The Open Secret to Health and Well-Being

Teaching this secret is my most powerful medical intervention

A hidden aspect of being a good primary care physician is being a lifestyle coach. Being a good doctor is not just about treating illness; it’s about creating good health*. 

These days the #1 cause of not having good health is probably insufficient exercise. Because of this, I start every physical by asking about exercise and do a mini-motivational session with everyone who is not getting sufficient exercise. My patients have widely varying abilities and levels of willingness to do exercise, requiring me to tailor this talk to each patient. 

The reward from this talk is that when I convince a patient to start exercising, I routinely see near-miraculous results. 

I am an exercise interventionalist

I learned this lesson early on. Somehow, a very rich and prominent businessman** ended up on my schedule as a new doctor. When I asked him what he did for work, I was too new to the area to recognize the name of the company. Or that his family name matched a large public structure in town. I saw him as a 50-year-old guy who had a big gut, worked too hard, had pre-diabetes, and was on the edge of needing blood pressure medicine. 

Back then I had only one exercise motivational spiel. Start small. Get yourself to put your exercise clothes on and drive three times a week to the parking lot of the fitness club you already have a membership at. If you do that, you declare victory. You do not have to go inside or work out. You can. If getting there works well, after a few weeks, you can add something more energetic like going inside and walking on the treadmill for five minutes.

I scheduled a follow-up appointment for three months later to assess whether we needed to start him on blood pressure medication. When I saw him next, I was amazed. His blood pressure was fifteen points lower, he had lost twenty pounds, and he had defined biceps. 

“My wife says to thank you.” He winked. “I’ve inspired the young guys in the office now. People who haven’t seen me in a while think I’ve had surgery, but you don’t get pipes like these from surgery.” He flexed, “I’m going to get a personal trainer to see if I can get a six pack.” 

What amazed me more was that my five-minute chat had produced a change that would affect him for the rest of his life, potentially even his children and grandchildren. Who knew that my career as a doctor would not just be about making cool diagnoses or clever treatment plans but that people would take my advice to lead healthier lifestyles? 

Patients who have had long-term exercise routines are usually distinctly different from my other patients. A good example is Claire, who became my patient when she was 79. In my first visit with her I learned that ever since she retired she had taken up the practice of walking three miles a day along the side of her dirt road, no matter the weather. I don’t think I have ever seen her for a sick visit, but she does her annuals like clockwork. When she turned 86, she mentioned that she no longer walked when it was raining or sleeting or snowing really hard, but she was still doing 3 miles every day the weather would allow. Two years later, at this year’s physical, I asked her if she was still walking 3 miles daily and she said, “Some days I am very tired and I only walk one and a half miles in the morning,” and my heart sank, “but then I go out in the afternoon and do the other 1.5 miles.” At 88, she lives independently, drives, and has an active social life. 

Exercising outdoors in the winter is harder than indoors

Convincing the patient to take up exercise is the hard part, and it’s hardest of all to do during our long, cold, snowy winters in New Hampshire. Not everyone is as weather-hardy as Claire. I have a sizable number of patients who do fine in the warm months - which here is from early May to late November - then they plop themselves down next to their fireplaces and accrue several months of muscle atrophy, resulting in an annual ratcheting down of their strength and stamina that is never fully regained in the summer. If this ratcheting down could be stopped, it would have huge benefits for my patients both in terms of longevity and in quality of life.

Janelle is typical of this kind of patient. Janelle is 52 years old, diabetic, and is about 30 pounds over the upper limit of an ideal weight for her. As usual, I begin her visit for her annual physical by asking about exercise. Janelle responds,

“Doctor Mary, I should move my physical to the summer because every year you ask me what I’m doing for exercise and every year my physical is in January. It’s winter. It’s cold, dark, and icy outside. During the rest of the year, I get plenty of exercise, going for walks and working in my garden. But in the middle of winter? There’s nothing I can do.”

“I hear this so often, Janelle! I know I don’t need to start with reminding you how exercise helps prevent dementia, keeps your glucose under better control, helps build muscles, prevents falls, lengthens your lifespan, and improves your quality of life. So, we can skip that. I know you really like being outside, so let’s start with outdoor things and see if we can’t find one that sounds doable to you.”

“My favorite recommendation is to take up a winter sport. For people in their forties and fifties, I think there’s no better winter sport to take up than cross-country (Nordic) skiing. People routinely ski into their seventies and even eighties. It’s great for young people, too, but there are no young people in the exam room today.” 

Fortunately, Janelle thinks I’m funny. 

“It uses nearly every muscle group and it’s great for your heart. Your balance and cardiac fitness are good enough to be able to do it. Unless a person is super athletic, they are unlikely to get going fast enough to get any kind of serious injury - except for an injury known as skiers’ thumb, which is almost entirely avoidable by learning proper technique.”

