Top secret

One afternoon, toward the end of 2003, I received a phone call from my doctor. He wanted to clear something up. Earlier that day, I had called his office to schedule an office visit and lab work. He was calling back to ask what lab test I thought I needed, and why I thought I needed it.

Surprised that this question would even be asked, I stammered that I thought I was due for another blood test for Hemoglobin A1c, lipids, and so on. After all, he'd had me doing this, at six-month intervals, ever since I'd been diagnosed with type 2 diabetes three years earlier. I had understood that this was the way it was going to be from now on.

Well, he said, for his diabetic patients he usually ordered these tests every six months, but I really wasn't diabetic any more. He said that he had been looking over my lab records, and he wasn't seeing any abnormal results over the past two-and-a-half years. I had managed to get my blood sugar under good control within a few months of my original diagnosis, and I had got it under even better control since then. I had done the same for my cholesterol, and my weight, and my blood pressure. He didn't have me on any prescription drugs, so he knew that there was only one possible explanation for these improvements: I must have adopted a healthy lifestyle, and that I must be sticking to it. Given all that, he didn't see a need to continue testing me so often -- unless, of course, something had changed for the worse.

He asked me if the results of my daily glucose tests had gone up. I said they hadn't. Was I still getting a lot of exercise? I said I was. I wasn't gaining weight, was I? I said no. My blood pressure hadn't increased, had it? I said it hadn't Did I feel good? I said I did. Well then, he said, there wasn't any need for me to see him, or go in for lab work, more than once a year.

I offer this anecdote as an illustration of a basic fact about type 2 diabetes which is so little-known, it might as well be a military secret: your health can actually get better, not worse, after you are diagnosed with the disease. At least, it happened in my case, so nobody's going to tell me it can't be done but I know that a lot of people are going to try to tell you it can't be done, and I don't feel like letting them get away with it.

If you have been diagnosed with type 2 diabetes, even very recently, there's a good chance that you have already heard enough scary things about this disease to become pretty discouraged about your prospects. Perhaps you have begun to feel that everything about your life is sure to get worse from this point on. Well, if you have been hearing nothing but the conventional, defeatist view of diabetes, I can hardly blame you for losing heart, but I take a very different view of the matter myself, and I hope to persuade you to do the same.

I have my reasons for rejecting the gloom-and-doom view of diabetes. I was 43 when I was diagnosed with the disease. At 51, I'm measurably healthier than I was then, and it might not be going too far to say that I'm healthier than I have ever been. Not only am I getting better lab results than I used to, I am also much more active and fit than I was in my youth. Strange as it seems, my experience with the disease has been more positive than negative. For that reason, I have little patience with people who talk about diabetes as if it were a hopeless downhill slide into illness, disability, and early death.. Diabetes can be that, and if you let someone talk you into assuming that it can't be anything else, it will be that, because you'll give up and let everything go to hell. Don't do that, please. You don't have to, after all. Giving up is not your only option. It's a very popular option, I regret to say, but it isn't the only one you've got.

A diagnosis of type 2 diabetes offers you a choice between two contrasting futures. It can be your opportunity to turn your life around, and get your health back. It also can be your opportunity to lose hope and sink into decline. The main thing that will determine the difference between those two possible outcomes is your attitude -- and that is why I don't want you to become discouraged by what you hear about diabetes. Discouragement is a luxury you cannot afford. You have a lot of important things to do right now, and getting depressed is not one of them.

I read once about a psychological study comparing how much time different kinds of people spent worrying. The people who spent the smallest amount of time worrying turned out, rather surprisingly, to be mothers of newborn infants. And why did these women spend less time worrying than other people? Because they were so busy that they didn't have time for it. Well, you dont have time for it, either.

Of course, it's barely possible that you haven't yet picked up on the prevailing pessimism about diabetes. Often this pessimism is merely hinted at, behind a facade of good cheer, so you might not notice it at first. For example, if you were to leaf through a few medical pamphlets on the subject of type 2 diabetes, your initial impression would be that this is a disease which mainly afflicts handsome, fit-looking people who have excellent taste in sweaters and scarves, and that its chief impact on them is to make them spend a lot of time outdoors, raking the autumn leaves and playing catch with their adorable children. To pick up the voice of doom, you actually have to read the text -- and even then, you may have to read between the lines a bit.

