Well: Are You a ‘Fun Dad’?

This week, President Obama described himself as a "fun dad" who "teeters on the edge of being embarrassing sometimes."

While the comment probably elicited a few eye-rolls from his daughters, Sasha and Malia, there are plenty of other fathers out there who also have claim to "fun dad" status. Are you one of them? In the comments, tell us briefly why you are a fun dad. If you ended up embarrassing your child with your fun dad antics, we'd love to hear from you. And if you are the son or daughter of a fun dad, tell us about him.

Please share your stories and we'll post a roundup of the best answers to celebrate all of our dads on Father's Day weekend.

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Well: More Protein in Diet May Lower Stroke Risk

Getting more protein in your diet, though not red meat, may reduce your risk for stroke, a review of studies found.

Scientists reviewed seven prospective studies involving more than 250,000 people and found that after adjusting for various stroke risks and for other nutrients consumed, those who had the highest consumption of protein had a 20 percent decreased risk for stroke compared with those with the lowest.

Each increase of 20 grams per day in protein — about the amount in a 3-ounce serving of chicken or fish or a cup of beans — was associated with a 26 percent decrease in risk, a dose-response relationship that further strengthens the association.

The finding, published in Neurology, does not apply to red meat, which has been shown to increase the risk for stroke and was not evaluated in the studies reviewed.

Some evidence suggested that animal protein was slightly more effective than vegetable protein, although there was not enough data on vegetable consumption to reach a definitive conclusion about the exact difference.

"Moderate dietary protein intake may lower the risk of stroke," said the senior author, Dr. Xinfeng Liu, a neurologist at the Nanjing University School of Medicine in China. "This does not mean that people should avoid red meat entirely," he added, but "increasing intake of fish or vegetables is recommended."

 

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Well: Threat Grows From Liver Illness Tied to Obesity

Despite major gains in fighting hepatitis C and other chronic liver conditions, public health officials are now faced with a growing epidemic of liver disease that is tightly linked to the obesity crisis.

In the past two decades, the prevalence of the disease, known as nonalcoholic fatty liver, has more than doubled in teenagers and adolescents, and climbed at a similar rate in adults. Studies based on federal surveys and diagnostic testing have found that it occurs in about 10 percent of children and at least 20 percent of adults in the United States, eclipsing the rate of any other chronic liver condition.

There are no drugs approved to treat the disease, and it is quickly becoming a leading cause of liver transplants around the country.

Doctors say that the disease, which causes the liver to swell with fat, is particularly striking because it is nearly identical to the liver damage that is seen in heavy drinkers. But in this case the damage is done not by alcohol, but by poor diet and excess weight.

"The equivalent of this is foie gras," said Dr. Joel E. Lavine, the chief of pediatric gastroenterology, hepatology and nutrition at NewYork-Presbyterian Morgan Stanley Children's Hospital. "You have to force feed ducks to get fatty liver, but people seem to be able to develop it on their own."

Gavin Owenby, a 13-year-old in Hiawassee, Ga., learned he had the disease two years ago after developing crippling abdominal pain. "It's like you're being stabbed in your stomach with a knife," he said.

An ultrasound revealed that Gavin's liver was enlarged and filled with fat. "His doctor said it was one of the worst cases she had seen," said Gavin's mother, Michele Owenby. "We had no idea anything was going on other than his stomach pain."

With no drugs to offer him, Gavin's doctor warned that the only way to reverse his fatty liver was to exercise and change his diet. "They told me to stay away from sugar and eat more fruits and vegetables," Gavin said. "But it's hard."

Most patients have a less severe form of the disease, with no obvious symptoms. But having nonalcoholic fatty liver is a strong risk factor for developing heart disease and Type 2 diabetes. And in 10 to 20 percent of patients, the fat that infiltrates the liver leads to inflammation and scarring that can slowly shut down the organ, setting the stage for cirrhosis, liver cancer and ultimately liver failure. Studies show that 2 to 3 percent of American adults, or at least five million people, have this more progressive form of the disease, known as nonalcoholic steatohepatitis, or NASH.

"This is the face of liver disease in the United States," said Dr. Shahid M. Malik of the Center for Liver Diseases at the University of Pittsburgh Medical Center. "If you're at any liver transplant center in the country, there's no doubt that this is a big problem."

Three decades ago, NASH was so rare that there was no medical name for it. Many doctors assumed that fat that accumulated in the liver was fairly harmless. But today, NASH is a growing strain on liver clinics and the fastest rising cause of liver transplants.

A study by the Mayo Clinic found that the percentage of all transplants performed nationwide because of NASH had reached 10 percent by 2009, up from 1 percent in 2001, even as the rates for hepatitis C, alcoholic liver disease and other conditions remained stable. NASH is projected to surpass hepatitis C as the leading cause of liver transplants by 2020, in part because of new drugs that can effectively cure hepatitis C, but also because of the rapid growth of fatty liver disease.

