Effects of Intra-Session Exercise Sequence and Circadian Rhythms on Physical Capacity and Sleep Quality in Obese Women

doi:10.21203/rs.3.rs-3936001/v1

This study aimed to determine the effects of exercise orders and circadian rhythms on body composition, blood lipids, physical fitness and upper- and lower-extremity muscular functions in adult obese women. Forty-four women with obesity were divided into the obesity control group (OCG), aerobic-resistance exercise in the morning group (ARMG), resistance-aerobic exercise in the morning group (RAMG), aerobic-resistance exercise in the evening group (AREG), and resistance-aerobic exercise in the evening group (RAEG). The combined exercise program consisted of treadmill exercise and weight training, and all participants performed the exercise for 8 weeks. Body weight, body mass, body mass index and fasting glucose were significantly decreased in the RAMG at post. while other body compositions and blood lipids did not change at the post compared the baseline. Upper-and lower-extremity muscular functions and Pittsburgh Sleep Quality Index value was significantly lower in all exercise groups versus OCG. Our findings provide new evidence that resistance-aerobic exercise order in the morning might positively improve body weight, body mass, body mass index and fasting glucose in obese women. In addition, physical fitness and upper- and lower-extremity muscular functions and sleep quality might be improved by performing regular exercise programs regardless of exercise order and timing.

Health sciences/Diseases

Health sciences/Health care

Obesity is a serious social problem that increases the prevalence of metabolic diseases such as diabetes, high blood pressure, dyslipidemia, hyperinsulinemia, and metabolic syndrome ¹. In recent studies, morning, and evening exercises as well as concurrent aerobic and resistance exercise were highlighted as effective obesity prevention and management methods^2,3. The circadian rhythms are governed by the body’s rhythm in the suprachiasmatic nucleus within the hypothalamus of the human brain ⁴. This rhythm is closely related to various physiological changes such as heart rate, stress, metabolism, sleep quality, immunity, and obesity-related hormone secretion ^5,6 suggesting a more effective approach to preventing and managing obesity^7,8.

According to exercise physiology and sports medicine researchers, regular aerobic and/or anaerobic exercise is the most economical and effective way to manage obesity. Aerobic and resistance exercises are mainly used to treat obesity, but the two induce different physical changes ⁹. Aerobic exercise is used to reduce body fat by promoting fatty acid oxidation and improving cardiovascular endurance ¹⁰, whereas resistant exercise is known to increase muscle mass and strength by activating anabolic hormones such as testosterone and insulin-like growth factor-1, which synthesize proteins in the skeletal muscles ¹¹. Many previous studies have applied concurrent aerobic and resistance training programs to improve physical fitness and body composition in obese people and reported its efficacy at regulating body fat, muscle mass, blood lipid concentrations, and anabolic hormones ¹². However, several studies have reported the interference effects of the sequence of concurrent exercises can counteract the positive effects induced by a single exercise ^13,14.

In terms of circadian rhythms and exercise, evening exercise significantly increases the secretion of neurotransmitters and muscle functions compared to morning exercise ^15,16. Previous study observed that anaerobic exercise capacity was higher in the afternoon than in the morning and recommended exercising in the afternoon accordingly ¹⁷. In contrast, other studies reported that exercise performance was more effective at 6:00 AM than at 6:00 PM.

Based on these results, circadian rhythms and exercise order are believed to be therapeutic methods for preventing obesity. However, the effect of concurrent exercise sequence in the morning or evening on obesity improvement and prevention remains unclear. We hypothesized that exercise performance order in the morning or evening could change the quality of life of obese women by promoting body composition, muscular functions, and sleep quality. Therefore, this study aimed to investigate the effect of intra-session exercise sequence and circadian rhythms on physical fitness, upper- and lower-extremity muscle functions, and sleep quality in obese women.