Still, the message, once you have become sensitive to it, soon becomes hard to ignore. And sometimes the message is right out there in the open anyway, where anyone could spot it. Journalists trying to raise public awareness of America's diabetes epidemic are especially fond of describing the disease, and its "devastating" impact on patients, in nightmarish terms. To read their brand of journalism is to know despair.

Because the pessimistic view of diabetes is so much in the air today, many of us find it hard not to equate diabetes with declining health. We almost can't help assuming that it's the sort of medical problem which, by its very nature, is bound to spin out of control before long. I want to encourage you to see the situation differently, but I'll be competing with an army of people who are going to have a lot of gloomy thoughts to share with you on the subject. (Even when they attempt to bring you good news, they will spoil it by dropping hints that, where diabetes is concerned, the news never stays good for long.) I don't want my message to be drowned out by theirs, especially as these people have so many misleading and dangerous things to tell you. Without wishing to appear spiteful, I must ask you to bear in mind that those people have their heads up their asses.

I beg your pardon; what I meant to say is that these people are confused. The precise nature of their confusion I will explore elsewhere. For now, I just want to make it clear that, no matter what you may have heard, it is quite possible that you can experience an improvement rather than a decline in your health, even though you now have the chronic condition known as type 2 diabetes.

Let me clarify something at once: when I say that improvement is possible, I don't mean that it happens to certain lucky people, and you should sit around waiting to see whether or not it is going to happen to you. Trust me: if you sit around waiting, it isn't going to happen to you. The kind of improvement I'm talking about is possible in the sense that it can happen if you choose to make it happen. The probability that it will just happen by itself is, unfortunately, zero.
To improve your health, you will actually have to do something about it. I guess you could say that's the bad news. The good news is that there's a lot you can do. I don't mean that there's a lot your doctor can do (because, in the final analysis, there really isn't); I mean that there are a lot of things you can do about your diabetes that are known to be effective. If you do these things, your diabetes (and your health in general) will be greatly improved. If everyone did these things, diabetes wouldn't be such a big problem for our society.

One aspect of type 2 diabetes which makes it especially hard to cope with emotionally is an embarassing fact about the disease: although genetic differences make some people more suceptible to it than others, personal habits seem to determine whether or not you actually develop the condition. You got yourself into this mess, in other words. that's depressing, if you look at it the wrong way. The right way to look at it is to say to yourself, If I got myself into this mess, then I can get myself out of it. To a surprisingly large extent, this is true. Type 1 patients don't need to have any personal regrets, because (so far as we know) there isn't anything they could have done to avoid becoming diabetic. On the other hand, there isn't anything they can do to stop being diabetic, either. People with type 2 have both the grief of knowing they prepared the ground for their own disease and the relief of knowing they have the power to do something about it.

I don't mean to suggest, by the way, that diabetes is curable in the usual sense of the word. When my doctor said I was no longer diabetic, he didn't mean that I had put the whole issue behind me and should forget about it. What he meant was that I had reduced my average blood sugar level to normal and had proved that I was capable of keeping it normal on a consistent basis. (At that time, I had kept it normal for more than two years; now I have kept it normal for more than six years.) But let me be realistic here: the only reason my blood sugar level stays normal is that I work hard at keeping it that way. The underlying problem that caused me to become diabetic in the first place is still lurking in the background, waiting for its chance to make me diabetic again. I have noticed that if I become temporarily inactive (due to an illness or injury), or if I am eating too much for the amount of exercise I'm getting (around the holidays, say), my test results start creeping upward. The change is not large or sudden, but there is no mistaking the trend. I estimate that, if I should ever let my guard down and go back to living the way I once did, my blood sugar would probably climb back up to diabetic levels within three weeks. Because I have this possibility constantly hanging over me, it would be misleading to say that I am cured of diabetes.

Still, in terms of the measures by which diabetes is formally defined and diagnosed, I don't have it. Theres no test they can give me that I cant pass. (I even gave myself a glucose tolerance test at home, just to see what would happen, and I passed it with room to spare.) If my medical records were lost, and I decided to deny that I had ever been diabetic, I could get away with it. (I mention this sinister idea only to be clear about how much progress it is possible to make in combatting this famously incurable disease. After all, I don't have well-controlled blood sugar I have normal blood sugar.)

