Sunday, June 4, 2023

Exercise Versus Diet For Losing Weight


Picture of visceral fat from FitTrack
My colleagues and friends think that eating less (calorie restriction) or dieting is much more effective compared to exercise for losing visceral fat (fat stored deep inside our belly, wrapping our liver, intestines and other organs). Subcutaneous fat is fat that is stored underneath our skin.

Visceral fat makes up about one tenth of all the fat stored in our bodies. Visceral fat represents a much bigger metabolic risk than subcutaneous fat and can lead to cardiovascular disease, Type II diabetes metabolic syndrome, cancer and other chronic diseases.

Previous obesity management guidelines recommend the use of exercise and calorie restriction for weight loss. exercise causes fat loss via an increase in energy intake. Calorie restriction (or dieting) results in fat loss via a decrease in energy intake.  Both interventions achieve fat loss via a negative energy balance.

This systematic review used a weekly caloric deficit to control for the overall effects of the 2 interventions. Data from 40 studies involving 2190 individuals were analyzed. 

While both exercise and calorie restriction (dieting) effectively reduced viseral fat, only exercise showed increasing amounts of exercise result in greater visceral fat loss.

The effect of calorie restriction was not dose dependent, meaning that greater calorie deficits do not translate to greater visceral fat loss. You can eat less, but that does not mean you lose more visceral fat.

The authors found that increasing amounts of exercise translate into greater reductions in visceral fat in people who are overweight and obese compared to just eating less. 

A substantial loss of body weight by dieting will also result in a loss muscle mass and this will subsequently decrease basal metabolic rate. A lower metabolic rate would require a further reduction in calories for weight loss and this cannot be continued. Exercising to lose weight may be achievable while preserving or even gaining muscle mass (leading to increase in basal metabolic rate).

The authors conclude that exercise is more effective than dieting for metabolic health improvements, and supports its use for reducing visceral fat in people who are overweight and obese.

Of course it will be quicker and more effective if you eat less and exercise at the same time. But it has to be sustainable, otherwise you cannot keep it up.


Recchia F, Leung CK, Yu AP et al (2023). Dose-response Effects Of Exercise And Caloric Restriction On Visceral Adiposity In Overweight And Obese Adults: A Systematic Review And Meta-analysis On Randomised Controlled Trials. BJSM. DOI: 10.1136/bjsports-2022-106304.

*Thanks to Hui Meng for getting me the article.

Sunday, May 28, 2023

How Much Does The Heat Slow You Down?

I was caught in the rain halfway through my run 2 days ago. Since it has been so hot recently, the coolness the rain brought was very welcomed. I also noticed that I managed to run faster with lesser effort. 

So if the heat (and humidity) affects a short run so easily, how much does it affect us when we race?

When running in hot weather, we need more oxygen since some of the blood flow is redirected from working muscles to the skin to cool us down. This requires more energy usage, increases lactic acid production and a higher heart rate at a given pace compared to cooler weather.

Warmer weather can also cause us to fatigue faster by making us sweat more. This can lead to reduced stroke volume, cardic output and blood pressure.

Research has shown that the optimal temperature range for most groups of runners are between 7-15 degrees Celsius (or 44 to 59 degrees Fahrenheit). Below and above this range, marathon finishing times tend to be slower on average.

Most published research studied elite marathoners timings. At the Boston marathon (Miller-Rushing et al, 2012) more than two-thirds of the men and women's course records were set below 13.3 degrees Celsius (56 degrees Fahrenheit). More than a third were set when the temperature was under 9 degrees Celsius (48 degrees Fahrenheit).

The top 10 fastest marathon performances of all time were set when temperatures were between 10-15 degrees Celsius (50 to 59 degrees Fahrenheit). 

However, I found a comprehensive study (El Helou et al, 2012) that included data from the Paris, London, Boston, Chicago and New York Marathons. The researchers found that most non elite runners (finishing times between 3:30 and 5:00 hours) performed best at temperatures around 6.67 degrees Celsius (44 degrees Fahrenheit).

Once the temperature is higher than 15 degrees Celsius (59 degrees Fahrenheit), perceived effort rises and pace slows for most runners. Runners averaging 5:45 min per mile pace slowed approximately 1 second per mile for each 1 degree Celsius (1.8 degrees Fahrenheit) increase in temperature.

You can use this information on race day for your pace. Say you are capable of a 3:30 hrs marathon. You will need to add 2 to 2.5 seconds to your race day pace for every degree above 15 degrees Celcius (59 degrees Fahrenheit).