Change in anthropometric characteristics and body composition

To examine the differences in body composition according to circadian rhythms and exercise order, we identified anthropometric characteristics, body composition, and hip and waist circumferences (Table 3). In comparison between pre-experimental groups, anthropometric characteristics, body composition, and hip and waist circumferences were no significant (all baseline p-values >0.05). At Post, body weight (p<0.003), body fat mass (p<0.010) and body mass index (p<0.002) were significantly decreased in the RAMG, while anthropometric characteristics, body composition, and hip and waist circumferences did not change significantly in the OCG. In addition, % fat, fat-free mass, waist circumference, hip circumference, and waist-hip ratio were not significantly different all groups. There was a significant group × time interaction in the body weight (p<0.004), body fat mass (p<0.042) and body mass index (p<0.003) except for percent body fat (p<0.984), free fat mass (p<0.275), waist and hip circumference (p<0.731, p<0.991, respectively), and waist-hip ratio (p<0.169).

Change in basic physical fitness

We measured various physical fitness parameters to identify maximal strength, muscular endurance, flexibility, and cardiorespiratory endurance according to circadian rhythms and exercise order (Table 4). In comparison between pre-experimental groups, physical fitness parameters were no significant (all baseline p-values >0.05). At Post, back strength was significantly increased in the ARMG (p<0.048), RAMG (p<0.021), AREG (p<0.004). Sit up was significantly increased in the AREG (p<0.001) and RAEG (p<0.006). Physical efficiency index was significantly increased in the RAMG (p<0.025) and RAEG (p<0.050), while physical fitness parameters did not change significantly in the OCG. There was a significant group × time interaction in the sit up (p<0.046) and sit and reach (p<0.049) except for grip and back strength (p<0.827, p<0.377, respectively) and physical efficiency index (p<0.088).

Change in Upper and lower extremity muscle functions

To examine upper- and lower-extremity muscle function, we performed the FAPT, SAPT, TFET, vertical jump, and sit-to-stand tests (Table 5). There was no significant difference at baseline between groups in upper- and lower-extremity muscle functions (all baseline p-values >0.05). At Post, front abdominal and right-side abdominal power test were significantly increased in the ARMG (p<0.031, p<0.031, respectively), RAMG (p<0.003, p<0.022, respectively), AREG (p<0.003, p<0.034, respectively). Left side abdominal power test, trunk flexor endurance test and sit to stand test were significantly increased in ARMG (p<0.041, p<0.016, p<0.008, respectively), RAMG (p<0.006, p<0.001, p<0.001, respectively), AREG (p<0.006, p<0.013, p<0.001, respectively), RAEG (p<0.001, p<0.011, p<0.013, respectively), while all upper- and lower-extremity muscle functions did not change in the OCG. There was a significant group × time interaction in the front abdominal power test (p<0.018), trunk flexor endurance test (p<0.006) and sit to stand (p<0.024) except for left and right abdominal power test (p<0.373, p<0.925, respectively) and vertical jump (p<0.372).

Change in blood lipids and Pittsburgh sleep quality index

We measured the levels of TC, TG, HDL-C, LDL-C, and FG in the blood and PSQI values to identify blood lipids and Pittsburgh sleep quality index according to circadian rhythms and exercise order (Table 6). There was no significant difference at baseline between groups in blood lipid and sleep quality index (all baseline p-values >0.05). At Post, Pittsburgh sleep quality index was significantly decreased in the ARMG (p<0.003), RAMG (p<0.010), AREG (p<0.008), RAEG (p<0.010), while OCG did not change significantly different. All blood lipid s was no significantly different in all groups except for fasting glucose. fasting glucose was significantly decreased only the ARMG (p<0.019). All groups were no significant group × time interaction in the blood lipid parameters (p>0.127) except for Pittsburgh sleep quality index (p<0.015).

Recent clinical studies on the effect of obesity prevention reported that exercise order and circadian rhythms can improve body composition, physical fitness, sleep quality, cardiovascular disease–related factors, and inflammation ^18,19. However, there is somewhat controversial. Thus, we attempted to demonstrate the effect of exercise order and circadian rhythms on health-related physical fitness and cardiovascular disease–related risk factors in obese adult women. The major findings indicated that resistance-aerobic exercise order in the morning was improved body composition. In addition, physical fitness and upper-and lower-extremity muscular functions were increased regardless of exercise order and circadian rhythms.

