***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: PURPOSE The aim of this study was to determine the effects of Tai Chi exercise on glucose control , neuropathy scores , balance , and quality of life in patients with type 2 diabetes and neuropathy . METHODS A pretest-posttest design with a nonequivalent control group was utilized to recruit 59 diabetic patients with neuropathy from an outpatient clinic of a university hospital . A st and ardized Tai Chi for diabetes program was provided , which comprised 1 hour of Tai Chi per session , twice a week for 12 weeks . Outcome variables were fasting blood glucose and glycosylated hemoglobin for glucose control , the Semmes-Weinstein 10-g monofilament examination scores and total symptom scores for neuropathy , single leg stance for balance , and the Korean version of the SF-36v2 for quality of life . Thirty-nine patients completed the posttest measures after the 12-week Tai Chi intervention , giving a 34 % dropout rate . RESULTS The mean age of the participants was 64 years , and they had been diagnosed with type 2 diabetes for more than 12 years . The status was significantly better for the participants in the Tai Chi group ( n=20 ) than for their control ( i.e. , nonintervention ) counterparts ( n=19 ) in terms of total symptom scores , glucose control , balance , and quality of life . CONCLUSION Tai Chi improved glucose control , balance , neuropathic symptoms , and some dimensions of quality of life in diabetic patients with neuropathy . Further studies with larger sample s and long-term follow-up are needed to confirm the effects of Tai Chi on the management of diabetic neuropathy , which may have an impact on fall prevention in this population OBJECTIVE This study aim ed to vali date the effects of a simplified , gentle form of t'ai chi chuan in patients with type 2 diabetes and who are also obese . DESIGN The study was design ed to be a r and omized controlled trial . SETTING This study was conducted in the department of metabolism and endocrinology at Cheng Ching Hospital , in Taichung , Taiwan . SUBJECTS The study subjects were hospital-based patients with type 2 diabetes and who were also obese ( ages 40 - 70 , with a body-mass index [ BMI ] range of 30 - 35 ) . The patients were r and omly selected and grouped into t'ai chi exercise ( TCE ) and conventional exercise ( CE ) groups . INTERVENTIONS After receiving instruction in t'ai chi , the TCE group and the CE group practice d three times per week , including one practice session lasting up to 1 hour , for 12 weeks . OUTCOME MEASURES Hemoglobin A1C , serum lipid profile , serum malondialdehyde , and C-reactive protein were measured . Physical parameters of body weight and BMI were also measured . Diet and medications of participants were monitored carefully while biochemical and physical conditions were analyzed . RESULTS After 12 weeks , hemoglobin A1C values of the TCE group did not decrease ( 8.9 ± 2.7 % : 8.3 ± 2.2 % ; p = 0.064 ) . BMI ( 33.5 ± 4.8 : 31.3 ± 4.2 ; p = 0.038 ) and serum lipids , including triglyceride ( 214 ± 47 mg/dL : 171 ± 34 mg/dL ; p = 0.012 ) and high density lipoprotein cholesterol ( 38 ± 16 mg/dL : 45 ± 18 mg/dL ; p = 0.023 ) had significant improvements . Serum malondialdehyde tended to decrease from baseline ( 2.66 ± 0.78 μmol/L : 2.31 ± 0.55 μmol/L ; p = 0.035 ) , and C-reactive protein also decreased ( 0.39 ± 0.19 mg/dL : 0.22 ± 0.15 mg/dL ; p = 0.014 ) . No improvements occurred in BMI , lipids , and oxidative stress profiles in the CE group . CONCLUSIONS T'ai chi exercise practice d by patients who are obese and have type 2 diabetes is efficient and safe when supervised by professionals and helps improve parameters , such as BMI , lipid profile , C-reactive protein , and malondialdehyde . Periodic monitoring of blood glucose , blood pressure , heart rate , breathing , physical fitness , and symptoms of discomfort of patients who exercise helps prevent injury . Simple , gentle TCE can be applied as regular daily exercise for patients with type 2 diabetes even when such patients are obese Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more BACKGROUND a large proportion of adults with type 2 diabetes remain sedentary despite evidence of benefits from exercise for type 2 diabetes . Simplified Yang Tai Chi has been shown in one study to have no effect on insulin sensitivity in older adults . However , a modified Tai Chi form , Tai Chi for