Tools for Physical Activity Counseling in Medical Practice

Health-care providers can play an important role in promoting weight loss among their overweight and obese patients by promoting regular physical activity. Regular physical activity, performed at moderate-to-vigorous intensities has substantial health benefits. Physical activity is effective in reducing the risks for complications of obesity, such as hypertension, hyperlipidemia, insulin resistance, and diabetes. Regular physical activity is also associated with appetite suppression. The amount of physical activity recommended for promoting health and prevention of disease and early mortality by the Surgeon General's Report on Physical Activity and Health—150 kcal/d or 1000 kcal/wk—is equal to a 1.5-mile brisk walk ((1)). If the energy is not replaced, this accumulated energy expenditure is sufficient to prevent a weight gain and/or promote a weight loss of nearly 10 pounds a year. In 1989, the U.S. Preventive Services Task Force adopted guidelines for physical activity counseling (see Table 1) ((2)). The guidelines recommended that health-care providers counsel all patients to engage in a program of regular physical activity that is tailored to their health status and personal lifestyle. The task force defined three criteria to be used in evaluating the appropriate use of preventive interventions in the clinical setting: 1) burden of suffering, 2) efficacy, and 3) characteristics of the intervention. In a review of studies of the efficacy and characteristics of physical activity counseling in health-care settings, Simons-Morton et al. ((3)) concluded that physical activity interventions in health-care settings were effective in increasing physical activity among patients. Interventions that used multiple components for behavior change and that had sustained continued maintenance strategies were most successful in promoting long-term behavior changes. Programs that involved several members of the health-care team were more successful in delivering an effective program than those that relied on a single provider or counseling strategy alone. Despite evidence that provider counseling for physical activity is effective and feasible, the proportion of physicians providing physical activity counseling is generally low. In a 1984 survey of primary-care physicians, Rosen et al. ((4)) showed that 29% of physicians reported they counseled on exercise during a preventive exam, and 64% brought up exercise only for high-risk patients. In the 1995 National Health Interview Survey, only 34% of 9299 respondents reported they had been counseled about exercise at their last medical exam visit ((5)). Counseling was higher among women, patients between 40 and 49 years, and those classified as overweight to obese, diabetic, or having cardiac disease. Damush et al. ((6)) conducted random telephone surveys of 893 community residents about having health-care provider counseling for physical activity at a recent medical office visit. Forty-eight percent reported receiving counseling for physical activity. The odds of being counseled were highest for younger, sedentary, and overweight-to-obese respondents and lowest among those not planning to start an exercise program. Determinants of provider counseling for physical activity have been identified in several studies ((2), (3), (7)). The biggest challenge to providing physical activity counseling relates to the costs in terms of provider and staff time. The lack of financial reimbursement for individualized counseling and competing demands to address other preventive health recommendations are the most common barriers to provider based counseling for physical activity. For some, a perceived lack of organizational support for the involvement of staff is seen as a cost too high to provide physical activity counseling. A second challenge to providing counseling for physical activity is the perceived lack of knowledge or counseling skills for physical activity among the providers. Instead of recommending physical activities that may cause harm to the patient and increase provider liability, some providers avoid making any recommendations at all. A third barrier to provider counseling is an expressed doubt in the patient's ability or intention to comply with the physical activity recommendations. This, coupled with a perceived ineffectiveness in the level of activity that patients could do, is often cited as a reason to avoid physical activity counseling. However, contrary to this notion, in a review of the impact of provider counseling for physical activities, Pinto et al. ((7)) cited that patients felt provider counseling had a positive impact on their physical activity habits. Provider-based physical activity counseling programs have been shown to be acceptable to providers and patients ((3), (8), (9), (10), (11), (12), (13), (14)). In a review of physical activity counseling programs, Simons-Morton et al. ((3)) identify qualities of successful programs as: 1) having multiple contacts between providers and patients, providing behavioral approaches to increasing physical activity behaviors, 2) providing supervised exercise classes and/or exercise equipment, and/or 3) providing continuing interventions for physical activity over time. Successful programs also recognize the time constraints on providers and minimize contact time between the provider and the patient to 2 to 5 minutes. With the exception of the Green Prescription Physical Activity Promotion Program ((13)), which calls for a provider to write a physical activity prescription—similar to a pharmaceutical prescription—most provider-based programs incorporate theoretical strategies for behavior change. For example, the physical activity interventions designed for the Activity Counseling Trial ((10)) draw from social cognitive theory. In an experimental setting, they compared three counseling approaches, ranging from minimal involvement (provider counseling only) to extensive support from office staff (provider counseling plus health educator activities and/or provider counseling with behavior change counseling). The Physical Activity for Life program also used social cognitive theory in physical activity counseling targeted toward older adults in health clinic settings ((7)). The Patient-Centered Assessment and Counseling for Exercise (PACE) program ((15), (16)) integrates the social cognitive theory and the Stage of Change theory ((17)) in a physical activity counseling program for health-care providers. PACE calls for minimal involvement of the medical staff and has been shown to be effective in increasing physical activity in patients and is feasible to administer in health-care settings ((14), (15)). For this reason, the PACE program is recommended as an effective tool for provider counseling about physical