Our study confirmed the effects of anthropometric characteristics and body composition, hip- and waist-circumference according to circadian rhythms and exercise order. Percent body fat, fat free mass, hip and waist circumference, and waist-to-hip ratio were not significantly improved all groups. While body weight, body fat mass and body mass index were significantly decreased in the RAMG. Several previous studies suggested that morning exercise reduces body weight, body fat mass and body mass index in overweight/obese women compared to evening exercise ^20,21. In additional, early exercise (sessions completed between 7:00 and 11:59 am) was significantly decreased more body weight than late exercise (sessions completed between 3:00 and 7:00 pm) 10 months after applying exercise intervention in female with overweight and obese ²². Resistance exercise performed before aerobic exercise has been reported to increase fat oxidation and energy consumption ²³. It has also been shown to increase the concentrations of fatty acids, glycerol, and growth hormone ²⁴. The results of these previous studies support our findings that aerobic exercise performed after resistance exercise in the morning improved body weight, body fat mass, and body mass index. This cause can be attributed that fasting aerobic exercise in the morning accelerated fatty acid oxidation compared to the evening exercise group performed after carbohydrate intake ^25,26. Moreover, resistance exercise before aerobic exercise is thought to contribute to increased body temperature and promotion of fatty acid oxidation by excess post oxygen consumption (EPOC) ²⁷. However, the study found no oxygen intake, body temperature, or fatty acids. Therefore, further research is needed to overcome the limitations of this study.

Our study confirmed the effects of basic physical fitness and upper-and lower-extremity muscular functions according to circadian rhythms and exercise order. Strength, endurance and upper-and lower- extremity muscular functions tests were significantly improved almost all exercise groups after intervention. Meta-analysis study reported that concurrent endurance and resistance exercises had a negative effect on muscle hypertrophy, strength, and power depending on frequency and duration ²⁸. In contrast, alteration of intra-session exercise sequence (endurance exercise after resistance exercise) has been reported to have a positive effect on changes in physical fitness, muscle strength, and insulin sensitivity ²⁹, and exercise capacity and performance are higher in the evening than those in the morning because body temperature and heart rate are increased to an appropriate level ³⁰. In another previous studies, morning versus evening exercise training was reported to lead to improvement of physical fitness of subjects, but there was no significant time effect ³¹. These previous studies consistent with our findings that regular exercise improved physical strength and upper and lower extremity muscle functions regardless of exercise order and timing. However, changes in physical fitness and muscular functions according to intra-session exercise sequence and circadian rhythms are still controversial. These causes are not well documented that exercise sequence during day and night may activate protein metabolism including AMPK and mTOR signaling pathway and hormone secretion including cortisol and melatonin ^16,32. Thus, the limitation of this study is that the molecular biological interference effect according to the exercise sequence and the hormonal change during day and night could not be confirmed. In future study, we believe that the perspective of protein and hormone synthesis on intra-session exercise sequence and circadian rhythms are needed to analyze.

Our study investigated blood lipids and sleep quality according to exercise orders and circadian rhythms. Specifically, TC, TG, HDL-C, LDL-C levels were not significantly changed in all groups except for fasting glucose. Fasting glucose was significantly decreased only the ARMG. However, the fasting glucose level is within the normal range and does not mean much. In addition, Pittsburgh sleep quality index was improved in all exercise groups compared the obesity control group. Looking at previous studies that confirmed changes in blood lipids according to exercise sequence and circadian rhythms, exercise ameliorated blood lipids with no difference between morning and evening exercise ³³. Also, regular exercise tends to improve blood lipid regardless of the exercise sequence ³⁴. It has been known that sleep quality can be changed by circadian rhythm and exercise. Previous study reported that combined endurance and resistance exercise was improved the PSQI value ³⁵. Also, regular exercise did not differ sleep quality between the two groups (morning vs evening) ³¹. The results of previous studies support our findings that concurrent aerobic and resistance exercise performed in the morning or evening might effectively improve sleep quality in obese women. The reason is that circadian rhythms and physical activity are closely related to the sleep-wake cycle, bring about a positive effect on melatonin and cortisol curves ³⁶. Given the findings reported in previous and present studies, circadian rhythms and exercise order play an important role in improving body composition, physical fitness and sleep quality in obese women. However, this study has two limitations. First, we could not confirm hormonal and molecular biological interference effects and second, we could not recruit enough participants to generalize the study’s results. Thus, in future studies, it will be necessary to perform new experiments by mechanism study and recruiting sufficient subjects to enable generalization of the findings.

