The patient, who was in her early 50s and had obesity, agreed to cut back her daily one-pound bag of gummy bears to half a bag and start walking a day each week. Gradually, over the course of a few months, she increased her walking to three times weekly.
“By the time I saw her back three months later, she had lost 10 pounds,” said Christopher Bunt, MD, an associate professor of family medicine at the Medical University of South Carolina in Charleston. After a year, she was walking daily and had shed 25 pounds. “She had stopped eating gummy bears entirely,” he said.
Despite years spent by the health care community urging Americans to get more active, the latest federal data show that only one out of every four adults meets the minimum federal recommendations for physical activity: at least 150 minutes of moderate or 75 minutes of vigorous activity each week, along with two days of muscle-strengthening activities. Meanwhile, U.S. adults have become more sedentary, with time spent sitting increasing from 5.5 hours daily in 2007 to 6.4 hours in 2016, according to findings published in the April 23/30, 2019, JAMA.
Inducements to slow down seemingly stem from all corners, from long workdays at desk jobs to binge watching favorite shows. Add to that mix a year-long pandemic, which has boosted stress and curtailed group sports, spin classes, and other exercise outlets.
But physicians like Dr. Bunt said they have achieved some success by talking to patients about incremental changes they can make in their activity levels, and also by highlighting the more immediately visible payoffs, said Laura Q. Rogers, MD, MPH, FACP, a professor and an associate director in the division of preventive medicine at the University of Alabama at Birmingham. Though studies consistently show that exercise can help guard against cardiovascular disease, diabetes, and other chronic illnesses, “that seems so far into the distance for some people, they don't necessarily feel the immediate threat,” she said. “I do focus more on the here and now.”
The low-dose benefits
When meeting with patients, it's important for physicians to regularly ask, “What's your exercise routine?” said Paul D. Thompson, MD, chief of cardiology emeritus at Hartford Hospital in Hartford, Conn., who coauthored the editorial that accompanied the federal government's most recent physical activity guidelines, published Nov. 20, 2018, in JAMA.
“It's like smoking,” Dr. Thompson said. “If I don't ask you whether you smoke or not, it's almost like giving you permission to continue smoking.”
Physicians also should stress the positive findings that it doesn't take much activity—150 minutes of walking a week breaks down into slightly more than 20 minutes a day—to reap health benefits, Dr. Thompson said. Research shows that even shorter bursts of activity spread out over the day can help, he said.
More time spent exercising, particularly at a higher intensity, will fast-track fitness, Dr. Thompson said. But exercise, much like some drugs, exerts its largest effect at the lowest starting dose, he said. “You get the biggest reduction in cardiovascular events according to the epidemiological studies when you go from being a total couch potato to doing something.”
Dr. Thompson was one of the authors on a review article, published Jan. 26, 2016, in the Journal of the American College of Cardiology, that looked at the full range of exercise, including intensity, and found that “a change from an inactive to a mild or moderately active lifestyle yields a relatively large risk reduction” in terms of preventing cardiovascular disease.
Another more recent epidemiological study, looking at all-cause mortality, also found life-extending benefits with little time investment. Adults who completed 10 to 59 minutes of exercise each week had an 18% lower risk of death than their totally inactive counterparts, and those who completed 150 to 299 minutes weekly saw a 31% reduction, according to the findings, published November 2019 in the British Journal of Sports Medicine. 
The latest federal physical activity guidelines recognize that adults ages 65 years or older, as well as those with a chronic condition or disability, may be unable to meet that 150-minute minimum threshold. If so, they should pursue as much activity as their abilities permit, working with a clinician, the authors wrote. Ideally, older adults should incorporate balance exercises along with muscle-strengthening activities to guard against the greater risk of falls with advancing age.
Dr. Thompson's strategy is to encourage patients who are largely sedentary to commit to half an hour of exercise a day and then, he noted wryly, “There's a prayer that they will do it three times a week.”
Dr. Bunt and other experts recommend figuring out what activity the patient is interested in doing and hammering out a plan, possibly even writing it down on a prescription pad or entering it into the electronic health record. At each visit, a medical assistant or another clinician can ask about exercise when blood pressure and other vital signs are taken.
Physicians should also remind patients about the importance of mixing in weight-bearing exercise as they age, since people are now likely to live longer thanks to reduced rates of smoking and drugs that treat chronic conditions, such as hypertension, Dr. Thompson said.
“You can outlive your muscles,” he noted. “So it's very important as you get older to do some things to keep your thigh strength good, your calf strength good, your arm strength good.”