Those who averaged between 7:25 to 10:00 per mile slowed between 4 to 4.5 seconds per mile for 1degree Celsius (1.8 degrees Fahrenheit) higher than 15 degrees Celsius (59 degrees Fahrenheit).

Optimal running performances for women tend to be at the cooler end of the range (especially for faster female runners. Women tend to be less affected by rising temperatures than men since women (and elite runners) tend to be lighter. They will usually have lower metabolic heat production due to their lower body mass and their higher surface area to body mass ratio. Less energy is then needed to cool the body, this translates to less stress on the cardiovascular system.

Faster runners also spend less time exposed to hotter temperatures (since they finish ealier) which may be a reason they are less affected than slower runners.

The only consolation is that running in the heat does get easier (especially for those of us who live here in Singapore) with repeated exposures to running in the heat (Lorenzo et al, 2010). If you race in a cooler climate, chances of a faster time is much higher.

Organizers of the Singapore International Marathon used to offer a 1 million dollar bonus to world class runners to break the break the world record here. Rumour has it that the organizers (back in 2014) tried to convince Haile Gebrselassie to make an attempt but was turned down immediately after he learnt about our temperature. He did agree to run the 10 km event though and won it.

Now you know that it will never happen. I do not even think a sub 2:10 hrs run will be possible given our heat and humidity.


El Helou N, Tafflet M, Berthelot G et al (2012). Impact Of Environmental Parameters On Marathon Running Performance. PLoS One. 7(5): e37407. DOI:10.1371/journal.pone.0037407.

Ely MR, Cheuvront SN and Montain SJ (2012). Neither Cloud Cover Nor Low Solar LoadsAre Associated With Fast marathon Performance. Med Sci Sports Ex. 39(11): 2029-2035. DOI: 10.1249/mss.0b013e318149f2c3.

Lorenzo S, Halliwill J, Sawka M et al (2010). Heat Acclimation Improves Aerobic Performance. J App Physiol. 109:1140-1147. DOI: 10.1152/japplphysiol.00495.2010.

Miller-Rushing AJ, Primack RB, Phillips N et al (2012). Effects Of Warming Temperatures On Winning Times In The Boston Marathon. PLoS One. 7(9): e43579. DOI:10.1371/journal.pone.0043579.

*Note that wind, wet-bulb temperature, dew point, precipitation and cloud cover can affect running performance to some degree. But none of them have more influence than air temperature. 

Sunday, May 21, 2023

Do Orthotics Reduce Kneecap Loads In People With Knee Pain?

Many of our patients wear insoles (or orthotics) as they have been told that it 'corrects' their flat feet while helping to reduce excessive forces on their patellofemoral (kneecap) joint. This then helps to prevent kneecap pain.

Customed made orthotic
Well, if you have been told (by your health professional) that you need insoles/ orthotics for the same reasons, now you can tell them that this latest published systematic review/ meta analyses from the BJSM suggests otherwise. This is a very important study since kneecap pain is very commonly seen in in our clinics (and many others) affecting both the young adolescents and older adults. 

The authors identified 33 eligible studies and did 3 different comparisons during walking and running combined. Using insoles/ orthotics with medial (arch) support versus no insoles, minimalist shoes versus conventional footwear and lastly rocker versus non-rocker footwear.

Arch supports
Analyses by the authors showed that insoles/ orthotics that support your medial arches DID NOT alter kneecap loads during walking or running. This questions results from previous research that suggests the pain reducing effects of insoles/ orthotics. The reduction in pain may have been due to other influences and not the reduction in kneecap loads.

Results also show that mimimalist type footwear reduced peak kneecap loads when compared to conventional footwear during walking and running combined. This systematic review demonstrated an average 9.5 percent reduction in kneecap load in minimalist type footwear compared to conventional footwear over a run of just 1 km. This translates to 1,462 kg for an 80 kg person. This is clinically relevant considering the cumulative load reduction that can occur over numerous loading cycles during running.

I've written about this known fact many times over the years. Using results from Daniel Liberman's study (2010), runners who land correctly in their running technique will have benefits as impact is a lot less (even less than landing on your heels with cushioned shoes on).  If you land wrongly (with minimalist type shoes) the impact is 7 times greater thus greatly increasing the chance of injury. See picture below.

Because kneecap loads are reduced, they are transferred to the ankle and foot bones leading to fractures in the foot bones especially when you do too much too soon. Hence, correct technique and patience is crucial using minimalist type footwear. This is why many podiatrists say minimalist type footwear is not good (for you) since they cause foot  and metatarsal fractures, but bear in mind podiatrists also cannot sell you orthortics to place in your minimalist type footwear. 