My blood pressure is also normal now, by the way. So are my cholesterol levels. In fact, everything on my lab reports that used to show up as outside the normal range, at the time I became diabetic, is now normal. One by one, I eliminated every item on the problem list in my file at the doctors office. These days, when I go in to see my doctor, he has no dire warnings to give me, no issues he wishes I would start working on, no weight he wants me to lose. I go there in the expectation of being congratulated rather than nagged. When I have a doctors appointment coming up, I no longer dread it; I look forward to it. (Well, I don't look forward to all aspects of it, but the part that consists of conversation is fine.) Some years ago, I didn't think Id ever live to see the day when I could leave the doctors office feeling pleased with myself, rather than anxious and ashamed, but that's the way it works for me these days.

Does this sound impossible? Do you find it hard to imagine that you will ever hear your doctor say that youre doing just fine and shouldnt change a thing about the way youre living? If so, you are underestimating (as most people do) the power that you have over your own health, the capacity you have to make yourself better. Just how much you can improve your health will depend on various factors, including a few genetic factors which, admittedly, are beyond your control. But the really big factors are the ones within your control. Very few people, with diabetes or without it, ever come to understand this. They never learn to do even half of what they could be doing to make themselves well. I consider it tragic that so many of us have an opportunity to become healthy and strong, and don't take advantage of it. I wouldnt want that to happen in your case.


Getting the news

Being informed that you have a serious chronic disease is a bound to be a critical moment in your life. Different people experience different emotions in this situation. I'm told that the more popular options include shock, disbelief, resentment, and self-pity. When I got the news in February of 2001 (from a message my doctor left on my answering machine), what I felt was in a way even worse: total embarrassment. During a previous office visit my doctor had warned me of the consequences he expected me to suffer if I did not lose weight, and diabetes headed the list, but I had done nothing about the problem. Well, that's not quite true. I had done one thing: I had gained some more weight.

Now I had seemingly forced his prediction to come true ahead of schedule. I felt like an idiot, which was only natural, given that I had unquestionably been one. The message from my doctor instructed me to make an appointment with him, so that he could tell me about diabetes and what I would need to do about it. I called my doctors office to make the appointment, but I felt so ashamed of myself that I dreaded the upcoming office visit and wondered how I could possibly get through it. I know it may sound strange to you that I was worrying about feeling embarrassed during a medical visit, instead of worrying about, say, dying. I cant really explain this, because it doesnt sound plausible to say that you fear embarrassment more than you fear death, yet that is apparently the way my mind works. Anyway, embarrassment was what preoccupied me at the time.

Then it dawned on me that I could might be able to regain my dignity if I first regained the initiative. I should educate myself about diabetes, develop a plan for managing it, and begin to implement that plan immediately. Then I could go into my doctors office fully prepared. Instead of waiting nervously for him to tell me what to do, I would explain to him what I was already doing, and see what he thought of it. I began my research immediately, and plunged into it as if my life depended on it, which of course it did.

In conducting my research (mostly by looking at diabetes-releated web sites, at least to begin with), I did not focus on the what can diabetes do to me? question, or even on the what can doctors do about diabetes? question. My focus was on the what can I do about my diabetes? question. As far as I was concerned, diabetes did whatever diabetes did, and doctors did whatever doctors did; those things were not under my control, so thinking about them was a waste of my time. But my behavior was under my control, and changing my behavior might make a big difference, so that was where I was going to put my attention. This choice was all about regaining the initiative, and recovering from my embarrassment about the way I had messed up my health. But, by sheer good luck, it also turned out to be precisely the right choice to make.

Finding out what I could do about my diabetes wasn't as easy as I hoped it would be. As anyone who attempts to conduct medical research on the internet soon learns, there is far more controversy than consensus on most health issues. Diabetes, in particular, seems to be a topic which inspires sharply divergent recommendations from various experts, each of whom can brandish a study which proves beyond doubt that everyone but him has got it all wrong. Trying to guess which of these controversialists was right and which was wrong drove me crazy for a little while, until I decided to ignore the controversies, and see if I could find any practical recommendations which were not controversial. Was there anything I could do which all the experts agreed would be helpful (no matter how bitterly they differed about, say, oatmeal)? It turned out that there were, in fact, two things I could do which (according to virtually everyone) would help me get my diabetes under control: I could shed excess weight, and I could exercise regularly. I never found a single expert who didn't think those two things were worth doing.

