I usually write about an item in this week’s news or in the recent medical literature.  Forgive me from straying from that path this week to share some personal reflections.

For sedentary patients there is an enormous psychological barrier to exercise.  All primary care doctors face that barrier daily.  We encourage, cajole, practically shove our patients to become more physically active.  The vast majority of the time, despite the patient’s and the doctor’s best intentions, no change occurs.  The patient never starts exercising, or abandons his efforts after two or three days.  Habits are very hard to change.

This is very frustrating for both the physician and the patient.  Physicians knows that cardiovascular exercise lowers blood pressure, lowers blood glucose, improves mood and energy, lowers cholesterol (while increasing, HDL, the good cholesterol), decreases anxiety and improves sleep.  The scientifically proven benefits of cardiovascular exercise exceed those of many medicines and tests that we use routinely.  Patients know this too.  They know they should be exercising, but they can’t overcome the sedentary inertia.

Patients always have excellent reasons why they can’t exercise.  Usually they’re too tired or too stressed.  This is a trap, a spiral that inevitably leads to less and less activity which causes more fatigue and more stress.  The irony is that the most effective remedy for fatigue and stress (assuming serious medical and psychiatric problems are ruled out) is exercise.  So the only way to break out of the trap is to start exercising despite the fatigue and despite the stress.  “Just start exercising anyway”, doctors beg.

Don’t misunderstand; I’m not trying to get patients to compete in triathlons or climb mountains.  I just want them to start walking for 30 minutes on most days.  Shopping, chasing your kids and walking around in the office do not count.  You have to be walking just to walk.

Then, in a tiny number of cases, through psychological processes that are completely mysterious to me, a miracle happens.  A patient starts exercising.  The transformation is unbelievable.  His blood pressure drops a few points.  A few pounds are shed.  Her heartburn resolves.  And even more impressive than the physical effects are the mental benefits.  Patients tell me they can concentrate better.  They’re less anxious.  They feel great!  After a few months, they can’t imagine skipping their exercise.  It just feels too good.  It’s as much a part of their routine as showering and dressing.  It’s a habit.  Habits are very hard to change.

In the last year I’ve told three of my patients that they are on the borderline of developing diabetes.  They have each, in his own way, made the exercise transformation.  All three are more active, leaner and happier.  For the time being, none of them needs medications for diabetes.

How can doctors better encourage that transformation?  I wish I knew, and I’d love your suggestions.  All I can recommend is that you pick something you like, start slowly, do it for at least 30 minutes almost every day, and start today.