Diabetes ( TCD ) has recently been composed , cl aim ing to improve diabetes control . METHODS subjects were r and omised to Tai Chi or sham exercise , twice a week for 16 weeks . Primary outcomes were insulin resistance 72 h post-exercise ( HOMA2-IR ) , and long-term glucose control ( HbA(1c ) ) . RESULTS thirty-eight subjects ( 65 + /- 7.8 years , 79 % women ) were enrolled . Baseline BMI was 32.2 + /- 6.3 kg/m(2 ) , 84 % had osteoarthritis , 76 % hypertension , and 34 % cardiac disease . There was one dropout , no adverse events , and median compliance was 100 (0 - 100)% . There were no effects of time or group assignment on insulin resistance or HbA(1c ) ( -0.07 + /- 0.4 % Tai Chi versus 0.12 + /- 0.3 % Sham ; P = 0.13 ) at 16 weeks . Improvement in HbA(1c ) was related to decreased body fat ( r = 0.484 , P = 0.004 ) and improvement in insulin resistance was related to decreased body fat ( r = 0.37 , P = 0.03 ) and central adiposity ( r = 0.38 , P = 0.02 ) , as well as increased fat-free mass ( r = -0.46 , P = 0.005 ) . CONCLUSIONS TCD did not improve glucose homeostasis or insulin sensitivity measured 72 h after the last bout of exercise . More intense forms of Tai Chi may be required to produce the body composition changes associated with metabolic benefits in type 2 diabetes Diabetes is the leading cause of major complications , such as end-stage renal disease and lower extremity amputations , and is a significant contributor to ischemic heart disease , stroke , peripheral vascular disease , and vision loss ( 1 ) . There has been increasing acceptance of the importance of individualizing glycemic management and assessment of risk for adverse events , especially hypoglycemia ( 26 ) . This is of great importance for all patients , especially older adults ( aged 65 years ) with comorbid conditions . In 2013 , 12.0 million older adults in the United States had diabetes , comprising 40 % of the 30.2 million persons with the disease ( 7 ) . Older adults account for an estimated 60 % to 70 % of the U.S. Department of Veterans Affairs ( VA ) and U.S. Department of Defense ( DoD ) diabetic population ( largely retirees ) ( VA/DoD. Unpublished data ) . These considerations make safe and effective diabetes management a policy priority for health care providers ( physicians , nurses , dietitians , and pharmacists ) and policymakers in both the VA and the DoD. The 2017 VA/DoD Clinical Practice Guideline ( CPG ) for the Management of Type 2 Diabetes Mellitus in Primary Care offers health care providers an evidence -based framework to evaluate , treat , and manage persons with type 2 diabetes  mellitus in the context of their individual needs and preferences ( 8) . The current article is a summary of key CPG recommendations , which was developed with multiple stakeholders to ensure representation by a broad spectrum of clinicians . It provides practice recommendations for the care of patients with diabetes , with an emphasis on shared decision making . Guideline Development and Review Process These recommendations were developed using methods established by the VA/DoD Evidence -Based Practice Work Group ( EBPWG ) ( 9 ) , which are aligned with st and ards for trustworthy guidelines ( 10 ) . The EBPWG and the U.S. Army Medical Comm and selected guideline panel cochairs ( 1 each from the VA and the DoD ) . The cochairs then selected a multidisciplinary panel of practicing clinician stakeholders , including primary care physicians ( family and internal medicine ) , endocrinologists , medical nutritionists , pharmacists , diabetes educators , and nurse practitioners . At the start of the CPG development process and at other key points throughout , all members were required to su bmi t disclosure statements for potential conflicts of interest in the previous 24 months . Verbal affirmations of no conflicts were used during meetings throughout the development process . The project team was also subject to r and om Web-based surveillance ( for example , ProPublica ) . The VA/DoD contracted with The Lewin Group , a third party with expertise in clinical practice guideline development , to facilitate meetings . The guideline panel , in collaboration with the ECRI Institute , developed 9 key questions using the PICOTS ( population , intervention , comparator , outcomes , timing of outcomes measurement , and setting ) format . A systematic search of the peer- review ed literature from January 2009 through