So now I had my plan. I would start losing weight as fast as I could, and I would start exercising frequently.

Then I started trying to figure out how I would do these things. I had heard once that the most reliable way to lose weight was to go on a vegetarian diet, so I chose that approach. My initial diet was very low in fat, which meant that most of my calories were coming from carbohydrate. Some of the controversialists claimed that was a good thing for diabetes management, others said it wasn't, but that was the diet I chose. Maybe it wasn't ideally balanced, but it certainly was low in calories, so I started losing weight at a rate of 2 or 3 pounds per week. I was hungry a lot, but in my zeal for results I managed to cope with that.

For exercise, I started going to the YMCA and using the aerobic exercise machines there (stationary bicycles, stair-steppers, that sort of thing). I found it miserably difficult and uncomfortable, but in my zeal for results I managed to cope with that, too.

After a week or two of this, I bought a glucose meter, and started testing myself. It was clear that a positive transformation was already underway. My fasting tests in the morning were above normal, but not as high as what my doctor had measured, and there seemed to be a gradual downward trend. I was rather surprised that my lifestyle changes were already making a significant difference, when I hadnt even lost much weight yet and I didn't yet have the stamina to do workouts that lasted more than 15 or 20 minutes.

So now I had a specific plan, and I was putting it into effect, and it seemed to be bringing about a positive change. Suddenly I found myself looking forward to the meeting with my doctor instead of dreading it. I began to think with pleasure about how startled he would be by my changed attitude. I was sure that, by this point, his confidence in me must have reached a very low ebb, because I had seemingly ignored (or at least failed to act on) his previous warnings. Well, if he had low expectations of me, wouldnt that make my turnaround all the more impressive?

Although medical crises have a way of stripping away human dignity, in the long run this is not always a bad thing. Sometimes a sudden loss of dignity is exactly what we need to help us make changes in our lives that we needed to make anyway. Failures that seem spectacular and conspicuous leave you with nothing else to lose, no position to defend. When you find that you have fallen on your ass, and you are sitting uncomfortably in the dirt, and people are staring at you... well, you might as well climb back on the horse and start over. And maybe youll be a better rider for the experience. This seems to be what happened to me.

With my doctor's encouragement, I continued doing what I was doing (a low-fat vegetarian diet combined with regular workouts), and within six months I had changed everything about myself, medically speaking. I reduced my blood glucose, blood pressure, triglycerides, LDL cholesterol, and Hemoglobin A1c to normal, and I lost nearly 50 pounds. I was able to do all this without taking any diabetes drugs (although, for a while, I continued taking the blood pressure medication I had already been on for several years before I became diabetic).

There were other benefits to my new lifestyle. Over time I found that it was making me feel better in general, both physically and emotionally. My natural tendency (if natural is the right word to describe what someone is like when he is fat and sedentary) was to be nervous, oversensitive, and moody. After several months of regular exercise, I found that my emotions were under much better control. I was more confident, more relaxed, and a good deal less likely to waste time on unproductive worrying. I don't wish to overstate this; I don't want to make it appear that I have become a cool, fearless, worry-free superman. My problems didn't vanish, they just became milder and easier to deal with. I learned to recognize that a vague worry was only a worry, not a crisis. I became a little detached, a little more inclined to think well, its not the end of the world when something went wrong. Before I changed my lifestyle, everything that went wrong seemed like the end of the world to me. The life Id been living kept me in a state of constant stress, and I never quite realized that until I was forced to find a different way to live.

The New Yorker once printed a cartoon by Leo Cullum that showed two characters sitting in a bar, one of them a man, and the other a rather sullen-looking snake. The man was saying, Gimme a break. Being driven out of Ireland was the best thing that ever happened to you. The snake in the cartoon didn't appear to be welcoming this insight. But when a friend told me that being diagnosed with Type 2 diabetes was the best thing that ever happened to me, I had to admit that he had a point. No one could be more surprised than I was to discover that you can become healthier with diabetes than you were without it, but its true.


Not hating it

If you have to start exercising a lot (and you do), it might occur to you worry that hating exercise will be a bit of an obstacle in your path (and it will). Do not, however, make the mistake of assuming that this is an unsolvable problem. don't take it for granted that liking exercise is not humanly possible. It is possible to enjoy exercise, and a lot of non-insane people do. Furthermore, it is possible (amazing as it might seem) for a person who hates exercise to learn to enjoy it. I am sensing that you doubt me on both points, but I'm going to do my best to persuade you to take another look at the issue.

