Eight hundred years ago, Maimonides wrote that "as long as a man exercises and exerts himself... he will not be visited by disease... and anyone who sits idly and does not exercise... all his life he will be visited by pain and weakness." But even the great Jewish physician also known by his acronym, Rambam, probably wouldn't have dreamed that cancer - a rare disease in his time - could be avoided or the risk of recurrence reduced with exercise. A new project called Tze'adim Le'eichut Hayim (Steps to Quality of Life) - aimed at encouraging cancer patients at three major hospitals to exercise according to their physical ability and eat right - has been launched by the Israel Cancer Association (ICA) with funding from the Janssen-Cilag pharmaceutical company. It has begun with patients at Hadassah University Medical Center's Sharett Institute of Oncology in Jerusalem's Ein Kerem with staff from Hadassah Optimal; Sheba Medical Center at Tel Hashomer; and Tel Aviv Sourasky Medical Center. While waiting to get the results of blood tests to find out whether their counts are suitable for chemotherapy, they can spend time exercising and learning how to promote health. The free lessons come with the gift of a pedometer to monitor how many steps they walk (10,000 a day are recommended), an elastic band for stretching plus an explanatory booklet that includes a daily diary for entering how many steps were walked and how long they performed aerobic and anaerobic (muscle-building) exercise and flexing, as well as how they felt afterwards. "We provide cancer drugs and other treatments, but patients can do some things by themselves to prevent cancer from returning," said Dr. Beatrice Uzieli, in charge of the day hospital at the Sharett Institute, who greeted cancer patients who attended the first lecture at Hadassah. "In the modern age, our brains are programmed to save on energy and minimize exertion," said Dr. Naama Constantini, a sports medicine expert at Hadassah's orthopedics department and head of sports medicine at Hadassah Optimal. "Most Israelis do very little physical exercise. According to a recent survey, most Israelis do their work sitting or standing, and 84% get to their jobs in a private car, bus or other means of transportation rather than walking. While only 20-30% of Israelis do planned exercise, and even when they are not 'couch potatoes' and go to the gym, they usually take the elevator or escalator to reach it. In Norway, 80% of the population exercise regularly." DISEASES RESULTING from physical inactivity, she continued, are the main causes of death around the world. But people who exercise regularly have 50% less heart disease, lower cholesterol and blood pressure, 30% less breast, colon and lung cancer. With exercise, the blood doesn't coagulate as much; people suffer fewer falls, less osteoporosis and back pain, and there is improved cognition. They feel better and are in a better mood due to the endorphins produced by the body during exercise. "Most cancer patients, especially those with breast cancer, gain weight in the long term," added Constantini, who designed an exercise program with Hadassah Optimal physiologist Shachar Nice. "Steroid treatment also can cause bone-density problems, and chemotherapy can damage the heart or raise blood sugar. We want to use exercise to prevent a recurrence of the tumor, and there are studies showing that more exertion makes cancer less likely to return." A US study of 1,000 cancer patients recently showed that exercise also reduced nausea from therapy and improved their general condition. There has been a meta-analysis of 14 large clinical studies of patients after surgery, even at Stage 3 of the disease. Half an hour of daily exercise reduced their body-mass index, improved their feeling and reduced tiredness. A large study of nurses treated for breast cancer showed that it was less likely to return in those who exercised. So physical activity is a kind of "medication" that produces more energy, improved daily functioning, less fat, more muscle, less nausea and a greater ability to cope with stress and reap enjoyment from life. "YOU HAVE no more excuses," Constantini told the cancer patients. "Our aim is to encourage you to exercise twice a week." The booklet distributed to them includes encouragement to do a "virtual walk" around the Kinneret by gradually toting up 64 kilometers, with 1,600 steps to a kilometer. Those who want to go farther can do a virtual trek from Metulla to Eilat, which covers 515 kilometers. Edna Bukstein of Netanya's Wingate Institute for Physical Education, which is also participating in the ICA's program, addressed the patients. Bukstein was Israel's champion in fast walking, in which - unlike running - one foot must always be on the ground. "Check with the pedometer you have received and see how many you steps you usually walk every day; then