activity in the treatment of overweight and obesity. PACE was designed by physicians, behavioral scientists, and public health professionals to provide primary health-care providers with a quick, safe, and effective physical activity program for apparently healthy adults within a limited time of 2 to 5 minutes during an office visit ((16), (17)). The PACE intervention is based on the Stages of Change theory developed by Prochaska and DiClemente ((18)), which suggests that people make behavioral changes in stages. Three stages of change used in PACE are as follows: Stage 1, Precontemplation—patients are not active and they have no intention or interest in becoming more active; Stage 2, Contemplation—patients do little or no regular activity, but are interested in becoming more active; Stage 3, Action—patients are regularly participating in some form of moderate- or vigorous-intensity physical activity. Three distinct PACE counseling strategies have been developed that address the needs of patients in each stage. The PACE behavioral counseling strategies are based on social cognitive theory ((19)) that suggests that behavior results from an interaction of multiple influences including personal, interpersonal, social, and environmental conditions. Approaches to behavior change include goal setting, identifying barriers, contracting, identifying sources of social support, and improving self-efficacy through success in meeting short-term goals. The PACE materials include a Provider Manual, assessment forms, and three distinct counseling protocols. The assessment forms include a Physical Activity Readiness Questionnaire (PAR-Q) ((20)), used to identify any medical contraindications to physical activity that may be missing from the patient's chart and a PACE Current Activity Status Questionnaire. The PAR-Q is a seven-item questionnaire that has patients identify whether they have had signs or symptoms of cardiovascular disease, orthopedic conditions, or are taking medications that could affect physiological responses to exercise. The PACE questionnaire has 8 items intended to identify the patient's stage of readiness to begin a physical activity program. Counseling tools include information about the frequency, intensity, type, and time needed to meet the moderate- ((21)) and vigorous-intensity physical activity recommendations ((22)), a patient activity worksheet tailored to each stage of readiness to become more physically active, and a physical activity tip sheet. The worksheets are tailored to the patient's readiness to change and are designed to identify the patient's knowledge of the benefits of physical activity, steps they can take to adopt or maintain a physical activity program, and ways to overcome barriers to being physically active. Depending on the stage, the worksheets may provide a space for provider's health recommendations related to exercise and a space where the provider and patient can sign a contract for a specified physical activity program. Table 2 provides an overview of the three stages of PACE for 1) inactive patients not ready to change (precontemplators), 2) inactive patients who are ready to become more regularly active (contemplators), and 3) regularly active patients (action). Based on national studies of medical practices using PACE ((15)), it is estimated that the percentage of the patient population in each stage of change will be ∼10% for Stage 1, 50% for Stage 2, and 40% for Stage 3 ((23)). The stages for percentages of the patient population defined as overweight and/or obese have not been determined. The counseling materials for each stage are based on current understandings of what is needed to change patient behavior and are described briefly below. The first stage in PACE is targeted to patients who have no intentions to start a physical activity program. The worksheet is designed to increase patients’ awareness of the benefits of physical activity and to help them identify benefits that are important to them. The worksheet also informs the patient about the public health recommendations for moderate- and vigorous- intensity physical activity and lists examples of activities for them to think about what it means to be physically active. The second stage of PACE is targeted to patients who are ready to begin a physical activity program. The worksheet is designed to help patients identify the type and duration of activities they can perform, locations where they can perform the activities, and sources of social support for being physically active. Potential barriers to starting and maintaining a physical activity program also are identified. Suggested negotiation strategies are provided to help patients overcome the barriers. Last, the worksheet serves as an activity log that patients can fill in during the first week of activity. The third stage of PACE is targeted to patients who are already performing a regular physical activity program at recommended moderate- or vigorous-intensity recommendations. The worksheet is designed to have patients identify what motivates them about being regularly active and provides a format to reassess their current activity program. Suggestions to prevent relapse are provided and the provider reviews the current physical activity plan and recommends modifications, if appropriate. The PACE program is administered in two phases during an office visit with each phase taking from 3 to 5 minutes to complete. The first phase occurs after the patient checks in with the receptionist and is waiting for his or her appointment. The receptionist gives the PAR-Q and the PACE questionnaires to the patient to complete to identify contraindications for activity and the patient's readiness for physical activity, respectively. The receptionist then assigns a PACE score from 1 to 8. Depending on the score (Stage 1 = 1; Stage 2 = 2–4; Stage 3 = 5 to 8), the receptionist assigns the patient into one of three tailored physical activity counseling stages and gives them an appropriate worksheet to complete. When the patient has completed the worksheet, the receptionist places the forms in the patient's chart. The second phase occurs in the examination room during the provider-patient visit. The provider reviews the counseling worksheet completed by the patient and checks the PAR-Q and medical chart to identify potential contraindications to physical activity. If no further evaluation of the patient's health status is needed, the provider discusses the physical activity recommendations with the patient and schedules a follow-up visit, if possible, to chart the patient's progress. The efficacy of PACE has been reported by Calfas et al. ((15)) in a quasi-experimental study of 255 apparently healthy sedentary patients. Seventeen provider practices (10 intervention and 7 control) comprising intervention and control