Sunday, June 25, 2023

Healing with CBP After ACL Tear

Previous common belief among clinicians and researchers was that after tearing your anterior cruciate ligament (ACL), chances are you will need reconstuctive surgery. Especially if it affects your activities of daily living like climbing stairs, squatting etc. More so if you wish to return to sports.

Well, latest research shows that one may not need surgical intervention to achieve healing after all. The following paper (Filbay et al, 2023) showed excellent results with the Cross Bracing Protocol (CBP) in patients who tore their ACL. 72 out of 80 participants (90 percent) with a total tear of their ACL at baseline had MRI signs of ACL healing (a continuous ACL) after only 3 months.

Of the 8 participants whose ACL's did not heal, 6 had attached to the lateral wall ± PCL (post cruciate ligament), with MRI evidence after 3 months.

The subjects studied were between 10-58 years old who saw a sports doctor in private practice in Sydney, Australia and followed up from 2016-2021 with MRI confirming acute ACL rupture. They were all managed with the CBP.

The CBP aims to reduce the gap distance between the torn ACL remnants by immobilizing the knee at 90 degrees flexion (or bending) for 4 weeks in a knee brace after acute rupture. This to facilitate bridging of tissue and healing between the torn/ ruptured bits. The subjects also used crutches (or wheelchair, i-walker etc) for up to 8 weeks. After 4 weeks the range of motion is increased weekly whilst the subjects underwent physiotherapist-supervised rehabilitation

Previous published research by Filbay et al (2023) support current findings. The KANON (Knee Anterior Cruciate Nonsurgical versus Surgical treatment) trial found at least 30 percent of participants (16 out of 54 participants) with ACL ruptures had signs of  healing (shown on MRI) with conservative management. (Note:  In the KANON trial, subjects with ACL tears had better outcomes when randomized to rehabilitation and optional delayed ACL reconstruction or early surgery and rehabilitation).

The high rate of healing observed after 3 months on MRI suggests that this CRP can be conducive to ACL healing. It is also heartening to note that patients with other associated injuries at baseline became asymptomatic after the CBP.

But it is not known whether a continous ACL observed on MRI demonstrates restoration of pre injury ACL function. 14 percent (11 patients) had re-ruptured their ACL at time of follow up. This rate of reinjury is comparable with re-injury rates following ACL surgery. 90 percent of these re-ruptures occur after return to high risk sports.

Note that data from this study was collected in the course of clinical practice rather than in a research setting so some adaptations were made to the CBP over time. The study design also did not allow comparison of outcomes with people managed with surgery or rehabilitation alone. 

Looking at the protocol in detail (supplementary detail in appendix 1), one would need to wear a knee brace for 12 weeks while using crutches for up to 10 weeks. Some would definitely choose that considering the potential for positive outcomes. 

Results from the KANON trial and the CBP clearly suggest that there may be more ACL healing than what was commonly known. I would add that larger randomized cohorts with longer follow up duration will add more weight to this protocol. Take collagen at the same time to help with further healing.


Filbay SR, Roemer FW, Lohmander LS et al (2023). Evidence Of ACL Healing On MRI Following ACL Rupture Treated With Rehabilitation Alone May Be Associated With Better Patient-Reported Outcomes: A Secondary Analysis Fom The KANON Trial. BJSM. 57: 91-99. DOI: 10.1136/bjsports-2022-105473. *

Filbay SR, Dowsett M, Chaket JM et al (2023). Healing Of Acute Anterior Cruciate Ligament Rupture On MRI And Outcomes Following Non-Surgical Management With The Cross Bracing protocol. DOI: 10.1136/bjsports-2023-106931

*Some of the authors from this study like Frobell and Roemer first investigated ACL healing with papers published back in 2013. You can read more from our other blog.

Sunday, June 18, 2023

Artificial Sugars Are Not Better

I am sure you know of someone who is trying to cut back on sugar for health reasons since consuming too much sugar is not good for your health. 

