May 15, 2007

Welcome to the Harvard Health Publications e-Newsletter.

This e-Newsletter is one in a series of monthly e-Newsletters. Each issue will bring you valuable information on various topics — news you can use to live a healthier, happier, and more fulfilling life. We hope you enjoy this and all of the issues to come.

In this issue:
+ Couple therapy
+ Moderate exercise: No pain, big gains
+ Why regular check-ups are still a good idea
+ What the latest diet trial really means

Couple therapy

Psychotherapy for two and two for psychotherapy

The problems that confront the clients and patients of mental health professionals arise mostly in marriages and other intimate relationships. Marriage and family difficulties account for about half of all visits to psychotherapists, family therapy is increasingly popular as a mental health specialty, and most family therapists work chiefly with couples. The term “couple therapy” (or “couples therapy”) is gradually replacing the older “marital therapy” in order to include unmarried and gay couples.

Licensed couple therapists include psychiatrists, psychologists, clinical social workers, psychiatric nurses, pastoral counselors, and marriage and family therapists who have taken specialized courses and undergone supervised training in the field. The therapist assumes that the unhappiness of a couple amounts to more than the sum of their individual problems and symptoms. They may be concerned about emotional distancing, power struggles, poor communication, jealousy, infidelity, sexual dissatisfaction, and violence. The therapist helps them examine their lives together and decide what changes are needed. They work on eliminating mutual misunderstandings, unreasonable expectations, and unstated assumptions that perpetuate conflict.

Couple therapists make little use of psychiatric diagnosis, but they do use many of the same methods employed by individual therapists: interpreting emotional conflicts and the influence of the past; assigning exercises for behavior change; challenging beliefs; offering advice, reassurance, and support; teaching social skills and problem solving. If the relationship is moribund, some couple therapists believe that they can help the couple make a break with a minimum of recrimination, bitterness, and suffering.

Family systems and patterns

Family systems theory was once dominant and is still influential as a blueprint for couple therapists. It emphasizes the patterns of communication, action, and reaction that create and reinforce a family environment. In an unhappy couple, the system resists change because it has reached a maladaptive equilibrium, just as individual symptoms may resist change because they preserve individual emotional balance. The couple may have unknowingly set rules for themselves that are working poorly. The therapist helps them become aware of these rules and patterns as a prerequisite to changing them.

Sometimes each partner demands too much of the same thing from the other — service, protection, care. Sometimes they adopt complementary roles. One member of the couple takes charge and the other becomes incompetent. An overbearing and emotionally distant husband responds to his dependent or melodramatic wife by becoming still more overbearing. A strong wife is constantly angry at her passive husband, whose passivity only increases. The husband or wife of a depressed and hypochondriacal person may act as a healer and savior.

Couple therapists try to help both individuals understand the function of their contributions to the system. The passive partner might learn about his need to suppress rather than productively express anger. “Saviors” may see how that role helps them deny their own sense of helplessness. An emotionally distant husband could learn about the fear of strong emotion. A dependent wife might confront her wish to avoid managing her own anxieties. By acknowledging their own contributions to the conflict, members of a couple can begin to weigh the benefits and costs of the bargain they’ve made with a partner.

When the two are not communicating well, verbally or nonverbally, each one may behave as though certain principles are accepted when they are not. For example, one partner believes the other has agreed that he or she can stay at work as long as he or she thinks is necessary, but the other thinks he or she has implicitly agreed to be home for dinner. Other misunderstood implicit promises include: I need a certain amount of sex, a certain degree of financial security, or a certain number of friends.

Family systems therapists often employ the concept of the double bind, a situation that results when members of a couple send mutually contradictory messages — often one in words and the other through the silent communication of emotion. The partner must not acknowledge the contradiction or respond to the underlying intentions if he or she wants to maintain the relationship. For example, one partner asks the other to come to him or her and stiffens at the other’s approach. The second partner withdraws, and the first one says, “Why are you so cold?” The second person has no response: To point out what is going on would only alienate the first partner further. Eventually people who are communicating — or failing to communicate — in this way find it difficult to say what they mean, understand what the other person means, or even distinguish real from simulated feelings. Family systems therapy is designed to uncover and solve problems of this kind.

Behavioral couple therapy

Behavioral treatment of couples provides three kinds of help: behavioral exchange, communication training, and problem-solving training.

In behavioral exchange, each partner is helped to identify a desired change in the other partner’s behavior, and they agree to reciprocate. The therapist encourages them to follow through and show gratitude. Communication training shows the couple how to listen sensitively and express their needs without accusations. From exercises in problem solving, they learn how to define the issues that generate conflict, find specific solutions, negotiate, and compromise.

Either during therapeutic sessions or as homework, behavior therapists may prescribe tasks that reveal maladaptive patterns. A woman might be told to exaggerate her criticism of her partner until he challenges her. If a couple is drifting apart, the therapist might arrange for the man (or woman) to be sure to come home for dinner four or five nights a week.