We investigated whether the sequence of aerobic and resistance exercises according to circadian rhythms could improve body composition, upper- and lower-extremity muscle functions, blood lipids and Pittsburgh sleep quality index in obese women. Our findings provide new evidence that resistance exercise in the morning followed by aerobic exercise might promote fat metabolism. Furthermore, physical fitness, upper and lower extremity muscular functions, and quality of sleep might be improved by performing regular exercise regardless of order and timing.

Participants and Study Design

The study design is presented in Fig. 1. This study recruited obese women (n = 55) who had a body fat percentage of 30% or more and had not been diagnosed with cardiovascular or musculoskeletal diseases in the previous 6 months. Ultimately, fifty participations participated in this study according to the exclusion criteria. As shown in Table 1, the participants were randomly divided into the aerobic-resistance exercise in the morning group (ARMG, n = 10), resistance-aerobic exercise in the morning group (RAMG, n = 10), aerobic-resistance exercise in the evening group (AREG, n = 10), resistance-aerobic exercise in the evening group (RAEG, n = 10), and the obesity control group (OCG, n = 10). Three participants in the ARMG (n = 2) and RAMG (n = 1) withdrew from the study for personal reasons. Three participants (two in the AREG, one in the RAEG) with an exercise participation rate of less than 80% were excluded from the analysis. In the baseline-test, body weight (F = .113, p = .977), body fat mass (F = .410, p = .800), % body fat (F = .751, p = .563), fat-free mass (F = .041, p = .997), or body mass index (F = .277, p = .891) were not significantly difference between groups. Written informed consent was obtained from all participants after they were informed about the study aims and the potential risks derived from the tests and methods. This study was conducted in accordance with the Declaration of Helsinki and was approved by the Jeju National University Institutional Review Board (JJNU-IRB-2021-045-001).

Combined exercise intervention

This study applied a combined exercise program that was performed 3 days a week for 8 weeks, and the different groups followed different orders of aerobic and resistance exercise in the morning or evening (Table 2). All participants had a 1-week adaptation exercise period before the main experiment, following which the maximum heart rate and 1 repetition max (1RM) were measured to set the exercise intensity for participants before starting the exercise program. The aerobic exercise intensity was set using the Karvonen formula (206.9 - (0.67 × age)), and treadmill exercise was performed for 30 min at the most effective 60–70% maximum heart rate (HRmax) intensity for fat burning ³⁷. The resistance exercise intensity was set up using the 1RM indirect estimation formula (1RM = wt + (wt × 0.025 × reps)). Resistance exercise was performed by applying the progressive overload principle at 0–4 weeks (60–80% 1RM) and 5–8 weeks (70–80% 1RM). The resistance exercise consisted of exercises involving push-and-pull and weight bearing, and all participants performed three sets (8–15 RM) with a 2-min rest between sets using concentric contraction for 1 s and eccentric contraction for 2 s. Intensities in treadmill and resistance exercises were equally applied to all exercise groups. Resistance exercises used weight training machines to minimize the possibility of injury. Dynamic stretching using foam rollers was performed for 5 min during warm-up and cool-down to induce the best condition and rapid muscle fatigue recovery, respectively. The morning exercise group performed an exercise program from 7 AM to 08:30 AM, while the evening exercise group performed an exercise program from 7 PM to 08:30 PM under the supervision of a professional trainer.