Ratcheting up activity
Don't make assumptions about how much someone exercises based on their body shape or the number on the scale, said Angela Fitch, MD, FACP, an obesity medicine specialist at Massachusetts General Hospital in Boston and an assistant professor of medicine at Harvard Medical School. She described how one of her patients with obesity regularly runs marathons. Meanwhile, some postmenopausal patients can weigh in at a normal body mass index but carry 40% body fat because they're skimping on exercise and instead restricting calories, she said.
When patients admit to being largely sedentary, Dr. Fitch prefers to brainstorm about ways they can boost their daily activity. “The word ‘exercise’ can be intimidating to the point that people don't even move,” she said.
Suggesting that patients track steps with their phone or some other fitness device is a good place to start, Dr. Fitch said. One approach is to recommend that they gradually ratchet upward from that baseline, increasing their daily step count by 500 steps each week, so a 2,500 daily goal one week can be bumped up to 3,000 steps the following week.
While any physical activity is good, Dr. Fitch is specific about the level of effort required to be considered moderate-intensity exercise, telling patients that they should feel like they're exerting themselves. “If you are walking, you are walking like you are late for the bus or late for the airplane,” she said. “You should feel like you could have a conversation but you may not want to.”
For patients to count exercise as vigorous, whether that's running or pushing themselves on the elliptical, they shouldn't be able to talk at all because they're breathing so hard out of their nose and mouth, Dr. Fitch said.
Ideally, adults of all ages should be completing 150 to 300 minutes of moderate exercise each week, according to the 2018 federal physical activity guidelines. The guidelines for vigorous exercise are half of that, up to 150 minutes a week, as one minute of vigorous exercise can substitute for two minutes of moderate intensity, the authors wrote.
Physicians or others in the practice can work with patients to develop an exercise routine using the FITT (Frequency, Intensity, Time, Type) formula, said Selina Shah, MD, FACP, a Walnut Creek, Calif., physician who is board certified in internal medicine and sports medicine. That plan enables patients to think through which exercise is most feasible, along with making a commitment as to how often and intensely they will pursue it, she said.
The physician can add the plan to the electronic health record or fill out a written form, essentially prescribing exercise, Dr. Shah said. (The American College of Sports Medicine, as part of its Exercise is Medicine campaign, includes such a prescribing form on its website.) Dr. Shah also advises patients to book exercise on their calendar just as they would for any other appointment.
Among Dr. Shah's patients, the pandemic has shaken up their exercise routine for both good and bad. For some, stopping the commute and working from home has opened up more time and they've tried new routines, such as video exercise classes. Others have struggled to find a reliable substitute for previous exercise, with less access to the gym or pool, she said.
That's the persistent challenge for patients whether amid a pandemic or not—staying on the exercise track, Dr. Rogers said. For instance, fitness tracking devices can initially be helpful, but she has noticed that some patients over time may lose their device or decide not to replace them once they break. Patients who count on exercise to lose weight can underestimate how much effort is required, closer to 300 minutes a week on moderate-intensity activities, she said.
“Even when I'm talking to them about weight loss, I try to get them to focus on the health benefits of the exercise and not the weight loss,” Dr. Rogers said. “It's difficult to lose a lot of weight with exercise alone. So people get discouraged and think, ‘Oh, exercise doesn't work for me.’”
Both the 2018 federal guidelines, as well as the more recent World Health Organization guidance published last year, recommend that individuals reduce desk sitting, television watching, driving, and other sedentary time as much as possible. But neither set of guidelines specifies a limit, with the WHO authors stating that there was “insufficient evidence to set a precise threshold (or ‘cut-off’) for the amount of sedentary or recreational screen time.”
For his most sedentary patients, Dr. Bunt said that he'll start small, suggesting that they walk in place as they watch their favorite show, or if they can see the TV or computer screen from their stairs, to instead walk up a few steps and down.
One man was so sedentary that Dr. Bunt asked him to stand as long as he could while watching television before he became weary. Over time, the patient increased from 10-minute intervals to an hour. Then he began to step in place while holding onto a nearby table. “I'm playing the long game,” Dr. Bunt said.
With a little more activity, and hopefully then intentional exercise, patients will see other motivations to continue, Dr. Bunt said. One immediate bonus is that they sleep better, he said.
“The other big one is mood,” Dr. Bunt said. “People just feel better when they're exercising regularly. They're less depressed. They're less anxious. Even though their body feels tired, they feel like they have more mental energy.”