Friday, March 27, 2020

Boosting Your Immune System While Exercising During The Coronavirus Outbreak

My cycling group has been discussing how to do our regular Saturday group ride after new restrictions by the government to restrict groups to not more than 10 people together. Or risk a $10,000 fine and a stint in jail for six months or both.

With non stop news regarding the coronavirus alerts, we definitely still need to exercise as we need a break from all the stress and anxieties that have come up daily. Don't know about you, I do definitely.
Beautiful morning
Personally, I feel that running or cycling outside is great for clearing my mind and releasing all that pent up energy. Getting out early in the morning, seeing the sun come up, hearing the birds and smelling the morning air is really nice for me. Both our minds and bodies need that.

So how do we stay safe and ensure that our exercise/ workouts now helps rather than suppress our immune system?

For those of you who are like me and need to keep on exercising, here are some basic guidelines. Do watch your intensity and duration of your exercise. Evidence suggests that being physically active makes you less vulnerable to falling sick. Data by researchers show that physically active people are 40-50 percent less likely to have days ill with acute respiratory infections.

Evidence suggests limiting sustained efforts greater than 60 percent heart rate max to not more than 60 minutes at a time. To get more bang for your buck, you can mix some high intensity efforts with rest or periods of lower intensity. That happens during our group bike rides. After riding hard for a while, we do slow down to recover. I guess stopping at the traffic lights counts too.

However, before you go out and train/ exercise harder with all the time you have now, take note that more is not always better. If you train too hard (a hard long run or a few hours of training), it actually leads to an increase in stress hormones, inflammatory changes and an increase in free radicals that will be harmful to your body.

Though this is a temporary effect, if you are under mental or emotional stress, not sleeping enough and eating poorly, it can make you more susceptible to falling sick.

In their laboratory, the researchers found that the stress starts when your intense efforts exceeds 60 minutes. It gets really bad after 90 minutes.

This is not the time to push your limits. Even for elite athletes, it's more about your health than your fitness levels.

There is plenty of data supporting regular, moderate exercise being protective of your health. You will get the most out of your exercise when you allow time for sufficient recovery. If you're tired, take a rest day, especially if you feel a slight hint of an illness coming. Do get enough sleep, eat well and manage your stress.

In this time of fear, danger and uncertainty, please take care of yourself and stay safe.



Nieman DC and Wentz LM (2019). The Compelling Link Between Physical Activity And The body's Defense System. J Sp Health Sci. 8(3): 201-217 DOI: 10.106/j.jshs.2018.09.009.

Nieman DC, Lila MA and Gillitt ND (2019). Immunometabolism: A Multi-omics Approach To Interpreting The Influence Of Exercise And Diet On The Immune System. Ann Rev Food Sci Tech. 10: 341-363. DOI: 10.1146/annurev-food-032818-121316.

Sunday, March 22, 2020

Her Coach Asked Her to Skip Breakfast

I wrote about the ketogenic diet the week before and a runner I treated two days ago was advised to skip breakfast before her runs to get into the "ketogenic zone" so that she can burn more fat.

I was fairly skeptical as I doubt you can be ketogenic and start burning ketones just by skipping breakfast despite not eating from dinner time the night before.

Anyway, I told her an article I'd just read on a similar topic while doing research writing the earlier ketogenic diet article.

British researchers studied elite cyclists who were habitual breakfast eaters on two occasions. One one occasion, they arrived at the laboratory in an overnight fasted state and ate breakfast. On the other occasion the did not eat breakfast (like my patient).

Researchers found that elite cyclists had a 4.5% drop in a 30 minutes time trial race in the evening after skipping breakfast. This is even after allowing the cyclists to eat as much as they want for lunch.

Due to our busy schedules, we may not be able to exercise in the mornings. While rushing to work, we may even skip breakfast.

The results showed that skipping breakfast may only be effective in reducing calories for people who eat breakfast regularly (and this helps to lose weight) in the short term.

However exercise performance may be compromised through out the whole day if you skip breakfast. Not great at all if you're exercising or training again later in the day. This will be worse if you're competing later in the day.

Don't skip breakfast.


Clayton DJ, Barutcu A et al (2015). Effect Of Breakfast Omission On Energy Intake And Evening Exercise Performance. Med Sci Sp Ex. 47(12): 2645-2652. DOI: 10-1249/MSS.0000000000000702.

Have a look at this article where a high-carb diet trounces low-carb one for endurance athletes.