You have also never seen Kipchoge or any elite marathoners wear these minimalist type shoes in a race. The body's muscles will not be able handle absorbing the load (while wearing minimalist type shoes) while running at the high intensities at which these races are contested.  They are good for training definitely, but not for racing, especially if you are not patient enough to get used to them. 

Evidence regarding the effect of rocker-soled shoes (see below) during walking and running were uncertain due to limited studies.

Take home message from the researchers is that minimalist type footwear reduces kneecap loads compared to conventional footwear in people with or without kneecap pain during running. 

Insoles/ orthotics that support the arches do not alter kneecap load during walking or running. Now you know for sure.


Liberman DE, Venkadesan M et al (2010). Foot Strike Patterns and Collision Forces in Habitually Barefoot Versus Shod Runners. Nature. Jan 463(7280): 531-535.

Kayll SA, Hinman RS, Bryant AL et al (2023). D Biomechanical Foot-based Interventions Reduce Patellofemoral Joint Loads In Adults With And Without Patellofemoral Pain Or Osteoarthritis? A Systematic Review And Meta-analysis. BJSM. DOI: 10.1136/bjsports-2022-106542

MBT rocker-sole shoes
*Thanks to Hui Meng for getting me the article

Sunday, May 14, 2023

Does Eating Fried Food Make You Anxious Or Depressed?

I have a weakness for french fries, I can eat them for all my meals and not get sick of it. Hence, I was not happy when I read that high fried food consumption (particularly potatoes) can affect your mental health.

This recently published study studied data on depression, eating patterns and anxiety levels on eating patterns of 140,278 people collected over 11 years. Subjects diagnosed with depression in the first 2 years were excluded. Follwing that, the researchers found 8,294 cases of anxiety and 12,735 cases of depression in people who ate fried food.

All in all, the researchers found that people who regularly ate fried food (particularly fried potatoes like french fries) were 12 percent more likely to be anxious and 7 percent higher risk of depression compared to those who did not eat fried food. Those who ate fried potatoes had a 2 percent higher risk of depression than those who eat fried chicken (white meat). The associations were more pronounced among male and younger consumers.

The researchers suggested that a chemical called acrylamide formed during frying is responsible for the higher risk of depression and anxiety. This affects the brain lipid (fat) metabolism and affects permeabilty of the blood brain barrier inducing stress mediated neuro (brain) inflammation

An earlier study on 715 Japanese workers (Yoshikawa et al, 2016) also found that there was a "significant positive indirect association" between eating fried food and experiencing depression. The Japanese authors concluded that "frequency of fried food consumption was associated with lower resilience to depression".

I need to point out that the researchers did not prove that eating fried food actually caused anxiety and depression. They merely found a link between eating fried food and an increased risk of anxiety and depression.

The researchers also did not determine whether people were more likely to become anxious and depressed from eating fried food or because they ate fried food when they were feeling down. We all know that fried food is comfort food for many people. People who are feeling anxious or depressed may turn to fried food for comfort.

People who are feeling down and depressed may also have less energy to prepare their own meals. They may then resort to easy and fast (fried) food as do people with overwhelmingly busy schedules. High trans fat in fast food is linked to inflammation leading to mood disorders. Being low in nutrients, fried food also contributes to poor overall diet quality.

So, are we supposed to consume less fried food? Eating too much fried food affects your gut (stomach) microbiome and when your gut does not feel great, it affects your physically and emotionally. 

We definitely need more research to look at how food, weight, diet, mood and other factors interact and affect us. For now, I will continue to eat french fries, but in much smaller amounts.


Wang A, Wan X, Zhuang P et el (2023). High Fried Food Consumption Impacts Anxiety And Depression Due To Lipid Metabolism Disturbance And Neuroinflammation. PNAS. 120(18) e2221097120. DOI: 10.1073/pnas.2221097120.

Yoshikawa E, Nishi D and Matsuoka YJ (2016). Association Between Frequency Of Fried Food Consumption And Resilience To Depression In Japanese Company Workers: A Cross-sectional Study. Lipids Health Dis. 15:156. DOI: 10.1186/s12944-016-0331-3.

Thursday, May 11, 2023

Team Building Event

At first some members of our team suggested trying laser tag for our team building event this quarter. However, after some discussion, we decided to go bowling for our team building event this morning instead. 

Reckon we can be 'professional' bowlers? Have a look.

