J Physiol 0.

0 (2023) pp 1–15 1

Temporal optimization of exercise to lower fasting glucose

levels
Jill A. Kanaley1 , J. W. Porter1 , N. C. Winn2 , G. Lastra3 , A. Chockalingam4 , R. J. Pettit-Mee1 ,
G. F. Petroski5 , C. Cobelli6 , M. Schiavon7 and E. J. Parks1
1
Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, Missouri, USA
2
Department of Molecular Physiology & Biophysics, Vanderbilt University, Nashville, Tennessee, USA
3
Department of Endocrinology, Internal Medicine, University of Missouri, Columbia, Missouri, USA
4
Department of Cardiology, University of Missouri, Columbia, Missouri, USA
5
Office of Medical Research, Biostatistics Unit, University of Missouri, Columbia, Missouri, USA
6
Department of Women’s and Children’s Health, University of Padova, Padova, Italy
7
Department of Information Engineering, University of Padova, Padova, Italy

Handling Editors: Paul Greenhaff & Josiane Broussard

The Journal of Physiology

The peer review history is available in the Supporting Information section of this article
(https://doi.org/10.1113/JP285069#support-information-section).

OB OB+IFG Non-Ob
Glucose at time t- baseline (mg/dL)

130
120
110
100
90
80
70
60
50
40
30
20
10
0
-10
-20
0 120 240 360 480 600 720 0 120 240 360 480 600 720 0 120 240 360 480 600 720
Time (minutes)
AMEX NOEX PMEX

Abstract Exercise stimulates glucose uptake and increases insulin sensitivity acutely. Temporally
optimizing exercise timing may minimize the nocturnal rise in glucose levels. This study examined
the effect of exercise timing on evening and overnight glucose concentrations in individuals who
were non-obese with normal fasting glucose levels (Non-Ob; n = 18) and individuals with obesity
(OB) with impaired fasting glucose levels (OB+IFG) and without (n = 16 and n = 18, respectively).
Subjects were studied on three occasions (no exercise (NOEX)), morning exercise (AMEX; 0700 h)

© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society. DOI: 10.1113/JP285069
 14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 J. A. Kanaley and others J Physiol 0.0

and evening exercise (PMEX; 2000 h). The evening meal was provided (1800 h) and blood samples
were taken from 1740 to 0700 h and morning endogenous glucose production (EGP) was measured.
Glucose and insulin concentrations increased with the dinner meal with peak concentrations being
higher in OB+IFG than in OB and Non-Ob (P = 0.04). In OB+IFG, evening glucose concentrations
rose above baseline levels at about 2300 h, with the glucose concentrations staying somewhat
lower with AMEX and PMEX until ∼0500 h than with NOEX. In OB+IFG, insulin concentrations
decreased following the dinner meal and waned throughout the night, despite the rising glucose
concentrations. In the OB and Non-Ob individuals following the dinner meal, no increase in glucose
concentrations occurred in the evening period and insulin levels mirrored this. No difference was
observed in the morning fasting glucose levels between study days or between groups. Regardless of
time of day, exercise delays the evening rise in glucose concentrations in adults with OB+IFG but
does not lower morning fasting glucose levels or improve the synchrony between glucose and insulin
concentrations.

(Received 25 May 2023; accepted after revision 30 August 2023; first published online 20 September 2023)
Corresponding author J. A. Kanaley: Department of Nutrition and Exercise Physiology, University of Missouri, 204
Gwynn Hall, Columbia, MO 65211, USA. Email: kanaleyj@missouri.edu

Abstract figure legend Individuals with obesity and impaired fasting glucose (IFG) wake with elevated glucose levels.
Exercise is known to lower glucose concentrations but the effect of exercise timing on nocturnal glucose and hormone
concentrations are not well understood. These findings show that exercise (either at 0700 or 2000 h) suppressed the rise
in glucose levels in individuals with OB+IFG for many hours during the night but did not lower morning fasting glucose
levels. Interestingly, the rise in glucose concentrations occurred while nocturnal insulin concentrations are waning.

Key points
r Insulin resistance and type 2 diabetes have been linked to disturbances of the core clock, and
glucose tolerance demonstrates a diurnal rhythm in healthy humans with better glucose tolerance
in the morning than in the afternoon and evening.
r Skeletal muscle is a primary site for insulin resistance in people with impaired glucose tolerance.
r In individuals with obesity and impaired fasting glucose levels (OB+IFG), following a dinner
meal, glucose concentrations started to rise and continues throughout the night, resulting in
elevated glucose levels, while concomitantly, insulin levels are waning.
r Exercise, regardless of the time of day, suppressed the rise in glucose levels in OB+IFG for many
hours during the night but did not lower morning fasting glucose levels. Morning exercise was
not quite as effective as evening exercise.

Introduction increased endogenous glucose production (EGP) (Poitout

& Robertson, 2008; Robertson, 2004). These metabolic
The development of insulin resistance leads to elevated processes are regulated by a master clock in the brain
fasting and postprandial glucose levels due to impaired (Gabriel & Zierath, 2019) as well as at the tissue level,
tissue glucose uptake, pancreatic β-cell dysfunction and creating a diurnal rhythm. Insulin resistance and type

0 Jill Kanaley is a Professor and Interim Chair in the Department of Nutrition & Exercise Physiology at the University of Missouri.
Dr Kanaley conducts human research studying lifestyle factors (sleep, diet and exercise) and their impact on cardiometabolic
variables and glycaemic control. Her research has included using both stable and radioactive isotopes, mass spectrometry,
hyperinsulinaemic–euglycaemic clamps, muscle and adipose biopsies, and exercise training studies in individuals with obesity
and with/without type 2 diabetes. Dr Kanaley has received a Citation Award from the American College of Sports Medicine for
her contributions to exercise science.

© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.