Sunday, March 15, 2020

Coronavirus And Running

My patient who saw me yesterday was complaining that the Boston Marathon originally scheduled on 20th April next month has been postponed to 19th September. She had also planned to run Berlin originally, but with the change in dates that may not pan out.

This is the first time in the race's 124 year history that the race will not take place in April. Other than the Boston marathon, new reports of other international race cancellations are coming in on a regular basis.

In sunny Singapore, The Sunday Times today reported that the Sundown Marathon on May 23rd has been cancelled. This race had 23,000 runners last year. Other local postponed races this year includes next month's JP Morgan Corporate Challenge and the 2XU Compression Run (picture above).

I can understand how runners are disappointed that all their training may have come to waste. After all the sacrifices, preparation and training done, it must be terrible not to be able to race.

The Singapore government has rolled out "social distancing" guidelines to further limit the spread of COVID-19. As many of my patients who run have commented, running is the optimal sport now since everyone is encouraged to avoid crowded, enclosed spaces whenever possible. All of us who run or cycle alone sometimes are already practicing a form of "social distancing" unprompted.

Of course we are not running away from others when we go running alone. We run or cycle alone to preserve our sanity, to analyze and solve problems that crop up.

With so many races in limbo, some of you may question why you train hard when there seems to be nothing to train for. To run hard means to subject yourself voluntarily to varying degrees of discomfort. And pushing yourself hard in a workout means you're resisting the urge to stop.

Yes, because of the coronavirus, many races have been and will be cancelled. But we have other reasons to run, we can run for the satisfaction that comes from confirming our resilience to no one else but ourselves, our ability to endure, to not stop.

I don't race anymore, but I'm definitely still running to get my adrenaline rush.

If you have to self quarantine and cannot go out for a run, maybe you can try emulating Pan Shancu who ran 6,250 laps around two large tables set up inside his apartment. One lap around the tables measured about 8 meters and he ran 50 km in 4:48:44 hours!!

Sunday, March 8, 2020

Can The Ketogenic Diet Help With Weight Loss And Sporting Performance?

Picture from The Star
I couldn't believe my eyes when I saw two of my patients two days ago (both husband and wife are in their 50's). Both had lost 12-15 kg while on a ketogenic diet supplemented by going to the gym occasionally in less than three months. The husband even showed me a six-pack for his abdominal muscles. He said that he hadn't had them since his teenage years. I was shocked to say the least.

It seems like the ketogenic diet (eliminating carbohydrates) is all the rage in the fitness world nowadays. The ketogenic diet is similar to the caveman diet I've written about way back in 2009. It is probably time for me to revisit that low carb, high fat diet since I get questions on whether it is a good to be on a keto diet? Whether it helps to lose weight and most importantly whether it makes you stronger or faster as an athlete?

Those on the ketogenic diet follow a strict guideline to consume 80 percent of their calories from fat, 15 percent from protein and just 5 percent from carbohydrates.

After you eliminate carbs from your diet, your body goes into a state of ketosis where it uses fat for fuel. It uses the available fatty acids to produce ketones such that when your body is in ketosis, eating more fat will enable you to burn more fat.

While it is clear that you can definitely lose weight (or fat) while on the ketogenic diet, I am more interested if it helps sporting performance.

Previously I had questioned if carbohydrate loading was still relevant. The 1983 article quoted in that post is frequently quoted in the ketogenic community. The cyclists in that study underwent a 4 week ketogenic diet showed they used significantly more fat compared to a high carbohydrate diet.

Yes, fat burning was significantly ramped up (since they had 4 weeks to get used to the diet), time trialing ability remained unchanged but high intensity power was affected. There was a severe restriction on the ability of the cyclists to do anaerobic work.

Sports scientists around the world subsequently experimented with various fat adaptation protocols and kept coming up with same problem. The ability to sustain race pace was not a problem but sprint ability was always compromised.

Louise Burke, head of Sports Nutrition at the Australian Institute of Sport got together 19 elite 50 km race walkers preparing for the 2016 Rio Olympics over two training camps. They spent 3 weeks adapting to a low carb, high fat diet as the 1983 Phinney study had prescribed. Results confirmed that these elite walkers became super efficient at fat burning. The bad news was these fat adapted walkers became less efficient, requiring more oxygen to sustain their pace. This is a big liability while racing.