But first: hating it

If you asked a number of American adults to make a choice between exercising daily and crawling naked through broken glass, most of them would have to stop and think it over. Then they would ask, How much glass, and how far would I have to crawl? Ours is not an exercise-loving society.

Presumably, the 20% of Americans who get as much exercise as good health requires have somehow learned to like it. The remaining 80% not only don't like it, they have trouble understanding how anyone could. They are either struggling to overcome their dislike of exercise (in which case they cant bring themselves to do quite enough of it) or, even worse, they are not struggling to overcome their dislike of exercise. This is a serious problem for our society, and it surely contributes to the rising rates of obesity, diabetes, and heart disease in surprisingly young people.

A foreign visitor might be able to deduce our attitude toward exercise from the layout of our cities alone. In an American community, everything is designed to accommodate the automobile. We don't just assume that everybody owns a car; we assume that they never attempt to go anywhere without it. We build cities in which it is impossible to get around safely on foot or on a bicycle. To be sure, we do include walkways and bike lanes here and there but just try using them to get across town! For a few miles, everything is fine, and then the path youre on comes to an abrupt end, in the middle of a high-traffic intersection, and youre stranded. In American society, getting around without a car is considered an eccentric minority activity (we might choose to tolerate it, if were in the mood, but we certainly arent about to encourage it, by making it practical or safe).

We are doing our best to pass these attitudes on to the next generation. Most American children who live within one mile of school are taken there in a car. Of course, we do think that children should get exercise, but only in the form of team sports which wont be part of their lives as adults. (Pop quiz: how many of the adults you know play soccer regularly? Yes, that's what I thought.)

Lets face it: most adults watch sports. A sports fan is one who manifests his enjoyment of athletic activity by gazing at it while seated. Nearly all popular forms of popular entertainment are passive, and increasingly they are centered in the home, so that we don't have to get out of reach of the potato-chip bowl, or tire ourselves by walking out to the car. Our idea of interaction is something that involves a keyboard and mouse, and our idea of a game is something that involves a joystick.

Well, why do so many of us hate exercise? Its an attitude which clearly is causing problems for us, so we might as well examine it.

Choosing teams

I think most Americans hate exercise because they were taught to hate it. As children, they were trained to associate exercise with unpleasant things such as punishment, conflict, humiliation, and failure. I assume that this is not the result intended by those who create compulsory physical education programs for the nations schools, but it certainly is the result they are getting. It is amazing that such programs, which have produced a society in which most adults don't get enough exercise to stay healthy, are still widely regarded as a public benefit. How can this look like a success to anyone? I mean, what do people imagine would happen if these wonderfully effective programs didn't exist? That the 20% of us who are working out would stop?

I'm sorry if I seem over-critical, but I don't think a 20% success rate is very impressive. Even if exercise were illegal, 20% of the population would probably do it. In fact, if the government tried to ban exercise, we might see more people doing it, because then it would then have a certain outlaw glamour attached to it. Instead, what exercise has attached to it are unhappy memories. If you doubt this, try asking a roomful of adults to reminisce about the playground ritual of choosing teams and then stand back. This gruesome procedure (in which team captains choose players alternately, until only the undesirable players are left) is so hurtful to the children who are chosen last (and who may be subjected to open mockery in the process) that, decades later, they remember it as if it had happened an hour ago.

The adults who are nominally in charge of school athletic programs, and who turn a blind eye to ritualized cruelties of this sort, have more to answer for than the immediate hurt they are causing. They are creating a future population of adults who will regard the athletic world as hostile territory in which they can have no place. Most Americans do not learn to see exercise as part of the daily business of life, along with bathing and eating dinner. Instead, they see exercise as a kind of hobby something to be pursued by those who are very good at it, and prudently avoided by everyone else.

