Sunday, June 16, 2024

Does Eating Just Before Sleeping Make You Fat?

My elder son (pictured above) is on a muscle building spree. He's been trying to strength train while eating lots of protein. I've also mentioned to him that consuming protein right before sleeping would lead to greater improvements in muscle strength and muscle size. 

When he was 9 in 2019
He then mentioned that he had watched videos on Tik Tok that suggested that eating just before sleeping will make one fat

Is that what you think too? That eating before sleep makes you accumulate fat because you are resting for many hours after you eat. Well, let me show you that this is untrue. Note that this is with pre-sleep protein consumption. 

Data from men and women show that consuming protein pre-sleep does not change overnight fat metabolism (breakdown of fats to be used as energy). When research participants consume either caesin protein (found in milk, cheese and yoghurt) or a non caloric placebo, there was zero difference in the overnight fuel use or energy expenditure. There was also no difference in the amount of fat liberated from the fat cell measured with a technique called microdialysis.

This may be a big surprise to you as it is often thought that eating before bed will inhibit fat metabolism. Now you know it is not true. Protein consumption helps improve strength, recover from strenuous exercise as well as maintain and improve metabolic and structural health. Evidence suggests that the average person should consume 1.2 grams of protein per kilogram of body weight per day. Athletes should consume closer to 2 grams per kilogram of body weight.

Pre-sleep protein has also been found to decrease next morning hunger. Adequate protein consumption also promotes satiety, leading to a reduction in over-eating.

Plant protein my son consumes
What type of protein should you eat before bed? Recent literature suggest no difference in muscle recovery after pre-sleep consumption of dairy/ animal or plant-based (rice/pea) combination as long as enough of each is consumed. It also comes down to dietary preference. Most of the earlier research used whey or casein proteins due to a high leucine (thought to trigger growth) content. 

Whey and casein protein were more popular previously due to their ease of digestion and availability. Especially since plant based protein were not so easily available then and they cost more. Most pre-sleep protein research uses casein followed by whey protein since plant-based protein has less leucine. A greater amount of plant-based protein is needed to be consumed to elicit the same response compared to a lower amount of animal-based protein.

Hence pre-sleep protein consumption does not make you gain fat. Now you know.


Allman BR, Morrisey MC, Kim Js et al (2020). Lipolysis And Fat Oxidation Are Not Altered With Presleep Compared With Daytime Casein Protein In Resistance-trained Women. J Nutr. 150(1): 47-54. DOI: 10.1093/jn/nxz186.

Kinsey AW and Ormsbee M (2015). The Health Impact Of Nighttime Eating: Ols And New Perspectives.Nutrients. 7(4): 2648-2662. DOI: 10.3390/nu7042648

Saracino PG, Saylor HE, Hanna BR et al (2020). Effects oF Pre-sleep Whey Vs Plant-based Protein Consumption On Muscle Recovery Following Damaging Morning Exercise. Nutrients. 12(7): 2049. DOI: 10.3390/nu12072049.

Snijders T, Trommelen J, Kouw IWK et al (2019). The Impact Of Pre-sleep Protein Ingestion On The Skeletal Muscle Adaptive Response To Exercise In Humans: An Update. Front Nutr. 6(16). DOI: 10.3389/fnut.2019.00017.

Sunday, June 9, 2024

Understanding The Recovery Of The Intervertebral Disc

Picture from Wikipedia
I came across a recent paper (Feki et al, 2024) about the positions which help our intervertebral discs recover and heal when we sleep. I have written at least 5 articles on intervertebral discs. This is definitely still a topic that I get questions from most often among my friends and patients alike. Almost every single one of my friends and patients are fearful of having a 'slipped intervertebral disc' whenever they have low back pain (LBP). The intervertebral discs (IVD) have a really bad reputation for causing significant pain and disability in many people.

Here's a quick review if you did not read those 5 articles.

The IVD consists of a very tough outer layer called the annulus fibrosis (AF). It is made of of several layers of fibrocartilage consisting of Type I and II collagen fibers. The AF protects the soft, gel-like substance in the middle known as the nucleus pulposus (NP). The NP helps distribute pressure evenly across the IVD and prevent excessive forces on the spine.

See how thick the AF is from the picture above? Here's something else you need to know. There is a cartilaginous endplate between the AF and the vertebra (the spine). The endplates hold the IVD in place. It allows load to be spread evenly and to provide attachment to the IVD. This creates a super strong connection to the AF making it impossible for the IVD to 'slip' out of position.