Of course we got hungry and had lunch together. 

We also celebrated Bryon's birthday (it was yesterday). 

Guess how young he is?
We missed Aized who was not feeling well this morning. Get well soon. Stay tuned for the next team building session.

Sunday, May 7, 2023

Why Agility Matters

I recently had a patient who was was hit by an oncoming skate scooter. Remember when e-scooters and other mobility devices were really popular before being banned for causing too many accidents? They were a nuisance along pedestrian sidewalks where I live and probably everywhere else. 

See who catches it first
I was explaining to her how she needed some agility training to avoid a similar situation. Chances are if she was more agile, she would have had a higher chance of avoiding that skate scooter. 

Agility balls
Agilty is defined as a quick whole body movement with a change in speed or direction in response to a stimulus. Being agile means being able to start, stop, move, hold and quickly change your position.

For example, when you have friend near you who accidentally drops a pen (or worse, their phone), you react quickly to help them catch it. That means you can able to respond quickly to environmental cues. Like moving quickly out of the way on the pedestrian path when a cyclist suddenly swerves into your walking or running path. Being agile (or nimble) can help ward off injury for athletes and non athletes alike. With this skill, you can stay 'forever' young.

Don't mistake agility for speed as agility requires sharper reactions as well as smoother movements. You definitely need speed when running to reach the ball while playing tennis, but agility is what helps re-establish your on court position to prepare for the next volley or drop shot. 

While speed is definitely part of agility, it does not include mutidirectional changes and real time decision making processes. And that is critical to getting ahead in many sports, and in life too.

Other than speed, muscle strength and power as well as stability are important in agility. They also help with activities of daily living like getting the laundry, getting in and out of your car or walking on uneven ground since all of the above needs spatial awareness and physical control.

Agility also engages your brain since it requires mental acuity and awareness. So even non athletes need agility to ward off falls. You need to be mindful of your movement and not just be on autopilot. This helps to reduce the risk of injury as well as prevent falls since you are both mentally and physically spry.

While playing on court or field, agility can determine how a player reponds to different manoeuvers or reacts to an opponent. It can mean being beaten to the ball or scoring the winner. In all ball sports, anterior cruciate ligament (ACL)injuries most often occur during sudden deceleration and change of direction movements. So agility related training can decrease incidences of injuries. This could be the difference between staying healthy or getting injured.

For my patient, I would get her to do some work with deceleration first, to enable her to learn how to absorb impact and stabilize her body. Following that, we can work on agility. I normally get her to practise movements in 3 planes of motion. The sagittal plane (left and right), the transverse plane ( this divides the body into top and bottom sections) and the frontal plane (forward and backward movements).


Sheppard JM and Young WB (2006). Agility Literature Review: Classifications, Training And Testing. J Sp Sci. 24(9): 919-932. DOI: 10.1080/02640410500457109.

Monday, May 1, 2023

How Credible Are Online Fitspiration Accounts?

Lots of fitness influencers have sprouted up especially during Covid-19. They often have photographs and videos showing you how they exercise in the latest fitness fashion attire and accessories. They are also fit-looking, tanned and toned. Popular fitness inspiration hash tags on Instagram include #fitspiration and #fitspo. They appear in more than 100 million posts.

I do not have an Instagram account but if you do, try scrolling through #fitspiration or #fitspo  and you can see lots of thin, athletic women (and men) promoting fitnessexercise and healthy lifestyles.

These 'fitspiration' accounts by health and exercise influencers usually post content to empower other individuals to pursue healthy lifestyles. 

Since so many people look to social media (such as Instagram and TikTok) for information and motivation to exercise, we need to be mindful of the content being presented. How legit are these fitness influencers?

Personally, I feel it is inspiring and easier to get motivated when someone shares his/ her inspirational photos, videos, quotes etc on fitness and health

However, research from Adelaide, South Australia (Curtis et al, 2013) found that nearly 66 percent of the top 100 influencers put up dubious fitness information. 25 percent presented hypersexualized content, nudity, as well as potentially harmful or unhealthy content. Some of these influencers also degraded others.

Many of the accounts promoted unrealistic or unhealthy body shapes with a strong focus on ultra fit, lean and slim physiques. This implies that only thin and toned bodies are considered healthy and beautiful.

A lack of reliable, credible health and fitness content on a platform like Instagram which has more than a billion users all over the world is concerning since body image and self esteem are so important.

So much focus on outward appearances can drive unhealthy reasons to exercise and diet, leading to unhealthy body image issues and concerns.