Many behavior therapists also try to change the way each member of the couple responds to undesired behavior. They may also employ cognitive restructuring — changing the way the partners interpret one another’s behavior. They learn to avoid using words like “always” and “never,” to examine evidence before blaming the other, and to consider the consequences of living by doubtful implicit assumptions (such as the belief that you should never be angry at your partner).

Emotionally focused couple therapy

Another kind of treatment, drawing on ideas from the client-centered therapy of Carl Rogers as well as family systems theory, concentrates on emotion rather than behavior. The therapist helps the couple recognize the emotions that drive their conflict as a precursor to stopping the resulting troublesome behavior patterns. They expose their vulnerability and express unacknowledged feelings, then reconsider their situation in the light of these feelings to work out new solutions.

Often the problem is stated as a matter of interrupting or escaping from rigid response patterns or cycles. In one pattern that arises repeatedly, an angry, critical, complaining partner confronts one who is defensive and withdrawn. The therapist helps the angry partner to feel his or her desperation about not getting through and the consequent fear of abandonment, while urging the withdrawn partner to temporarily disregard the feeling of being attacked and — instead of acting defensively — to listen to the concerns and respond with support.

Emotionally focused couple therapy may encourage the couple to reframe their problems in terms of attachment needs. The premise of attachment theory is that a safe emotional bond with another person is a basic survival need, providing a home base in the world. From infancy on, we all need contact with others who care for us and respond sensitively to our needs. Attachment patterns usually appear first in the relationship between parent and child and are often repeated throughout life.

A secure attachment provides both comfort and room for independent exploration. When attachment is insecure, people may become angry, and — if there is no response — depressed and despairing. They may also develop a distorted attachment that takes the form of anxious clinging, or a combination of the two, exemplified by the double bind: “Come here to me, I need you” and “You are dangerous, go away.”

Couples often seek help when they have sustained an “attachment injury” — a crisis involving infidelity, financial deception, violence, deeply insulting words, or another apparent betrayal. One of the partners may feel emotionally abandoned at a critical moment such as job loss or serious illness. Divorce or separation may be threatening.

In therapy, at first the injured partner may angrily or sadly recount the incident while the offending partner minimizes the damage or becomes defensive. The injured partner is encouraged to show grief and fear instead of anger, and the offending partner is encouraged to acknowledge responsibility and show remorse. Then the injured partner may ask for comfort and care that was unavailable at the time of the incident, and the offending partner may come through, helping heal the attachment injury.

An example: Mary has discovered that her husband John had an affair three years ago. They’ve never discussed it, but John complains that she repeatedly reminds him of it. It is a typical pattern of anger and defensiveness. She worries about what he does when he goes out alone, and when he is at home he feels under siege and retreats to a room alone. Over a period of several months, the therapist helps him talk about his feelings of shame, and he tearfully expresses his sorrow and his love for her. As the complete range of their feelings becomes more apparent to both of them, she begins to move past her injury and expresses genuine forgiveness.

Psychodynamic couple therapy

Psychodynamic therapists believe that the way adult couples treat each other is strongly influenced by patterns established in childhood — lessons learned, mostly unconsciously, in their birth families. The therapist emphasizes unconscious wishes and the defenses, also mostly unconscious, that divert or prevent the full expression of those wishes.

Psychodynamic couple therapists sometimes pay special attention to projective identification, a defense that involves disavowing your own impulses or wishes, attributing them to another person, and behaving in a way that elicits responses that convince you that your attributions are right. A husband can’t bear his own dependency or weakness and overcompensates by being controlling and rigid as an expression of strength. This evokes dependent behavior in his wife — which he can both identify with and resent. Projective identification can perpetuate a painful attachment when, as often happens, the partner uses the defense in a complementary way. In this example, the wife may need to disavow her own aggression, so her dependency also evokes even more rigidity and hostility in her husband. Such complementary patterns, psychodynamic therapists believe, often originate in childhood relationships with parents.

Psychodynamic therapists explore the influence of the past partly by pointing out how feelings originally directed at members of the birth family have been transferred to the partner, and sometimes to the therapist, too. They also show how emotionally charged fantasies blend with present reality. If all goes well, the members of the couple succeed in separating their feelings about one another from their feelings about their own parents and past experiences.

The individual and the couple

Individual psychiatric symptoms and the problems of couples are related in complicated ways. Often there is a vicious cycle in which a relationship is endangered by the withdrawal and irritability of a depressed person, the aggressive and impulsive behavior associated with mania, the need for constant reassurance resulting from anxiety, or the multifarious ravages of alcoholism and drug addiction. Conflict between the members of the couple exacerbates these symptoms until it is difficult to tell where the cycle began. According to some versions of family systems theory, individual symptoms serve to maintain arrangements that prevent change both partners need but fear.