Yes, our discs are actually very strong and hardy. How strong are our IVD's? In a published study on thoracic discs in the young (28 years old plus minus 8 years) , it took about 740 pounds of force to compress the disc height 1 mm. For the older subjects (70 years young plus minus 7 years), it took almost 460 pounds of force. Note that these are on cadavers with the muscles and bones cut away (Stemper et al, 2010).

The IVD's withstand a whole variety of complex forces in our daily activities and also when we exercise. This can lead to significant structural changes in terms of volume, area and height of the intervertebral disc. It can lead to an increase in disc stiffness and a decrease in interdiscal pressure.

In order for your discs to remain healthy and strong, it is dependent on a recovery phase which serves to prevent premature disc degeneration. This happens during a period of nocturnal rest i.e. when you sleep at night.

This phenomenon of disc recovery has been documented extensively through many studies using MRI and intradiscal pressure measurement. Fluid dynamics (water content) within the disc are considered a primary factor in recovery, while it's intricate multiscale structure and viscoelastic (behaving with both liquid-like and solid-like) properties also play key roles.

Feki et al (2024) in their review collated, analyzed and evaluated the existing in vivo (human) and in vitro (in controlled environments) on this topic to provide a comprehensive understanding of this recovery process to enable future advancements in medical treatment and biomedical enginerring solutions to enhance the natural recovery processes of intervertebral discs.

As it is a very long (and complex) review article (Feki et al, 2024), I am simply highlighting the optimal recovery positions (pictured below) for intervertebral disc rehydration. 
Picture from Feki et al, 2024
(a) prone (b) modified press up/ push up position (c) supine with under knee and back support
(d) and (e) side lying with lumbar flexion with pillows between legs
(f) and (g) side lying with and without manual distraction
(h) 50 degrees gravity assisted position (i) 110 degrees supported sitting
(j) inclined sitting with lumbar support

So, you see from the pictures that some of the supposedly 'poor' posture/ positions you were told, are actually good for your intervertebral discs.


Feki F, Zairi F, Tamoud A et al (2024). Understanding The Recovery Of The Intervertebral Disc: A Comprehensive Review Of In Vivo And In Vitro Studies. J Bionic Eng. DOI: 10.1007/s42235-024-00542-2

Fournier DE, Kiser PK, Shoemaker JK et al (2020). Vascularization Of The Human Intervertebral Disc: A Scoping Review. JOR Spine. 15: 3(4): e1123. DOI: 10.1002/jsp2.1123.

Stemper BD, Board D et al (2010). Biomechanical Properties Of Human Thoracic Spine Disc Segments. J Craniovert Junct Sp. 1(1): 18-22. DOI: 10.4103/09774-8237.65477

Sunday, June 2, 2024

A Better Way To Train Your Quads

Leg extension exercise
Those of you who go to the gym would have been told to sit up straight when doing the leg extension exercise. Well, perhaps that may not be the best way to do the leg extension exercise. Especially if you want to get bigger and stronger quadriceps femoris muscles (below).

Right quadriceps femoris muscle
A recent study (pictured below) was initiated by Larsen et al (2024) to compare the effects of sitting upright (90 degrees hip flexion) versus recumbent sitting (40 degrees hip flexion).

The participants' right and left lower limbs were randomly assigned to the hip flexion 40 degrees or 90 degrees for the leg extension exercise. Note that 0 degree is no flexion (or bending) in the hip joint, like in standing.The participants in the study had a familiarization session at week 1 so they knew what to do.

The subjects then completed a 10 week training program comprising of 2 strength training sessions each week. This consisted of 3 sets of exercises from week 1-5 and from week 6-10 onwards, 4 sets of exercises. They performed either 15-20 reps of leg extension or if they cannot reach 15-20 reps to failure (where the quads cannot do another rep).

2 pre and post training measurements on the proximal and distal rectus femoris and vastus lateralis muscles were done with ultrasound imaging to compare results.

The findings were that the quadriceps femoris muscle hypertrophied following the 10 weeks of strength training. The rectus femoris part of the quadriceps femoris had significantly greater hypertrophy in both the proximal and distal regions at 40 degrees of hip flexion compared to 90 degrees hip flexion. 

There were however no hypertrophy changes in the distal proximal and distal regions of the vastus lateralis muscle. This finding was expected as the vastus lateralis is a single joint muscle and its muscle length was constant and did not change during both hip positions.

The authors concluded that performing the leg extension exercise with 40 degrees of hip flexion had superior increases in hypertrophy of the rectus femoris muscle compared to 90 degrees hip flexion. So definitely not always true that you need good posture/ exercise form when exercising.

