Duke University Alumni Magazine

HABITS FOR THE HEART FITNESS MATTERS BY ROBERT J. BLIWISE Illustration by Chris Obrion '86 An education in putting stress under control, eating intelligently, and excercising faithfully.

e're part of an age of reinvention--the primary objects of reinvention, of course, being ourselves.

We know we need to be living better, or at least looking better. Even as we lead stressful lives, we try to avoid the detrimental effects of stress, like weakening of the immune system, disturbing sleep, and increasing risk of heart disease. We can't pass a supermarket checkout counter without magazines whose cover lines advertise the painless pursuit of better abs, even better abs, and the best of abs. If we leave the supermarket and turn on our Web search engine, we find 918 sites for "exercise" and 2,390 for "fitness." At the same time, we are consumed by an insatiable interest in eating: A quirky new culinary memoir of Barbados, Pig Tail 'N Breadfruit, describes the omelet as "something precious and fragile, like the body of a woman you love."

So where to learn about putting stress under control, eating intelligently, and exercising faithfully? The Duke Executive Health program thinks it's found a niche for itself. I like identifying myself with the language in the program brochure: "Someone who is active and involved. Decisive. Ambitious. Perhaps even somewhat competitive." But some of the more sobering information in that brochure would seem to give one healthy pause: About half a million Americans have strokes each year. Prostate cancer strikes three out of every ten men by the age of sixty. A tendency toward heart disease appears to be hereditary. About half of diabetes cases go undiagnosed.

As I mull over my executive-health credentials, I'm reminded that my most remarkable executive accoutrement is my genuine canvas Duke carrying case. And so long as I continue to outlast undergraduates on the tennis and racquetball courts, I'm not frustrated over my state of fitness. Still, a couple of days spent at the reassuringly named Center for Living, just off Duke's West Campus, seems like a worthy retreat. As the brochure puts it, with a healthy outpouring of adjectives, this is an "authoritative, comprehensive health and lifestyle enhancement program" aimed at helping those "who have taken charge of their lives to complete the picture by taking charge of their health." This is also a sign of a larger grabbing after the executive-health market: The Mayo Clinic in Scottsdale, Arizona, offers a "streamlined yet comprehensive" medical evaluation for executives; the Scripps Center for Executive Health in La Jolla, California, advertises "a custom-designed, whole-person, preventive maintenance health-care program that can enhance and enrich your life."

Check-up time: the author and executive wannabe along with some of his good-health team (clockwise from left), Executive Health physician Kevin Waters, massage therapist Howard Anderson, fitness trainer John Hinkle, and psychologist Mark Wolever Photo: Les Todd

Duke Medical Center informally worked in executive health for decades; the department of medicine offered executive-health examinations at the request of companies. But there wasn't a defined group of people assigned to executive health, or set-aside space. The formal program began in 1991. In large part it reflects a growing accent on prevention in health care, according to its director, James Clapp '54. Some 600 executives annually go through a version of the routine that I'm about to follow. Those executives--some of whom are corporate-sponsored, some of whom schedule a visit on their own--come from such recognizable companies as Corning, John Deere, and General Motors.

In an initial visit to the program, an executive will receive a comprehensive health assessment, which includes a battery of laboratory tests, a medical history and examination, and a stress-EKG test. There's also a consultation with a nutritionist, a fitness assessment with an exercise physiologist, and a session with a behavioral-medicine specialist. The price for that package is $1,962. Executives can extend their stay into an "Executive Escape," which includes the comprehensive health assessment plus services at the Center for Living--perhaps sessions with a physical trainer, classes on nutrition and stress management, or counseling in diabetes control and smoking cessation.

I show up on the first morning at 8:30 for blood work and a chest X-ray ("Service begins with me," reads the nametag on the attending technician), and I self-righteously bypass the promised reward--a rather modest breakfast offering of fruit and mini-muffins. Then I meet my assigned doctor, Kevin Waters, an associate in medicine for the Executive Health program. He does my comprehensive health evaluation, which he'll later review with me and summarize in writing.

Comprehensive is the appropriate term for the check-up, which lasts a full hour. Waters' gently inquisitive tone and leisurely pace through the examination are a throwback to a doctor-patient relationship that predates assembly-line health care. The conversation delves into my family history, experience with medications, allergies, and health-related habits; the examination delves into bodily systems that I don't particularly think about. Waters tells me a bit of a weight loss wouldn't be bad, reinforces the need to include flexibility and strengthening in my exercise routine, talks about the virtues of avoiding excessive carbohydrates, and advises taking a multi-vitamin and baby aspirin every day.