That same study (Curtis et al, 2013) from South Australia developed a reliable audit tool to help identify credible and non credible fitness and health Instagram accounts. Credible fitspiration accounts can help promote correct participation in exercise and fitness activity. 

Looking for some inspiration to exercise? Make sure you screen the influencers that you follow. You can find the evidenced based audit tool at the end of the article.


Curtis RG, Prichard I, Gosse G et al (2023). Hashtag Fitspiration: Credibility Screening And Content Analysis Of Instagram Fitness Accounts. BMC Public Health. 23,412. DOI: 10.1186/s12889-023-15232-7

Sunday, April 23, 2023

The Millenial And Generation Z Strength Decrease

*Erin and Vean trying to 'outgrip' each other
When I was just starting to work, my dad (from the boomers generation) felt that that my generation was weaker, softer and more fragile than him and his peers. Guess what? I now think the generations after mine (I am Generation X) are even softer. We even call them the *strawberry generation. I suppose every generation thinks that the generation after theirs is weaker than theirs.

Looks like my dad is right. A group of researchers (Fain and Weatherford, 2016) looked at the grip strength of millenials (born between 1981-1996) and compared the data with that of people in the 1980's. They found that grip strength (which is a good indicator of overall strength) dropped by 22 percent in men, proving that millenials are in fact weaker than the previous generation. Generation Z is even weaker.

Hand grip strength assesses the amount of force a person can generate with their grip. Researchers can find out a person's health, rate at which they are aging and diagnose certain health conditions such as heart disease, bone mineral density, cognitive impairment, falls etc.

Grip strength is usually tested with a dynamometer, which a person grasps the same way they would hold a glass, but with the elbow tucked into the side and positioned at right angles. The dynamometer is squeezed for 5 seconds, usually 3 times on each hand and performed on both hands, with the avearge taken.

Research shows that having grip strength lower than average compared to people of the same gender and age group was associated with heart failure risk, death from any cause and even predicting survival from cancer. Note that cancer survival is also dependent on cancer type and time of diagnosis.

Please note that grip strength is also correlated with height, weight and age. Taller, heavier and younger people tend to have better grip strength.

These declines in strength matter because we need a reserve of strength to maintain a high quality of life as we live to our 70's and 80's. 

What is causing each generation to be weaker than the previous? Modern life is less demanding for almost everyone except those still working in high activity jobs like labourers and construction workers. Our children have less physical education, spend less time playing outside and this continues in the army (for boys) and the workplace.

This a sign for our youth to get outside, move your bodies, take care of your physical health just as much as you're spending time on your screens. Then maybe, just maybe, we can stop this trend.

*Thanks to Byron for getting me the articles, and to Erin and Vean for posing for the picture.


Bohannon RW, Bear-Lehman J, Desrosiers J et al (2007). Average Grip Strength: A Meta-Analysis Of Data Obtained With A Jamar Dynanometer From Individuals 75 Years Or More Of Age. J Geriatr Phys. 30(1): 28-30.

Dodds RM, Syddall HE, Cooper R et al (2016). A Global Variation In Grip Strength: A Systematic Review And Meta-Analysis Of Normative Data. Age Aging. 45(2): 209-216.DOI: 10.1093/aging/afv192

Fain E and Weatherford C (2016). Comparative Study Of Millenials' (Age 20-34 Years) Grip And Lateral Ponch With The Norms. J Hand Ther. 29(4): 483-488. DOI: 10.1016/j.jht.2015.12.006.

*The strawberry generation was first described in Taiwan as a term that describes today's young generation who have good ideas and creativity, but bruise easily like strawberries when put under pressure. Meaning they cannot withstand social pressure or hard work like their parents' generation.

Sunday, April 16, 2023

The Longest Race

I definitely remember watching Kara Goucher racing in her first Boston Marathon in 2009. In fact, I always played a video of how her running style was different from Salina Kosgei and Dire Tune when I was giving talks on running technique.

Picture by Tim Kelley from Flickr
The trio ran shoulder to shoulder from Kenmore Square to the final right turn on Hereford Street. Kosgei and Tune broke away from Goucher, and sprinted down Boylston Street. Kosgei was behind Tune before hitting the finishing tape one stride in front, timing her kick to perfection. Goucher finished third, 9 seconds back in 2:32:02 hours. She was sobbing visibly and no one could have guessed what she went through for that podium placing.

I bought a copy of her just released autobiography "The Longest Race" as she reveals her experience of living through and speaking out against the secretive and lavishly funded " Nike Oregon Project" - one of the biggest scandals in distance running.

