and TG were the outcome
variables. All blood samples were taken after
an overnight fast. HbA1C was measured by
high performance liquid chromatography
(Tosoh automated HLC-723 G7; Tokyo,
Japan). Lipid profiles were measured on an
Olympus AU640 automated analyzer (Mishima,
Japan). Serum TC was measured enzymatically
with cholesterol esterase-cholesterol oxidase-
peroxidase reagent. Serum TG concentra-
tions were determined enzymatically with a
lipase-glycerolkinase-glycerol-3-phosphate oxi-
dase-peroxidase reagent. HDL-C was deter-
mined by a homogeneous enzymatic colorimetric
method. LDL-C was determined by using direct
selective detergent. Laboratory examiners were
blinded to group assignment of participants. All
laboratory measurements were run within the
same hospital laboratory.
Data Collection Procedures
For the experimental group, data on personal
characteristics were collected at their group
education session in the first week. For the con-
trol group, they were collected at the clinic in
the first week of intervention. Baseline HbA1C,
TC, HDL-C, LDL-C, and TG measures were
collected from participants’ medical records,
with the latest values recorded at the time per-
sonal characteristics were collected. To measure
the HbA1C, TC, HDL-C, LDL-C, and TG at the
8th and the 16th weeks of intervention, blood
samples were drawn from participants of both
groups when they visited the clinics at the 8th
and the 16th weeks of the study.
Research in Nursing & Health
5
Ethical Considerations
The study was approved by the Ethics Commit-
tee of the hospital at which the study was
conducted. All participants were informed that
there was no penalty for refusal to participate
and that they had the right to withdraw from the
study at any time. Signed informed consent was
obtained from all patients before their inclusion
into the study.
Statistical Analysis
Chi-squared tests, Fisher’s exact tests, and
independent t-tests were used to compare differ-
ences in personal characteristics and outcome
variables between the two groups. Paired t-tests
were used to examine within-group differences
at baseline, the 8th week, and the 16th week of
intervention. Mixed model analysis, adjusting
for the corresponding baseline outcome
variable, was used to analyze differences in
change in HbA1C and lipid levels from baseline
to the 8th week and to the 16th week between
experimental and control groups. In the parame-
ter estimates of the mixed models, the intercept
represented the change from baseline at the 8th
week for the control group. The estimates of
treatment variable represented the difference in
amount of change between experimental and
control groups at the 8th week. The estimates of
the week variable represented the amount of
change from the 8th week to the 16th week
in the control group. The treatment
week
variable represented comparison of the amount
of change from the 8th week to the 16th week
between experimental and control groups.
Participants were considered as a random effect.
Unstructured covariance was used in the mixed
models analysis with the restricted maximum
likelihood (REML) approach. Statistical soft-
ware programs SPSS 14.0 (SPSS, Inc., Chicago,
IL) and SAS version 9.1.3 software package
(SAS Institutes Inc., Cary, NC) were used for
conducting the above analyses.
Results
Distribution and Comparison of
Personal Characteristics and Outcome
Variables at Baseline
Preliminary analysis was conducted to assess
the equivalence between the experimental and
6 RESEARCH IN NURSING & HEALTH

Table 1. The Distribution of Personal Characteristics and the Comparisons Between Experimental and
Control Groups (N ¼ 76)

Control Group (n ¼ 38) Experimental Group (n ¼ 38)

Variables n % n % x2/t p-Value

Gender 0.00 1.00

Male 8 21.1 8 21.1
Female 30 78.9 30 78.9
Education 0.49 .48
Below (equal) middle school 24 63.2 21 55.3
Above middle school 14 36.8 17 44.7
Marital status .34
Single 4 10.5 1 2.6
With spouse 34 89.5 37 97.4
Employed 0.21 .65
No 19 50.0 17 44.7
Yes 19 50.0 21 55.3
Complications 0.63 .43
No 11 28.9 8 21.1
Yes 27 71.1 30 78.9
Medications for diabetes 1.00
Oral 35 92.1 35 92.1
Oral and insulin 3 7.9 3 7.9
Smoking .43
No 36 94.7 33 86.8
Yes 2 5.3 5 13.2
Alcohol use .48
No 35 92.1 32 84.2
Yes 3 7.9 6 15.8
Exercise intensity 1.50 .22
Light 30 78.9 27 71.1
Medium-to-high 8 21.1 11 28.9
Exercise frequency 0.91 .34
<3 Times/week 26 68.4 22 68.4
3 Times/week 12 31.6 16 42.1
Age (years) 53.55  8.25 54.11  9.07 0.28 .78
Duration of disease (years) 6.17  2.79 6.12  2.92 0.08 .94
BMI (kg/m2) 28.52  3.60 27.48  4.22 1.15 .25

Note: BMI, body mass index.


p-Value in the Fisher’s exact test.

control groups on all personal characteristics
and outcome variables at baseline. As shown in
Tables 1 and 2, there were no significant group
differences with respect to any personal charac-
teristic or outcome variable.
and 10.50 (1.34) at the 16th week. The self-
perceived intensity significantly decreased
from baseline to the 16th week [t(31) ¼ 13.69,
p < .001].