J Physiol 0.0 Optimizing exercise timing for glycaemic control
2 diabetes (T2D) have been linked to disturbances of
the core clock, which can modify metabolism (Gabriel &
Zierath, 2019). Glucose tolerance demonstrates a diurnal
rhythm in healthy humans with better glucose tolerance
in the morning than in the afternoon and evening
(Saad et al., 2012; Shapiro et al., 1991; Van Cauter
et al., 1989). This decline reaches a minimum around
midsleep in healthy subjects (Carroll & Schade, 2005;
O’Neal & Luther, 2022), and in subjects with T2D it
is followed by a rise that occurs from ∼0300–0900 h,
referred to as the dawn phenomenon (O’Neal & Luther,
2022). This increase in overnight glucose concentrations
is attributed to elevated EGP in the overnight period (Basu
et al., 2004). The dawn phenomenon can have a remnant
effect on overall diabetic control and is associated with
significant increases in HbA1c level by 0.4% (Monnier
et al., 2013). Currently, medication does not affect this
nocturnal rise, and alternative strategies such as exercise
are needed to minimize the rise in glucose concentrations.
Skeletal muscle is a primary site for insulin resistance
in people with impaired glucose tolerance and T2D.
Both acute and chronic exercise improves insulin
action in skeletal muscle (Colberg et al., 2010; Hawley,
2004), such that regular aerobic exercise increases
whole-body insulin-mediated glucose uptake in patients
with obesity and T2D, independent of alterations in
the insulin-signalling cascade. Recently, numerous
studies (Manders et al., 2010; Poirier et al., 2000, 2001)
have reported that post-meal exercise lowers glucose
concentrations more effectively than pre-meal exercise,
particularly in individuals with T2D. However, much of
this research has been conducted around the breakfast
meal following a 10 h fast and only a few studies have
examined the effect of exercise on glucose responses
around the evening meal (Colberg et al., 2009; Heden,
Winn et al., 2015). The timing of exercise during the day
may optimize glucose uptake (Heden & Kanaley, 2019)
and more specifically evening exercise (post-dinner)
(Colberg et al., 2010; Heden, Liu et al., 2015) may lower
overnight glucose levels by enhancing hepatic glycogen
replenishment from prior exercise. These effects may be
particularly important in individuals with obesity and
impaired fasting glucose levels (OB+IFG). To date, there
is little research focusing on exercise timing, glucose
excursions and EGP during the evening and overnight
periods. Optimizing the timing of exercise during the
day may be critical in aiding overnight responses and
controlling fasting glucose levels the next day.
The purpose of this study was to: (1) examine the
postprandial glucose and hormonal responses during the
overnight period following a day with controlled meals
in individuals with obesity (OB) and impaired fasting
glucose levels (OB+IFG), weight-matched individuals
with OB, and normal weight individuals with no obesity
© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3
(Non-Ob); (2) determine whether there are differences
in the glucose and hormonal responses between morning
and evening exercise; and (3) establish whether exercise
timing differentially impacts the overnight responses and
fasting glucose levels the subsequent morning. We hypo-
thesized that poorer glucose and insulin responses during
the overnight period would occur to a greater extent in
OB+IFG than in the Non-Ob and OB individuals with
normal fasting glucose levels. Further, it was hypothesized
that exercise following a dinner meal would lower evening
glucose levels and improve EGP more than morning
exercise. Lastly, we speculated that the time of day of
exercise would be most critical in improving glucose
metabolism in individuals with OB+IFG compared with
individuals with OB or Non-Ob.
Methods
Ethical approval
This study conformed to the standards set by the
Declaration of Helsinki and was approved by the
University of Missouri Health Science Institutional
Review Board (Protocol # 1202202). All participants
provided written, informed consent. This study is
registered at ClinicalTrials.gov (#NCT03019510).
Participants
Fifty-four participants (18 Non-Ob, 18 OB and 16
OB+IFG) completed this study and ranged in age from
25 to 65 years. Non-Ob had a body mass index (BMI)
<25 kg/m2 , while all OB had a BMI of 30–45 kg/m2 .
Subjects were non-smokers, had no history of surgery
for weight loss and were weight stable. The OB group
had normal fasting glucose levels (<100 mg/dL), while
the OB+IFG group had fasting glucose concentrations
>110 mg/dL. Morning glucose concentrations were
verified as being >110 mg/dL on 4 out of 7 days
during screening unless they were physician-diagnosed
with T2D, receiving standard medical care. The OB+IFG
group was not on insulin. The participants took their
medication at the usual dose, frequency and time on
the days leading up to each metabolic study, and
glucose-lowering medication was halted the evening
before each study day. All OB+IFG subjects were on at
least one glucose-lowering medication and many were
on statins and blood pressure medication. None of the
OB and Non-Ob were on glucose-lowering medication
and overall only a few were on statins or antidepressants.
Non-obese subjects had a fasting glucose <100 mg/dL and
a 2 h glucose level <140 mg/dL. Women on oral contra-
ceptives were tested in the pill phase. Pregnant women
were excluded.

4 J. A. Kanaley and others
Experimental design
All subjects underwent screening that included
questionnaires, a health inventory, an oral glucose
tolerance test (OGTT) and an exercise stress test. After
baseline testing/screening, all participants completed
three overnight study days: a no exercise day (NOEX), a
morning exercise day (AMEX) and an evening exercise
day (PMEX). An overnight study day resulted in subjects
reporting to the Clinical Research Centre at 1700 h,
and a standardized dinner meal served at 1800 h. Blood
sampling started at 1740 h and continued until 0700 h the
following morning (Fig. 1).
Screening. This visit consisted of assessments of
height, weight and body composition (Bod Pod, Life
Measurements, Concord, CA or DEXA, Horizon A,
Hologic, Marlborough, MA). Additionally, a health
inventory questionnaire (Heden, Winn et al., 2015) and
the Berlin questionnaire for sleep apnoea determination
(Chung et al., 2008) were administered. A 2 h OGTT
(75 g of glucose) was administered; fasting blood glucose
and the 2 h glucose concentrations were used to establish
inclusion in this study.
Subjects completed a stress test with oxygen uptake
(VO2 peak) as part of screening. This test was a continuous
treadmill test (Kanaley et al., 2009) with subjects walking
at 2.5 miles per hour (mph) for 2 min, and then the
treadmill speed was increased by 0.5 mph every 2 min
until reaching 3.5 mph. The gradient was then increased
by 2.5% every 2 min until volitional fatigue (Kanaley
et al., 2009). The True One 240 Metabolic Measurement
Cart (ParvoMedics, Sandy, UT) was used to measure
the percentage oxygen and carbon dioxide concentration
and ventilation, and VO2 was calculated. Heart rate and
blood pressure were measured throughout. Subjects were
actively cooled down and monitored for 5–10 min until
heart rate and blood pressure returned to near baseline. A
physician was present at testing according to the American
College of Sports Medicine guidelines, and the electro-
cardiogram was evaluated by a cardiologist for the subject
to be cleared for exercise.
Study days. Three days prior to a study day, subjects had
their sleep monitored with an Actiwatch Spectrum Plus
Meal
IV placed
AM exercise PM exercise
Blood sampling (time (min)
Sampling Time (min) -20 0 120 300
0700 1700 1800 2000
Clock Time (h)
14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
J Physiol 0.0
(Philips Respironics, OR, USA), as well as during the study
night at the Clinical Research Centre. Dietary records were
also kept for the 3 days prior to the study night. Sub-
jects were provided with meals to consume as outpatients
on the evening before the study night (∼800 kcal; 56.1%
carbohydrate, 21.5% fat and 22.4% protein), as well as
breakfast and lunch on the study day. Breakfast was
consumed between 0700 and 0800 h and lunch between
1200 and 1300 h; subjects then fasted, except for water
for the remainder of the day. For the 24 h before the
study day, subjects were asked not to exercise or consume
alcohol.
At 1630 h, subjects reported to the Clinical Research
Centre ∼5 h fasted. Intravenous catheters were placed.
Baseline blood sampling began at ∼1740 h. At 1800 h, sub-
jects consumed a mixed meal providing 10 kcal/kg of body
weight with 1 g/kg of carbohydrate (target macronutrient
composition: 40% carbohydrate, 35% fat, 25% protein).
Due to nausea or mild cramping, carbohydrates were
capped at 90 g for subjects with OB (n = 7) and
OB+IFG (n = 6); otherwise, subjects received the 1 g/kg
of carbohydrate. Five individuals with OB and OB+IFG
(n = 1) received >90 g of carbohydrate before the decision
to cap the total amount of carbohydrates; these subjects
were given the same test meal across all of their study days.
Following the meal, subjects sat quietly until bedtime.
Lights were turned off at 2200 h and turned back on at
about 0630 h. Sleep was monitored with an Actiwatch. At
∼0100 h, an IV bolus [6,6-2 H2 ] glucose was administered
followed by a primed continuous infusion of [6,6-2 H2 ]
glucose (Mass-Trace, Woburn, MA). This was continued
for 6 h to measure the EGP.
On an exercise study day, subjects walked for 45 min at
60% VO2 peak which was supervised in the lab. To ensure
the correct intensity, subjects had VO2 measured during
exercise. On one study day, subjects walked at 0700 h in
the morning of the study day (AMEX), while on another
study day subjects walked at the same intensity at 2 h
post-dinner (2000 h) (PMEX). On the NOEX day, sub-
jects did not exercise for 48 h prior to the study night. The
order of the study days was counterbalanced so all sub-
jects completed all study days. There was a minimum of
3 weeks between study days.
Blood samples were collected at the following time
points: −20, 0, 5, 10, 15, 20, 30, 40, 50, 60 and
Figure 1. Experimental Design
Subjects arrived in the clinical research
center ∼1700 h when the IV was placed.
D2 glucose
Blood sampling started at ∼1740 h and
continued until 0700 h the next morning.
Subjects were fed a standard meal at
1800 h. There were 3 study conditions: no
420 780
exercise, morning exercise (AM) at 0700 h
2300 0100 0700 or evening exercise (PM) at 2000 h. Subjects
completed all study conditions.
© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.