He also draws me an elaborate diagram charting out body biochemistry. I get lost in some of the details, but I do come away with a rough understanding of my lipids: "good cholesterol," which transports cholesterol away from the cells lining the arteries; "bad cholesterol," which gets deposited on artery walls and promotes heart disease; and triglycerides, a fatty acid circulating in the bloodstream that helps transport food immediately after eating. My "bad cholesterol" level bears watching, Waters says, and can be controlled by decreasing saturated fat and eating more starches, fruits, and vegetables.

During my time with Executive Health, I have two nutrition consultations. Nutritionist Franca Alphin seems generally pleased with my eating habits, and says soothing things about my addiction to low-fat yogurt. I had neglected to complete my "Food Record for Computer Analysis," a document meant to record everything I would eat and drink all day, including preparation method and exact quantities consumed. So Alphin draws me out on my eating habits. She advises me to consume at least two or three glasses of water daily, echoes physician Waters in suggesting a multi-vitamin and a vitamin E supplement, and tells me to increase my intake of tomato products, which lower the risk of prostate cancer.

My other eating adviser, Elisabetta Politi, was raised in Italy. She wins me over with her affection for an Old World culture that frowns on eating on the run and exercises as a matter of daily living, rather than out of self-conscious obsession. She says Americans too often eat for the wrong reasons--because they're bored, or to relieve anxiety. Variety is important, she says; you can't eat the same food over and over and feel satisfied. You also can't strive for perfection with every meal. "Life has to be enjoyed," she says. She sees aiming for a reasonable balance, rather than self-deprivation, as the route to weight control.

Wary of the consequences of my own enjoyable embrace of food, I prepare for a body-composition assessment. The hands-on assessment, as it were, comes when little clamps are applied in three places: my chest, abdomen, and thigh. That skin-folding procedure is one determination of how much of my body weight is lean mass and how much is fat mass. I'm also subjected to the less interventionist standard body-mass index, or BMI--computed by dividing my weight in kilograms by my height in meters squared. The BMI is thought to be more sophisticated than the familiar height/weight tables. It doesn't differentiate between fat and muscle, though. And since muscle mass actually weighs more than fat, an athlete can be gauged as overweight.

I figure that I'm not subject to that anomaly. My BMI comes to 23, the same figure that results from the skin-fold test. That puts me in the "desirable" range.

From there I undergo an exercise performance evaluation--that is, a treadmill exercise. The exercise-stress test is a diagnostic tool for uncovering cardiac problems; it's also a screening device in advance of an exercise program. Treadmill encounters have always struck me as nasty, brutish, and not short enough. Here, my EKG is taken at every stage--meaning whenever the grade or the speed is increased--and during recovery. My heart rate is taken every minute, and my blood pressure is taken every two or three minutes. I feel thoroughly monitored. The grade and the speed are changed according to a standard protocol, depending on whether the stress-tested person is sedentary or athletically involved. I'm also asked regularly how hard I feel I'm working, according to a scale with a range from "very, very light" to "very, very hard."

I go for thirteen minutes before feeling uncomfortably breathless. And I learn my training heart range, calculated using the maximum heart rate I attained on the exercise test and my resting heart rate. That range, in beats per minute--132 to 162 for me--doesn't register at first. But later, an exercise physiologist, Maria Nardini, puts it all in context. She explains that this isn't the endurance exercise that I had taken it to be. What's significant isn't how long I lasted on the treadmill, but how I was doing from stage to stage. She says my self-rating of workout intensity, or "rate of perceived exertion," will be a useful guide as I exercise.

The idea is to get in tune with how my body feels when it's working at various levels, to sense my level of intensity without needing to take my heart rate. My cardiovascular benefits will kick in optimally, then, with exercise in the range between "fairly light" and "hard." Below that range, I'm not getting much in the way of benefits. The same is true beyond that range: One of the drawbacks of exercising to excess is that I'm not going to be enjoying it, and so I could become an exercise avoider.

Wanting to be an exercise partaker, and just back from my lunch of soup and a hefty salad with low-calorie dressing (every Center for Living offering comes with a calorie count; I opted for my salad day over a "Sloppy Turkey Joe" day), I meet with my personal fitness trainer, Greg McElveen. As my warm-up event, I take my first-ever virtual bike ride. I find the shifting seat and the shifting scene on the monitor hard to get used to. During my ride through a small New England town, I manage to have several pedestrian and vehicle run-ins. McElveen--an avid long-distance biker--is less worried about my virtual biking ineptness than about how thoroughly lunch was digested. He is instantly attentive to my desired dividends from exercise. I mention vaguely an interest in body toning and basic strength. He probes my habits in tennis and swimming, and

seems intrigued by my impending hiking tour through England.