Couple therapists may concentrate on specific actions that exacerbate individual symptoms, or they can enlist one partner as a surrogate therapist or coach. Partners can help with treatments such as relaxation training, exposure and response prevention, or cognitive restructuring, while monitoring changes as the therapy progresses and providing the therapist with information.

Alcoholism has been treated successfully with forms of behavioral couple therapy called community reinforcement and Project CALM (Counseling for Alcoholic Marriages). Emotionally focused couple therapy may be helpful for depressed people when the depression is associated with an insecure attachment. It has also been used for survivors of child abuse and Vietnam veterans suffering from traumatic stress reactions. Dialectical behavior therapy for couples can relieve depression and reduce emotional volatility in people with borderline personality disorder.

Individual and couple therapy are often combined. For example, a woman marries a divorced man with two young sons from a previous marriage, gives birth to a girl, and develops a postpartum depression. Her stepsons, already feeling displaced by the new baby, become angry and defiant. She is reminded of her own unhappy relationship with her stepmother and feels as though she is turning into an evil stepmother herself. The marriage is affected, and the couple seeks therapy. Her depression is part of the problem and might best be treated additionally with medications and her own psychotherapy.

In cases of serious domestic violence, the trend is to separate the partners instead of treating them jointly. Some professionals reject the idea of couple therapy for batterers because it may suggest that someone or something other than the instigator of violence is to blame. But others believe that a combination of individual and couple therapy may be workable as long as the violence has stopped, the victim does not fear retaliation, and the perpetrator admits responsibility. The therapist must always make it clear that no alleged provocation justifies violence.

How effective is couple therapy?

Most studies find that couple therapy can be helpful, at least for a while, but not all studies meet the highest standards. It’s also unclear whether the treatment can transform unhappy relationships into satisfactory ones, and whether the effects last. Behavioral couple therapy and emotionally focused couple therapy have been found more effective than a waiting list in controlled studies. The American Psychological Association approves behavioral couple therapy as “well established” and emotionally focused couple therapy as “probably efficacious.” Other reviews support the value of cognitive behavioral couple therapy and family systems therapy.

Some of the research has raised doubt about whether all the components of behavioral or emotionally focused couple therapy are necessary, and whether these techniques work in the way that the underlying theory proposes.

Improvement is usually maintained for six months, but often there is a relapse after a year or two. In a four-year follow-up, the longest so far, researchers found that 38% of couples treated with behavioral couple therapy were divorced. But in some cases, a divorce — especially if it is amicable — may represent a good outcome. A two-year follow-up indicated that a year of therapy for a couple in which one partner was depressed gave better results — and produced fewer dropouts — than antidepressant drug treatment.

There is only a little evidence on who couple therapy works best for. Younger couples seem to improve more in some studies. One study found that couples did better when they had been together longer; another, that couples with the most serious problems were least likely to benefit; and still another, that in heterosexual couples, therapy worked out better when the woman was the main problem solver in the family.

Like individual therapists, couple therapists are becoming more eclectic in their approach. A method called integrative couple therapy combines emotional acceptance with behavioral strategies. Therapists are also trying different approaches with different couples, or emphasizing features that all treatments have in common, such as the therapeutic alliance.

According to the United States Department of Health and Human Services, the number of specialists in marriage and family therapy has increased from about 2,000 in 1966 to almost 50,000 in 2007. The American Association for Marriage and Family Therapy estimates that more than 3% of the nation’s 57 million married couples see a psychotherapist for marital difficulties each year. The line between enhancement and therapy is becoming blurred with the development of programs aimed at preventing marital conflict and improving relationships. Because it is increasingly understood that emotional disturbances and behavior problems originate between people as well as within them, psychotherapy for two will continue to thrive.


American Association for Marriage and Family Therapy
(703) 838-9808

National Registry of Marriage Friendly Therapists

All rights reserved.
Harvard Mental Health Letter
Volume 23 - Number 9 - March 2007

Moderate exercise: No pain, big gains

America is in the grip of an energy crisis. The rising costs and dwindling supplies of fossil fuels get all the press, but from a medical view the real crisis involves human energy — or the lack thereof. In the United States and throughout the industrial world, insufficient exercise is a major cause of disability and death. In America, it is an important contributor to four of the six leading causes of death: heart disease, cancer, stroke, and diabetes. In all, sedentary living accounts for some 250,000 premature deaths annually. That means about 10% of all the deaths in America are caused by sloth, as are about 23% of our chronic illnesses. It’s a staggering burden of illness, death, and expense, and it’s all the more tragic because it’s unnecessary.

Scientific studies have been documenting the health benefits of exercise for decades, but fewer than 25% of Americans get the exercise they need. What accounts for the gap between theory and practice?

In part, we are victims of our own success. Before the industrial revolution, about a third of all the energy used in American agriculture and manufacturing was provided by human muscles; now, that contribution is minuscule. We don’t exercise because we no longer have to.