J Physiol 0.0 Optimizing exercise timing for glycaemic control
then every 15 min until the completion of the study.
Blood was collected in EDTA tubes with and without
dipeptidyl peptidase-IV inhibitor and aprotinin, placed
on ice, centrifuged, aliquoted and stored at −80°C until
analysis. Blood samples were analysed for glucose (YSI
2300 STAT PLUS, YSI Incorporated, Yellow Springs,
OH), and insulin, c-peptide and glucagon concentrations
(Human Metabolic Hormone Panel, Milliplex, Millipore
Sigma), as well as other hormones not reported here.
Additionally, four blood samples were taken starting at
0000 h and 0600 h and analysed for plasma 6,6-2 H2
enrichment. Samples were derivatized and measured by
gas chromatography–mass spectrometry in our lab (Parks
et al., 1999).
Statistical analysis for glucose and hormones
Glucose and hormone concentrations were adjusted for
group differences at baseline by subtracting the average
of the t = −20 and t = 0 measurements from each sub-
sequent value. For all analyses the outcome at time t is the
difference from baseline.
Spline methods were used to model the nonlinear
time-trends of glucose and hormones. Specifically, let Yigvt
denote the difference from baseline at time t, for the ith
subject in study group g (g = 1, 2, 3) and experimental visit
v (v = No, AM, PM). For each outcome we fit the following
regression model,
Yigvt = μgv + τi + G ∗ V ∗ S(t ) + εigvt
Where μgv is the overall mean for group G and exercise
visit V. τ i is a random subject effect to account for
the within-subject correlation between exercise occasions.
S(t) is a cubic B-spline for time (De Boor, 2001) with
14 evenly spaced knots corresponding to a rule of
thumb suggested by Ruppert et al. (2003). G and V are
indicators of the subject’s group and exercise time. The
G×V×S(t) interaction term allows the spline coefficients
to differ by experimental condition and group, thus
modelling different shapes over time. The εigvt term
is a normally distributed random error term with a
one-dimensional spatial covariance structure. For a sub-
ject/visit combination, the serial correlation decays with
distance between time points, much like an autoregressive
process, but without the requirement for equally spaced
time points. Spline models are complex and not easily
communicated in terms of parameter estimates. To display
differences in time-course between study groups and
exercise sessions, pairwise differences were calculated by
time point and displayed with 95% confidence inter-
vals. The regression models were fit using the Glimmix
procedure in SAS/STAT software, Version 15.2 of the SAS
system for Windows. Copyright 2016 SAS Institute Inc.
© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
5
Power calculations. Sample size requirements for this
study were based on a type I error rate of 0.05, two-tailed
testing and a minimal power level of 0.80. Data from
Poirier et al. (2001) were used in this calculation. The
planned sample size was 18 per group for each of the
three groups, for a total overall sample size of 54 subjects.
Within a group this yields 83% power to detect an effect
size of 0.52, assuming a within-subjects standard deviation
of 36, which was estimated from our preliminary glucose
data.
Area measures
For each subject, the total area under the time curve
(AUC) was calculated using the trapezoidal rule. Separate
area calculations were made for each exercise condition,
and for three time intervals within a session: 0–300,
315–540 and 555–780 min. These time intervals were
selected to represent the meal/postprandial period
(0–300 min), late evening (315–540 min) and early
morning when the dawn phenomena are frequently
observed (555–780 min). As in the regression analyses,
the data for the area estimates were the baseline-adjusted
values, i.e. Y-Y0 . The statistical analysis of total area
was a three-factor (Group, Exercise condition, Time
interval) analysis of variance, with repeated measures
on two factors (Condition and Interval). The product of
unstructured covariance matrices was used to model the
dependencies induced by the repeated factors (Galecki,
(1) 1994). Results were summarized as mean area with
95% confidence intervals. The analysis of variance was
performed using the SAS Mixed procedure.
Calculation of endogenous glucose production
Endogenous glucose production was calculated in the
morning after an overnight constant intravenous infusion
of [6,6-2 H2 ]glucose tracer, while correcting for possible
residuals of [U-13 C]glucose in the circulation coming
from the evening meal. To do so, tracer and tracee
glucose concentrations were first derived from mass
spectroscopy mass percentage excess (MPE) and total
glucose concentration (Gtot ) in plasma. In particular,
assuming that both [6,6-2 H2 ] and [U-13 C]glucose tracers
are almost absent in natural glucose, the [6,6-2 H2 ]glucose
tracer concentration in plasma (G2H2 ) was obtained as
MPE 2H2 (t )
G2H2 (t ) = · Gtot (2)
(1 − MPE 2H2 (t )) · purity2H2 + MPE 2H2 (t )
while, similarly, the [U-13 C]glucose tracer concentration
in plasma (GU13C ) was obtained as
MPEU 13C (t )
GU 13C (t ) =   · Gtot (3)
1 − MPE U 13C (t ) · purityU 13C + MPEU 13C (t )
 14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6 J. A. Kanaley and others J Physiol 0.0

Table 1. Subject characteristics of each study group

Obese with impaired fasting

Obese (OB) (n = 18 glucose levels (OB+IFG) Not obese (Non-Ob)
(5 males)) (n = 16 (3 males)) (n = 18 (9 males))

Age (y) 42.5 ± 14.8 54.6 ± 5.5 45.7 ± 15.4

Body mass index (kg/m2 ) 33.8 ± 4.4 33.5 ± 5.3 24.4 ± 2.0∗
Weight (kg) 95.8 ± 9.3 94.3 ± 17.2 69.6 ± 9.6∗
Percentage fat (%) 44.3 ± 7.5 42.8 ± 7.9 27.9 ± 9.9∗
Fat (kg) 42.3 ± 10.2 42.5 ± 11.0 19.5 ± 7.1∗
Lean mass (kg) 53.3 ± 12.6 51.2 ± 9.7 50.2 ± 10.0
Fasting glucose (mg/dL) 84.5 ± 7.8 126.8 ± 25.3† 83.8 ± 10.6
Oral glucose tolerance test – 2 h 117.3 ± 27.6 218.3 ± 69.7† 119.8 ± 26.3
glucose (mg/dL)
Waist (cm) 106.5 ± 12.4 108.6 ± 13.7 86.9 ± 7.7∗
VO2 peak (mL/kg/min) 26.8 ± 4.7 23.2 ± 5.4 36.5 ± 15.9∗
‡
Mean ± SD.
∗
P = 0.0001 between Non-Ob vs. OB and OB+IFG; † P = 0.0001 between OB+IFG vs. Non-Ob and OB.