The most important thing you need to learn about exercise is how not to hate it. Unfortunately, this is also the most difficult thing to learn about exercise. Like most difficult things, though, it can be achieved if you're willing to chip away at it gradually. It took me about five years to progress from doing 15 minutes on the stair-climber to running my first marathon, and all I ever did to achieve that was to keep on pushing slightly beyond what I was comfortable with at any gven time. Over the years, the scope of what I was comfortable with kept expanding, slowly but steadily. I certainly didn't set out from the beginning to run a marathon, and in fact I spent years arguing with people who told me I ought pursue that goal. And yet, somehow, I got there. If you keep working away at a process of continual improvement, you end up in places you never thought you'd go. Also, as you pursue these difficult goals, you begin to find that your more ordinary workouts begin to seem easy, and even fun.

The first five minutes

A lot of people who hate execise base this opinion almost entirely on how awful they feel when they do just a little bit of it. They assume, reasonably enough but nevertheless incorrectly, that if they feel like they're dying after 2 minutes of exercise, it can only get worse from there. The reality is different. Let me explain why, in roundabout way.

Once, at a party, I fell into conversation with a scientist who turned out to be doing research on the human eye. I saw this as my opportunity to ask about something that had puzzled me for years: if the eye adjusts to dim light by dilating the pupil, and to bright light by contracting the pupil, why does it take so long, when you enter or leave a movie theater on a sunny afternoon, for your eyes to adjust to the change in brightness? Pupil-dilation seems to happen almost instantly (look at your eyes in a mirror and turn a flashlight on and off if you don't believe me) -- yet it takes five minutes or more before your eyes adjust fully to the dim light inside the theater, and when you leave it the sunlight hurts your eyes for a surprisingly long time, even though your pupils have already contracted as much as they're ever going to. So what is going on during this long delay?

It turned out that this issue was at the heart of his research. I had been waiting all my life to put this question to someone who could answer it, and I suspect he had been waiting all his life to give that answer to someone who was dying to hear it, so we had quite a conversation. I'll summarize it as simply as I can. Pupil dilation, it turns out,  is not the only thing that controls the eye's sensitivity. It seems that the eye has at least two entirely different chemical processes that it can use for detecting light, and one of them is much more sensitive than the other. These different modes of operation are suited to different light levels, and when the light level changes dramatically the eye needs to change over from one mode of operation to the other. His research was focused on the process by which this change happens, and a mighty complicated process it turns out to be -- a long series of chemical messages have to be exchanged between the retina and the nervous system to bring it about, and all of this back-and-forth exchange of signals takes time. That is why, when you make a sudden transition between full sun and a darkened room, you have to wait patiently for your eyes to get out of one operating mode and into the other.

The reason I am bringing all this up is that it gives you a familar example of a phenomenon which is relevant to exercise, and needs to be understood better. Vision isn't the only case in which the body uses alternative modes of operation for different conditions, and must make a gradual (and perhaps uncomfortable) transition between them. The process that the body uses to burn chemical fuel for energy is another such case. 

When you are at rest, or at least not doing anything very strenuous, your body gets most of its energy by burning fat rather than sugar. Fat is the body's preferred medium for stored energy, because it is so efficient: fat provides more than twice as much energy as an equivalent mass of sugar. There's a limit to how much sugar the body can store (the liver and muscles will only hold so much of it), but the body can easily store large amounts of fat, and even slender people usually have enough of it to meet their energy needs for a long time. The trouble with fat, though, is that it's a slow-burning fuel. The body can obtain more energy from fat than from sugar, but can't obtain it as fast. When the body needs to use energy at a rapid rate, it needs to start burning sugar. Therefore, at times of high energy usage (in other words, when you're exercising hard) the body switches over to another mode of operation, in which it obtains most of its energy from sugar rather than fat. Unfortunately, it can't make the transition instantly.

Just as you need to spend an uncomfortable interval waiting for your eyes to adjust to the sunlight when you leave a movie theater in the afternoon, you need to spend an uncomfortable interval (of about 5 minutes) waiting for your body to switch out of fat-burning mode and into sugar-burning mode when you start a workout. Until that transition is completed, you are going to be pushing beyond the limits of what your current mode of energy-production is able to support, and your body will be sure to let you know that you are overburdening it. The result is that, for the first five minutes, vigorous exercise tends to make you feel awful -- not just gasping for breath, but very likely nauseated as well. At least, nausea is the feeling I get; others may experiene different sensations during the transition, but whatever sensations they do experience are pretty sure to be unpleasant.