Measurements

Anthropometric and body composition measurements

Physique and body composition were measured using a height and weight auto measuring scale (DS-103M, Dong San Jenix, Seoul, Korea) and a body composition analyzer (Inbody 770; Inbody, Seoul, Korea). The participants visited the laboratory for pre-prandial analyses at 9 AM three times during the study (before and 4 and 8 weeks after) for 8 h. Waist circumference and hip circumference were measured using flexible metric measuring tape. Hip circumference was measured at the level of the maximum extension of the buttocks posteriorly in a horizontal plane and waist circumference was measured around the abdomen at the level of the umbilicus. Waist- hip ratio (WHR) was calculated as waist circumference divided by hip circumference.

Basic physical fitness

Grip and back strengths were measured using a digital dynamometer (T.K.K. 5101 and T.K.K. 5402; TAKEI, Tokyo, Japan). It was measured twice, and the maximum value was recorded in kilograms. Muscular endurance and flexibility were assessed using a sit-up device (T.K.K. 5505; TAKEI). Cardiorespiratory endurance was measured using the physical efficiency index (PEI) score through the Havard step test. The PEI calculation using the long form equation - fitness index formula is as follows: <Long Form Equation - Fitness Index = (100 × test duration in seconds) divided by (2 × sum of heartbeats in the recovery period)>.

Blood lipids

The blood lipids including fasting glucose (FG), total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C), were measured at baseline and post-exercise. FG levels were analyzed using a disposable blood collection needle (Accu-Chek®Softclix; Roche, Mannheim, Germany) and a blood glucose meter (Accu-Chek®Guide; Roche). TC, TG, HDL-C, and LDL-C levels were measured using a Mission Cholesterol Meter (Acon Laboratories, Inc., San Diego, CA, USA).

Upper extremity muscle function

The abdominal power test was performed according to a previously reported method ³⁸. This test consists of front and side abdominal power tests (FAPT and SAPT). The FAPT was performed as follows: the participant laid down while holding the medicine ball (2% body weight) with the knee bent at 90° and both arms spread on the mat. The SAPT was performed as follows: the participant sat on the mat (knee angle, 90°; hip angle, 45°), held the medicine ball (2% body weight), and the measurements were taken twice by turning the upper body 90° outward in the opposite direction and then inward again to throw the medicine ball from the knee line. The maximum distance between the FAPT and SAPT was measured from the toe of the participant to the point where the ball fell. The trunk flexor endurance test (TFET) was performed to evaluate abdominal muscle endurance. As described previously ³⁹, the ankle was fixed to the floor with the hip and knee bent at 90° and the arms crossed in front of the chest. Thereafter, the time (in seconds) required to remove the support and maintain the waist angle at 60° was recorded.

Lower extremity muscle function

The vertical jump test was performed twice using a digital vertical jump device (DW771A; SKARO, Seoul, Korea), and the maximum height (in centimeters) was measured. Fatigue was minimized by taking a break of approximately 2 min after the first vertical jump as previously described ⁴⁰. For the measurement, the participants sat on a 43-cm-high chair, crossed their arms at chest level, put their palms on their shoulders, and sat down and stood up for 30 s until their knees were completely straight. The number of repetitions performed in 30 s was recorded.

Morningness-eveningness questionnaire and Pittsburgh sleep quality index

The identification of circadian rhythm types developed previously was translated into Korean (MEQ-K) and applied in the present study ^41,42. The Cronbach's α coefficient for the item internal consistency of the MEQ-K was 0.77, and the reliability and validity were verified with a sample fit of 0.847. The MEQ consists of 19 questions, and a score of 0–6 points is assigned to each question. The results were divided into five categories according to the scores received.

Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI) before and 4 and 8 weeks after the experiment. The PSQI subjectively evaluates sleep quality, including amount, depth, and comfort. This study used the Korean version of the PSQI (K-PSQI) ⁴³. The K-PSQI showed high reliability in terms of internal consistency (Cronbach’s α = 0.84). The PSQI is divided into seven subdomains (subjective sleep quality, sleep latency, sleep time, usual sleep efficiency, sleep disturbance, use of sleeping pills, and daytime dysfunction), each with a score of 0–3. Therefore, the higher the average score over the seven domains, the poorer the sleep quality.