assuming that both the purity of the [6,6-2 H2 ] and
[U-13 C]glucose tracers (purity2H2 and purityU13C ,
respectively) are 99.9%.
The endogenous glucose concentration (Gend ) was then
calculated as
 
Gend (t ) = Gtot (t ) − G2H2 (t ) − GU 13C (t ) · 1 + 1 T T Rmeal
where TTRmeal is the tracer-to-tracee ratio in the ingested
glucose.
Finally, since the glucose system was in steady-state
condition after an overnight fast while [6,6-2 H2 ]glucose
tracer was constantly infused (Inf2H2 ), the tracer-to-tracee
‘clamp’ formula (Basu et al., 2003) was used for the
calculation of EGP as
In f 2H2 (t )
EGP (t ) =  2H2  end 
G (t ) G (t )
Of note, for each subject and visit, EGP was averaged
using the four samples collected between 0600 and 0645 h
(or 695–735 min after the start of the meal). Mean
[6,6-2 H2 ] glucose mole percentage excess/enrichment
(MPE) was not different between groups or by study day
(MPE (%) at baseline and end of infusion period: Non-Ob
0.006 ± 0.00028 and 2.15 ± 0.006, OB 0.005 ± 0.0003 and
2.77 ± 0.01, OB + IFG 0.004 ± 0.0007 and 2.46 ± 0.02,
respectively).
Results
Subjects recruited for this study were 25–63 years old,
with no significant difference in the mean age between
groups. At baseline as recruited, the OB and OB+IFG
were significantly heavier, had a higher BMI, body weight,
percentage body fat and greater waist circumference than
Non-Ob (P = 0.0001; Table 1). Further, fasting glucose
concentrations were significantly higher in the OB+IFG
group (P = 0.0001) and they had a higher 2 h glucose
value (P = 0.0001) in the screening OGTT than the groups
that were OB and Non-Ob. Of the 16 individuals in the
 OB+IFG group, nine individuals had T2D, while all but
(4) two subjects had impaired glucose tolerance at the 2 h
time point. Sleep duration, sleep efficiency and wake after
sleep onset were not different between study nights or
between groups, thus any changes observed were not due
to changes in sleep patterns. Sleep duration on the study
nights was slightly longer than the average of the three
nights prior to the study night when the subject slept at
home (NOEX pre 454 ± 8, NOEX study day 463 ± 12,
AMEX pre 421 ± 9, AMEX study day 484 ± 12, PMEX
pre 448 ± 12, PMEX study day 472 ± 13 min, P = 0.02).
(5)
Fig. 2A, B, C shows the changes in glucose
concentration from baseline for each group on each study
day. There was a significant group by visit (P = 0.001)
and group × visit × spline interactions (P = 0.0001)
for glucose. This is reflected by the greater increase in
glucose concentrations in the OB+IFG on each study day
in response to the meal, as well as the response through
the overnight period (Fig. 2B). The mean peak glucose
concentrations were higher in the group with OB+IFG in
response to the evening meal (P = 0.04) and glucose levels
reached a lower nadir (P = 0.03) in the Non-Ob than the
OB+IFG (Fig. 2C). Notably, the glucose concentrations
continued to rise following the postprandial period
(starting ∼300 min) and rose throughout the night in the
OB+IGF (Fig. 2B).
Comparison of the glucose responses between study
days (Fig. 3A) shows a group × visit interaction (P = 0.04)
such that in the postprandial interval (0–300 min) both
the Non-Ob and OB+IFG had lower glucose AUC with

© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
 14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
J Physiol 0.0 Optimizing exercise timing for glycaemic control 7

PMEX than NOEX, but not the OB. Further, the Non-Ob confidence intervals which do not cross the zero difference
had a greater glucose AUC with AMEX than PMEX are significantly different. This represents clock times of
(group × interval interaction P = 0.0001). Importantly, 1800–2300 h, 2305–0300 h and 0305–0700 h. However,
OB+IFG had a significantly lower glucose AUC in both fasting glucose concentrations the following morning
nighttime intervals with PMEX than NOEX. This is were not different between study days within each
further highlighted in Fig. 3B, where the OB+IFG show group.
significantly lower glucose concentrations through the Insulin concentrations for each group and study day are
nocturnal period with PMEX compared with NOEX, but shown in Fig. 2D, E, F. The OB and OB+IFG had higher
this response was not observed between the other study insulin responses to the meal than the Non-Ob on all
days or in the other groups. Mean lines and their 95% study days (spline × group × visit interaction, P = 0.0001)

A B C
OB OB+IFG Non-Ob

130
120
110
Glucose at time t- baseline

100
90
80
(mg/dL)

70
60
50
40
30
20
10
0
-10
-20
0 120 240 360 480600 720 0 120 240 360 480600 720 0 120 240 360 480600 720

Time (minutes)

AMEX NOEX PMEX

D E F
OB OB+IFG Non-Ob

Figure 2. Evening meal and nocturnal 165

glucose and insulin concentrations for 150
each group on each study day
A, B, C, glucose concentrations and (D, E, 135
Insulin at time t- baseline

F), insulin concentrations. Glucose or insulin 120

concentrations are at time t minus baseline
105
value. The mean data are presented for
(μ/U/L)

each study day that was modelled as a 90

cubic B-spline (put simply, a spline is the 75
pattern of response). Glucose: P = 0.0001
group × time × spline interaction and 60
insulin: P = 0.0001 spline × visit; 45
P = 0.0001 spline × group × visit. Dinner 30
15
meal, Exercise on PMEX; OB n = 18,
0
OB+IFG n = 16, Non-Ob n = 18. AMEX:
morning exercise day; NOEX: no exercise -15
day; Non-OB: not obese; OB: obese; 0 120 240 360 480600 720 0 120 240 360 480 600 720 0 120 240 360480 600 720
OB+IFG: obese with impaired fasting
Time (minutes)
glucose levels; PMEX: evening exercise day.

© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
 14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 J. A. Kanaley and others J Physiol 0.0

and no differences in the response between study days.
In the OB+IFG group, insulin concentrations went
below baseline concentrations starting around 360 min
and continued to decline for the remainder of the
night (Fig. 2E). This occurred regardless of study day
and despite the fact that glucose concentrations were
rising. Examining the AUC in the postprandial period
(0–300 min) revealed that the Non-Ob had lower insulin
AUC on the PMEX than the NOEX day and higher insulin
AUC on the AMEX than the PMEX day (Fig. 5A).
C-peptide followed a similar pattern to insulin with a
significant spline × group × visit interaction (P = 0.0001)
(Fig. 4A, B, C). The study day for PMEX was lower
than NOEX for both Non-Ob and OB+IFG. Examining
c-peptide AUC between 0 and 300 min PMEX had lower
AUC than NOEX for all groups. Non-Ob also had lower
AUC for PMEX than AMEX, while the OB+IFG group
had AMEX AUC less than NOEX. The OB group had
AMEX AUC greater than PMEX. A lower c-peptide AUC
was observed for PMEX than for NOEX for both the

A Minutes 0-300

∗
OB
OB+IFG

Non-Ob

Minutes 315-540
AMEX-NOEX
OB
OB+IFG PMEX-NOEX

Non-Ob AMEX-PMEX

Minutes 555-780
OB
OB+IFG

Non-Ob

-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7
Mean difference + 95% Confidence limits
(mg/dL)

B
AMEX-NOEX AMEX-PMEX PMEX-NOEX

50
25
OB 0
-25
-50
Figure 3. Total area under the glucose
50 curve (AUC) during time intervals and
differences in glucose concentration by
Estimate

25 visit for each group

OB+IFG 0 A, Total area = area above zero-area below
-25 zero; each study day was compared to
-50 another study day and the mean difference,
and 95% confidence limits were calculated.
Lines that do not cross 0 are considered
50 significant. ∗ P = 0.04 Group x visit;
‡ P = 0.001 Group x interval. B, Differences
25
Non-Ob 0 in glucose concentration by visit for each
group. Each study day was compared to
-25
another study day at every time point.
-50 Mean lines and their 95% confidence
0 120 240360 480 600 720 0 120 240360 480 600 720 0 120 240360 480 600 720 intervals which do not cross the 0 difference
are significantly different. OB n = 18,
Time (minutes)
OB+IFG n = 16, Non-Ob n = 18.

© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
 14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
J Physiol 0.0 Optimizing exercise timing for glycaemic control 9

Non-Ob and OB+IFG. AMEX was lower than NOEX for baseline was similar between groups on the PMEX day
the 555–780 interval (data not shown). Lower c-peptide and was not as large on the AMEX and NOEX, with
concentrations were observed on PMEX vs. NOEX from the overall response being smaller in the OB+IFG group
time 360 min until the next morning for the OB+IFG. (Fig. 4E). Examining the glucagon AUC for each time
Fig. 4D, E, F shows the glucagon response to the three interval revealed greater glucagon release with PMEX than
study days. For all groups, in response to the meal, there with NOEX for all groups (Fig. 5B). Within both OB
was initially a decrease in glucagon levels from baseline and OB+IFG, glucagon responses were lower with AMEX
followed by an increase about 120 min postprandially than with NOEX. During the middle of the night there
(spline × group × visit interaction, P = 0.0001). The were no differences in the glucagon response by group or
rise in the glucagon response was greater with PMEX study day, but glucagon levels started to fall below base-
than with AMEX or NOEX. The glucagon response above line levels at about 540 min in both OB and OB+IFG

A OB B OB+IFG C Non-Ob

1.5
C-peptide at time t- baseline (ng/mL)

1.0

0.5

0.0

0 120 240 360 480 600 720 0 120 240 360 480 600 720 0 120 240 360 480 600 720
Time (minutes)

AMEX NOEX PMEX

D OB E OB+IFG F Non-Ob
100
90
Figure 4. Evening meal and nocturnal
Glucagon at time t- baseline (pg/mL)

80
c-peptide and glucagon concentrations
for each group on each study day 70
A, B, C, C-peptide and (D, E, F) glucagon 60
concentrations. C-peptide or glucagon at
time t minus baseline value. The mean data 50
are presented for each study day that was 40
modelled as a cubic B-spline (put simply, a
spline is the pattern of response). 30
C-peptide: P = 0.04 group × visit, 20
P = 0.0001 visit; glucagon: P = 0.0001
group × visit, P = 0.0001 spline × group × 10
0
visit. Dinner meal, Exercise on PMEX.
-10
OB n = 18, OB+IFG n = 16, Non-Ob n = 18.
AMEX: morning exercise day; NOEX: no -20
exercise day; Non-OB: not obese; OB: 0 180 360 540 720 0 180 360 540 720 0 180 360 540 720
obese; OB+IFG: obese with impaired fasting
Time (minutes)
glucose levels; PMEX: evening exercise day.

© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
 14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
10 J. A. Kanaley and others J Physiol 0.0

Minutes 0-300 †

A OB

OB+IFG

Non-Ob

Minutes 315-540

OB

OB+IFG

Non-Ob

Minutes 555-780

OB

OB+IFG

Non-Ob

-50 -40 -30 -20 -10 0 10 20 30 40

Mean diference + 95% Confidence limits (μU/ml ∗ min)
B Minutes 0-300 †

OB

OB+IFG

Non-Ob ‡
Minutes 315-540
AMEX-NOEX
OB
PMEX-NOEX ∗
OB+IFG
AMEX-PMEX ∗ Figure 5. Total area under the insulin
Non-Ob and glucagon curve (AUC) during each
time intervals
Total area = area above zero-area below
Minutes 555-780 zero; each study day was compared to
another study day and the mean difference,
OB and 95% confidence limits were calculated.
Lines that do not cross 0 are considered
OB+IFG significant. A, Insulin. † P = 0.0001 interval,
‡ group x interval. B, Glucagon. ∗∗ P = 0.001

Visit; † P = 0.0001 Interval; ‡ P = 0.0001 visit

Non-Ob
x interval. NOEX - no exercise day; AMEX -
morning exercise day; PMEX - evening
-12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12 exercise day (Total area = area above
∗
Mean difference + 95% Confidence limits (ng/L min)
zero-area below zero); OB n-18, OB+IFG
n = 16, Non-Ob n = 18.

© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.