The biggest problem with this transitional period is that it makes a strong negative impression on people who don't realize it is both normal and temporary. Exercise novices, shocked by how bad they feel as soon as they start a workout, tend to assume that it can only get worse from there, and they may give up at once. (This is like saying "I tried going to a movie once. It was awful! It was dark in there, I couldn't see anything. I had to leave.")

Even after they get more experienced with exercise, a lot of people assume that they ought to feel good during the first five minutes of exercise; when they realize that they've been working out regularly for months and those initial minutes still feel bad every time, they may conclude that there is something wrong with them which makes them ill-suited to exercise. If they were the right sort of person to be working out, they'd feel great from the start; instead they feel bad, so apparently they're not cut out for this kind of thing.

The reality, I'm afraid, is that feeling good during the first five minutes of exercise is about as unlikely as finding that the sunshine on a July afternoon doesn't hurt your eyes when you emerge from a darkened theater. The transitional phase that occurs during the first 5 minutes of exercise become a little more bearable if you exercise a lot for a long time, but I doubt that it ever feels great to anyone. Athletes just take this in stride; they hardly notice it (because they don't have the mistaken notion that it shouldn't be this way), and they realize that it's temporary.

So here's the bottom line: no matter how hard an aerobic workout you're doing, in a sense you only have to get through the first five minutes. After that, it gets so much easier that you won't have a problem. Just don't form the unrealistic expectation that, somewhere along the way, the first five minutes will become a lot easier. They won't. On the other hand, a five-minute interval is really not that long.

Exercise & me

Since being diagnosed with diabetes, I have transformed myself into a rather athletic person. This has surprised my acquaintances, but not half as much as it has surprised me. Before the diagnosis, I would not have thought that becoming athletic was even a remote possibility for me. I would I have considered it a desirable goal, either. Up to that point, Id had no interest in athletic activity, and I was not expecting the situation to change. The situation did change, but even so, I still have difficulty seeing myself as an athlete. Perhaps the problem is that the word athlete implies youth, skill, and winning gold medals. By those standards, I don't qualify. I'm just a middle-aged guy who exercises a lot. Lately I do take part in organized exercise events such as foot-races, but when I do, the majority of the other participants finish ahead of me. To my mind, an athlete is someone a lot stronger and faster and more competitive (well, a lot more successfully competitive) than myself.

All the same, a lot of the exercise I do is challenging enough that anyone who does it surely qualifies as an athlete of some kind. I'm just a very unlikely person to end up in that situation. It didn't come to me easily or quickly. I had to overcome a well-established dislike of exercise, initially to reach a point where I could tolerate it, and later to reach a point where I could actually enjoy it.

Contrary to popular belief, such a transformation is possible. It just isn't likely to happen overnight. Achieving my new, positive attitude about exercise was a gradual process which took me more than two years to complete. I say complete only in the sense that exercising came to feel more comfortable and natural to me than not exercising; I don't mean to suggest that I have no further progress to make. Anyway, this transformation wont necessarily take two years in your case; you might be less rigid than I am (most people are, I hear), and you might not hate exercise as much as I did when I started. But however long it takes for you to learn to like exercise, the important point is not to let yourself become frustrated or discouraged if you don't succeed immediately. It will definitely take time.

Starting out

When I first started incorporating exercise into my life, I could barely handle 15 minutes on the stair-climber at the gym, and those 15 minutes seemed to last an eternity. But after a while these mini-workouts didn't seem quite so difficult, and I was able to move it up to 20 minutes, and then 25, and then 30. Also, I gradually increased the intensity of the exercise I was doing (using slightly more difficult settings on the exercise machines, or running a little faster, or lifting slightly heavier weights). I didn't have a schedule of the progress I was trying to make; I just made enough small adjustments to make sure that whatever exercise I was doing always remained challenging for me. Whenever things reached a point where I could no longer pretend that my workouts were still difficult, I raised the bar a little.

At first, my workouts were confined to the gym, because I felt conspicuous when exercising (in fact, I felt like an impostor, and not a very convincing one), so I wanted to do it on a relatively private stage. Jogging right out there in broad daylight, where anyone might see me, seemed like an ill-advised public display. I thought I looked ridiculous running, partly from being too fat and partly from being too awkward and untrained. I thought I looked ridiculous in the gym, too, but there was a limit to how many people would see me there, and a fair number of them were fat and awkward, too, so I didn't feel quite so uncomfortable there.