Statistical analysis

The data were analyzed using SPSS version 23 (IBM, Armonk, NY, USA), with significance threshold of p < 0.05. All data are presented as mean ± standard deviations. To test if five groups presented similar characteristics at baseline, a between-group comparison was conducted using one-way ANOVA. Anthropometric characteristics and body composition, physical fitness, Upper and lower extremity muscle functions, and blood lipid and Pittsburgh sleep quality index data were analyzed with a two-way repeated-measures ANOVA that included between-subjects factor of groups and the within-subjects’ factors of time (Baseline vs Post repeated- measures analysis).

Acknowledgments

The authors have no acknowledgment.

Author contributions

Y.H.C. contributed to the conceptualization, data analysis & interpretation, and writing of the manuscript. T.B.S. takes responsibility for data integrity and contributed to the study design, interpretation of the data and revision of the manuscript. Y.H.C. conceptualized, interpreted the data, and revised the manuscript. All authors have reviewed and the approved the final version of the manuscript.

Data availability

The datasets generated and/or analyzed during the current study are available on Figshare. The URL is https://figshare.com/s/ef211a68a712bf1c639e. The DOI is http://doi.org/https://doi.org/10.6084/m9.figshare.25241926.

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Table 3. Baseline to post-intervention comparison of body composition and waist and hip circumference
Parameter		Baseline	Post	p-value
Parameter		Baseline	Post	G	T	G×T
Body weight (kg)
	OCG	68.55±17.41	68.34±17.87	.977	.001	.004
	ARMG	65.07±12.39	64.11±12.02
	RAMG	68.31±8.13	64.81±7.64*
	AREG	66.61±14.62	66.41±15.22
	RAEG	65.85±9.79	64.94±9.85
Body fat mass (kg)
	OCG	27.25±11.37	27.04±11.72	.795	.001	.042
	ARMG	23.22±6.70	22.53±6.12
	RAMG	25.55±5.49	23.06±5.69*
	AREG	25.16±7.79	24.76±8.10
	RAEG	23.70±6.27	22.90±6.12
Percent body fat (%)
	OCG	38.35±5.70	38.30±5.96	.551	.214	.984
	ARMG	35.37±4.21	34.80±3.95
	RAMG	35.82±5.17	35.15±4.38
	AREG	37.27±4.02	36.72±4.41
	RAEG	35.67±5.40	35.10±5.08
Fat-free mass (kg)
	OCG	41.30±6.39	41.37±6.41	.997	.235	.275
	ARMG	41.85±6.76	41.57±6.86
	RAMG	42.76±3.08	41.86±2.77
	AREG	41.45±7.60	41.65±7.75
	RAEG	42.15±5.35	42.03±5.19
Body mass index (kg∙m²)
	OCG	25.65±5.88	25.56±6.03	.898	.001	.003
	ARMG	24.73±3.50	24.37±3.46
	RAMG	26.01±3.01	24.65±3.02*
	AREG	26.06±5.11	26.48±5.29
	RAEG	24.90±3.52	24.54±3.43
Waist circumference (cm)
	OCG	83.10±13.71	80.80±15.03	.951	.001	.731
	ARMG	80.95±8.08	75.36±9.93
	RAMG	81.83±5.50	76.72±7.88
	AREG	85.20±13.75	77.37±16.92
	RAEG	82.03±8.78	77.46±11.70
Hip circumference (cm)
	OCG	100.65±9.70	98.16±12.09	.955	.018	.991
	ARMG	98.23±8.36	94.65±10.38
	RAMG	99.62±7.16	95.18±11.11
	AREG	100.28±8.72	97.57±13.24
	RAEG	100.67±5.98	97.20±11.45
Waist-hip ratio (%)
	OCG	0.82±0.08	0.81±0.07	.980	.002	.169
	ARMG	0.82±0.06	0.79±0.03
	RAMG	0.82±0.04	0.81±0.08
	AREG	0.84±0.07	0.78±0.08
	RAEG	0.81±0.06	0.79±0.04
Values are presented as mean± standard deviation. OCG, obesity control group; ARMG, aerobic-resistance exercise in the morning group; RAMG, resistance- aerobic exercise in the morning group; AREG, aerobic-resistance exercise in the evening group; RAEG, resistance-aerobic exercise in the evening group. G, group effect; T, time effect; G×T, group× time effect. Significantly different from Baseline, *P<0.05