Fatty liver strikes people of all races and ethnicities. But it is particularly widespread among Hispanics because they frequently carry a variant of a gene, known as PNPLA3, that drives the liver to aggressively produce and store triglycerides, a type of fat. The variant is at least twice as common in Hispanic Americans compared with African-Americans and non-Hispanic whites.

In Los Angeles, liver disease is diagnosed in one out of two obese Hispanic children, and it is a leading cause of premature death in Hispanic adults.

At the University of California, Los Angeles, home to one of the largest liver transplant centers in the world, nearly 25 percent of all liver transplants are performed because of NASH, up from 3 percent in 2002. If the prevalence of NASH continues to increase at its current rate and effective treatments are not found, about 25 million Americans will have the disease by 2025, and five million will need new livers, said Dr. Ronald W. Busuttil, chief of the division of liver transplantation at the David Geffen School of Medicine at U.C.L.A.

"I'm really afraid that the explosion of this condition is going to overrun the resources available to the transplant centers around the country," Dr. Busuttil said. "In the United States right now, we do about six to seven thousand liver transplants a year. Can you imagine if we have millions of people on the list? It's unfathomable."

With NASH rates rising rapidly, drug companies are racing to produce the first drug to treat it.

In January, Intercept Pharmaceuticals, a small biotechnology firm, announced that its clinical trial of obeticholic acid showed promise in treating NASH, causing its stock price to soar. The National Institutes of Health, which sponsored the trial, are expected to present results from it later this year.

Another company, Galectin Therapeutics, was granted a special fast-track designation by the Food and Drug Administration to speed its development of GR-MD-02, a drug that may help reverse some of the more advanced symptoms of the disease.

But it will be several years before any drugs for NASH reach the market, said Dr. Kathleen Corey, the director of the Massachusetts General Hospital Fatty Liver Clinic, which was founded four years ago.

"We see patients with undiagnosed cirrhosis in their teens and 20s," she said. "That's something we never would have thought was possible in the past."

Yubelkis Matias, 19, an honors student at Bronx Community College, was told she has NASH several years ago. She is reminded of the trouble brewing in her liver by the sharp abdominal pains that come and go. Like Gavin, she has been told by her doctors that diet and exercise may be her only shot at reversing the disease. But at 5-foot-5 and 200 pounds, she finds every day a struggle.

"I'm on a roller coaster," she said. "I eat healthy, then not healthy — pizza, McDonalds, the usual. My doctor told me I have to quit all of that. But it's cheap, and it's always there."

Like many hepatologists, Dr. Corey helps her patients manage their high cholesterol, blood sugar and other metabolic problems that coincide with fatty liver. She counsels them to avoid sugar and alcohol, and she offers them high dosages of vitamin E, an antioxidant that studies show can relieve some symptoms of the disease. And she urges them to lose weight, the only proven way to reduce fat in the liver.

In adults, the rising prevalence of fatty liver has mirrored the increase in obesity. But in children, fatty liver is increasing at a rate "faster and above" the increase in childhood obesity, said Dr. Miriam Vos, the lead author of a study in The Journal of Pediatrics last year that estimated that one in 10 adolescents have the disease.

"That suggests that there's something else going on," said Dr. Vos, a pediatric hepatologist at Children's Healthcare of Atlanta. "We don't know, but some of the research has shown there may be early exposures in pregnancy or diet exposures that could be helping to drive this."

In studies, Dr. Vos and other researchers have found that when children with fatty liver consume sugar, they produce far more triglycerides than children without the disease, and this may be exacerbating fat accumulation in the liver. Cutting out sugary drinks often leads to "a big improvement" in her patients, Dr. Vos said. "But I don't know if that improvement is specifically because of the sugar or because they cut back on a lot of calories" and have lost weight.

Some researchers believe that insulin resistance, a hallmark of Type 2 diabetes, may be an underlying cause of fatty liver. But not everyone who has the disease is insulin resistant. Nor is every fatty liver patient overweight. People of Asian descent, for example, develop the disease at a lower body mass index than others, said Dr. Rohit Loomba, a fatty liver specialist at the University of California, San Diego, School of Medicine.

Doctors are also trying to figure out why some people with fatty liver progress to NASH and cirrhosis, while others do not. Dr. Loomba said that continual weight gain seems to be one driving force behind the progression.

As a result, doctors who treat fatty liver stress the urgency of diet and exercise to their patients. But many find it too hard, especially those who are obese and in the late stages of the disease, said Dr. Malik at the University of Pittsburgh.

"A lot of times when I see a patient with fatty liver," he said, "the first thing out of their mouth is, 'Well, is there a pill for this?' And there's not. There just isn't. You have to make lifestyle changes, and that's a much more difficult pill for people to swallow."

A version of this article appears in print on 06/14/2014, on page A1 of the NewYork edition with the headline: Threat Grows From Liver Illness Tied to Obesity.

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Well: Living With Cancer: ‘The Fault in Our Stars’

Living With Cancer

Susan Gubar writes about life with ovarian cancer.