I've long perceived strength and flexibility conditioning as self-torture, if perhaps virtuous self-torture. The easygoing McElveen, though, is hardly a pain-through-gain drill sergeant; his message is, find something you enjoy, and you're bound to keep it going. He puts me through a repertoire including bent-over rowing, for the back and biceps; abdomen crunching, using nothing fancier than light weights held high; overhead and tricep press-downs, for the shoulder and arm; lat pulls and curls, for the biceps and the latissimus dorsi (a name that brings to mind a Renaissance painter); and bench-press incline, for the chest and arm. He invents some stretchable-cord routines to help the tennis serve, forehand, and backhand, and a bench-stepping exercise for getting me in step with the demands of hiking. And he calls me "relentless," which, of course, keeps me pumped up.

Obviously concerned to make this a routine of mine rather than a soon-to-be-forgotten exposure, McElveen largely confines his instruction to equipment carried in my own workout facility. He explains the need to raise and lower weights slowly, to breathe with each repetition, and to perform a set of exercise two or three times a week on non-consecutive days. One exercise set a week will produce 70 percent of all possible results, he says; with two sets, the figure goes to 90 percent, and with three, 97 percent. McElveen also emphasizes the virtues of stretching--which I've rarely bothered with--and runs me through stretching exercising for the upper calf, lower calf, quadriceps, hamstrings, and hips. As he notes about lower-back stretching, ten seconds counts, thirty seconds is better, and two minutes is best.

I sample the Center for Living's pool for classes in water aerobics and muscle toning. For a couple of hours, I'm playing with styrofoam "noodles" and "power buoys," an activity that's the equivalent of working out with weights on land. I find the aquatic experience surprisingly challenging: The buoyancy-based resistance in water is much greater than the gravity-based resistance on land. As I pull down on the water toys, the resistance is increasing. For that matter, keeping my balance through the exercise routine isn't easy. Yet, water pressure helps the blood pump more efficiently just as water itself keeps the exerciser cool, so I could keep on going without overheating. Also, water-based exercises can be exaggerated or reined in according to the abilities of the exerciser. I try to show my aquatic exuberance by running in place and skipping aggressively from side to side, though it all feels a bit silly--particularly since group consensus has it that our best workout is to the theme of The Andy Griffith Show.

From Andy Griffith, it's only a small step to "Mindfulness Meditation," with Mark Wolever, a clinical health psychologist who works with Executive Health. I've never before put myself in a meditative environment. Wolever tells our group of about a dozen that the idea is to get relaxed, refreshed, and energized. It's all about evoking a relaxation response. I semi-close my eyes and try to follow his guidance --which is really all about following my breath, through my chest, my belly, and my appendages. I'm supposed to be "mindful of the moment," as he puts it, and to observe the distractions that arise in thoughts, feelings, and sensations. In particular, I shouldn't be worrying about something that happened or something that's bound to happen. For the moment, the breath is supposed to anchor everything. And everything is in this moment.

I also join Wolever for an "Imagery Field Trip," a guided, sensations-rich mental journey with features that, he says, change from trip to trip. This time I find myself on a forest walk, then on a mountain path, and finally floating on a cloud; I pass a flock of sheep and wildflowers, gaze on stands of tall pines and poplars, walk by a deserted cabin, and spot a rushing stream and a still lake. I find the conjured images intersecting with some vivid mental pictures from my trip through Yosemite Park, just weeks earlier. As we return to non-imagined reality, Wolever notes the contrast between this form of relaxation response, which had me make a great escape, and mindful meditation, with its here-and-now focus.

Later, Wolever tells me that the breath is basic to relaxation strategies. It's unrealistic to think about leading a stress-free life, he points out. In fact, an optimal level of stress can charge up those busy executives or give them a needed adrenaline rush; it can be a helpful motivator and can sharpen concentration. But chronic stress is linked with heart disease, depression, and early mortality. And some of those executives don't realize that stress may be affecting them negatively, causing, for example, short tempers, poor eating habits, and reckless smoking or drinking behavior. From a physiological standpoint, when I was sitting and meditating, my heart rate was down, my blood pressure was down, and there were other metabolic shifts, all good in and of themselves.

Theoretically, as I practice this art--and it does take practice--I'll be more adept at achieving clarity of thought and calmness in the moment, and so I'll be better able to manage situations when confronted or challenged.

The ultimate calmer during my Executive Health stint is massage therapy. With Beethoven's Ode to Joy in the background, masseur Howard Anderson applies his hands in short, repetitive strokes to my neck, knees, back, and hips. He mentions different stylistic techniques; he tends to apply his massaging hands pretty deeply into the tissue, but he says he's attentive to signals that would prompt his lightening up. I like the feeling of being worked on through a not-so-soft touch. Every style of massage, he says, will increase blood circulation and the fluidness of tissue. The body nurtures itself and heals itself through blood flow, so massage can be thought of as promoting self-renewal. Tissue can get stuck like a rusty door hinge, he says, that needs to be worked on for easy movement. He says he constantly sees victims of the "work, work, work, go, go, go" style of executive living: The executive spends too much time sitting still and operating under stress, all of which causes muscles to tighten up.