Differences in Outcome Variables

Distribution of Subjective Intensity
of Exercise
Participants in the experimental group rated
their subjective intensity of exercise with an
average score of 13.37 (1.33) at baseline,
12.09 (1.31) at the 4th week, 11.26 (1.33) at
the 8th week, 10.78 (1.45) at the 12th week,
Research in Nursing & Health
Between Experimental and Control
Groups at Baseline, the 8th Week,
and the 16th Week
As shown in Table 2, HbA1C, TC, TG, and
LDL-C levels of the experimental group were
significantly lower than those of the control
group at both the 8th week and 16th week.
 EFFICACY OF FEG IN GLUCOSE AND LIPID CONTROL/ HUANG ET AL. 7

Table 2. The Distribution of Outcome Variables at Baseline, the 8th Week, and 16th Week and
Comparisons Between and Within Groups

8th Week 16th Week

Baseline 8th Week 16th Week Versus Baseline, Versus Baseline,
M (SD) M (SD) M (SD) t (p) t (p)

HbA1C
Control 8.2 (0.7) 8.5 (1.0) 8.5 (0.8) 2.21 (.03) 2.63 (<.01)
Experimental 8.5 (0.7) 7.7 (0.7) 7.4 (0.7) 5.91 (<.01) 6.77 (<.01)
t-Test (p) 1.87 (.07) 3.90 (<.01) 5.56 (<.01)
Total cholesterol
Control 173.3 (24.6) 177.5 (38.6) 174.4 (24.7) 0.84 (.41) 0.69 (.39)
Experimental 161.9 (45.6) 158.7 (30.0) 156.0 (24.4) 0.25 (.81) 0.40 (.70)
t-Test (p) 1.35 (.14) 2.29 (.03) 3.07 (<.01)
Triglycerides
Control 157.6 (78.8) 166.4 (79.6) 141.7 (55.0) 0.98 (.33) 0.69 (.50)
Experimental 154.7 (69.2) 132.7 (59.4) 110.2 (50.1) 1.37 (.18) 3.82 (<.01)
t-Test (p) 0.18 (.83) 2.03 (.05) 2.43 (.02)
LDL-C
Control 98.7 (21.4) 101.7 (28.1) 98.9 (21.8) 1.19 (.24) 0.92 (.37)
Experimental 92.0 (27.8) 84.0 (17.0) 85.7 (16.5) 2.17 (.04) 1.61 (.12)
t-Test (p) 1.06 (.16) 3.25 (<.01) 2.81 (<.01)
HDL-C
Control 47.3 (16.3) 44.0 (8.3) 45.3 (8.1) 1.20 (.24) 0.10 (.92)
Experimental 47.6 (18.3) 46.4 (9.0) 47.1 (8.7) 0.62 (.54) 1.40 (.17)
t-Test (p) 0.09 (.96) 1.20 (.23) 0.86 (.40)

Note: HbA1C, glycosylated hemoglobin A1c; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipopro-
tein cholesterol.

However, HDL-C levels of the experimental
group did not significantly differ from those of
the control group at either the 8th week or the
16th week.
Difference in Outcome Variables
Between Baseline and 8th Week As Well
As Baseline and 16th Week Within
Experimental and Control Groups
We compared HbA1c and lipid levels between
the 8th week and baseline as well as between
the 16th week and baseline within experimental
and control groups (Table 2). In the experimen-
tal group, HbA1C levels at the 8th week and
16th week were both significantly lower than
those at baseline. LDL-C levels at the 8th week
were significantly lower than those at baseline,
but there was no significant difference between
the 16th week and baseline levels. There was
no significant difference in TG between the
8th week and baseline levels; however, TG
levels at the 16th week were significantly lower
than those at baseline. There were no significant
differences either between the 8th week and
baseline or between the 16th week and baseline
Research in Nursing & Health
for TC and HDL-C. In the control group,
HbA1C levels at the 8th week and 16th week
were both significantly higher than those at
baseline. There were no significant differences
in TC, LDL-C, HDL-C, and TG levels either
between the 8th week and baseline or between
the 16th week and baseline.
Differencing of Changing Amount of
Outcome Variables Between
Experimental and Control Groups at
the 8th Week and the 16th Week
As shown in Table 3, after adjusting for the
baseline measurement, the decrease in HbA1C,
LDL-C, and TG at the 8th week in the experi-
mental group was significantly higher than that
in the control group. However, amount of
change in TC and HDL-C at the 8th week
between experimental and control groups was
not significantly different.
The decreasing amount of HbA1C from the
8th week to the 16th week in the experimental
group was significantly higher than that of the
control group. The change in amount of TC,
LDL-C, HDL-C, and TG from the 8th week
8 RESEARCH IN NURSING & HEALTH