"Cancer books suck," says 16-year-old Hazel Grace Lancaster. But she has a favorite and so do I. Mine is the novel John Green wrote about her.

With an allergy to cheesy sentiments resembling Holden Caulfield's, Hazel is the derisive yet tender narrator of Mr. Green's best-selling book and now movie, "The Fault in Our Stars."

Hazel undergoes drug therapy to extend her life, not to cure the thyroid cancer that has metastasized in her lungs. Despite a terminal prognosis, she tries to focus on living with disease instead of dying from it. In the midst of scares and incapacity, Hazel manages to relish jokes, books, her parents and eventually her love affair with 17-year-old Augustus Waters, who "had a touch of osteosarcoma a year and a half ago," requiring the partial amputation of one of his legs.

Through Hazel's wry perspective, the author circumvents what his heroine calls "the (expletive) conventions of the cancer kid genre." No need for a spoiler alert here. You may be or become as enthralled as I am by the sometimes funny, sometimes sad plot twists of this narrative, but what stays with me is Mr. Green's analysis of the experiences of teenagers with disease.

Like many sick children, Hazel displays unusual maturity. Pulled out of school, she has spent inordinate amounts of time learning at home. In the process, she has had to cope with a dysfunctional body, with terrifying breakdowns in the I.C.U., with lugging around an oxygen tank and sleeping with a machine that forces air "in and out of my crap lungs." Precocious, she fully comprehends the double-binds of chemical that extend her life by disabling her.

Early on, physical evidence of cancer separated Hazel from other people. She cherishes the cancer novel "An Imperial Affliction" because its dying heroine refers to herself as "the side effect."

"Cancer kids are essentially side effects of the relentless mutation that made the diversity of life on earth possible," Hazel believes. Contra Shakespeare, in other words, the fault resides in the stars, not in ourselves. Intimate with the look of death, she pledges her love to her boyfriend with the word "O.K.," not the word "always."

Hazel's fear of wounding the people who love her emerges in her sentence "I am a grenade." Dread of shattering those close to her impedes her evolving relationship with her boyfriend, but it also strains her bond with her parents.

"There is only one thing in this world (worse) than biting it from cancer when you're 16," she explains, "and that's having a kid who bites it from cancer."

Hazel's desperate desire to know what happens to the heroine's mother in "An Imperial Affliction" after the book's abrupt conclusion reflects her anxiety about what will happen to her own mother after all the devoted caretaking ends. Will her mom stop being a mom after Hazel's death? When a foundation sponsors Hazel's trans-Atlantic trip to meet the author of her favorite novel, she encounters the testimony of Otto Frank, the father of Anne Frank. She thinks of him "not being a father anymore, left with a diary instead of a wife and two daughters."

Upon her return to Indianapolis, Hazel's father broaches a third point Mr. Green makes, in this case about a potential balm for young cancer patients. "I believe the universe wants to be noticed," Hazel's father says. At this task, Hazel is a pro — she admires, ridicules, reflects, mourns — and this is partly so because of her avid reading of writers who take notice of the universe. "The Fault in Our Stars" suggests that the scrutiny we give the world as well as representations of it yield special rewards to teenagers with cancer.

According to Mr. Green, the insecurity of cancer transforms but does not inhibit personal growth in awareness. Hazel's robust responsiveness derives from acts of attention — undertaken by reading Literature with a capital L and Authors with a capital A, but also through intense engagements with video games and websites.

Mr. Green qualifies and extends his ideas through a number of adolescent characters with quite different experiences of cancer. And just as adolescents sometimes resemble children and sometimes adults, his cast of characters speaks to all ages.

Yet Hazel, with her distinctive mix of realism and humor, most extravagantly pays her debt to the universe "and to everybody who didn't get to be a person anymore and everyone who hadn't gotten to be a person yet."

Currently I am reading "This Star Won't Go Out," a collection of journals and letters composed by the real girl who inspired John Green to create Hazel: Esther Earl died in 2010 at the age of 16. The memory of the person she managed to become continues to steer us in precisely the compassionate direction that, I believe, Esther would have wanted. Let's hope the movie does too.

---

Susan Gubar is a distinguished emerita professor of English at Indiana University and the author of "Memoir of a Debulked Woman," which explores her experience with ovarian cancer.

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Well: Low Vitamin D Tied to Premature Death

People with low blood levels of vitamin D are more likely to die prematurely than those with normal levels, a new analysis has found.

Previous studies have suggested that low levels of the vitamin are associated with higher risk for breast and other cancers and for coronary heart disease.

There is still no general agreement about what constitutes an ideal level of Vitamin D. But for the current analysis, researchers pooled data from 32 studies and found that people with a blood level below 9 nanograms per milliliter had almost double the risk of premature death compared with those with levels of 50 or higher. Levels above 50 conferred no extra benefit. The study was published online in The American Journal of Public Health.