J Physiol 0.0 Optimizing exercise timing for glycaemic control
(Fig. 4D, E) while this occurred at about 450 min for
the Non-Ob group (Fig. 4F). In the early morning inter-
val (555–780 min) both OB and OB+IFG had higher
glucagon levels with PMEX than with NOEX (Fig. 5B).
Endogenous glucose production
Fig. 6 shows the EGP for each group on each study day. A
group effect (P = 0.006) was observed, such that EGP in
the OB group was significantly lower than the OB+IFG
group (P = 0.001) on each study day but there was no
difference between OB+IFG and the Non-Ob group. In
the Non-Ob group, EGP was lower on the NOEX day than
the PMEX study day (P = 0.001).
Discussion
The aim of this project was to examine the glucose
and hormonal responses during the evening and over-
night period following a day with meals in individuals
with OB+IFG and weight-matched individuals who were
OB versus Non-Ob controls, and to determine whether
exercise timing differentially impacts these responses as
well as the fasting glucose levels the subsequent morning.
As expected, the change in glucose concentrations in
response to a meal were greater in the OB+IFG than
in the OB and Non-Ob on all study days. However, in
the OB+IFG, following the postprandial period, glucose
levels started to rise and this continued throughout the
night such that they woke with elevated glucose levels,
while concomitantly, insulin levels were waning. An acute
NOEX
AMEX
PMEX
25 ∗ a key player in the rising glucose concentrations during
EGP (unmol/kg FFM)/min
†
20
15
10
5 and were independent of medication used (Monnier et al.,
0 The temporal pattern of insulin concentrations
Non-Ob OB OB+IFG
Figure 6. Endogenous glucose production (EGP) by group and
study day
EGP is calculated as the mean of four samples taken between 0600
and 0645 h. ∗ P = 0.001 OB vs. OB+IFG; † P = 0.001 PMEX vs. NOEX;
means ± SD; OB n = 18, OB+IFG n = 16, Non-Ob n = 18. AMEX:
morning exercise day; NOEX: no exercise day; Non-OB: not obese;
OB: obese; OB+IFG: obese with impaired fasting glucose levels;
PMEX: evening exercise day.
© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
11
bout of exercise the day before (AMEX and PMEX)
suppressed the rise in glucose levels after a mixed meal
compared with NOEX in OB+IFG but did not prevent
the elevated glucose levels upon awakening. Exercise had
no effect on the peak glucose or insulin responses to the
dinner meal or during the nocturnal period in individuals
with Non-Ob and OB.
Earlier research has shown that with prolonged fasting,
glucose levels decreased throughout the day and then
began to rise until morning in both individuals with and
without T2D (Shapiro et al., 1991). Likewise, in OB+IFG,
following the evening meal, glucose concentrations began
to rise, and increased until the morning, while in both
the OB and Non-Ob, glucose levels rose slightly before
levelling off near their fasting pre-dinner glucose levels
from the evening before. This rise was initiated at
approximately midnight (time point 360 min, Fig. 2B)
and continued to rise until 0700 h. The OB+IFG had
glucose concentrations 37% higher the following morning
compared with pre-dinner values, while the values for
OB and Non-Ob were 10% and 7.5% higher, respectively.
The dawn phenomenon affects about 50% of patients with
diabetes (Carroll & Schade, 2005). These phenomena had
been previously considered to start about 0300–0500 h
and be linked to the rise in cortisol or growth hormone
(Carroll & Schade, 2005). However, with the rise in
glucose occurring earlier, this suggests that cortisol is not
a primary driver of this elevation. On the other hand,
growth hormone typically rises about 1 h after sleep onset
during slow-wave sleep. It is possible that growth hormone
contributed somewhat to the rise in nocturnal glucose
concentrations. However, there has been considerable
research showing that growth hormone concentrations
decrease with age (Ho et al., 1987) and are lower with
obesity (Kanaley et al., 1999). Thus, it does not seem
plausible that the nocturnal rise in growth hormone is
the night. Further, the variability in the occurrence of the
dawn phenomenon highlights that more attention needs
to be paid to the evening/nocturnal period in individuals
struggling to control their glucose levels. Monnier et al.
showed that both the HbA1c levels and the average 24 h
mean glucose values were greater in those subjects who
exhibited the dawn phenomenon than those who did not
2013).
paralleled the glucose levels in both the OB and Non-Ob
groups, but in OB+IFG insulin concentrations continued
to decline throughout the night, despite the rising glucose
levels. Concomitantly glucagon levels also remained low
during the overnight period. Furthermore, during PMEX
while glucose concentrations decreased rapidly, we still
observed the expected increase in glucagon with exercise
in all groups, indicating that OB+IFG are responsive to

12 J. A. Kanaley and others
the rapidly falling glucose concentrations. In individuals
without T2D, previous work (Shapiro et al., 1991) has
also shown that insulin secretion mirrored the glucose
levels, while individuals with T2D had a low point in
insulin secretion (∼2000 h) which remained low until
waking. More recently, Basu et al. (2018) also noted a
decline in insulin levels nocturnally but they did not
observe an increase in the glucose levels in individuals
with T2D despite their subjects having higher fasting
glucose concentrations (9.5 mmol/L) than observed
in our study (7 mmol/L). Interestingly, in their study,
glucagon concentrations remained low throughout the
night in all groups and do not seem to account for the
rising glucose levels observed in OB+IFG. Polonsky et al.
(1998) have shown a tight temporal coupling between
glucose and insulin secretion in individuals without
diabetes but the coupling was impaired in individuals
who had T2D or impaired glucose tolerance. Potentially,
synchrony between glucagon and insulin pulsatile phases
are shifted such that they oppose each other’s actions.
Direct measurement of this synchrony is not feasible in
human subjects given limited access to hepatic vascular
beds.
Intracellular circadian clocks help to modulate physio-
logical responses throughout the day (Gabriel & Zierath,
2019). The mechanism for the nocturnal rise in glucose
levels has not been conclusively established but Ding et al.
(2021) recently showed in mice that nuclear receptors
REV-ERB-α and REV-ERB-β (or ‘REV-ERB’) in the
GABAergic (γ -aminobutyric acid-producing) neurons
in the suprachiasmatic nucleus control the diurnal
rhythm of insulin-mediated suppression of hepatic
glucose production. They demonstrated mechanistic
insights into how disruption of the central circadian
clock can regulate the diurnal rhythm of hepatic insulin
sensitivity. This may be related to the dawn phenomenon
in individuals with T2D. Supporting this, our striking
insulin findings of a gradual decline throughout the
evening and overnight period in the OB+IFG with a
concomitant increase in glucose concentrations (Fig. 2B,
E) align with their findings, suggesting that there may
be disturbances in the circadian rhythm in the OB+IFG
group, and particularly in those individuals showing a rise
in nocturnal glucose levels. Further, this suggests that in
OB+IFG the gradual increase in glucose concentrations
is not stimulating insulin secretion, which may be a
loss of pancreatic sensitivity. This circadian suppression
of insulin responsiveness may not be of consequence
in individuals who have preserved peripheral insulin
sensitivity, but it may become limiting in individuals with
worsening insulin resistance.
Further, the skeletal muscle molecular clock can be
manipulated by physical activity such that it can affect
the circadian rhythms (Saner et al., 2018; Wolff & Esser,
2012). Disturbance to the molecular clock can alter
© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
J Physiol 0.0
metabolism and is hypothesized as potentially misaligned
or disrupted in individuals with obesity and T2D. Exercise
is known to acutely modify muscle metabolism, substrate
storage and utilization and hormonal control (Gabriel
& Zierath, 2019). Thus, in this study, optimization of
exercise timing was utilized as a potential therapeutic
tool to reset a disrupted metabolism in individuals
with obesity and T2D. We hypothesized that evening
exercise would increase glucose clearance thus resulting in
lower glucose concentrations during the nocturnal period,
altering the hormonal profile and potentially lowering
morning fasting glucose levels. We found that both AMEX
and PMEX suppressed the glucose levels through the
nighttime period (Fig. 2B), but early in the morning
the glucose levels began to rise such that morning glucose
levels were similar despite the study condition. Thus, one
bout of exercise the previous day did not significantly
modify glucose metabolism or the overnight hormonal
response.
To establish how obesity, diabetes and exercise timing
affect glycaemic control in the early morning hours, we
measured EGP. EGP was ∼19% greater in the OB+IFG
than in the OB group and about 7% greater than in the
Non-Ob group during the NOEX condition. Likewise,
others have reported higher EGP in individuals with T2D
compared with a group with OB and non-diabetic (Basu
et al., 2004, 2018). This higher EGP was observed despite
the fact that no early morning rise in glucose occurred
in the group with T2D, although they had substantially
higher nocturnal glucose levels (Basu et al., 2018).
They noted that nocturnal regulation of glycogenolysis
and gluconeogenesis was altered in individuals with
T2D, such that glycogenolysis and gluconeogenesis
remained constant in non-diabetics but the contribution
of glycogenolysis to EGP fell throughout the night while
gluconeogenesis increased (Basu et al., 2018). In the
present study, exercise had no impact on EGP in either
group with obesity but was found to be elevated in the
Non-Ob with PMEX compared with NOEX. Although
glucose concentrations were not lower with PMEX, the
glucose utilized during exercise may have resulted in the
enhanced EGP during the nocturnal hours to maintain
nocturnal glucose levels. PMEX did not increase EGP in
OB+IFG as we had hypothesized.
A strength of the current study is that we only removed
the subjects’ medication (i.e. metformin, etc.) starting the
previous evening and we provided our subjects with meals
for the 24 h before coming to the study night. Our study
is novel as we studied the glucose responses to a day with
meals and not during a period of prolonged fasting as has
been done previously (Polonsky et al., 1988; Shapiro et al.,
1991). Additionally, the dawn phenomenon was observed
in about half of our subjects even though we fed them
the evening before and we also exercised them. One study
(Beebe et al., 1990) noted that the early morning increase