This is attributed to the longer muscle length in the rectus femoris when the leg extension exercise is performed with the hip at 40 degrees flexion. Note that the rectus femoris is a 2 joint muscle where it can both flex the hip and extend the knee. The other 3 muscles in the quadriceps femoris are capable of only extending the knee. This makes the rectus femoris most prone to muscle strain injuries especially when sprinting and kicking.

The authors suggest that training the rectus femoris with 40 degrees hip flexion would make it stronger and offer a protective effect against rectus femoris strain injuries.


Larsen S, Kristiansen BS, Swinton PA et al (2024). The Effects Of Hip Flexion Angle On Quadriceps Femoris Muscle Hypertrophy In The Leg Extension Exercise. Sport Rxiv. DOI: 10.51224/SRXiv.407

Sunday, May 26, 2024

What Does The Fibularis Longus Muscle Have to Do With Knee Pain?

R Peroneal Longus (Peroneal Longus)
After 3 previous knee surgeries, and also seeing many patients (with knee pain) over the last 25 years I've learnt a lot about treating knee pain. So I was pleasantly surprised to learn more and hopefully get even better at treating knee pain.

Many of our patients come to our clinic with patellofemoral joint pain (PFP) or pain in the front/ side of the knee especially during loading activities like running, walking, squatting, jumping and going up and down stairs. Studies have shown that 23 percent of all adults will get PFP, and 50 percent of them will experience PFP that lasts up to 20 years!
I've written previously that the hip often affects the knee too. Well, a group of researchers found differences in fibularis longus (or peroneal longus) muscle size and even activation between individuals with PFP and healthy controls. This was done using ultrasound imaging in weight bearing (Jaffri et al, 2024).

Of the 60 subjects (30 healthy, 30 with PFP) investigated, there was a statistically significant result for the healthy group in the size (larger) and activation for the fibularis longus (or peroneal longus) muscle.  The group with knee pain had smaller fibularis muscle and it did not work (or switch on) as quickly as those without knee pain.

Note that besides its role as a evertor of the foot, the fibularis longus works together with abductor hallucis longus to stabilize the medial longitudinal arch after heel strike. Hence slower activation and smaller (weaker) of the peroneal longus muscle in a weight bearing position may contribute to arch flattening in PFP subjects. This add to faulty mechanics at the foot and ankle joints. 

This further explains the fact that the smaller (and weaker) the fibularis longus is, the higher likelihood of the foot pronating. This leads to knee valgus (knee facing inwards), which is a major biomechanical abnormality in individuals with PFP.

I am certain not every health professional reading this will agree since clinical treatment guidelines to treat PFP are still being developed as there is a lack of agreement about what actually causes PFP. Not everyone agrees that hip adduction, increased knee internal rotation, foot pronation etc causes PFP.

If you have persistent knee pain that does not seem to go away, please show the health professional treating you this article. Other than the hip, your fibularis longus muscle may help with your knee pain. And I am not talking about just strengthening it.

Better still, come see us at our clinics.


Jaffri A, Schwarting A and Beallow A (2024). Impairments In Peroneal Muscle Size And Activation In Individuals With Patellofemoral Pain In Weight-bearing Position. J Foot Ankle Res. 17: e12014. DOI: 10.1002/jfa2.12014

Fiblaris logus is part of the lateral line

Sunday, May 19, 2024

10 Bodyweight Squats Or Walk 30 minutes?

Last week I wrote about how a fast or slow metabolism does not influence your weight gain or weight loss. For those of us who run or exercise to manage our weight, it definitely does burn calories while you are exercising, but it does not boost your metabolism, at least not in the long term. 

Well, I can suggest a fairly simple way to improve your blood sugar regulation better than a single 30 minute walk if you're pressed for time. Also helps to lower cancer and cardiovascular related mortality.

A recently published study (Gao et al, 2024) on overweight and obese subjects who either sat uninterrupted for 8.5 hours or had interruptions while sitting with matched energy expenditure and duration. A 30 minute walk at 4 km/hr, sitting with 3 minutes walking at 4km/hr or squatting 10 times every 45 minutes.

The authors found that doing 10 body weight squats every 45 minutes or short frequent walking breaks during a 8.5-hour period of sitting improved blod sugar regulation better than a single 30 minute walk (at 4 km per hour).

These superior benefits seemed to be associated with increased muscle activity intensity in their targeted muscle groups during frequent transitions from sitting to activity.

These brief, intense bursts of activity (bodyweight squats in the study) termed 'exercise snacks' offer a simple yet strong strategy to mitigate the health risks associated with our sedentary lifestyles. It is not too difficult to get up from sitting and do 10 bodyweight squats every 45 minutes (or when you can). You can also do burpees or run up stairs to break up sedentary periods. Those at home may want to do some dumb bells/ kettle bells swings.