All the studies adjusted for age, and some for B.M.I., physical activity, race, smoking or other variables. One study adjusted for 17 other risks, but the association of low vitamin D with premature death persisted.

Should people be taking supplements to raise their vitamin D blood levels?

The lead author, Cedric F. Garland, a professor of family and preventive medicine at the University of California, San Diego, said there was little danger in taking vitamin D supplements, "as long as we keep blood levels below 200 nanograms per milliliter."

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Well: Should Runners Get Pedicures?

Jackie Cartier of Boulder, Colo., has been running for 10 years. That has left her feet beaten up and bruised, with thick calluses and the occasional missing toenail. But she won't step foot in a salon to have a pedicure.

"I really need the calluses I've built up," said Ms. Cartier, 27. Whenever she's gotten the full pedicure treatment in the past, she said, those calluses have been removed. And without that extra layer of protection, her next few runs really hurt.

As for her toenails, she says that she's embarrassed about the way they look. But she'll paint on top of however many nails remain, some of them bruised and blackened, and wear open-toed shoes anyway.

Runners shy away from pedicures for a lot of reasons. Not only may they want to preserve protective calluses, they may also think having pretty toenails doesn't really matter when you're losing them so often. Others are just too embarrassed to sit in a chair and have a stranger evaluate their battered feet. Still others don't want to inflict any more pain on nails that are already put through so much.

Lost or discolored toenails are a perpetual problem for runners because running is "blunt trauma" on the feet, said Dr. Albert D'Angelantonio, an assistant professor of plastic and reconstructive surgery at the Perelman School of Medicine at the University of Pennsylvania. "Imagine if I beat on your skin a few times and hit you in the same spot," he said. "You would get black and blue. The same thing happens underneath the nail."

Dr. Ken Jung, a foot and ankle surgeon at the Kerlan-Jobe Orthopedic Clinic in Los Angeles, likens the nail trauma that comes with running to stress fractures. "When the stress overcomes what your body's able to handle, you get stress fractures," he said. "The same thing is true with the nail."

It's not the actual nail that is damaged, but the nail bed, the tissue under the nail that is rich in blood vessels, Dr. Jung says. Running, particularly running downhill or while wearing shoes that are too small, puts pressure on the front of the foot and can traumatize the nail that protects that bed. As a result, the nail bed bleeds, making the toenail appear black.

The buildup of blood also creates pressure that can push up the nail. The nail can then detach from the nail matrix, the area at the base of the nail from which new nails grow. For the majority of runners, Dr. Jung says, that matrix remains unharmed. That's why often when a dead nail pops off, a new one is already growing underneath. After I ran the New Jersey Marathon, I had seven and a half toenails — I say half because by the time one popped off, half a nail had already grown back underneath.

If the nail matrix is damaged, however, then the nail sometimes won't grow back. That typically occurs after a more intense trauma. I didn't start losing toenails until I was training for and running marathons, but for some runners it can also occur when the toes jam against the front of an overcrowded, too-tight shoe or if the second toe is longer than the big toe. Some ultramarathoners actually have the matrix and nails from problem nails removed to end constant pain. Getting rid of toenails means they don't need to worry about the nails popping off in a race.

Lauren Parker, a 28-year-old publicist in New York City, uses pedicures as a treat, visiting a salon every time she finishes a marathon. She's run three so far. "It's my reward for putting my feet through a lot of training," she said.

While training for the race itself, she keeps her nails trimmed and moisturizes her feet often. That, she said, "keeps my feet healthy, not necessarily beautiful."

Spas and salons have been catering to runners' feet, too. As part of the Las Vegas Rock 'n' Roll Marathon, the Mirage Hotel and Casino last year offered a pedicure as part of a V.I.P. package.

Go! Spa, a St. Louis-based salon, has been offering the Perfect 10K pedicure for the last eight years. "A lot of our clients who are runners want that callus," said Katy Oliver, a spokeswoman for the salon. So instead of sloughing them off, the spa technicians leave them on. They also cut the nails to a medium length – too short, you risk ingrown toenails; too long, and you're more likely to bang the nail against the front of your shoe.

The main benefit of a pedicure from a health perspective, says Dr. Jung, is that it keeps the nails properly trimmed. The nails should be cut straight across instead of rounded, he said, to prevent ingrown toenails.

Of course, you should take care to visit a salon that is hygienic in its practices – one that sterilizes its tools, including nail files and buffers. Dr. D'Angelantonio recommends bringing your own instruments, and also patronizing a salon that uses a plastic inlay inside of the soaking tub that the technician can replace after each customer to assure you're putting your feet in a sterile solution.

And if you have an underlying medical condition like diabetes, which can increase the risk of infection, he says, check with your doctor before getting a pedicure.

Ultimately, there's not much people who run a lot can do to prevent lost or discolored toenails entirely. Making sure your running shoes fit properly may help. So can avoiding downhill running, which jams your toes against the front of your footwear, though that's not really practical.