Table 3. Comparison of Changes in HbA1C and Lipid Levels at 8th Week and 16th Week Between the
Two Groups

Variables B 95% CI p-Value

HbA1C
Intercept 0.19 0.05, 0.42 .12
Treatment at 8th week (Exp vs. Con) 0.93 1.26, 0.59 <.01
Week (16th week vs. 8th week) <0.01 0.17, 0.16 .99
Treatment
week 0.28 0.53, 0.04 .02
Total cholesterol
Intercept 7.72 2.35, 17.79 .13
Treatment at 8th week (Exp vs. Con) 14.50 29.03, 0.03 .05
Week (16th week vs. 8th week) 0.88 11.12, 9.37 .86
Treatment
week 0.48 15.39, 14.43 .95
Triglycerides
Intercept 10.25 7.74, 28.24 .26
Treatment at 8th week (Exp vs. Con) 27.74 53.58, 1.90 .04
Week (16th week vs. 8th week) 19.96 36.60, 3.32 .02
Treatment
week 2.34 21.71, 26.40 .85
LDL-C
Intercept 5.30 0.86, 11.47 .09
Treatment at 8th week (Exp vs. Con) 15.07 23.93, 6.21 <.01
Week (16th week vs. 8th week) 0.73 8.11, 6.64 .84
Treatment
week 1.86 8.93, 12.64 .73
HDL-C
Intercept 3.57 6.37, 0.78 .01
Treatment at 8th week (Exp vs. Con) 2.39 1.62, 6.40 .24
Week (16th week vs. 8th week) 1.25 0.38, 2.87 .13
Treatment
week 0.65 3.03, 1.73 .59

Note: adjusted mean at baseline.

HbA1C, glycosylated hemoglobin A1c; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein
cholesterol; Exp, Experimental group; Con, Control group.