Cultural preferences and economic pressures add to the problem. The average American adult spends 170 minutes a day watching television and movies and 101 minutes a day driving but less than 19 minutes a day exercising. “Spectator” is a kind word for it; we are truly a nation of couch potatoes.

The medical profession can’t do much about America’s entertainment industry, advertising empire, or economic imperatives. And even if we could turn back from the information age, few would want to. But doctors can, and should, deal with another set of barriers to healthful exercise that they have erected themselves. The first is the confusing mix of exercise guidelines; for example, the surgeon general advocates 30 minutes of moderate exercise a day, while the Institute of Medicine calls for 60 minutes and the 2005 Dietary Guidelines for Americans recommend 30 to 90 minutes. The second barrier has its roots in the very movement that put exercise on the map, the aerobics revolution.

The aerobics doctrine

The scientific study of exercise blossomed in the 1960s and ’70s. Its principal research tool was the maximum oxygen uptake test, which measures the amount of oxygen sucked up by the lungs, pumped by the heart, and delivered to the muscles during maximal exertion on a treadmill or stationary bicycle. Improvements in the maximum oxygen uptake, or VO2 max, quickly became the gold standard for judging the efficacy of exercise.

Research in many labs demonstrated that optimal improvement in the VO2 max depends on vigorous exercise. The best results come from exercise intense enough to raise the heart rate to 70% to 85% of its maximum, prolonged enough to sustain that intensity for 20 to 60 minutes, and frequent enough to occur three to seven times a week. The aerobics doctrine was born.

In 1975, the American College of Sports Medicine issued its first exercise guidelines, calling for all healthy adults to exercise at aerobic intensity (60%–90% of maximum) continuously for 20 to 30 minutes at least three times a week. These standards were soon adopted with only minor modification by the American Heart Association and the U.S. Department of Health, Education, and Welfare, and they remained in effect for more than two decades.

Unintended consequences

The aerobics doctrine gained acceptance just as Frank Shorter, Bill Rodgers, and Joan Benoit Samuelson showed that Americans could run, so running became the emblem of aerobic exercise and the marathon was installed as the icon of success. Despite extraordinary individual achievements, however, the aerobics revolution did not succeed in getting our nation off its duff.

The aerobics doctrine inspired the few but discouraged the many. A relatively small number of lucky people discovered the benefits (and pleasures) of aerobic exercise. But based on the data at hand and with the best of intentions, doctors discouraged people who found aerobics too hard from getting moderate exercise by proclaiming that aerobic intensity was essential for benefit. For example, the Gospel of Aerobics preached that golf was the perfect way to ruin a four-mile walk, but we now know that’s wrong.

Fitness vs. health

Sound studies showed that aerobic training is required to build optimal aerobic fitness. Epidemiological studies soon confirmed that fit people are healthy people, with reduced risks of coronary artery disease, hypertension, stroke, and diabetes, and a reduced mortality rate. These data remain valid: Aerobic training is excellent for fitness and health.

Without contradicting the value of aerobics, studies show that it is possible to get nearly all the health benefits of exercise without reaching high levels of aerobic fitness. The answer is moderate exercise. In this formulation, intensity is less important than the net amount of exercise, and intermittent exercise is as effective as continuous activity. In fact, golf is very beneficial indeed as long as players walk the course and play two to three times a week.

The benefits of moderate exercise

For most people, aerobic exercise is daunting. Moderate exercise should be much more appealing and accessible, but the message has not yet produced results. Part of the problem is the lingering belief that it’s a distant second best to aerobics — that walking is a pale imitation of running. When most people think of exercise, be they health care professionals or other folks, they hear the voice of their old coach barking, “No pain, no gain.” For the 100-yard dash, your coach was right — but for health, moderate, painless exercise is extraordinarily beneficial.

Table 1 summarizes 22 studies that show how moderate exercise influences the risk of cardiovascular disease and mortality. Covering more than 320,000 people around the world, the studies are eye-opening.

Table 1: Some recent studies of moderate daily activities

Population group

Type and amount of activity

Observed benefit

10,269 Harvard alumni

Walking at least 9 miles a week

22% lower death rate

Climbing at least 55 flights of stairs a week

33% lower death rate

836 residents of King County, Wash.

Gardening at least 1 hour per week

66% lower risk of sudden cardiac death

Walking at least 1 hour per week

73% lower risk of sudden cardiac death

1,453 middle-aged Finnish men

At least 2.2 hours of leisure-time activity a week

69% lower risk of heart attack

4,484 Icelandic men aged 45–80

Spending at least 43 minutes a day on leisure time physical activity after age 40

16% lower risk of stroke

73,743 American women aged 50–79

Walking for at least 2.5 hours per week

30% lower risk of cardiovascular events

44,452 American male health professionals

Walking at least 30 minutes a day

18% lower risk of coronary artery disease

39,372 American female health professionals

Walking at least 1 hour a week

51% lower risk of coronary artery disease

72,488 American female nurses

Walking at least 3 hours a week

35% lower risk of heart attack and cardiac death

34% lower risk of stroke

30,640 Danish men and women aged 20–93

Spending 2–4 hours a week on light leisure-time activity

32% lower mortality rate

4,311 British men aged 40–59

Performing light to moderate physical activity

35%–39% lower mortality rate

1,404 female residents of Framingham, Mass.