As for my own feet, I'm not embarrassed enough about my toenails to want to avoid my nail salon. Right now I have my toenails painted American flag-red – all nine of them.

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Well: Should Runners Get Pedicures?

Jackie Cartier of Boulder, Colo., has been running for 10 years. That has left her feet beaten up and bruised, with thick calluses and the occasional missing toenail. But she won't step foot in a salon to have a pedicure.

"I really need the calluses I've built up," said Ms. Cartier, 27. Whenever she's gotten the full pedicure treatment in the past, she said, those calluses have been removed. And without that extra layer of protection, her next few runs really hurt.

As for her toenails, she says that she's embarrassed about the way they look. But she'll paint on top of however many nails remain, some of them bruised and blackened, and wear open-toed shoes anyway.

Runners shy away from pedicures for a lot of reasons. Not only may they want to preserve protective calluses, they may also think having pretty toenails really matters when you're losing them so often. Others are just too embarrassed to sit in a chair and have a stranger evaluate their battered feet. Still others don't want to inflict any more pain on nails that are already put through so much.

Lost or discolored toenails are a perpetual problem for runners because running is "blunt trauma" on the feet, said Dr. Albert D'Angelantonio, an assistant professor of plastic and reconstructive surgery at the Perelman School of Medicine at the University of Pennsylvania. "Imagine if I beat on your skin a few times and hit you in the same spot," he said. "You would get black and blue. The same thing happens underneath the nail."

Dr. Ken Jung, a foot and ankle surgeon at the Kerlan-Jobe Orthopedic Clinic in Los Angeles, likens the nail trauma that comes with running to stress fractures. "When the stress overcomes what your body's able to handle, you get stress fractures," he said. "The same thing is true with the nail."

It's not the actual nail that is damaged, but the nail bed, the tissue under the nail that is rich in blood vessels, Dr. Jung says. Running, particularly running downhill or while wearing shoes that are too small, puts pressure on the front of the foot and can traumatize the nail that protects that bed. As a result, the nail bed bleeds, making the toenail appear black.

The buildup of blood also creates pressure that can push up the nail. The nail can then detach from the nail matrix, the area at the base of the nail from which new nails grow. For the majority of runners, Dr. Jung says, that matrix remains unharmed. That's why often when a dead nail pops off, a new one is already growing underneath. After I ran the New Jersey Marathon, I had seven and a half toenails — I say half because by the time one popped off, half a nail had already grown back underneath.

If the nail matrix is damaged, however, then the nail sometimes won't grow back. That typically occurs after a more intense trauma. I didn't start losing toenails until I was training for and running marathons, but for some runners it can also occur when the toes jam against the front of an overcrowded, too-tight shoe or if the second toe is longer than the big toe. Some ultramarathoners actually have the matrix and nails from problem nails removed to end constant pain. Getting rid of toenails means they don't need to worry about the nails popping off in a race.

Lauren Parker, a 28-year-old publicist in New York City, uses pedicures as a treat, visiting a salon every time she finishes a marathon. She's run three so far. "It's my reward for putting my feet through a lot of training," she said.

While training for the race itself, she keeps her nails trimmed and moisturizing her feet often. That, she said, "keeps my feet healthy, not necessarily beautiful."

Spas and salons have been catering to runners' feet, too. As part of the Las Vegas Rock 'n' Roll Marathon, the Mirage Hotel and Casino last year offered a pedicure as part of a V.I.P. package.

Go! Spa, a St. Louis-based salon, has been offering the Perfect 10K pedicure for the last eight years. "A lot of our clients who are runners want that callus," said Katy Oliver, a spokeswoman for the salon. So instead of sloughing them off, the spa technicians leave them on. They also cut the nails to a medium length – too short, you risk ingrown toenails; too long, and you're more likely to bang the nail against the front of your shoe.

The main benefit of a pedicure from a health perspective, says Dr. Jung, is that it keeps the nails properly trimmed. The nails should be cut straight across instead of rounded, he said, to prevent ingrown toenails.

Of course, you should take care to visit a salon that is hygienic in its practices – one that sterilizes its tools, including nail files and buffers. Dr. D'Angelantonio recommends bringing your own instruments, and also patronizing a salon that uses a plastic inlay inside of the soaking tub that the technician can replace after each customer to assure you're putting your feet in a sterile solution.

And if you have an underlying medical condition like diabetes, which can increase the risk of infection, he says, check with your doctor before getting a pedicure.

Ultimately, there's not much people who run a lot can do to prevent lost or discolored toenails entirely. Making sure your running shoes fit properly may help. So can avoiding downhill running, which jams your toes against the front of your footwear, though that's not really practical.

As for my own feet, I'm not embarrassed enough about my toenails to want to avoid my nail salon. Right now I have my toenails painted American flag-red – all nine of them.

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Phys Ed: Overestimating How Hard We Exercise

Phys Ed

Gretchen Reynolds on the science of fitness.