March 2016 was conducted to find evidence relevant to the key questions that focused on r and omized trials , systematic review s , and meta-analyses of fair or better quality . One key question was up date d through 14 June 2016 . The search methods and results are detailed in the full guideline ( 8) . The guideline panel rated recommendations by using the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) method ( 11 ) . The guideline panel focused on developing new and up date d recommendations using the evidence review for the key questions . The panel also considered , without a complete review of the relevant evidence , the current applicability of recommendations that were included in the 2010 CPG . As part of the development process , a patient focus group was also convened to better underst and the perspectives of patients receiving diabetes treatment in the VA and the DoD. Five patients were included , consistent with the requirements of the federal Paperwork Reduction Act . All patients had type 2 diabetes and were veterans receiving care in the VA . The focus group explored knowledge of treatment options , views on the delivery of care , patients ' needs and preferences , and the effect of diabetes on their lives . Important concepts that emerged from the focus group were shared with the panel and informed guideline development . It was acknowledged that this convenience sample may not be representative of all VA and DoD patients receiving treatment for type 2 diabetes . The draft guideline was sent to more than 15 expert review ers inside and outside the federal sector . Comments were review ed and , where appropriate , were incorporated into the final guideline based on panel consensus . The VA/DoD EBPWG approved the final document on 3 April 2017 and released it on 17 April 2017 . Recommendations are presented in the Table , and an algorithm for establishing a personalized glycemic goal and treatment plan is presented in the Figure . Key recommendations are review ed in this article . Table . Summary of Recommendations From the 2017 VA/DoD CPG on the Management of Type 2 Diabetes Mellitus Figure . Algorithmic approach to evaluating glycemic control risk factors , setting a personalized glycemic control target range , providing self-management ( including lifestyle and nutrition ) education , and initiating or reevaluating medication therapy . Recommendations Provide Patient-Centered Care and Incorporate Shared Decision Making The CPG strongly encourages clinicians to incorporate shared decision making and partner with their patients . Shared decision making is the process by which the patient and family , in conjunction with the care provider , reach an agreement about a plan of care and treatment . Key principles include readiness of the patient and family , tools with underst and able information about the benefits and harms of all options , and strategies to identify and incorporate patient preferences . Patients can not effectively participate in care and shared decision making unless they underst and diabetes and how they can be involved in planning and carrying out the jointly developed care plan . Shared decision making reinforces a trusted therapeutic relationship and increases patient satisfaction and treatment buy-in with regard to the methods used to reach a particular goal or treatment plan ( 1214 ) . It should be used not only for patients with stable glycemic control but also to assist those who are not able or willing to make lifestyle changes and decisions that affect their diabetes at any time during the course of treatment . At a minimum , shared decision making should be included at the time of diagnosis , during difficulties with management , and at times of transition or development of complications ( 14 ) . Benefits include greater knowledge of medications ( 13 ) and underst and ing of risks ( 14 ) . In addition , patient-centered care and shared decision making together may decrease patient anxiety , increase trust in clinicians ( 15 ) , and improve treatment adherence ( 16 ) . Family involvement 
    Output:
    
The observed effect was more pronounced for interventions that were medium range in duration ( i.e. , > 3-<12 months ) .
TCE interventions also showed improvements in the secondary outcome measures .
Conclusion Among patients with type 2 diabetes , TCEs were associated with significantly lower hemoglobin A1c and fasting blood glucose .