do 2,000 more. You don't have to run, you can walk. It's better for the joints. The Rambam specifically recommended walking as exercise, saying that if you sink into a bad mood, listen to music and walk in gardens and among lovely buildings." The Wingate expert suggested to the patients that they choose any type of physical activity they like. "And when you talk on the [cordless] phone, walk around the room instead of sitting in a chair. In aerobic activity, the whole body works together. Fast walking expends even more calories than running." She noted that it's easier for men, who are more muscular, to lose weight than women, and that exercise changes the body's fat/muscle ratio. PATIENTS WHO don't have the strength to walk for half an hour at once can divide it up into two daily sessions that offer the same accumulated benefits. "Go up stairs. Avoid elevators if possible. Don't exercise on a full or totally empty stomach. And when you go out in the sun, don't forget sunscreen," said Bukstein. Hadassah clinical dietitian Odelia Sasson, who works with Hadassah physician and trained chef Dr. Rani Pollak, has developed dietary advice and menus for cancer patients. Getting down to normal weight (body-mass index) and following a healthful diet can reduce the risk of cancer returning, she said. A new study of one million women in UK showed that development and return of 10 types of cancer, including breast, lymphoma, esophageal and colorectal, are reduced by lower body weight. "But you should not drastically lose weight; always consult your doctor," said Sasson. . She recommended avoiding sweet drinks, especially colas (which have five teaspoons of sugar in every glass), and high-calorie foods such as French fries and hamburgers. Instead of unnatural junk food like burekas (which have a lot of transfats and calories), eat more fruits, vegetables, pulses and whole grains. "I myself never eat or buy those processed meal-in-a-cup products to which hot water is added. Even simple crackers have a lot of fat, salt and margarine. The fruits and vegetables should come in a variety of colors, as these have different minerals and phytochemicals. By doing this, you can prevent the growth of cancer cells and lower blood pressure. Nine servings of vegetables and fruits a day are recommended, and one big carrot can be two units." She also advised eating whole wheat grains, oatmeal, granola, whole corn, rye, burghul and whole-grained rice while avoiding baked goods from white flour, even those in which a bit of whole-wheat flour is added. "Minimize the amount of red meat and salty foods you eat, and stay away from processed meats such as salami and hot dogs, which are involved in colorectal cancer. Baking rather than grilling to a crisp is recommended, as burnt foods contain carcinogens," said Pollak. She advised avoiding alcohol, but if patients do drink, they should reduce consumption. For women, one glass of beer or a little glass of whiskey per day is the limit. "And don't take high doses of food supplements that you think will prevent cancer. Consult an expert. Smokers who take a high dose of the antioxidant beta carotene, which usually helps protect against cancer, have been found to have a higher risk of contracting lung cancer." POLLAK NOTED that when he looked at 50-year-old issues of the Archives of Internal Medicine, he found studies of weight-loss programs, but most of those who participated dropped out. "Today, there are lots of places to exercise and endless numbers of diet programs. You would expect that things have improved over the past half-century. But the American Journal of Clinical Nutrition published a meta-analysis of articles that have appeared in the New England Journal of Medicine and the Journal of the American Medical Association over the past five years, and there hasn't been much progress. "Many didn't lose weight, and of those who initially lost, many regained. Dr. David Ludwig of Harvard Medical School says we live in a "poisonous atmosphere. Restaurants that offer the largest portions are considered the best. Gaining weight comes from a poor diet plus an unhealthful way of life. All this leads to an accumulation of kilos and a vicious cycle. While you can't change your genes, you can change diet and behavior." At Hadassah Optimal, the doctor/chef opened a "medical kitchen" to teach people what and how to cook in order to lose weight and promote health. He even brought enough food - baked garlic, leeks and mushrooms in olive oil, soy sauce and balsamic vinegar - to the Sharett Institute to serve a buffet for the patients at the lecture. "We have to to learn to cook differently," he told them, as "we didn't learn to cook this way from our parents." All the principles and suggestions offered during the ICA workshop are certainly relevant for cancer patients, but can be beneficial for everyone else as well.