Most of us know that moderate exercise is good for us. But surprisingly few of us know what moderate exercise means, research shows. An instructive new study found that many of us underestimate how hard we should exercise to achieve maximum health benefits, and overestimate how vigorously we are actually working out.

It's been six years since the federal government published exercise guidelines for adults. Straightforward and flexible, they recommend that adults complete 150 minutes of moderate or 75 minutes of vigorous aerobic exercise each week. Either prolonged sessions or multiple, shorter workouts are O.K., and the form is never specified. Jog, cycle, swim, walk, do tai chi, rake leaves or jump rope — any activity is fine, the recommendations suggest, as long as you reach and maintain the specified intensity.

Since then, the governments of many other nations, including Canada and Britain, have endorsed essentially the same guidelines for their citizens, and doctors now routinely advise their out-of-shape patients to begin exercising moderately. So does this column.

But no scientific studies had determined whether average people know what the recommended intensities feel like in action. So for a study published last month in PLOS One, researchers at York University in Toronto recruited 129 sedentary adult Canadians ages 18 to 64 and set out to see what they knew about exercising for health.

The formal exercise guidelines do offer guidance for determining the intensity of your workout. You can use heart rate, for instance. During moderate exercise, according to the Canadian guidelines, your pulse should rise to about 64 percent to 76 percent of your maximum heart rate; during vigorous exercise, your pulse should hover between about 77 percent and 90 percent of your maximum. More casually, the American guidelines suggest that during moderate exercise, you should be able to "talk, but not sing," while during vigorous activity, "you will not be able to say more than a few words without pausing for a breath."

The Canadian researchers began by asking their volunteers if they were familiar with the national exercise guidelines. A few said that they were, although most were not. So the researchers handed out copies of the guidelines for the volunteers to study, and then asked if they felt that they understood the guidelines, could comply with them, and were, perhaps, already complying.

With surprisingly little demur, almost all of the volunteers said that the guidelines were clear and they felt confident that they could complete the requisite amounts of moderate exercise. Quite a few of the volunteers said that they believed that they indeed were already meeting the guidelines.

The scientists then measured the volunteers' actual maximum heart rate with a treadmill test before having them walk or jog on the treadmill at a pace that they felt to be alternately light, moderate and vigorous. The volunteers were asked to maintain each of the desired intensities for about three minutes, so that the researchers could track their heart rates. Finally, the volunteers were asked to walk at the slowest pace that they felt would qualify as moderate, meaning the slowest pace at which someone could expect to gain significant health benefits from the exercise.

The volunteers were, as it turned out, quite inept at judging intensity. Few maintained a heart rate above 65 percent of their maximum when they were supposedly exercising moderately; even fewer reached a heart rate above 75 percent of maximum during their version of vigorous exercise.

Perhaps most telling, a majority of the volunteers walked at a decidedly languorous pace when asked to estimate the lowest-intensity exercise that would qualify as moderate and provide robust health benefits. Only about 25 percent reached a pace that raised their heart rate into the moderate range. The rest gently strolled.

In general, during each of the tests, "the volunteers overestimated how hard they were exercising," said Jennifer L. Kuk, a professor of kinesiology at York University, who oversaw the experiment.

The implications of that finding are worrisome, she continued, on both a personal and public health level. At present, 15 percent to 25 percent of American and Canadian adults report in surveys that they exercise intensely enough to meet the national guidelines. But if many of them are exaggerating their efforts, however unintentionally, Dr. Kuk said, "the problem of physical inactivity may be even larger" than the surveys suggest.

At a more intimate level, those of us who misjudge our exertions may be gaining fewer health benefits than we expect from exercise, she said. If you are unsure of how well you gauge intensity, she said, take your pulse frequently during a workout. If it lingers below about 65 percent of your maximum heart rate, raise your pace. (The standard formula for determining maximum heart rate — 220 minus your age — is notoriously inaccurate. A more precise formula, as described here, is 211 minus 64 percent of your age.

And, without belaboring the obvious, remember that "any amount of physical activity at almost any intensity will have some health benefits," Dr. Kuk said.

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Personal Health: Outsmarting Breast Cancer With Evolving Therapies

Personal Health

Jane Brody on health and aging.

Picture Your Life

Faces of Breast Cancer

We asked our readers to share insights from their experiences with breast cancer. Here are some of their stories.

Over the past few decades, changes in the treatment of breast cancer amount to a revolution in patient care. And it's not over yet. There was a time when the standard approach was a radical mastectomy, which involved removal of not just the breast, but all the lymph nodes in the armpit and underlying muscles in the chest wall. This approach has been replaced by less extensive surgery that, through decades of clinical trials, has proved to be equally effective at treating patients, as well as safer and less disfiguring. Even simple mastectomies, in which most nodes and the muscles were left intact, have become far less common. Dr. J. Dirk Iglehart, director of the Susan F. Smith Center for Women's Cancers at Dana-Farber Cancer Institute in Boston, estimated that he now performs a tenth of the number of mastectomies than when he entered the field in the 1970s.