Performing moderate physical activity

37% lower mortality rate

802 Dutch men aged 64–84

Walking or biking at least 1 hour per week

29% lower mortality rate

707 retired Hawaiian men, aged 61–81

Walking at least 2 miles a day

50% lower mortality rate

9,518 older American women

Walking up to 10 miles a week

29% lower mortality rate

229 postmenopausal American women

Walking 1 mile a day or more (a 10-year randomized clinical trial)

82% lower risk of heart disease

7,951 pairs of Finnish twins

Exercising at least 30 minutes on at least 6 days per month

43% lower mortality rate

6,017 Japanese men aged 35–60

Walking (to work) for 21 minutes or more on work days

29% lower risk of developing hypertension

1,645 Americans aged 65 and older

Walking more than 4 hours a week

27% lower mortality rate

31% lower risk of hospitalization for heart disease

3,206 Swedish men and women aged 65 and older

Performing physical activity at least once a week

40% lower mortality rate

3,316 Finnish men and women with type 2 diabetes

Performing moderate leisure-time physical activity

18% lower mortality rate

1,204 Swedish men and women aged 45–70

Walking or performing demanding housework

54% (men) and 84% (women) lower risk of heart attacks

2,229 European men and women aged 70–90

Performing moderate physical activity

37% lower mortality rate

Source: Simon, HB, The No Sweat Exercise Plan: Lose Weight, Get Healthy, and Live Longer (New York: McGraw-Hill, 2006).

Because all but one of the research publications summarized in Table 1 are observational studies, they cannot prove a cause-and-effect relationship between a particular activity and an observed benefit. Still, it’s highly likely that a causal relationship exists. Scientists have demonstrated the clear health benefits of exercise in animal experiments. Randomized clinical trials in humans prove that regular moderate exercise can produce a broad range of improvements in risk factors (cholesterol, blood sugar, blood pressure, body fat, etc.) that can be expected to improve health and reduce the risk of many diseases. Moreover, the large number of observational population studies done around the world suggests strongly that the biological plausibility of benefit is a clinical reality.

Although we don’t have the advantage of randomized clinical trials to evaluate the effects of exercise on cardiac events and mortality in healthy people, doctors have performed 48 such trials in patients with proven coronary artery disease. About half of the 8,940 patients were randomly assigned to receive the best medical and surgical care available; the others got the same standard of care plus enrollment in cardiac rehabilitation programs based on moderate exercise. The exercisers came out on top; in all, they enjoyed a 26% reduction in the risk of death from heart disease and a 20% reduction in the overall death rate. It’s powerful evidence that exercise protects the heart — and what’s good for ailing hearts should be at least as beneficial for healthy ones.

If cardiovascular risk reduction were the only benefit of moderate exercise, it would still be vitally important for every physically able individual. But it has many other benefits. Exercise is an essential partner with a healthy diet for people who need to lose weight. And many observational studies also suggest that “no sweat” exercise can help reduce the risk of stroke (by 21%–34%), diabetes (16%–50%), dementia (15%–50%), fractures (40%), breast cancer (20%–30%), and colon cancer (30%–40%). If that’s not enough to get Americans moving, consider that exercise is also one of the two available ways to slow the physiological changes associated with aging; severe caloric restriction is the other. None of these benefits requires aerobic intensity; in science, as in the fable, the tortoise will do very nicely indeed.

A 2005 analysis of data from the famed Framingham Heart Study reports that people who exercise regularly enjoy 3.7 years of additional life expectancy when compared with sedentary individuals. An intensity equivalent to walking at a pace of 17 minutes per mile was sufficient. And another 2005 study showed that moderate exercise (walking 8.6 miles a week at 40%–55% of maximum) will even increase the VO2 max, though not to the same degree as aerobic training.

Cardiometabolic exercise

One of the barriers to getting people moving is the academic distinction between exercise (formal structured activity to promote fitness) and physical activity (everything else). In our busy world, most people do not feel they can set aside time for formal exercise, especially intense workouts. In fact, the distinction is both arbitrary and misleading. Any physically active undertaking will contribute to health if it is part of an active lifestyle. Raking the lawn and cross-country skiing are at opposite poles of a single spectrum of benefit. Activities at the low end of the spectrum require more time than those at the high end, but they are also safer and less likely to produce injuries — and the health benefits are remarkably similar.