'Fake' sugars (artificial sweenteners and sugar substitutues) are very popular since many people consider them to be a healthier alternative to the real thing. Low and zero calorie sweeteners have been used in diet drinks for decades.

Under new Food and Drug Administration (FDA) guidelines (in USA), companies will no longer be allowed to label a food as "healthy" unless it adheres to strict new limits on added sugars. One way food companies can adhere to these proposed rule is to replace added sugars in foods with artificial sweeteners.

So the food industry 'helps' by quietly replacing sugar in packaged food with sucralose, stevia, allulose, erythritol and many other artifical sweeteners and sugar substitutes. These packaged foods include bread, yogurt, muffins, oatmeal, salad dressings, canned soups, condiments and snack bars.

Researchers and scientists used to think that sugar substitutes were mostly inert, that they just activate sweet receptors on our tongues and pass through our bodies without causing any metabolic changes.

Well, latest guidelines from WHO now say that consuming too much 'fake' sugar is much worse. Yes, artificial sweenteners and sugar substitutues might sweeten your food without increasing calories, but studies show that they can affect your gut, metabolic, heart health, promote stronger sugar cravings and affect your insulin resistance, a precursor to Type 2 diabetes.

Since these low calorie sweeteners are so commonly found in the food we consume, most people are not even aware that they are there. They are high intensity sweeteners because the are often hundreds of times sweeter than table sugar. Some are synthetic like aspartame, saccharin and sucralose while others like allulose, stevia and monk fruit extract are referred to as "natural" since they are derived from plants.

Sometimes, they are listed as adventame, neotame and acesulfame potassium, names that are not so easily recognizable at all.

Just so you know, many of these sweeteners are also found in cereals, juices, chocolate milk and other packaged food marketed to kids despite opposition from public health groups.

When subjects were given aspartame, saccharin, stevia or sucralose (even well below FDA's daily allowances), they caused changes both in function and composition of their gut's microbiomes, bacteria, viruses and fungi (Suez et al, 2022) that become detrimental to our metabolic health. 

These microbiomes are very important as they transform the food we eat into enzymes, hormones and vitamins. The microbiomes produce compounds that reduces inflammation, and other health benefits when we eat nutritious fiber rich food like fruits, vegetables and nuts.

In that same study (Suez et al, 2022), saccharin and sucralose worsened subjects' blood sugar control, some more dramtically than others suggesting that these sweeteners have different effects on different people.

Drinking beverages made from sucralose can cause insulin resistance (Yamina, 2018), a precursor to diabetes. Food we eat is normally converted to glucose, which causes the pancreas to release insulin. Insulin either uses the glucose for energy (especially when we exercise) or store the glucose. 

Insulin resistance happens when too much sugar substitute is consumed, disrupting the process (of the pancreas releasing insulin), causing your cells to stop responding properly to insulin and leads to chronically elevated blood sugar levels.

These artificial sweeteners also affect our brains and appetites. The sweet taste receptors on our tongues tells our brain that we are eating something sweet, signaling to the brain and body that an influx of calories are coming. However, these artificial sweeteners are much more potent than normal sugar with fewer or none of the calories, they can confuse the brain and taste receptors causing stronger sugar cravings. 

A large study also found that a high intake of artificial sweeteners increased the risk of strokes and coronary heart disease (Debras et al, 2022), while another study found  that erythritol consumed in large amounts stayed in subjects' system for days and had the potential to cause blood clots (Witkowski et al, 2023).

So what do you do? Eat sugar and be damned. Eat fake sugar and be even more damned. My suggestion is to learn to read food labels and ingredient lists to avoid them or have as little as possible.

Coke Zero is worse than the original

For those less geeky, be very cautious about replacing sugary food with sugar substitutes. It is best not to consume any kind of low or no calorie sweentener in moderation or none at all. Yes! I get to drink real Coke after my long Saturday rides before work! (Me thinking out loud). I never liked diet Coke or Coke Zero anyway. Remember, real sugar is not your enemy during long exercise sessions and definitely not immediately after an intense exercise session.