Currently, most women with early-stage breast cancer have a lumpectomy; only the tumor and a small margin of surrounding normal tissue are removed, along with a few lymph nodes. Patients then receive localized radiation therapy and often drug therapy to head off a recurrence.

Even though this approach is less aggressive, breast cancer death rates have dropped steadily since 1990, a combined result of earlier diagnosis and medical therapies developed largely through a major national investment in cancer research, according to Dr. Clifford A. Hudis, chief of breast cancer medicine service at Memorial Sloan Kettering Cancer Center in New York.

"Treatment today is getting much more individualized," Dr. Hudis said. Depending on the molecular nature of a woman's tumor, postoperative hormonal or other drug treatments are routinely prescribed to prevent or delay a recurrence of disease.

Still, with nearly 40,000 breast cancer deaths annually in this country, more needs to be done.

Instead of waiting for cancer to recur in certain high-risk patients, scientists are now developing techniques to outsmart the cancer cell's aggressive tactics by prompting the patient's immune system to launch a continuous attack that keeps the disease at bay indefinitely.

Even lumpectomy could eventually become a thing of the past if these techniques achieve their early promise.

Another nonsurgical approach under study involves destroying the tumor by freezing it with an ice probe, but leaving it in place so that the immune system can be trained to attack it, Dr. Hudis said. The patient then would be given an immune stimulant to help overcome the molecular obstacles that had kept the immune system from recognizing the cancer as foreign tissue. When tumors are more advanced at diagnosis, it is already sometimes possible to minimize the extent of surgery without compromising a woman's chances of disease-free survival.

Fran Saunders, 63, is one of the estimated 232,500 American women who will this year learn they have invasive breast cancer. The tumor, which she noticed herself after skipping mammograms for a few years, is confined to the breast region, but too large for a lumpectomy.

So Ms. Saunders, an administrative assistant from Brooklyn, is now undergoing 20 weeks of chemotherapy at New York University Langone Medical Center to shrink her tumor, after which surgical options will be discussed with her doctor.

"The size of the tumor and presence of positive nodes may not matter as much as we thought," said Dr. Deborah M. Axelrod, a surgeon who directs breast cancer programs at the center. "It's not even true that if the cancer is metastatic, it's curtains."

Tests are being developed to help doctors predict an individual patient's response to various therapies, Dr. Axelrod said.

Patients are encouraged to become well-informed about their disease and possible therapies and to participate in treatment decisions. What a woman chooses may depend on such factors as her age, values, personal circumstances, professional concerns and risk tolerance.

"There's no right or wrong decision, as long as patients are well-informed and choose what is best for them," said Dr. Jennifer K. Litton, a surgical oncologist at M.D. Anderson Cancer Center in Houston. "The old days of paternalistic medicine are gone."

Also gone is the simplistic notion that cancer is a disease of abnormal cell division, said Dr. Larry Norton, deputy physician-in-chief for breast cancer programs at Memorial Sloan Kettering. "It's a disease of abnormal relationships between the cancer cell and other cells in its environment."

This new perspective "is leading to changes in treatment," he said. For example, current surgery for breast cancer involves removing only a few lymph nodes for testing, which avoids complications like a chronically swollen arm.

"We know that in many cases we're leaving behind nodes that contain cancer cells, but it doesn't hurt the patient to leave them there," Dr. Norton said.

"Cancer cells require other cells in their vicinity to help them grow," he added. "Understanding how the cells communicate is opening new opportunities to keep cancer cells from forming a tumor. It's not true that if there's one cancer cell left it will definitely grow and cause trouble."

Knowing that the effectiveness of treatment is reduced once cancer has metastasized — that is, spread to other regions of the body — researchers are now testing creative ways to prevent such recurrences. One, a specially designed vaccine called NeuVax, is in the final stage of multinational clinical tests under the direction of Dr. Elizabeth A. Mittendorf, a surgical oncologist at M.D. Anderson.

The vaccine is made from a peptide, a small piece of a cancer protein, that is combined with an immune stimulant. Early results suggest that the vaccine can reduce the risk of recurrence by 50 percent among breast cancer patients whose tumors produce low levels of the protein HER2, a marker for more aggressive breast cancer.

Without the vaccine, such patients have a 20 percent chance of a recurrence, Dr. Mittendorf said. Rather than waiting to see if a patient's cancer comes back, the vaccine is given at the time of initial treatment, when few if any cancer cells are present, she explained.

Changes have already taken place in postoperative radiation for breast cancer that reduce side effects and minimize potential long-term damage to organs under the breast. After surgery to remove the tumor, the breast may be only partly irradiated. Radiation can be focused on the cancerous area using a more intense but shorter course of treatment, Dr. Axelrod said.

And while chemotherapy is anything but pleasant, measures ranging from anti-nausea medication to massage are now commonly used to minimize patient discomfort.