“It’s not a particularly expensive hobby, at least for us here in New Hampshire, because we have a lot of cross-country ski areas, but it’s not exactly cheap either. Daily ski passes for groomed trails are around $15-25; season passes are around $150-$250. There are lots of places to ski for free on “backcountry” (not-groomed) trails, although the snow conditions make the number of days this is doable more limited. Rental equipment is around $25/day at commercial, groomed ski areas. You can buy a set of entry-level equipment for $300 to $500 (or less during pre- and post-season sales), and if you’re a good and lucky shopper, you can find used equipment for much less. The big issue here is getting equipment that’s correctly sized for you. You’ll need the help of someone who knows what they’re doing.

“Taking up cross-country skiing has made winter one of my favorite times of the year. Also, I ski so much that the very best shape I’m in during the entire year is at the end of the ski season. 

The author and her husband at Jackson Ski Touring in Jackson, NH. We’ve had season passes here for years. Photo by Bill, the ski patroller.

Realistically, though, unless you’re lucky enough to live close to a ski area, you’ll need to supplement cross-country skiing with some other forms of exercise. This is what I do.

“Ice skating is wonderful, too. I used to enjoy it before I fell and broke my wrist. Ice skating is harder to learn to do than cross-country skiing, and - obviously - not all that safe for people like me with osteopenia.”

You can walk on sidewalks or trails if you got ‘em

“Winter hiking  - or just walking in the woods - is good exercise. Entry-level snowshoes cost about $100 to $150. Used ones*** are pretty easy to find around here for much less than new ones. Pretty much anyplace you can go for a walk in the woods in the summer you can snowshoe in the winter. 

“Once the snow gets compacted, hard, and icy, what you need are microspikes. Microspikes give secure traction on even the most slippery of icy surfaces. A decent set costs just $25, but if you’re going to go on long hikes up mountains, I’d recommend a higher quality set costing around $75.

“City or town walking is good in winter if you live within driving distance of a big enough expanse of sidewalks. Sparsely traveled dirt roads are good for walking. I walk a lot on the ones in my neighborhood, but busier roads aren’t safe for pedestrians.

Janelle tells me that she sees people who snowshoe on a neighborhood walking path she uses when it’s warm. She’ll look into getting snowshoes and microspikes so she can walk it in the winter. I put a note about this in her chart to ask her at her next visit whether she followed through with this. If we’re lucky, she will have, but most likely she won’t and I’ll have to try a different exercise idea with her next year. The key is to find an exercise program that clicks with the patient.

Getting your steps in indoors can be a challenge, too

Later in the day I do a physical for John, whose situation is much different from Janelle’s. When I ask him about what exercise he does, he tells me,

“Not much. You know, with my COPD, it’s too cold to be outside. In the summer, I can walk around my neighborhood, but every winter I lose a little bit of my stamina because it’s too hard to breathe most of the winter, even if I use my rescue inhaler before I go out. I can walk to the car okay, or to the store, but I can’t get enough breath to go very far outside. When I’m going grocery shopping, I’ll often walk all the aisles once and then walk the whole store again while I’m getting my stuff, but I only do that a couple times a week.”

“Have you considered a gym membership?”

“It’s too expensive! I don’t have that kind of money.”

“The cheapest gym around us starts at $15 a month. If you watch, they will have sales where you don’t have to pay the $49 entry fee. Sometimes, our clinic offers free memberships to patients who qualify - and you would qualify for what we usually do.”

“I’ve seen those ads. I’ve always figured that a gym that cheap would have to be dirty and would be nasty to go to.”

“Nope. They’re perfectly fine. I’ve had a membership at one of them for ten years or so. The place is always clean. It’s never smelly. They have lots of equipment and almost always it’s in good working order. While I personally prefer exercising outside in nature, when the weather is bad or when the mosquitos, ticks, and black flies are conspiring to try to take every drop of blood I have, I go to the gym.”

“They even have showers. They don’t have free soap and shampoo like the fancy gym, but the water is just as wet. You have to bring your own towels, though. Maybe they should invest in some of that dry water.”

John rolls his eyes. I think I’m funny.

“Some of my patients could not afford $15 a month, but I think you could. Is that something you’d consider?” 

John tells me he’ll think about it. I make a note to follow up with John at his next appointment if he’s able to make a commitment to it.

My clinic used to have some free memberships at the local Y that I could give to particularly cash-strapped patients. One of my patients accepted this offer, and went faithfully every day except Sunday for months. His stamina got better and the other people in his church choir even noticed his breath support had improved so much that he became a better singer. He was 67 and told me that he hadn’t felt so good since he was in his forties. He made exercise friends. Then, the free program ended. He told the people at the Y’s front desk that his free membership was ending and he couldn’t afford to continue being a member. He didn’t want them to worry that something had happened to him. The front desk staff talked to the manager. The Y found a way for him to keep his free membership. He was a little teary when he told me the story and he was so proud of himself for making such a big investment in his own well-being.