What should we call the broad spectrum of activities that contribute to health? The usual scientific words (aerobic, anaerobic, endurance, isometric, isotonic) are not quite right. That’s why we’ve proposed the term cardiometabolic exercise (CME) to emphasize the health benefits of everything from moderate activity to aerobic training, from washing the car by hand to hitting the elliptical. And it is meant to emphasize that even at the low end of the spectrum, exercise has major benefits for the cardiovascular system (coronary artery disease, hypertension, stroke, arrhythmias, peripheral artery disease, etc.) and metabolism (body fat, blood sugar and insulin levels, cholesterol, etc.).

Coining a term is one thing, setting realistic goals another. Health professionals have access to a rich literature that evaluates the intensity of exercise in units such as METs, kilojoules, and kilocalories. But to help real people understand the relative value of various activities, we’ve translated these measurements into a simple CME point system. Table 2 shows some examples of “CME points.”

Table 2: Cardiometabolic exercise points for selected activities






CME points


Daily activities



30 minutes




30 minutes


Digging in yard


30 minutes




30 minutes


Mowing lawn

Pushing hand mower

30 minutes


Pushing power mower

30 minutes


Raking lawn


30 minutes


Sexual activity

Conventional, familiar partner

15 minutes


Stair climbing

Moderate, upstairs

10 minutes


Moderate, downstairs

10 minutes


Washing car by hand


30 minutes


Recreational activities

Aerobic dance


30 minutes




30 minutes




30 minutes



Pulling clubs

30 minutes



12 minutes/mile

30 minutes


Rope jumping


15 minutes



Downhill or water

30 minutes



30 minutes




30 minutes




30 minutes



30 minutes




30 minutes


Yoga (Hatha)


30 minutes


Excerpted from Tables 4.2 and 4.3, Simon, HB, The No Sweat Exercise Plan: Lose Weight, Get Healthy, and Live Longer (New York: McGraw-Hill, 2006).

The CME system should help you set realistic individual goals instead of wondering what to make of “guidelines” that call for 30 to 90 minutes of exercise a day. For general health and gradual weight loss, aim for 150 points a day or about 1,000 points a week. For faster weight loss, reduce dietary calories sharply and aim for 300 CME points a day, or both.

The system encourages people to view physical activities as opportunities, not punishments. Climbing stairs instead of riding the elevator is one example of a healthful choice that incorporates exercise into the fabric of daily life. People should choose whatever activities work for them as long as they add up to enough exercise to maintain good health. And as they experience the personal pleasures of moderate exercise, some will go on to aerobic training or to participate in sports.

Exercise, the prostate, and male sexuality

Protection against heart disease, stroke, diabetes, obesity, hypertension, memory loss, colon cancer, fractures, and depression — it should be enough to get all of us moving. But men who need extra motivation should consider the added benefits for men.

A 2006 study from Sweden reported that regular exercise is associated with a reduced risk of moderate and severe symptoms of benign prostatic hyperplasia (BPH). After taking other risk factors into account, the most active men were 28% less likely to have substantial lower urinary tract symptoms than the least active men. It’s nice to know that moving your body may help keep your urine moving, and it confirms a Harvard study from 1986.

Prostate cancer is more problematic. Some studies suggest that exercise can reduce risk, but others do not. Finally, although erectile dysfunction is not life-threatening, it can surely impair the quality of life. A Harvard study linked regular exercise to a 41% reduction in the risk of erectile dysfunction — all it took was about 30 minutes of walking a day. And in 2004, a randomized clinical trial reported that moderate exercise (averaging less than 28 minutes a day) can help restore sexual performance in obese, middle-aged men with erectile dysfunction.

People with medical problems or special needs require additional screening and supervision; in particular, everyone with known or suspected heart disease or major risk factors should have a thorough medical check-up and, in most cases, a stress test before starting an exercise program.

Cardiometabolic exercise is the key for health, but many people will get extra benefit by adding exercise for strength, flexibility, or balance — not necessarily at a gym under the watchful eye of a trainer, but at home in just a few minutes a day. And a prudent diet is an essential partner in the prevention of many of the chronic illnesses that plague industrial societies.

Medical science continues to make astounding advances. It has taken the collective effort of many dedicated scientists to bring us back to the wisdom of Hippocrates; some 2,400 years ago, the father of medicine said, “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”

All rights reserved.
Harvard Men’s Health Watch
Volume 11 - Number 10 - May 2007

Why regular check-ups are still a good idea

An annual “well woman” visit has important health benefits — especially the doctor-patient relationship it fosters.

For most of the 20th century, the yearly “head-to-toe” physical for adults with no medical complaints was the standard of care, a way to detect disease early and reduce mortality. It typically featured blood tests, urinalysis, and screenings that included a chest x-ray and electrocardiogram. But in the late 1970s, various health groups began to re-evaluate the practice — partly because managed-care organizations wanted to bolster efficiency and reduce costs.