She revealed for the first time in the book that her Nike Oregon Project coach Alberto Salazar sexually assaulted her twice while massaging her. He also sexually harassed her while flying to competitions (twice he had been drinking and taken Ambien). Salazar is currently banned for 4 years by the US Anti-Doping Agency and permanently banned by the US Center for SafeSport for sexual misconduct.

I was horrified (but not surprised) after reading the details Goucher shared about the sexual assaults since there were earlier stories from other athletes like Mary Cain and Amy Begley. They told of  the physical and verbal abuses they received from Salazar after they came forward earlier while training together.

Throughout the book, a group of men at Nike fostered this misogyny and abuse. Then Nike CEO, Mark Parker, John Capriotti (VP of Nike Track and Field), John Slusher (executive VP of Nike Marketing), Darren Treasure (Hired as Oregon Project's sports psychologist, but never licensed) and Alberto Salazar.

Goucher describes going to the Nike venue 11 days after giving birth, wearing "two sports bras and a diaper under my running tights while completing a timed mile on the track." She felt pressure to get back to training immediately since Nike had suspended her contract when she was pregnant since clauses mandated how often she had to race to receive payment. 

Slusher confirmed that Nike would dock Goucher US$325,000 in pay even though she had made many appearances on behalf of Nike during her leave from competition. Nike even timed her pregnancy annoucement for maximum marketing effect.

Meanwhile, USA Track & Field, governing body of the sport (whose funding is controlled by Nike) had cut off her family's health insurance because her marathon ranking had dropped while she was pregnant.

already know this is common practice thanks to Olympians Allyson Felix and Alysia Montano (pictured below) who shared similar maternal experiences with Nike while pregnant. If Allyson Felix, winner of seven Olympic gold medals and 14-times World Champion in athletics cannot secure maternity protection from Nike, who can?

After reading what happened, who was involved and how the biggest brand in sports allowed this to happen to the their country's top athletes, I'm wondering if we should still be buying that pair of Nike shoes or any Nike merchandise?

How about female athletes in Singapore? I'm hoping that none of our female athletes go through this. We need to make sports safe and fair for everyone.


Goucher K  and Pilon M(2023). The Longest Race: Inside The Secret World Of Abuse, Doping, And Deception On Nike's Elite Running Team. Gallery Books. Simon & Schuster Inc. New York..

*The 127th edition of the Boston Marathon takes place tomorrow on 17th April, 2023.

Sunday, April 9, 2023

Backward Running Is The Way Forward?

Picture from Uthoff et al (2018)
The very first post I did on this blog was back in Jan 2009 on running backwards. I was mainly writing from personal experience then. Did not expect to have written so many (> 900 posts) since then.

Looking back at those first few articles showed me how my writing has changed. The posts now are not purely from personal experience anymore. I always try to make sure it is evidence based. Of course this means it also takes me longer to write them up each week. Definitely have to rack my brains more (to come up with interesting topics) and put in more effort to read up the relevant articles.

I first learnt about the usefulness of running backwards after a guest lecturer taught it during my postgraduate physiotherapy studies in 2003. I definitely incorporated that during my rehab after my 3rd knee surgery done in Adelaide, South Australia.

Back to running backwards. I was naturally pleased to find that an article I read recently found some intriguing benefits. There was an increase both in aerobic and anaerobic demands when running backwards, which can be a good and significant form of training stimulus while running at lower speeds.

Running at lower speeds means it's less taxing on your muscles and joints. You're less likely to get injured. The maximum running speed while running backwards is approximately 70 percent of forward running speed. 

There is also an increase rate in force development and vertical leg stiffness which may help improve running economy.

There are decreased loads on the knee, very good news if you have knee pain and a good form of cross training. This is possibly due to reduced stride length and increased step rates compared to forward running. Definitely beneficial if you're over striding or taking too big steps.

There is also increased activation of quadriceps, hamstringsgastrocnemius and tibialis anterior
with some evidence that it may strengthen these muscles.

Other than my own personal experience, there is empirical evidence to support the use of backward running in training programs both to prevent injuries and improve performance. It can be used as part of warm up for runners and especially for team sports like football, basketball, hockey etc where backward running is essential. 

I did my almost all of my backward runs after my 'normal' runs barefoot on grass, in case you were wondering.