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This post has been revised to reflect the following correction:

Correction: June 12, 2014

Because of an editing error, the Personal Health column on Tuesday, about treatments for breast cancer, misidentified the medical center where Dr. Deborah M. Axelrod, who commented on treatment options, works. Dr. Axelrod, a surgeon, directs breast cancer programs at New York University Langone Medical Center, not at Memorial Sloan-Kettering Cancer Center.

A version of this article appears in print on 06/10/2014, on page D7 of the NewYork edition with the headline: Outsmarting Breast Cancer.

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Well: Rethinking the Colorful Kindergarten Classroom

Imagine a kindergarten classroom. Picture the vividly colored scalloped borders on the walls, the dancing letters, maybe some charming cartoon barnyard animals holding up "Welcome to School!" signs.

That bright, cheery look has become a familiar sight in classrooms across the country, one that has only grown over the last few decades, fed by the proliferation of educational supply stores. But to what effect?

A new study looked at whether such classrooms encourage, or actually distract from, learning. The study, one of the first to examine how the look of these walls affects young students, found that when kindergartners were taught in a highly decorated classroom, they were more distracted, their gazes more likely to wander off task, and their test scores lower than when they were taught in a room that was comparatively spartan.

The researchers, from Carnegie Mellon University, did not conclude that kindergartners, who spend most of the day in one room, should be taught in an austere environment. But they urged educators to establish standards.

"So many things affect academic outcomes that are not under our control," said Anna V. Fisher, an associate professor of psychology at Carnegie Mellon and the lead author of the study, which was published in Psychological Science. "But the classroom's visual environment is under the direct control of the teachers. They're trying their best in the absence of empirically validated guidelines."

In the early years of school, children must learn to direct their attention and concentrate on a task. As they grow older, their focus improves. Sixth graders, for example, can tune out extraneous stimuli far more readily than preschoolers, the study's authors noted.

But could information-dense kindergarten classroom walls, intended to inspire children, instead be overwhelming? Could all that elaborate décor impede learning? Some experts think so.

"I want to throw myself over those scalloped borders and cute cartoon stuff and scream to teachers, 'Don't buy this, it's visually damaging for children!' " said Patricia Tarr, an associate professor at the University of Calgary who researches early childhood education and art education. She was not involved in the study.

Dr. Tarr has long railed against the notion of decorating a classroom. In a 2004 paper called "Consider the Walls," published in Young Children, the journal for the National Association for the Education of Young Children, she argued that classrooms could become so cluttered with commercial posters and mobiles that they obscured the children's own drawings and writings, posing special challenges to any child with attention deficits.

For the new study, 24 kindergartners were taught in two classroom settings: one unadorned, the other festooned with commercial materials like posters and maps, as well as the children's artwork. The children sat on carpet squares in a semicircle facing the teacher, who read aloud from a picture book. They took six five- to seven-minute science lessons over two weeks on topics such as plate tectonics, the solar system and bugs. After each lesson, the children took multiple-choice picture tests. The lessons were videotaped, to monitor how often the children's gazes wandered.

In the austere classroom, the kindergartners — age-appropriately wriggly and restless — were inclined to be distracted by others, or even themselves. But in the decorated one, the visuals competed with the teacher for their attention. The children spent far more time off-task in the decorated classroom than in the plain one, and their test scores were also lower.

The researchers acknowledged that their study looked only at one small group of kindergartners, and that its results may not apply to older children. Moreover, the students sat in the rooms for one lesson at a time, rather than a full school day.

Sara E. Rimm-Kaufman, an educational psychologist at the University of Virginia who was not involved in the study, noted that relatively little had been written about how to make effective use of classroom walls. But she said that if young children were "seeing so much at once, they cannot independently differentiate what is important; they may tune out the teacher."

Yet teachers sometimes feel compelled to make those walls attractive, she said, "because they know parents are coming to an open house night, and parents expect to see a decorated classroom."

Some educators have resisted the trend toward the ever-more embellished classroom. Montessori schools, the Carnegie Mellon researchers noted, have long emphasized a calmer, understated look. Individual teachers have eschewed the pricey trend, too.

"We used to paper our walls from floor to ceiling, covering them 100 percent," said Ingrid Boydston, a kindergarten teacher at Bridgeport Elementary School in Santa Clarita, Calif.

Now Mrs. Boydston, a California teacher of the year in 1999, encourages teachers to let wall displays grow from the children's experiences. For a recent lesson about the artist Monet, she stood in front of a white board, wearing a wide-brimmed straw hat and smock and speaking in a French accent. Afterward, she filled the board with key words that her 27 young students remembered from her talk. They later used them to practice writing sentences.

Then the children went to the room's paint center, where they went to work with cotton swabs and paint.

Finally, it was time to adorn a blank wall. Mrs. Boydston filled it with artwork: the children's Monets, not Claude's.

A version of this article appears in print on 06/10/2014, on page D6 of the NewYork edition with the headline: A Wall as a Barrier to Learning.

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