to the 16th in the experimental group was not
significantly different from that of the control
group.
Discussion
The findings show that FEG was associated
with decreasing HbA1C, TG, and LDL-C levels
at the 8th week and a continuing decrease in
HbA1C at the 16th week of the intervention.
Most previous investigators have assessed the
effect of exercise on HbA1c at the 12th or
16th week (Yeh et al., 2007; Zhang & Fu,
2008). We found that FEG had significantly
decreased HbA1C by the 8th week, indicating
that FEG can decrease HbA1C at an early
stage of intervention. Furthermore, HbA1C
continuously decreased up to the 16th week,
indicating that it was having a continuously
positive effect.
A decrease of 1% in HbA1C levels has been
associated with a 15–20% decrease in major
cardiovascular disease events and 37% decrease
Research in Nursing & Health
in microvascular complications (Agel, Arendt,
& Bershadsky, 2005). In this study, FEG
reduced HbA1C levels at the 8th and the
16th weeks of intervention by 0.8% and
1.1%, respectively. Thus, FEG was potentially
associated with a decreasing risk of cardiovas-
cular disease and microvascular complications.
Tai Chi Chuan (Yeh et al., 2007) and Qigong
(Sun et al., 2010) exercises have been shown
to decrease HbA1C levels by .45% and .70%
respectively. Thus, FEG seemed to have
a greater effect on decreasing HbA1C than
any single type of traditional Chinese
exercise. However, this finding needs further
confirmation.
We found that TG and LDL-C levels signifi-
cantly decreased by the 8th week of intervention
in the experimental group. Compared with
previous findings showing that LDL-C and TG
levels significantly decreased after 12 weeks
of aerobic exercise (Chao et al., 2007;
Chiang, Lin, Ho, Tsai, & Chiou, 2003), the
FEG intervention was associated with an earlier
decrease in LDL-C and TG. However, FEG was
 EFFICACY OF FEG IN GLUCOSE AND LIPID CONTROL/ HUANG ET AL.
not associated with a continuous decrease in
LDL-C and TG to the 16th week. This may be
because the distributions of LDL-C and TG
were within normal ranges before the interven-
tion, thereby limiting continuous improvement.
FEG was not associated with either an
increase in HDL-C or a decrease TC. Previous
finding also indicate that 12 weeks (Chiang
et al., 2003) or 14 weeks (Zhang & Fu, 2008)
of exercise intervention had no effect in
increasing HDL-C. In a meta-analysis resistance
exercise had no effect on TC and HDL-C in
adults with type 2 diabetes (Kelley & Kelley,
2007). Thus, to increase HDL-C level, exercise
may need to be practiced regularly for at
least 3 months (Chiang et al., 2003; Sgouraki,
Tsopanakis, & Tsopanakis, 2001), and should
include high intensity and pulmonary endurance
exercise, such as running (Sgouraki et al.,
2001). In this study, FEG was medium-to-high
intensity and practiced only for 16 weeks.
Thus, the intensity and duration of the FEG
intervention may not have been enough to
influence HDL-C. Because TC and HDL-C also
are influenced by diet (Zhang & Fu, 2008), FEG
in combination with diet intervention might be
useful to improve HDL-L and TC control.
In this study, the participants of the experi-
mental group subjectively rated their intensity
of FEG exercise with a mean RPE score of
13.37, an intensity of medium-to-high level,
which was consistent with our intent. The rating
of subjective exercise intensity decreased to
10.50 at the 16th week, which may be due to an
improvement in physical fitness after practicing
FEG. To more objectively assess the exercise
intensity of FEG, objective indicators such as
pulse and oxygen uptake during practicing FEG
should be measured in future studies.
Personal characteristics of the sample may
have influenced the results. In this study, 13%
of the experimental group and 5% of the control
group reported currently smoking. The smoking
rate was lower than the 21.9% Taiwanese
national prevalence rate (Bureau of Health
Promotion, Department of Health, Republic of
China, 2009), perhaps because participants quit
smoking after being diagnosed with diabetes.
However, the sample was similar to national
norms for obesity. A national survey in Taiwan
found that 66.2% adult diabetic patients were
obese (DHEY-RC, 2011), and in this study
mean BMI in both groups was above the
criterion for obesity. That the intervention was
associated with decreasing HbA1C, TG, and
LDL-C may indicate that FEG is suitable
Research in Nursing & Health
9
for overweight adults with type 2 diabetes.
However, the participants may have differed
in other ways that were not assessed, for
example, in levels of endogenous beta cell
insulin production and liver function/stress
hormones. To prevent potentially confounding
results, these factors should be taken into
consideration in further studies. In addition, we
cannot exclude the possibility that participants
in the experimental group changed their health
habits in subtle ways due to the frequent contact
with study personnel. Such subtle changes
may have improved HbA1C and lipid control
regardless of the intervention. Control for this
possible bias is needed in future studies.
This was not a true randomized study;
nevertheless, we controlled for a number of
confounding factors, and baseline data were
homogenous in the two groups. The attrition
rate of the experimental group was higher
than that of the control group. However, for
both groups personal characteristics did not
significantly differ between participants who did
and did not continue the program (data not
shown). Numbers of participants who completed
the trial (31 and 35 in experimental and control
groups, respectively) represented sample sizes
close to the estimation at the beginning of
the study (32 per group). The post hoc power
estimation regarding HbA1c at the 16th week
was 1.00, thus the retained sample size was
adequate to examine the efficacy of FEG in
lowering HbA1C.
The possibility of HbA1C and lipid levels
being affected by drug use or measurement bias
was low. All the participants maintained their
same diabetic medications during the study. A
post hoc analysis found that the use of statins
did not significantly differ between the two
groups [x2 ¼ (1, N ¼ 66) ¼ .009, p ¼ .92].
Furthermore, laboratory examiners were blinded
to the participants’ group assignment. The
results of this study therefore can provide
useful evidence about the efficacy of FEG in
improving HbA1C, LDL, and TG control.
Some limitations should be acknowledged.
Participants were recruited from a single clinic
in Taiwan, thus results may be limited in their
application to patients treated by different
physicians or in different countries. Only
patients with type 2 diabetes diagnosed for
<10 years and with HbA1C <10% were
recruited; results cannot therefore be generalized
to patients with a longer duration of diabetes or
with HbA1c higher than 10%. To understand
the efficacy of FEG on diverse patients with
10 RESEARCH IN NURSING & HEALTH
type 2 diabetes, we need to apply FEG to
patients who visit different clinics, have a
longer duration of disease, and have HbA1C
levels higher than 10%. Furthermore, to
understand the long-term effects of FEG on
HbA1C and lipid levels, a follow-up of more
than 16 weeks is necessary in future studies.
Conclusion
In conclusion, FEG was associated with
decreasing HbA1c, TG, and LDL-C levels at
the 8th week for patients with type 2 diabetes.
FEG was also associated with a continuous
decrease in HbA1c through the 16th week.
Results indicate that FEG, which may be a
culturally preferable exercise for Asian adults
with type 2 diabetes, may also be suitable for
overweight adults who are limited in doing
strenuous exercises. Findings from the study
provide information for further development of
community-based exercise programs for patients
with type 2 diabetes.
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