A bit later, I read of a study published in The British Journal of Sports Medicine asserting that massage may not speed muscle recovery. In promoting blood flow, massage presumably speeds up the process of flushing lactate out of tired areas. The British tests showed no difference in lactate levels between a group of British boxers who had been given massages and a group of boxers who had just rested for the same time. Both groups saw their punching power fall by similar amounts. Still, the boxers who got the massages reported feeling much better than those who did not. Stressed executive or battered boxer, I could appreciate the simple therapeutic value of being touched.

Stress is an overarching theme for Executive Health--just as it is for a popular magazine like Psychology Today, whose April issue is all about stress. "We're all trained as children in the basics of reading and writing, but we're not taught about stress management," according to the article. It goes on to report that on an average workday, about a million employees are absent because of stress-related problems, costing American businesses more than $200 billion annually in absenteeism, workers' compensation claims, health-insurance costs, and lowered productivity. As Psychology Today notes, "'Desserts' spelled backward is 'Stressed.'" I can't quite figure out the significance of that wordplay, but I try not to stress about it.

I meet with Ruth Quillian, who, like Wolever, is a clinical health psychologist, for a psychological discussion. I had dutifully completed a set of mental-health surveys. On one I answered "I do not feel sad," "I am not particularly discouraged about the future," "I do not feel like a failure," and "I don't feel particularly guilty." A second form probed frequency of feelings like being "upset because of something that happened unexpectedly"; another explored relationships ("How often do your close friends and relatives make you feel loved and cared for?"). On a different survey, I struggled on a couple of true-or-false questions, like "I am sure I am being talked about" and "I do not try to cover up my poor opinion or pity of a person so that he won't know how I feel." The first seemed ambiguous, and the second was tough to unpack.

Quillian tells me that my score on a "Perceived Stress Scale" falls in the low range for people of my age and background. I also produced a low-hostility ranking and self-reported no depressive symptoms. She suggests being more attentive to social support, and talks about the tradeoffs and tensions between career-building and relationship-building. As her written comments put it, "Social support is perhaps the most important psychosocial buffer of disease of which we are currently aware. While developing a supportive and loving community around you can be quite challenging in the hectic lifestyles of this day, it is imperative for health and quality of life." Beyond its well-known links with mortality, strong social support apparently helps combat the common cold. That's something to reflect on in gearing up for next winter.

To enlarge on my social network, I visit with James Clapp, professor of medicine and director of the Executive Health program. Clapp, trained as a nephrologist (kidney specialist), has been on Duke's medical faculty since 1963. He moved to the Center for Living in 1991 as clinic director; Executive Health later became part of the Center for Living, which focuses on fitness and rehabilitation. Duke is distinctive, he says, in offering an executive health service that offers not just a freestanding clinic but the resources of a major medical center. "Nobody has a facility like this," he says. "We have a campus-like facility for executives and yet we're part of a major medical institution"--meaning if an executive visitor has a need for high-technology care, that kind of care is readily available.

Clapp says the program satisfies a need that's especially important in a period of managed health care. "It used to be that the physician knew every aspect of the patient's world, from his working habits to his family dynamics. Now, in most contexts, the patient visit is pared down to something like fifteen minutes. Most people can hardly say hello in a mere fifteen minutes, much less describe their physical state in depth."

According to Clapp, executives should view preservation of their health in the same way they view their retirement program: "Start planning early and invest all along the way." He tells me, "Many of the things that afflict people are lifestyle-related--having to do with how they eat, drink, exercise, handle stress. A heart attack doesn't begin when you have chest pain. It begins to evolve years before that."

So I leave Executive Health convinced that I'm achieving nicely, but in need of improvement. I feel a bit jarred on hearing about a Centers for Disease Control finding that half of Americans are overweight and half of the overweight group is trying to lose those extra pounds, but that they're not working out long enough or hard enough to make a difference.

But then I run across a newspaper article that makes me downright envious. It seems that medical researchers have bred a genetically modified mouse that can eat without getting fat. The researchers stripped away a gene that appears to play a role in helping mice store fat. Without the gene, the mice could eat with impunity. So much for consistent exercise, good eating habits, meditation, massage, and stress relief. How about some fat-busting genetic therapy?

Information on the Duke Center for Living--including the Executive Health and Healthy Escapes programs--is available online at ww.dukecenter.org.