Since then, several authoritative bodies have concluded that healthy adults don’t need comprehensive physicals every year. That’s the view, for example, of the U.S. Preventive Services Task Force (USPSTF), an expert panel that reviews medical evidence and issues guidelines. The USPSTF and other groups say there’s insufficient evidence that such exams actually pay off in the detection and prevention of disease. Instead, these experts recommend that doctors conduct less extensive exams in the course of routine medical care and tailor them to a patient’s age, sex, family history, and other individual risk factors. They also hold that procedures and tests should be limited to those of proven preventive value. For women, these include mammography; checking blood pressure, weight, and cholesterol levels; and Pap smears and colon cancer screening. Physicians can remind patients about screenings and counsel them about lifestyle and prevention during visits for various medical reasons.

But efforts to kill off the comprehensive annual physical and replace it with a more prevention-focused approach have met with resistance from those most directly affected — doctors and patients.

Guidelines and practice not in sync

Studies conducted since the USPSTF issued its first guidelines in 1989 indicate that patients want traditional yearly physicals and physicians continue to offer them. In a study published in 2002, researchers from the Denver Veterans Affairs Medical Center randomly surveyed adults in Denver, Boston, and San Diego on their attitudes toward physical exams. Nearly two-thirds thought annual physicals were necessary and expected one, and they wanted tests that aren’t officially recommended, such as a complete blood count; heart, lung, and abdominal exams; reflex testing; urinalysis; and hearing and vision tests.

In a later survey of primary care physicians in the same three cities, the Denver researchers found that 65% believed that annual physicals were necessary and 88% performed them, often including non-recommended tests. Why the disconnect between official guidelines and actual practice? An editorial accompanying the study, in the June 27, 2005, Archives of Internal Medicine, suggested that physicians and patients value the annual physical because it strengthens the doctor-patient relationship, whose many benefits can be hard to quantify.

Researchers are trying to specify these intangibles. For example, a study found that the annual physical can help relieve a patient’s worries about her health. The study — conducted by Johns Hopkins School of Medicine researchers for the Agency for Healthcare Research and Quality (AHRQ) — also found that the annual physical (described in the study as a “periodic health evaluation”) boosts the chances that patients will get recommended health screenings (Annals of Internal Medicine, Feb. 20, 2007). Such returns, the researchers say, justify the continued use of checkups. A study of 64,288 adults in a group health plan in Seattle had similar results (Archives of Internal Medicine, March 26, 2007).

Customized health care

So the annual physical — sometimes also called a “well visit” or “health maintenance visit” — isn’t obsolete. Rather, it’s a work in progress. There’s something to be said for discarding procedures or tests with no proven preventive value and for tailoring a woman’s care to her particular risk profile. For example, some women, but not all, need a thyroid function test. Moreover, any test (including those that turn out to be unnecessary) can result in false positives that lead to additional tests and possible harm.

Nevertheless, official recommendations are guidelines, not ironclad rules. They neither trump a physician’s experience and insight, nor overrule a patient’s personal preferences. If you’re used to an exam that includes non-recommended tests, you may not feel well cared for if you receive anything less. An open discussion with your physician about the evidence for and against certain tests and how it applies to you may allay your concerns.

If you don’t see a clinician regularly, be sure to get the tests and immunizations appropriate for your age and health situation. For a checklist of screenings, tests, and immunizations recommended for healthy women, visit the AHRQ Web site at www.ahrq.gov/ppip/healthywom.htm, or call 800-358-9295.

A doctor talks about: The periodic health exam

Celeste Robb-Nicholson, M.D.

Most of my patients see me in the office for a checkup at regular intervals — say, every 12 to 18 months, depending on their age and medical conditions. I find these periodic health evaluations important for several reasons.

Healthy women need to have several indices of health measured periodically — weight, height, and blood pressure — as well as certain preventive services (breast exam, Pap test, immunizations, and, starting at age 50, fecal occult blood testing). It’s also important to reassess a woman’s risk for various conditions and educate her about those risks. Family history, habits of living, and other factors affect a woman’s risk profile. Knowing if and how her risk has changed helps me target my questions, physical examination, and testing, and tailor my recommendations.

Seeing a patient for a periodic health exam gives me a chance to check in with her about new health concerns, many of which are triggered by news stories and direct-to-consumer advertising. The daily barrage of information — and misinformation — in the media and on the Internet can open patients to new knowledge and understanding or expose them to unnecessary fear and uncertainty. By asking questions, I learn how much a woman understands about her own health and what worries her. In turn, I help validate or assuage her concerns, and we can address them together.

A “well woman” visit also helps me learn what matters most to my patients and how their health affects their daily lives. A periodic review of a woman’s life context — her family, work, activities, stresses, and joys — helps us collaborate in making appropriate medical decisions. This may mean finding the best times to take needed medications, figuring out how to fit in exercise or a diet plan, or discussing how chemotherapy might affect her family and work schedule.

What matters to a woman also changes as she gets older. Health goals may shift, for example, from keeping cholesterol under 200 to becoming strong enough to pick up a grandchild or walk across the street unaided. When a patient and I discuss these matters, we can work together to help her achieve her most important goals instead of spending time on concerns of no real consequence to her.