Uthoff A, Oliver J, Cronin J et al (2018). A New Direction To Athletic Performance: Understanding The Acute And Longitudinal Responses To Backward Running. Sports Med 48(5). DOI: 10.1007/s40279-018-0877-5

Saturday, April 1, 2023

April Fool's Day

Our clinic was quiet when I saw my first patient at 830 am today. When I saw my next patient at 9 am, there was a long, long queue past our clinic. The queue started outside Tiong Bahru Bakery (TBB), they are located 2 doors down from our clinic.

Turns out that TBB was giving a free croissant if you buy a drink (limited to 2 per customer). NOT an April Fool's day joke. 

By the time I left the clinic after 4 pm, the line was still going strong. Definitely a very good marketing strategy by TBB. This benefited our clinic too since so many people stood in line watching our patients come and go. More people now know where Sports Solutions is. Perhaps they may even complain of pain after standing so long and visit us another time.

I definitely will not queue to buy a drink to get a free croissant though. But considering how many people came by, hmmm am I the April fool here?

Sunday, March 26, 2023

Sit Up!

I have written previously that there is no posture that fits everyone. What may be deemed as a 'bad' posture may be suitable for another person. Moreover, if 295 physiotherapists (from 4 different countries) can't agree exactly what 'good posture' is then how can the average or non medical professional know.

How to sit up comfortably?
*I won't say that you need to always sit up straight. Case in point, I often slouch and lean back while sitting as it is the most comfortable position for my twice broken back.

However, there are other benefits to sitting up straight it seems. Researchers compared subjects who sat up straight to subjects who slump and found that good posture was linked to higher confidence. 

The participants were asked to think about and write down their best or worst qualities while they were sitting with their backs erect and pushing their chest out (confident posture). Or slouched forward with their back curved (doubtful posture). They then completed a number of measures and reported their self evaluations. The ressearchers found that sitting up straight boosted their assuredness in their ideas (Brinol et al, 2009).

Another study by Peper et al (2018) tested how sitting position affected students tested on their feelings about math tests. Students who were good at Math experienced no difference taking the test slouching or sitting up straight. The students who were anxious about Math found the test more manageable when sitting up straight. 

So taking a brief moment to breathe and adjust your posture before a tough conversation with your boss or a big presentation at work can help you navigate important moments with confidence. How we carry ourselves doesn't just affect our bodies, it also affects our brains.


Brinol P, Petty RE and Wagner BC (2009). Body Posture Effects On Self-evaluation: A Self-validation Approach. E J Social Pysch. 39(6): 1053-1064. DOI: 10.1002/ejsp.607

Peper E, Harvey R, Mason L et al (2018). Do Better In Math: How Your Body Posture May Change Stereotype Threat Response. NeuroRegulation. 5(2): 67-74. DOI: 10.15540/nr.5.2.67

*Too many companies have spent money on ergonomic programs to prevent back pain. This usually involves a health professional/ physiotherapist (trained in ergonomics) checking your office chair/ desk height, screen height/ position with respect to your keyboard/ mouse to ensure everything is lined up in a straight line.

However, there is very little evidence linking back pain to poor posture. Oops, this basically means a huge profitable industry on work place/ home office ergonomics that has VERY LITTLE sound evidence. 

All the published research to date has shown that there is no relationship between any postural factors causing back pain. This includes the shape and curves of the back, asymmetries and how we use our backs.

Yes, if you already suffer from back pain, you may feel it more while sitting, especially for long periods. But not sitting up straight is not the cause of the back pain.

Wednesday, March 22, 2023

Should A Chiropractor Manipulate Your Neck?

ST article on 220323
An article from the Straits Times today, on page C4 under the Life section. It was originally published in the New York Times  2 days earlier. There was a big uproar last year because a chiropractor there caused a patient, Caitlin Jensen to be paralyzed after he manipulated her neck.

Actually there were already many complaints against chirpractors back in 2020 during the midst of the coronavirus pandemic. The International Chiropractors Association (ICA) posted 2 reports that claimed that chiropractic care can help the immune system implying that they may be helpful in preventing Covid-19. (Cote et al, 2020). 

More than 150 researchers from 11 countries found no valid clinical scientific evidence that chiropratic care can prevent impact the immune system. They asked that appropriate action be taken against those making unsubstantiated claims that spinal adjustments can boost immunity or benefit patients with infectious diseases, especially Covid-19 infections.

This recent episode merely added fuel to the fire.


Cote PB, Bussieres A, Cassidy JD et al (2020). A United Statement Of The Global Chiropractic Research Community Against The Pseudoscientific Claim That Chiropractic Care Boost Immunity. Chiropr Man Therap. 28, 21. DOI: 10.1186/s12998-020=00312-x

There has been previous unhappiness against chiropractors in Singapore too. Here's the Straits Times article.

