The authors have been involved in the treatment and research of lifestyle-related diseases for many years [1]. These diseases include type 2 diabetes (T2D), hypertension, dyslipidemia, cerebrovascular accident (CVA), ischemic heart disease (IHD), and peripheral arterial disease (PAD). The three principles of treatment for these are appropriate diet, exercise, and medication. Regarding diet, we have widely promoted low carbohydrate diet (LCD). Furthermore, we have encouraged continuous exercise for years [2]. What kind of exercise, when, and how long is recommended? Various reports have been published. In this article, we would like to describe recent trends in moderate-to-vigorous physical activity (MVPA).

From previous investigation, several evidence have been apparent. MVPA usually enhances glucose homeostasis for patients with obesity and overweight that have higher risk of insulin resistance [3]. However, optimal timing of performance of MVPA was not known for improving glucose variability in the daily lives. Then, some studies will be required for what timing is adequate and effective for strengthening the glucose homeostasis. Further, this research direction will be beneficial for the patients with impaired glucose regulation and others. Thus, the loading level, timing of MVPA and various situation will be taken into consideration for optimal glycemic control leading to general well-being and healthy situation.

Obesity/overweight has been closely associated with several problems of T2D, insulin resistance and cardiometabolic disorders [4,5]. When treating them, physical activity (PA) and adequate dietary patterns are evaluated to be the first-line therapy to achieve weight reduction and to improve glucose variability for cases of obesity/overweight [6]. Several previous reports have suggested that adequate timing of MVPA in a day may exert a beneficial influence on glucose control [7,8].

As human physiological function, circadian rhythms always regulate detail movements including glucose variability [9]. The changes in blood glucose and insulin have been found associated with higher values in the morning rather than those in the evening. In addition, skeletal muscles present decreased effects in glucose uptake in the period of afternoon to evening, which leads to reduced insulin responsive situation [10]. Then, performing MVPA during afternoon to evening may make more beneficial efficacy for obtaining preferable glucose homeostasis and variability [11]. From some previous reports, exercise performance during afternoon to evening seems to have more effective than those in the morning for improving glucose variability [12] and HbA1c value [13]. 

In the previous diabetic studies, the protocols tended to measure glucose values during fasting, but diabetic patients usually spend the daytime for postprandial state [14]. Then, applying continuous glucose-monitoring (CGM) devices can be useful for the evaluation of glycemic control associated with detail fluctuation and average levels of blood glucose [15,16].

For the latest report, 186 patients with obesity/overweight were included for the cross-sectional study [17]. MVPA data were monitored for 2 weeks using triaxial accelerometer at the non-dominant wrist and CBM devise. The results showed the relationship between MVPA data and nocturnal mean glucose values. When the case showed MVPA accumulating more than 50% during the evening, lower 24-hour mean glucose (-1.26mg/dL), diurnal (-1.10mg/dL) and nocturnal mean glucose (-2.16mg/dL) were found. This relationship showed stronger for those cases with impaired glucose regulation. This tendency was the same in male and female. In conclusion, the MVPA timing of human lifestyle seems to be crucial. In particular, accumulating MVPA during evening is likely to show beneficial efficacy on glucose homeostasis for sedentary people with obesity/overweight and also metabolic dysfunction.

Recently, clinical movement has been observed to individualize exercise prescriptions for each case advising applicable measures. From the current report, we can improve the concrete advice, in which it would be better to exercise as frequently as they can, and to perform the timing during evening to night associated with better controlling blood glucose variability.

As another research for the t exercise timing, patients with obesity and T2D (n=29836, 62.2 in average) were included [18]. The study showed 7.9 years follow up with 1425 death, 3980 CVD events, and 2162 microvascular disease (MVD) events. For the research design, the categorization used three patterns for morning, afternoon, or evening MVPA, when they undertook the main exercise period. As a result, evening MVPA showed the lowest risk of mortality of hazard ratio (HR) 0.39, whereas afternoon with HR 0.60 and morning HR 0.67, compared with the reference activity group. Similar results were found for CVD and MVD, where evening MVPA showed the lowest CVD risk as 0.64, an MVD as 0.76. Consequently, aerobic MVPA conducted in the evening showed the lowest risk of mortality, CVD and MVD. From now, adequate timing for physical activity will become important advice for future management.

Concerning the insulin resistance, physical activity may influence associated with the timing of the activity during the day. From Netherlands Epidemiology of Obesity (NEO) study, 775 cases were assessed for sedentary time, physical activity by activity sensors, and liver fat analysis using magnetic resonance spectroscopy (n=256) [19]. They were categorized for three groups by the active period, which are morning (6-12h), afternoon (12-18h) and evening (18-24h). As a result, total MVPA value and timing of MVPA showed association with decreased insulin resistance, but no association with liver fat content. Comparing with MVPA distribution during the day, insulin resistance was -3% for morning group, -18% for afternoon group, and -25% for evening group.

The latest report showed clinical effect of MVPA for reduced risk of progression to CKD in patients with T2D and overweight/obesity [20]. The participants (n=1746) were from Look AHEAD trial with eGFR ≥60 mL/min/1.73 m². MVPA was checked at 0, year 1,4,8 using RT3 accelerometer. For 12 years follow-up in median, 567 cases showed progression to CKD. A linear inverse relationship was found for cumulative MVPA, where HR 0.91 for 100 min/week and HR 0.81 for bouts of ≥10 min was observed. Consequently, longer MVPA time will contribute reduced risk of CKD progression for patients with T2D and overweight/obesity.

In summary, clinical importance of MVPA and recommended timing of evening exercise have been introduced with some perspectives in this article. Such beneficial information will be hopefully prevalent for medical and health care region in the future.

Conflict of interest: The authors declare no conflict of interest.

Funding: There was no funding received for this paper.

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