Consider an elite runner in the Boston marathon when a fellow runner surges on Heartbreak hill and he/ she cannot follow, the race may then be lost. Or for a cyclist (who on a low carb, high fat  diet) competing in the Tour De France on daily stages where breakaways or sprints to break up a pack is the norm and he cannot sprint to keep up then he definitely has no chance for a stage victory.

This is because high fat diets don't just ramp up fat burning, they actually decrease carbohydrate usage by decreasing the activity of a key enzyme called pyruvate dehydrogenase or PDH.

However, if you are doing ultra distance racing then the loss of sprint power isn't a big deal at all since you are more interested in completing the distance under a certain time rather than outsprinting a fellow runner. Especially when a bigger challenge for an ultra runner is refueling. Those of you who have done ultras will know what I mean when you are so sick of eating a sports gel or a banana after 12 hours without needing to go to the toilet.

It will be so much better and easier for your participation if you can rely less on external carbs while drawing on your fat reserves.

Take home message is that the low carb, high fat diet is effective for losing weight (but long term effects are not known).

If you're on the keto diet and exercising and/ or racing at 60% of your V02 max then your exercise efficiency should remain the same once you have gotten use to the diet. This mean that for moderate efforts no problemo, performance is not affected.

However if you're exercising/ racing over 70% V02 max, i.e. when you're going faster, charging uphills, it will not be the best diet plan for you.


Burke LM, Ross ML et al (2016). Low Carbohydrate, High Fat Diet Impairs Exercise Economy And Negates The Performance Benefit From Intensified Training In Elite Race Walkers. J Physiolo. DOI: 10.1113/JP273230

Phinney SD et al (1983). The Human Metabolic Response To Chronic Ketosis Without Caloric Restriction: Preservation Of Submaximal exercise Capability With Reduced Carbohydrate Oxidation. Metabolism. Aug 32(8): 768-776.

Thank you for reading this long article.

*Olympic 50 km race walkers were chosen for Louise Burke's experiment as the event is among the longest in the Olympics, with the winning time just under 4 hours. Also for the rules of sport that forbid race walkers from breaking into an all out sprint, making the loss of high end power less of a problem. Burke published a very famous article called "Fat adaptation for athletic performance: The nail in the coffin?" in 2006.

She, however softened her stance in 2015 with another article "Re-examining high-fat diets for sports performance: Did we call the nail in the coffin too soon?".

Also note that Kenyan runners get 76.5% of their calories from carbohydrates (including 23% from ugali, a sticky and stomach filling cornmeal starch) and 20% from loads of sugar in their tea and porridge.

Ethiopian runners get 64.3% of their calories from carbohydrates (biggest contribution from injera, a sourdour flat bread made from an Ethiopian grain called teff).

If there's a better alternative diet than carbs for better endurance performance, the Kenyans and Ehtopian runners certainly are not following that.

Sunday, March 1, 2020

Patient Has 'Tight' Upper Trapezius Muscles?

My patient came in to our clinic yesterday complaining of 'tightness' in his upper trapezius muscles. He saw me two weeks ago for his R knee pain and that had settled, but now it was discomfort in his upper trapezius area. He had been using the trigger ball in his upper trapezius area and there were marks all over the area.

Other than tightness, he was complaining of a deep ache and constant discomfort there. He thinks this sometimes causes him to have headaches and neck pain as well.
Upright scapula
What gave me the most clues was looking at him from the side view. While looking at him from his left side (I'm using the picture above to keep his identity anonymous), his trunk was tilting backwards with respect to his hips. However, when I got him to straighten up you can see his left scapula tilting forward (right side of the picture below).
See how his left scapula tilts forward
Having explained to him what I saw, I then proceeded to treat him. I did not do any deep tissue massages/ or release his upper trapezius muscles (the area of his complaint). Neither did I stick any needles there to relieve the 'tight' muscle tone. I did not even treat his neck.

So what did I do? I treated his Front and Back Arm Lines. Yes, you read correctly. I treated his arms. If you look at work done by Tom Myers, he's able to dissect the "arm lines" (see picture below) from a cadaver.

In the picture on the right, the Superficial Back Arm Line has been laid over a skeleton model to show the fascia connections.

My patient was amazed, fascinated and happy that I got him better just by treating his arms. He almost couldn't believe it.
Treating the Deep Front Arm Line is key to getting his condition better because of the anterior tilting scapula. Treat the cause of the problem, not the pain.
Deep Front Arm Line