Sunday, March 19, 2023

How To Wake Up Alert And Refreshed

Do you go to bed early, sleep through the night and still wake up tired and groggy? - Well, it happens to me quite regularly. Turns out that I'm not alone. A study found that fewer than 1 in 3 Americans are getting enough restorative sleep (Robbins et al, 2022). 

You may say that the Americans have more distractions, but in Singapore, 41 percent of adults get between 4 to 6 hours of sleep a night only, even though they should be clocking in 7 to 8 hours.

Not only do we have insufficient sleep, the vast majority of us are not getting the right kind of sleep. So we wake up less alert, have less energy and poor moods in the morning. Low quality and/ or quantity of sleep has terrible far reaching effects, from short term ability to focus to long term risk for chronic diseases.

The good news is that there is a way to fix this. Another published study by Vallat et al (2022) listed 3 steps we can do to eliminate that groggy feeling we get when we wake up. The researchers studied 833 twins and genetically unrelated adults and demonstrated that how effectively one wakes up during the hours following sleep is not assocated with genetics. 

They found 4 independent key factors. sleep quality/ quantity the night before, physical activity the day prior, a breakfast rich in carbohydrates and a low blood sugar level following that breakfast. 

The researchers found that sleeping in for an extra 30 minutes on a morning when you need it was associated with increased alertness in that morning. Physical activity (or exercise) the day before also had a strong link to feeling alert and awake the next morning. The more exercise the better it seems.

Breakfast matters. Participants who ate a breakfast high in low glycemic carbohydrates like whole wheat bread, oats, brown rice felt more alert. However, eating breakfasts that were sugary or high glycemic carbohydrates (muffin, cereal bar, white bread, potatoes) and excessive protein had the opposite effect. 

That's the secret to waking up alert and refreshed every morning. So definitely don't skip breakfast.


Robbins R, Quan SF, Buysse DJ et al (2022). A Nationally Representative Survey Assessing Restorative Sleep In US Adults. Frontiers In Sleep. Vol 1. DOI: 10.3389/frsle.2022.935228

Vallat R, Berry SE, Tsereteli SE et al (2022). How People Wake Up Is Associated With previous Night's Sleep Together With Physical Activity And Food Intake. Nat Commun 13,7116. DOI: 10.1038/s41467-022-34503-2

Sunday, March 12, 2023

Don't Ignore The Small Stresses

Breathtaking sunset
Most of us can ignore the smaller things that irk us. Like a rude sales staff, a terse message from your manager, or even a full basket of laundry not done. We ignore the smaller micro-stresses and just focus on the big stuff since the small things do not evoke the fight or flight mechanism. Unlike getting hit with big, bad news like getting fired from your job or a serious illness.

The small things that require our attention can definitely add up. Even when we ignore them our bodies do not. Small stresses can trigger some of the same physical effects as big stresses including increasing blood pressure and lower quality sleep (Cross and Dillon, 2023).

This is often why we feel exhausted or even defeated at the end of the day, even if nothing big went wrong. They can eventually have an outsized impact on our mental and physical health.

A really interesting study by Kiecolt-Glasr et al (2015) found that even a relatively minor social stress experienced within 2 hours of a meal can affect your metabolism of that meal by adding 104 calories to that meal. If that occurs daily, it adds up to 11 pounds (or 5 kg) a year.

We can all take steps to be more aware and address the micro stresses in our lives. Communication helps. Speak to your boss if he/ she is routinely annoying you by not giving you enough time for datelines. Or call your child if he/ she does not respond to your messages. You will be surprised at how much eradicating a small but repeated stressor can boost your mood.

Cross and Dillon's research shows that people with robust personal lives, i.e. those having family, friends and hobbies that keep them occupied tend to be less affected by work related micro stresses.

Practicing meditation and mindfullness can clear your mind and clear away the big and small stresses.  Being both grateful and thankful for what you have helps too.
So I am doing just that, enjoying the rainbow and the breathtaking sunsets while on holiday with my family now. 


Cross R and Dillon K (2023). The Microstress Effect: How Little Things Pile Up And Create Big Problems - And What To Do About It. Harvard Review Press. 18 April 2023.

Kiecolt- Glaser JK, Habash DL, Fagundes CP et al (2015). Daily Stressors, Past Depression, And Metabolic Responses To  High-fat Meals: A Novel Path To Obesity. Biol Psychiatry. 77(7): 653-660. DOI: 10.1016/j.biopsych.2014.05.018