Recommending the Appropriate Physical Activity to Your Patients
Abstract & commentary
By Rahul Gupta, MD, MPH, FACP, Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV. Dr. Gupta reports no financial relationships relevant to this field of study.
Synopsis: A newly developed instrument to measure brief physical activity counseling in primary care demonstrates that physicians need to do a better job.
Source: Carroll JK, et al. Evaluation of physical activity counseling in primary care using direct observation of the 5As. Ann Fam Med 2011;9:416-422.
Physical inactivity can lead to obesity and type 2 diabetes, in addition to a host of other chronic conditions. We also understand that when proper physical activity is conducted, it can help control weight, reduce the risk of heart disease and some cancers, strengthen bones and muscles, and improve mental health. National guidelines recommend that children should be active at least 60 minutes or more daily.1 Most of the 60 minutes should be either moderate- or vigorous-intensity aerobic physical activity. Adults aged 18 to 65 years should do at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic physical activity per week or an equivalent combination of the two. For additional health benefits, adults should do more than 300 minutes of moderate intensity or 150 minutes of vigorous intensity activity per week or an equivalent combination of the two. In fact, research has demonstrated that adherence to these physical activity guidelines is associated with reduced all-cause mortality risks among U.S. adults.2 While rates of leisure-time physical activity vary across the United States, only 3 in 10 adults get the recommended amount of physical activity. As rates for chronic conditions such as obesity, diabetes, and heart disease continue to be on the rise, little progress has been made over the past 10 years in increasing physical activity levels among adults in the United States. One setting where such people can obtain credible advice and can be assisted in developing a plan for physical activity is in their family doctorâs office. The question is whether our patients are getting that type of help when they visit their primary care physician.
In their current study, the authors utilized the 5As (ask, advise, assess, assist, arrange) framework for physicians to ask about the current behavior, advise a change, assess readiness to change, assist with goal setting, and arrange follow-up to examine patient-physician physical activity discussions. In the first phase of the study, the researchers developed a coding scheme to measure the 5As using audio recordings of primary care visits. Then they applied the coding scheme to describe the degree to which patients and physicians accomplished the 5As. For this study, 28 physicians (internal medicine and family medicine) and 361 patients were recruited from northeast Ohio. Results showed that there were 135 discussions of physical activity among the 361 patients, in response to a survey that demonstrated the patients not meeting the physical activity guidelines. For each of the 5 As, Ask tasks occurred in 91% (n = 123) of discussions; Advise tasks occurred in 53% (n = 71) of the physical activity discussions; Assess readiness tasks were accomplished in 56% (n = 76) of the discussions; Assist tasks were observed in 39% (n = 52) of the discussions; and Arrange tasks occurred during only 6% (n = 8) of the discussions. In about half of the instances when patients were found to be ambivalent about their physical activity, physicians offered only limited assistance and in the remaining half they provided no assistance. Researchers also found that patients actively contributed to accomplishing the 5As since the assessment of patient readiness to change was actually revealed by the patients rather than elicited by the physicians.
The results of the above study are disappointing, yet not unexpected. Specifically, the results demonstrate that primary care physicians do have the best intentions in mind when they ask their patients about physical activity and provide some advice as well as assess readiness to make a change. However, when it comes to providing active assistance with goal setting for specific physical activity, and arranging follow-ups to ensure that physical activity discussions translate into true change, the story begins to unravel a core defect at a policy level rather than at practice level. Similar to many other issues that are of major public health concern such as tobacco, substance abuse, teen pregnancy and obesity, there is often a fundamental mismatch with stated policies and the resulting resource allocation. As a consequence, while improving patient engagement may be useful in promoting behavioral change3 and physical activity discussions with physicians may assist patients in being more open to consider such a change, the busy private practice environment with ever increasing challenges makes it almost impossible for the primary care physician to play a meaningful role in contributing to several leading public health issues. Therefore, it is necessary for us to understand that major public health achievements â" smoking cessation, obesity, nutrition, physical activity, substance abuse, mental health screening, or others â" can only be achieved by advocating for coordinated policies that encourage collaboration with health educators, clinical psychologists, community programs, or other public health experts. We hope there will be a time when a team approach, rather than solely relying on the primary care physician, will become the norm to address major public health challenges.
1. Physical Activity Guidelines Advisory Committee, Physical Activity Guidelines Advisory Committee Report, 2008, USDHHS, Washington DC (2008). http://www.health.gov/paguidelines/ Accessed November 11, 2011.
2. Schoenborn CA, Stommel M. Adherence to the 2008 adult physical activity guidelines and mortality risk. Am J Prev Med 2011;40:514-521.
3. Orleans CT. Promoting the maintenance of health behavior change: recommendations for the next generation of research and practice. Health Psychol 2000;19(1 Suppl):76-83.