I probably wasn't entirely wrong in thinking that I looked ridiculous, but I was wrong to think that it mattered. If it is true that (as John Cleese has claimed) the British ideal of a successful life is to get into your grave without ever having suffered serious embarrassment, I recommend taking a less British approach to life. The American ideal of getting into your grave without noticing that you have suffered serious embarrassment seems more practical. Even if you have always thought of the irony-proof naivete of the American bumpkin as a trait you never wanted to exhibit, be aware that the cost of being too self-conscious for your own good can be awfully high. No matter how ungainly you suspect you may appear in the eyes of others when youre exercising, you need to let go of that thought. When you work out, try to do it with the guileless confidence of a Jethro Clampett. Easier said than done, of course but not impossible. Just focus on making your small, gradual improvements, and let everything else go.

You might expect, as I certainly did, that by following this process of gradual intensification (in my forties), I would soon come up against a dead end that I would reach a point where no further progress could occur, because I was up against the limits of what was physically possible for me. I suppose that will happen eventually, but it hasnt yet. So far, what I am finding is that if I ask my body to give me a little bit more (not a lot more, a little more), it delivers. I continue to make progress. Not rapid progress, but that doesnt matter. I'm not planning to enter the Olympics; I'm just trying to become more fit. But even if you are progressing slowly, its amazing how far a slow-but-steady rate of progress can take you over time.

Crossing the divide

For over a year, working out was something that I had to talk myself into, almost every time I did it. Even though I knew that I always felt better after a trip to the gym, I seldom felt a spontaneous urge to make that trip, because the exercise experience itself was not enjoyable for me. Depending on what kind of exercise I was doing, it either seemed like an ordeal or a bore, and at least part of the good feeling I experienced afterwards was relief at being done with it. Because my enthusiasm was so low, a trip to the gym would often be delayed for an hour or two while I gradually worked up the willpower to get up and go there.

I was able to stick with my exercise program through this period because I accepted it as necessary, and because I could see the benefit it was having on my BG and blood pressure. Still, I knew that a sense of dutiful compliance with the need to exercise would not be enough to keep me motivated forever. Human nature tends to rebel against drudgery, sooner or later. People who forge grimly ahead, doing something they don't enjoy because they think its their duty, are notoriously likely to burn out after a while. I knew that, if I wanted to avoid that commonplace diabetic hazard, I would somehow have to learn how to like exercise. I pursued that goal with great determination, even though I didn't know how I was going to reach it.

Fortunately I succeeded, eventually reaching the point where I could feel good during exercise, not just after it even in cases where the exercise was challenging my capacity for exertion. For me, routine exercise has become pretty easy, and even challenging exercise is sometimes fun. I usually work out six times a week, and my minimum is five; I don't find this difficult. If I miss a planned workout, because of travel or some kind of schedule change which cant be helped, I feel deprived (and also distinctly uncomfortable, as if I had left the house in the morning without taking a shower). Even on my one day off per week, I often feel an impulse to go for a run or something; I'm not claiming that its a strong impulse, or that I have any difficulty resisting it, but strangely enough the urge does occur. Exercise has become a basic necessity of life for me, something which I cant skip without feeling weird. Getting myself into this state of mind was not easy, and it wasn't quick, either, but the goal turned out to be attainable, and that's worth keeping in mind.

I succeeded mainly by exercising in circumstances that seemed, at least in some ways, pleasurable to me:
  • I took up cycling, and went on a lot of long rides out in the country. (Fortunately, I live in a region that includes a lot of beautiful cycling territory, including the wine-growing valleys of Sonoma and Napa and the coastal hills of Marin.)
  • I began to do a lot of hiking and trail-running in the local state parks.  
  • I got into the habit of exercising with others (friends, co-workers, members of sporting clubs in the area). There are a plenty of people around who are out there exercising in the fresh air, and it's a lot more fun to exercise with other people than it is to exercise alone.
  • I got into the habit of signing up for public exercise events, such as footraces, trail-runs, and organized bike rallies.
The effect of all these things was to gradually erase the negative feelings I had about exercise, and replace them with positive feelings.

I mention my struggles with exercise because I don't want you to think that I don't understand your negative feelings about the subject. I understand them as well as anyone could. But I also understand now that these feelings can be overcome with patient effort.