Table 4. Baseline to post-intervention comparison of basic physical fitness
Parameter		Baseline	Post	p-value
Parameter		Baseline	Post	G	T	G×T
Grip strength (kg)
	OCG	23.95±2.65	24.03±2.83	.764	.027	.827
	ARMG	24.69±5.23	25.98±3.89
	RAMG	25.63±2.81	26.91±2.60
	AREG	25.46±6.51	26.64±6.05
	RAEG	25.75±4.99	26.46±5.89
Back strength (kg)
	OCG	55.31±13.11	60.51±7.12	.763	.001	.377
	ARMG	48.78±13.79	60.85±13.03*
	RAMG	58.09±16.23	69.46±10.82*
	AREG	52.43±16.88	70.53±19.34*
	RAEG	57.29±27.24	63.51±19.41
Sit up (reps)
	OCG	15.00±9.32	15.66±8.09	.104	.001	.046
	ARMG	18.87±6.03	22.00±5.90
	RAMG	15.62±8.88	19.62±6.99
	AREG	22.25±8.90	29.25±6.92*
	RAEG	16.77±13.05	25.27±8.87*
Physical efficiency index (score)
	OCG	47.22±2.75	47.21±2.86	.564	.159	.088
	ARMG	46.90±2.17	47.34±4.90
	RAMG	47.28±2.14	49.12±2.30*
	AREG	46.54±1.89	48.78±3.90
	RAEG	44.68±4.44	46.86±5.62*
Values are presented as mean± standard deviation. OCG, obesity control group; ARMG, aerobic-resistance exercise in the morning group; RAMG, resistance- aerobic exercise in the morning group; AREG, aerobic-resistance exercise in the evening group; RAEG, resistance-aerobic exercise in the evening group. G, group effect; T, time effect; G×T, group×time effect. Significantly different from Baseline, *P<0.05

Table 5. Baseline to post-intervention comparison of upper and lower extremity muscle functions
Parameter		Baseline	Post	p-value
Parameter		Baseline	Post	G	T	G×T
Front abdominal power test (cm)
	OCG	1796.11±678.29	1749.44±740.90	.853	.001	.018
	ARMG	1506.25±530.31	2083.12±810.48*
	RAMG	1683.12±514.12	2165.00±501.82*
	AREG	1767.50±576.95	2253.43±755.89*
	RAEG	1988.88±896.22	2126.38±766.03
Left side abdominal power test (cm)
	OCG	1968.33±620.00	2147.33±335.28	.470	.001	.373
	ARMG	1998.75±460.51	2470.00±670.91*
	RAMG	2095.00±668.77	2538.75±396.60*
	AREG	2363.12±702.54	2688.43±661.50*
	RAEG	2076.11±594.19	2549.94±403.18***
Right side abdominal power test (cm)
	OCG	1836.66±528.75	2188.88±359.75	.277	.001	.925
	ARMG	2096.25±456.10	2490.00±662.26*
	RAMG	2063.75±570.83	2432.87±470.75*
	AREG	2345.00±757.92	2820.31±639.09*
	RAEG	2107.77±708.78	2391.77±426.76
Trunk flexor endurance test (cm)
	OCG	37.02±13.07	33.69±13.88	.031	.001	.006
	ARMG	46.40±26.11	88.65±39.00*
	RAMG	34.93±15.81	66.73±30.62**
	AREG	60.34±51.27	116.41±63.77*
	RAEG	50.19±39.10	106.73±76.40*
Vertical Jump (cm)
	OCG	23.61±4.10	23.58±5.55	.852	.001	.372
	ARMG	23.62±3.17	25.75±2.76*
	RAMG	23.43±2.73	25.68±2.83
	AREG	24.43±4.96	26.62±3.43
	RAEG	22.61±4.18	25.36±5.45
Sit to stand (reps)
	OCG	24.66±5.51	26.85±5.16	.838	.001	.024
	ARMG	21.37±3.50	27.37±2.32*
	RAMG	21.75±3.59	30.66±5.40**
	AREG	25.50±5.45	34.62±4.68**
	RAEG	23.88±4.59	31.55±6.28*
Values are presented as mean± standard deviation. OCG, obesity control group; ARMG, aerobic-resistance exercise in the morning group; RAMG, resistance- aerobic exercise in the morning group; AREG, aerobic-resistance exercise in the evening group; RAEG, resistance-aerobic exercise in the evening group. G, group effect; T, time effect; G×T, group×time effect. Significantly different from Baseline, P<0.05; * P<0.01, ** P<0.001