Seeing patients on a regular basis when they’re well also helps build a strong patient-doctor relationship, which is invaluable when serious health problems arise. It gives us an established history and a measure of trust that help my patients when they’re ill and frightened.

Even if there’s little change in a patient’s life context, medical status, or health goals between periodic health exams, there’s still a lot to accomplish in a single office visit. I have a mental checklist of things I want to address in our time together: questions to ask, exams to perform, and screening and disease-specific tests to talk about and order. It’s equally important for me to hear a patient describe her symptoms and voice her concerns.

Here are some ways to get the most out of your visit and help foster a relationship with your doctor that works for you:

  • Before you come to the office, jot down your concerns — whether they’re about something you’ve read or a symptom that worries you. Also, bring a list of the medications you’re taking, including prescription and over-the-counter drugs and herbal or other supplements.
  • Be sure to mention any changes in the health of your parents, siblings, and children since your last visit: It can inform your own risk assessment.
  • Bring up your concerns early in the office visit, so there is time to address them. Often a patient will save her biggest concern until the end of the visit, when we’ve run out of time.
  • If a medication or health strategy isn’t working for you, let your physician know, so that she or he can find a better approach.

All rights reserved.
Harvard Women’s Health Watch
Volume 14 - Number 9 - May 2007

What the latest diet trial really means

Any diet that helps you take in fewer calories will help you shed pounds.

The “Atkins is best” headlines you may have seen in March 2007 had champions of the low-carbohydrate, high-fat diet smiling — and hoping that people wouldn’t read the study on which the news reports were based.

An article in the March 7, 2007, Journal of the American Medical Association compared weight loss over the course of a year in 311 overweight but healthy women who used one of four popular diet plans: Atkins, the Zone (balanced protein, carbohydrate, and fat), Ornish (very low fat, very high carbohydrate), and the LEARN program (standard low fat, moderately high carbohydrate).

The women in all four groups steadily lost weight for the first six months. The most substantial weight loss occurred among women assigned to the Atkins plan, who lost an average of 14 pounds, compared with 6 to 8 pounds for the other three plans. After six months, most of the participants started to regain weight. At the end of a year, the women in the Atkins group were about 10 pounds lighter than when they had started, compared with 5.7 pounds for the LEARN group, 4.9 pounds for the Ornish group, and 3.5 pounds for the Zone group.

Read the fine print, though, and you realize that few of the women actually stuck with their assigned diets. Those in the Atkins group were aiming for 50 grams of carbohydrate a day but took in almost triple that amount. The Ornish dieters were supposed to limit their fat intake to under 10% of their daily calories, but got about 30% from fat. There were similar deviations for the Zone and LEARN groups.

Beyond carbs, protein, and fat

The real message of this and other head-to-head diet comparisons isn’t that one type of nutrient is better than another. Instead, it is that you can lose weight with any diet that helps you eat less. “In the long run, finding strategies that guide you to match your food intake to the calories you burn matters far more than macronutrients like protein, fat, or carbohydrates,” says Dr. George Blackburn, director of the Center for the Study of Nutrition Medicine at Harvard-affiliated Beth Israel Deaconess Medical Center. Diet books that focus on individual nutrients may be good for short-term weight loss but don’t necessarily offer good advice for a lifetime.

One worry about the Atkins diet is that eating meat, cheese, and other fatty foods will be bad for cholesterol and heart disease. In this trial, though, cholesterol levels in the Atkins dieters were fine.

To make the Atkins approach work for your heart as well as your waist, make smart protein choices. A study published in 2006 in the New England Journal of Medicine showed that over a 20-year period, women who followed low-carb diets high in plant protein and good (meaning unsaturated) fats were less likely to have developed heart disease than those whose low-carb diets were high in animal protein and fat. “If you plan to follow a low-carb diet, skip the butter and sausage and go for olive oil and fish,” says Dr. Walter C. Willett, professor of nutrition at the Harvard School of Public Health.

All rights reserved.
Harvard Heart Letter
Volume 17 - Number 9 - May 2007


Harvard Health Publications e-Newsletter is published monthly by the Harvard Health Publications division of the Harvard Medical School. Copyright © 2007 by the President and Fellows of Harvard College. All rights reserved.

This information is for educational purposes only. For personal medical advice, please contact your physician.

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Medical Disclaimer

Harvard Health Publications
Editor in Chief: Anthony L. Komaroff, M.D.
Publishing Director: Edward H. Coburn

Harvard Health Letter: Anthony L. Komaroff, M.D., Peter Wehrwein
Harvard Heart Letter: Thomas H. Lee, M.D., P.J. Skerrett
Harvard Men’s Health Watch: Harvey B. Simon, M.D.
Harvard Mental Health Letter: Michael C. Miller, M.D., James Bakalar, J.D.
Harvard Women’s Health Watch: Celeste Robb-Nicholson, M.D., Carolyn Schatz

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