Of course some other people may prefer to walk outside for fresh air, sunlight meeting other people and psychological/ mental health benefits. Or a combination of exercises and walks. Works well too. Go on and add some some exercise snacks into your day.


Gao Y, Li QY, Finni T ey al (2024). Enhanced Muscle Activity During Interrupted Sitting Improves Glycemic Control In Overweight And Obese Men. Scan J Med Sci Sp. 34(4): e14628. DOI: 10.1111/sms.14628

Stamatakis E, Ahmadi MN, Gill JMR et al (2022). Association Of Wearable Device-measured Vigorous Intermittent Lifestyle Physical Activity With Mortality. Nat Med.28: 2521-2529. DOI: 10.1038/s41591-022-02100-x

Sunday, May 12, 2024

Will My Metabolic Rate Slow Down As I Age?

Picture from Genesispersonalfitness
Looks like we have been very wrong about our metabolic rates. Whether our metabolic rate is fast or slow, it cannot predict weight gain. 

Metabolisms varies by 20 percent or more from person to person regardless of activity level or body composition (Rimbach et al, 2022). So for those of us who run or exercise to manage our weight, yes it does burn calories, but it does not boost our metabolism, at least not in the long term. 

The researchers also found that if you happen to be on the skinnier side, it is not that you have a faster metabolism (Rimbach et al, 2022).

The researchers measured metabolism using doubly labeled water. Participants in their studies drank water containing hydrogen and oxygen isotopes, which researchers can track in the body. How quickly they lost the isotopes through peeing, sweating and even breathing were monitored. These enabled them to ascertain how many calories are burned in that time, or what is known as total energy expenditure i.e. metabolism.

The total energy expenditures studied were measured at 2 time points, ranging from 2 weeks to more than 8 years. Body size and composition were adjusted for since more cells burned more calories and fat and muscle burned calories at different rates. 

The researchers found that the subjects' daily energy expenditures did not change over time. A person with high metabolism today will have it high in a few months or even a few years. Likewise, a person with slow metabolism today will still have it slow in a few months or a few years.

Here's the good news. The researchers found that having a slow metabolism did not make people more likely to gain weight. Nor did having a fast metabolism less likely to gain weight.This is attributed to the human brain's outstanding ability to match calories consumed to calories burned in the long run.

So, running or any exercise is not a magic metabolism booster. Exercise is complex and it affects how our body regulates all its cells, which in turn affects hunger, fullness, immune function and even behaviour. 

Those who exercise will obviously see day to day fluctations in the calories burned. More on long runs/ hard days compared to recovery days. Our bodies adjust how much energy we use during our non exercise hours to keep the total caloric burn within a fairly narrow range.

So, you do not gain weight as you age because your metabolism slows down (Pontzer et al, 2021). We have all been mislead by this myth. We should not use it as as excuse. You gained weight because we do not move and/ or exercise as much and because we may have lost some muscle mass.


Pontzer H, Yamada Y, Sagayama H et al (2021). IAEA DLW Database Consortium. Daily Expenditure Through The Human Life Course. Science. 373(6556): 808-812. DOI: 10.1126/ science.abe5017

Rimbach R, Yamada Y, Sagayama H et al (2022). Total Energy Expenditure Is Repeatable But Not Associated With Short-term Changes In Body Composition. Nat Commun 13,9. DOI: 10.1038/s41467-021-27246-z

Friday, May 10, 2024

Cold Play?

ST 100524
I just wrote about how cold (ice) immersions were not effective last week! And Straits Times does a full page article on the front of their Life Section today (100524).

"I noticed a significant improvement in my alertness and reduced muscle soreness after including cold therapy ....." said a business owner selling ice baths.

No, evidence says cold immersions does not help with recovery. Actually cold immersions inhibits recovery. Researchers (Roberts et al, 2015) have found that cold water immersion after hard exercise suppressed signaling pathways associated with recovery. This suppression lasted for several days.

The newspaper article also credited Wim Hof (the Dutch iceman) for popularising cryo or ice therapy - just like my post. Purveyors of commercial health and wellness have definitely jumped on the same bandwagon. I cannot comment on the various beauty and skincare benefits (such as reduction in cellulite and what not) as touted by the wellness professionals quoted. Please do your due diligence.


Roberts LA, Raastad T, Markworth et al (2015). Post-exercise Cold Water Immersion Attenuates Acute Anabolic Signaling And Long-term Adaptations In Muscle To Strength Training. J Physiol 593(18) : 4285-4301. DOI: 10.1113/JP270570.