J Physiol 0.0 Optimizing exercise timing for glycaemic control
in glucose levels in subjects with T2D was associated with
the size and timing of the last meal on the previous day
such that the rise in glucose levels was only observed when
the last meal ingested contained no more than 30% of the
total daily energy requirements. This observation suggests
that diurnal variations in glucose levels and insulin
secretion in T2D may be more prominent during fasting
than during normal dietary conditions. Our findings
demonstrate that the dawn phenomena exist with both
a day of feeding an evening meal greater than 30% of
total energy requirements and an exercise intervention
in individuals with T2D, and that this disturbance in
EGP and rate of disappearance of glucose is a problem
for these individuals. One limitation is that this study
only examined an acute bout of exercise on morning
glucose levels and was not an exercise training study,
potentially explaining why we were unable to observe an
impact on the fasting glucose level with exercise, either
in the morning or in the evening. Potentially, if we had
exercise trained subjects for a few days/weeks, we might
have impacted insulin sensitivity to a greater extent. Also,
we provided a standard meal the evening before, and
not for 3 days as usually recommended. This change
to some individuals’ eating patterns may have affected
their metabolism the following day, as research has shown
that 3 days are needed to establish an energy balance.
Additionally, sex differences may exist in these glucose and
hormonal responses, which we were unable to establish
as our sample was not large enough and did not have a
balanced number of males and females.
In conclusion, we have provided evidence of the
dawn phenomena in OB+IFG with rising plasma
glucose concentration in a milieu of waning insulin
concentrations and no rise in glucagon levels. This
nocturnal rise in glucose starts earlier than previously
reported. Exercise did not impact the early morning EGP
in OB and OB+IFG, although EGP was significantly
higher in OB+IFG than OB but not the Non-Ob. PMEX
suppressed the rise in glucose levels in OB+IFG for
many hours during the night but did not lower morning
fasting glucose levels. These observations have practical
implications in that exercise after the dinner meal helps
to attenuate the rise in glucose levels in OB+IFG and
this may have helped to minimize the sustained hyper-
glycaemia in these individuals. More research is needed
on the effect of meals and chronic exercise training on
these nocturnal hormonal responses and the fasting
glucose concentrations.
References
Basu, A., Joshi, N., Miles, J., Carter, R. E., Rizza, R. A., & Basu,
R. (2018). Paradigm shifts in nocturnal glucose control
in type 2 diabetes. Journal of Clinical Endocrinology and
Metabolism, 103(10), 3801–3809.
© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
13
Basu, R., Di Camillo, B., Toffolo, G., Basu, A., Shah, P.,
Vella, A., Rizza, R., & Cobelli, C. (2003). Use of a novel
triple-tracer approach to assess postprandial glucose
metabolism. American Journal of Physiology. Endocrinology
and Metabolism, 284(1), E55–E69.
Basu, R., Schwenk, W. F., & Rizza, R. A. (2004). Both fasting
glucose production and disappearance are abnormal in
people with “mild” and “severe” type 2 diabetes. American
Journal of Physiology. Endocrinology and Metabolism,
287(1), E55–E62.
Beebe, C. A., Van Cauter, E., Shapiro, E. T., Tillil, H., Lyons,
R., Rubenstein, A. H., & Polonsky, K. S. (1990). Effect of
temporal distribution of calories on diurnal patterns of
glucose levels and insulin secretion in NIDDM. Diabetes
Care, 13(7), 748–755.
Carroll, M. F., & Schade, D. S. (2005). The dawn phenomenon
revisited: Implications for diabetes therapy. Endocrine
Practice, 11(1), 55–64.
Chung, F., Yegneswaran, B., Liao, P., Chung, S. A.,
Vairavanathan, S., Islam, S., Khajehdehi, A., & Shapiro,
C. M. (2008). Validation of the Berlin questionnaire
and American Society of Anesthesiologists checklist as
screening tools for obstructive sleep apnea in surgical
patients. Anesthesiology, 108(5), 822–830.
Colberg, S. R., Albright, A. L., Blissmer, B. J., Braun, B.,
Chasan-Taber, L., Fernhall, B., Regensteiner, J. G., Rubin, R.
R., & Sigal, R. J., American College of Sports M & American
Diabetes A. (2010). Exercise and type 2 diabetes: American
College of Sports Medicine and the American Diabetes
Association: Joint position statement. Exercise and type
2 diabetes. Medicine and Science in Sports and Exercise,
42(12), 2282–2303.
Colberg, S. R., Zarrabi, L., Bennington, L., Nakave, A., Thomas
Somma, C., Swain, D. P., & Sechrist, S. R. (2009). Post-
prandial walking is better for lowering the glycemic effect
of dinner than pre-dinner exercise in type 2 diabetic
individuals. Journal of the American Medical Directors
Association, 10(6), 394–397.
De Boor, C. A. (2001). Practical Guide to Splines. Springer New
York, NY.
Ding, G., Li, X., Hou, X., Zhou, W., Gong, Y., Liu, F., He,
Y., Song, J., Wang, J., Basil, P., Li, W., Qian, S., Saha, P.,
Wang, J., Cui, C., Yang, T., Zou, K., Han, Y., Amos, C. I.,
Xu, Y., Chen, L., & Sun, Z. (2021). REV-ERB in GABAergic
neurons controls diurnal hepatic insulin sensitivity. Nature,
592(7856), 763–767.
Gabriel, B. M., & Zierath, J. R. (2019). Circadian rhythms and
exercise - re-setting the clock in metabolic disease. Nature
reviews Endocrinology, 15(4), 197–206.
Galecki, A. T. (1994). General-class of covariance-structures
for 2 or more repeated factors in longitudinal
data-analysis. Communications in Statistics Theory, 23(11),
3105–3119.
Hawley, J. A. (2004). Exercise as a therapeutic intervention
for the prevention and treatment of insulin resistance.
Diabetes Metabolism Research and Reviews, 20(5),
383–393.
Heden, T. D., & Kanaley, J. A. (2019). Syncing exercise with
meals and circadian clocks. Exercise and Sport Sciences
Reviews, 47(1), 22–28.