Table 6. Baseline to post-intervention comparison of blood rapid and Pittsburgh sleep quality index
Parameter		Baseline	Post	p-value
Parameter		Baseline	Post	G	T	G×T
Total cholesterol (mg/dL)
	OCG	195.22±23.43	194.03±29.60	.672	.009	.461
	ARMG	237.62±68.80	193.37±33.53
	RAMG	211.37±49.44	193.00±46.18
	AREG	226.25±72.78	209.00±40.01
	RAEG	224.77±56.51	206.66±26.48
Triglyceride (mg/dL)
	OCG	167.11±66.22	152.55±81.55	.312	.732	.790
	ARMG	175.37±73.86	141.37±63.87
	RAMG	210.50±96.52	209.48±86.86
	AREG	146.62±96.06	172.12±68.73
	RAEG	145.00±97.30	144.22±87.25
High-density lipoprotein cholesterol (mg/dL)
	OCG	54.66±11.74	59.44±15.83	.020	.004	.826
	ARMG	60.25±8.41	74.37±19.07
	RAMG	50.87±13.16	59.87±15.34
	AREG	64.62±20.96	70.62±6.63
	RAEG	69.11±18.07	76.00±15.36
Low-density lipoprotein cholesterol (mg/dL)
	OCG	100.00±25.15	83.13±28.12	.366	.664	.127
	ARMG	121.75±53.21	104.85±32.43
	RAMG	109.12±46.95	96.45±35.76
	AREG	116.37±38.14	127.20±66.86
	RAEG	104.16±21.61	126.82±32.04
Fasting glucose (mg/dL)
	OCG	99.66±7.64	101.77±15.88	.073	.162	.594
	ARMG	100.12±6.08	94.12±5.22*
	RAMG	94.75±8.65	91.50±6.36
	AREG	94.50±7.52	91.75±8.39
	RAEG	93.77±7.77	92.22±6.88
Pittsburgh sleep quality index (score)
	OCG	7.66±1.49	7.66±1.41	.003	.001	.015
	ARMG	5.37±2.13	3.87±1.80*
	RAMG	7.62±1.99	5.00±1.11*
	AREG	6.50±1.69	4.37±1.40*
	RAEG	6.88±2.57	4.77±1.48*
Values are presented as mean± standard deviation. OCG, obesity control group; ARMG, aerobic-resistance exercise in the morning group; RAMG, resistance- aerobic exercise in the morning group; AREG, aerobic-resistance exercise in the evening group; RAEG, resistance-aerobic exercise in the evening group. G, group effect; T, time effect; G×T, group×time effect. Significantly different from Baseline, P<0.05; * P<0.01, ** P<0.001

No competing interests reported.

Effects of Intra-Session Exercise Sequence and Circadian Rhythms on Physical Capacity and Sleep Quality in Obese Women

Status:

Version 1

Abstract

Figures

Introduction

Results

Disscusion

Conclusions

Material & Methods