A simple way is to reduce your intake of highly processed foods since they contain lots of artificial sweeteners and additives.


Debras C, Chazelas E, Sellem L et al (2022). Artificial Sweeteners And Risk Of Cardiovascular Diseases: Results From The Prospective NutriNet- Sante Cohort. BMC. 378: :e071204. DOI: 10.1136/bmj-2022-071204

Rios-Leyvraz M and Montez J (2023). Health Effects Of The Use Of Non-Sugar Sweeteners. A Systematic Review And Meta-Analysis. WHO. IBSN: 978-92-4-004642-9

Suez J, Cohen Y, Valdes-Mas R et al (2022). Personalized Microbiome-Driven Effects Of Non-Nutritive Sweeteners On Human Glucose Tolerance. Cell. 1;185 (18): 3307-3328.e19. DOI: 10.1016/j.cell.2022.07.016.

Witkowski M, Nemet I, Alamri H et al (2023). The Artificial Sweetener Erythritol And Cardiovascular Event Risk. Nat Med. 29: 710-718. DOI: 10.1038/s41591-023-02223-9.

Saturday, June 10, 2023

The Relationship Between Ready To Eat Cereal And Body Weight

Our cooked steel cut oats
A good friend of mine emailed me an article comparing ready-to-eat-cereal (RTEC) with other breakfasts or skipping breakfast altogether. He asked if that's how we remain trim. He knows that my wife and I have steel cut oats cooked with flax seeds, chia seeds, cocoa powder, and maca powder topped with blueberries, bananas, hemp seeds and granola, 6 times a week for breakfast. 

We use Champ Granola
This systematic review found that those who consume RTEC have higher diet quality (vitamins, fiber and wholegrains) and lower incidences of being overweight and obese in adults compared to having other breakfasts (especially meat and egg) or skipping breakfast totally.

A total of 28 relevant studies were found, 14 observational studies and 14 radomised controlled trials RCT). Results from the observational studies showed that frequent RTEC consumers (usually 4 or more servings/ week) have lower BMI, lower prevalence of overweight/ obesity, less weight gain over time compared with non consumers or less frequent consumers (of RTEC).

Definitely not this ready to eat cereal
Results from the RCT's did not have consistent results regarding effects of RTEC consumption on body weight and composition. The RCT's did not show significantly less loss of body weight or weight gain with RTEC consumption (unlike observational studies, which showed better weight outcomes). 

The RCT's suggest that RTEC may be used as a meal or snack replacement as part of a hypocaloric (less calories) diet although this approach may not be superior to other options (like exercise) for those hoping to achieve an energy deficit. Additional long term studies (longer than 6 months) where participants eat less or eat as often as much as they wanted are definitely needed.

My thoughts on the systematic review? I told my friend that the review did not include hot cereals (since they were not considered RTEC). Our breakfast is cooked and topped with RTEC along with a lot of other ingredients. We do not lead sedentary lifestyles, we exercise frequently and we do not sit down much at work.

Individuals with a higher BMI may also decide to skip breakfast to limit their calories and this will contribute to the higher BMI observed in those who skip breakfast compared to RTEC consumers. Moreover, RTEC consumption is generally associated with other healthy behaviours like increased physical activity, greater vegetable consumption and lower likelihood of smoking which will affect analyses.

How does mee pok for breakfast sound?
All the observational studies reviewed were from North America and Europe since people in these countries usually consume RTEC. A lot of Asian countries do not consume RTEC, it would also be interesting to see how data in these countries would differ. 


Sanders LM, Dicklin MR, Zhu Y et al (2023). The Relationshio Of Ready-To-Eat Cereal Intake And Body Weight In Adults: A Systematic Review Of Observational Studies And Controlled Trials. Advanc in Nutri. DOI: 10.1016/j.advnut.2023.05.001

Or nasi lemak?

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.