14 J. A. Kanaley and others
Heden, T. D., Liu, Y., Park, Y. M., Winn, N. C., & Kanaley, J.
A. (2015). Walking reduces postprandial insulin secretion
in obese adolescents consuming a high-fructose or
high-glucose diet. Journal of Physical Activity and Health,
12(8), 1153–1161.
Heden, T. D., Winn, N. C., Mari, A., Booth, F. W., Rector,
R. S., Thyfault, J. P., & Kanaley, J. A. (2015). Postdinner
resistance exercise improves postprandial risk factors more
effectively than predinner resistance exercise in patients
with type 2 diabetes. Journal of Applied Physiology, 118(5),
624–634.
Ho, K. Y., Evans, W. S., Blizzard, R. M., Veldhuis, J. D.,
Merriam, G. R., Samojlik, E., Furlanetto, R., Rogol, A. D.,
Kaiser, D. L., & Thorner, M. (1987). Effects of sex and age
on the 24-hour profile of growth hormone secretion in man:
Importance of endogenous estradiol concentrations. Journal
of Clinical Endocrinology and Metabolism, 64(1), 51–58.
Kanaley, J. A., Goulopoulou, S., Franklin, R. M., Baynard,
T., Holmstrup, M. E., Carhart, R., Jr., Weinstock, R. S., &
Fernhall, B. (2009). Plasticity of heart rate signalling and
complexity with exercise training in obese individuals with
and without type 2 diabetes. International Journal of Obesity
(Lond), 33(10), 1198–1206.
Kanaley, J. A., Weatherup-Dentes, M. M., Jaynes, E. B., &
Hartman, M. L. (1999). Obesity attenuates the growth
hormone response to exercise. Journal of Clinical End-
ocrinology and Metabolism, 84(9), 3156–3161.
Manders, R. J., Van Dijk, J. W., & van Loon, L. J. (2010).
Low-intensity exercise reduces the prevalence of hyper-
glycemia in type 2 diabetes. Medicine and Science in Sports
and Exercise, 42(2), 219–225.
Monnier, L., Colette, C., Dejager, S., & Owens, D. (2013).
Magnitude of the dawn phenomenon and its impact on
the overall glucose exposure in type 2 diabetes: Is this of
concern? Diabetes Care, 36(12), 4057–4062.
O’Neal, T. B., & Luther, E. E. (2022). Dawn Phenomenon. In
StatPearls. Treasure Island (FL).
Parks, E. J., Krauss, R. M., Christiansen, M. P., Neese, R.
A., & Hellerstein, M. K. (1999). Effects of a low-fat,
high-carbohydrate diet on VLDL-triglyceride assembly,
production, and clearance. Journal of Clinical Investigation,
104(8), 1087–1096.
Poirier, P., Mawhinney, S., Grondin, L., Tremblay, A.,
Broderick, T., Cleroux, J., Catellier, C., Tancrede, G.,
& Nadeau, A. (2001). Prior meal enhances the plasma
glucose lowering effect of exercise in type 2 diabetes.
Medicine and Science in Sports and Exercise, 33(8),
1259–1264.
Poirier, P., Tremblay, A., Catellier, C., Tancrede, G., Garneau,
C., & Nadeau, A. (2000). Impact of time interval from the
last meal on glucose response to exercise in subjects with
type 2 diabetes. Journal of Clinical Endocrine Metabolism,
85(8), 2860–2864.
Poitout, V., & Robertson, R. P. (2008). Glucolipotoxicity: Fuel
excess and beta-cell dysfunction. Endocrine Reviews, 29(3),
351–366.
Polonsky, K. S., Given, B. D., & Van Cauter, E. (1988).
Twenty-four-hour profiles and pulsatile patterns of insulin
secretion in normal and obese subjects. Journal of Clinical
Investigation, 81(2), 442–448.
© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.
14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
J Physiol 0.0
Polonsky, K. S., Sturis, J., & Van Cauter, E. (1998). Temporal
profiles and clinical significance of pulsatile insulin
secretion. Hormone Research, 49(3–4), 178–184.
Robertson, R. P. (2004). Chronic oxidative stress as a central
mechanism for glucose toxicity in pancreatic islet beta
cells in diabetes. Journal of Biological Chemistry, 279(41),
42351–42354.
Ruppert, D., Wand, M. P., & Carroll, R. J. (2003). Semi-
parametric regression. Cambridge University Press,
Cambridge; New York.
Saad, A., Dalla Man, C., Nandy, D. K., Levine, J. A., Bharucha,
A. E., Rizza, R. A., Basu, R., Carter, R. E., Cobelli, C.,
Kudva, Y. C., & Basu, A. (2012). Diurnal pattern to insulin
secretion and insulin action in healthy individuals. Diabetes,
61(11), 2691–2700.
Saner, N. J., Bishop, D. J., & Bartlett, J. D. (2018). Is exercise a
viable therapeutic intervention to mitigate mitochondrial
dysfunction and insulin resistance induced by sleep loss?
Sleep Medicine Reviews, 37, 60–68.
Shapiro, E. T., Polonsky, K. S., Copinschi, G., Bosson, D.,
Tillil, H., Blackman, J., Lewis, G., & Van Cauter, E. (1991).
Nocturnal elevation of glucose levels during fasting in
noninsulin-dependent diabetes. Journal of Clinical End-
ocrinology and Metabolism, 72(2), 444–454.
Van Cauter, E., Desir, D., Decoster, C., Fery, F., & Balasse, E.
O. (1989). Nocturnal decrease in glucose tolerance during
constant glucose infusion. Journal of Clinical Endocrinology
and Metabolism, 69(3), 604–611.
Wolff, G., & Esser, K. A. (2012). Scheduled exercise phase
shifts the circadian clock in skeletal muscle. Medicine and
Science in Sports and Exercise, 44(9), 1663–1670.
Additional information
Data availability statement
Data are available on request to the author.
Competing interests
None declared.
Author contributions
This research was conducted at the University of Missouri
(MU) on the Clinical Research Centre and MU-PAW (Physical
Activity and Wellness Lab). The contributions to the study are
as follows: Conception or design of the work – J.A.K., E.J.P.,
C.C. and acquisition, analysis or interpretation of data for the
work and drafting the work or revising it critically for important
intellectual content – J.A.K., E.J.P., J.W.P., R.J.P.-M., N.C.W., G.L.,
A.C., G.P., C.C., M.S. All authors have read and approved the
final version of this manuscript and agree to be accountable for
all aspects of the work in ensuring that questions related to the
accuracy or integrity of any part of the work are appropriately
investigated and resolved. All persons designated as authors
qualify for authorship, and all those who qualify for authorship
are listed.
 14697793, 0, Downloaded from https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP285069 by University Of Leiden, Wiley Online Library on [19/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
J Physiol 0.0 Optimizing exercise timing for glycaemic control 15

Funding Keywords
This project was partially funded by NIH R01DK101513. dawn phenomenon, endogenous glucose production, obesity,
time of day, type 2 diabetes

Acknowledgements Supporting information

Sincere thanks to all of the subjects who participated in this
project, and to all the nurses and paramedics who worked the
night shift at the Clinical Research Centre. Thanks to Alan
Maloney, MS, for assisting with compiling data and tables, and
editing.
Additional supporting information can be found online in the
Supporting Information section at the end of the HTML view of
the article. Supporting information files available:
Statistical Summary Document
Peer Review History

© 2023 The Authors. The Journal of Physiology © 2023 The Physiological Society.