Raising a sweat in the privacy of your home

For my patients with a bit of extra room in their houses, home exercise equipment can be an effective way to exercise in the winter. However, I find it difficult to predict whether a given patient will do well with home equipment. Some patients become dedicated users and see substantial benefits, while others end up just losing floor space in their homes. Because of this, I’m reluctant to suggest to patients that they go out and buy expensive equipment.

One can often find perfectly good home exercise equipment for free on local “buy nothing” Facebook groups, or even by the roadside on trash day. There are also lots of good deals on used equipment. 

For my patients who have successful home exercise routines, treadmills are the most popular by far, followed by stationary bikes, then ellipticals. Some patients use free weights in their homes and some do yoga from the internet (there are plenty of free programs).

Patients with home equipment often tell me they use psychological tricks to get themselves to exercise. For example, one patient hated to exercise and loved televised sports. He made a deal with himself that he could only watch a game if he did half an hour on the exercise bike at the beginning of the game. Another patient only allows herself to watch Hallmark movies if she does it while using the elliptical. One patient reads while using her exercise bike. She tells me, “I don’t go as fast as I could, but if I wasn’t reading a good novel, I wouldn’t exercise at all.”

Woof woof! Please, oh, please let’s go exercise!

For some patients, the best investment they can make in exercise “equipment” is to get a dog. Dogs not only need to be walked, it’s the highlight of their day. The dog’s enthusiasm rubs off on their owners, making these walks fun and rewarding. Neighbors will often talk to the dog and owner, adding a social benefit. There are approximately one million other benefits to having a dog in your life and I strongly encourage pets. 

If you’re not sure how a dog would fit in your life, you can foster one from your local humane society or pet sit for a friend. Also, some humane societies will happily accept your volunteer time to walk their dogs awaiting placement

Maggie, the best girl ever, and everything you could want in an exercise buddy, is ready for whatever activity I have planned. She probably picked up the grass in her mouth from her tennis ball. It looks like I might be about to throw it for the 2,473rd time that afternoon.

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If you like data, you might like a fitness tracker

Some patients find fitness trackers motivating. I long ago gave mine away, but my husband is a dedicated user. He checks his in the late afternoon each day to determine how much more exercise he needs to get. 

While 10,000 steps per day is bandied about as a magic number, getting to 6,000 would be a huge improvement for many of my patients and provides most of the benefit that 10,000 provides. I have a friend who finds the number 10,000 motivating. If she notices that she is nearly there, she goes out and walks around her block.

Most fitness trackers these days collect a lot more information than just steps. For patients with heart concerns, keeping the amount of time doing cardiovascularly moderate or higher exercise can be a useful metric. Trends in resting heart rate are interesting and the moderately fancy fitness watches can tell you if your heart goes into afib or some other arrhythmia. 

New fitness trackers can be quite pricey, but people often give away or sell cheaply their old trackers. Try a used one to see if you find it motivating.

The latest craze

Many towns, health clubs, and even some apartment complexes have pickleball courts. This can be a fun way to exercise your body and your competitive spirit. A paddle suitable for beginners costs about $20. The balls can be had for $10. The only other thing you need is tennis shoes.

I work with a doctor who is so devoted to pickleball that she arranges her time in the hospital around her pickleball league schedule. Be careful about picking up pickleball. You may find yourself addicted.

And that’s not a bad thing!

It’s more fun with a buddy

If you can find an exercise buddy who can hold you accountable to your goals, even just a person you text after exercising, that can help. Someone who will exercise with you can be even more helpful. My husband serves in this role for me, encouraging me to exercise with him. He got the exercise “religion” by observing the big health and well-being differences between his older family members as a function of exercise. Those getting minimal exercise became candidates for strokes and vascular dementia.

A personal trainer is a good investment if you can afford it. For some people, getting a trainer for a few months helps get them started with an exercise habit. For others, the fact that they’re spending so much money on a trainer motivates them to exercise. 

Exercise in the winter in New England is not as easy as in the summer, but the older we get, the more ‘use it or lose it’ applies. Our muscles and metabolism don’t care if it’s cold or icy; they want us in motion. 

If you already have a great exercise practice, hooray! If not, hopefully, you can find something in this article motivating. It will probably be the best investment in your health and well-being that you’ll ever make.

*None of this is personal medical advice. If you wonder if more exercise would benefit you, ask your doctor. If you wonder what exercise is safe for you to do or how much or how intensely, ask your doctor.

**Janelle, John, and every other patient mentioned here is a patient amalgam of the patients who were able to figure out how to take my advice and exercise. Any resemblance to an actual person is accidental. 

 *** There are several places on various social media platforms for local buying and selling of used equipment. A relatively new phenomenon is “Buy Nothing” groups on FaceBook. Many towns or even neighborhoods have Buy Nothing groups and the culture there is that you can ask for something you’d like. If someone has it gathering dust in their garage, they can offer it to you. I asked for a set of ankle weights once and a nice man gave me two sets that he didn’t use anymore. A few months later someone else made the same request and I gave her one of them.