sites were matched on medical practice variables for geographic location, specialty, ethnic background, and subject characteristics (mean age 39 years; 84% female; 28% ethnic minority). Patients were selected from clinic volunteers defined as sedentary (vigorous to moderate exercise <3 times/wk or moderate exercise <2 h/wk). Intervention subjects had two contacts with a health educator, first to receive the PACE counseling materials and second to receive a booster phone call 2 weeks later. Physical activity levels and an index of readiness to adopt or maintain their physical activity program were assessed by surveys at the beginning of the study and 4 to 6 weeks later. Results showed that patients receiving the PACE program reported 37 min/wk in walking physical activity compared with 7 min/wk in the control group patients. Changes in perceived readiness for behavior change were more favorable in the intervention than in the control group subjects. Mediators to the changes in behavior were attributed to increases in cognitive and behavioral processes associated with the readiness to become more active ((12)). The feasibility of the PACE program was tested in a multi-site field test among primary-care providers in four geographic sites in the U.S. ((14)). A total of 27 primary-care providers participated in the study. The focus of the study was to test the acceptability of the program among health- care providers. To facilitate implementation, 107 patients were non-randomly selected to participate in the program. Before the start of the study, participating providers completed a 1-hour training session and were given a manual describing the PACE program. All providers completed a 1-hour training session and were given program material describing the PACE procedures. Results showed that most health-care providers (>85%) responded positively to receiving PACE training and used the protocol ∼10 times per week with patients during the study period. All providers (100%) reported feeling more confident and better prepared to counsel patients about physical activity after the PACE training session. Having detailed written materials to use during counseling with the patients was noted as a positive feature of PACE among respondents. The most frequently cited barrier to using PACE in the health-care practice was “not remembering to do the counseling” (35% of providers). Despite this limitation, over three-fourths of providers felt their patients rated the program as “good” or “very good” and that patient levels of physical activity increased after implementing the program. Green et al. ((24)) studied the effectiveness of using PACE in a 6-month telephone-based randomized clinical trial designed to increase physical activity in 316 inactive patients who were interested in increasing their physical activity levels. Subjects were recruited from 1330 primary-care patients enrolled in a health-maintenance organization, ages 20 to 64 years, and randomized into a control group (n = 157) or a telephone-based counseling group (n = 159). Among the treatment subjects, 99 declined to participate in the intervention and 60 received the intervention. The intervention group received three 20- to 30-minute phone calls each month to assist patients in identifying strategies to increase and maintain regular physical activity. The control group did not receive physical activity counseling or the phone calls. The primary outcome was a change in physical activity levels as measured using the PACE instrument. Results showed significantly higher levels of exercise as measured using the PACE score after the 6-month treatment period among subjects in the intervention group compared with the control subjects (PACE score of 5.37 vs. 4.98, p < 0.05). It was concluded that telephone-based exercise intervention programs could be an effective method to increase self-reported physical activity levels among patients enrolled in a primary-care clinical practice. Norris et al. ((25)) studied the effectiveness of physician counseling to increase physical activity among inactive patients enrolled in a health-maintenance organization. The study design was a randomized controlled trial of 812 patients, ≥30 years, registered for well visits at 32 primary-care physician offices. Physicians were trained to deliver the PACE exercise-counseling protocols with the intervention subjects receiving PACE counseling at a clinic visit and one reminder telephone call a month later. The control subjects did not receive PACE counseling or a phone call. The outcome measures were changes in estimated weekly energy expenditure as measured by a physical activity questionnaire and changes in the PACE exercise score. Results showed no significant differences in the energy-expenditure score between the intervention and control groups (p = 0.99); however, the stages-of-change exercise score among Contemplators increased significantly after 6 months compared with the control group (p = 0.03). It was concluded that a one-time PACE counseling session with minimal reinforcement was not effective in increasing physical activity levels among subjects with high baseline levels of activity. However, it may be an effective method to advance stages of exercise behavior change among adults with lower levels of baseline activity. According to the Canadian Task Force on Preventive Health Care, a general approach to assisting patients in behavior change programs should involve the construct of the five A's: Assess, Advise, Agree, Assist, and Arrange. The U.S. Preventive Services Task Force has adopted the construct as a clinical approach to behavior change programs ((26), (27)). The constructs are as follows: Assess—Ask about or assess behavioral health risk(s) and factors affecting a patient's choice of behavior change goals and methods. Advise—Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits. Agree—Collaboratively select appropriate treatment goals and methods based on the patient's interest in and willingness to change the behavior. Assist—Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-on goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate. Arrange—Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment. The PACE program is a structured physical activity counseling program that presents the constructs in a simple, coherent way. Within each construct, the provider has the flexibility to expand the amount of information and behavior change activities given (e.g., provide instructive videotapes to assist the patient in performing exercises safely, schedule group exercise sessions to provide social support for adherence to an exercise program). Simkin-Silverman and Wing ((9)) showed that provider counseling for obesity is effective when providers are trained in methods to provide weight control counseling to patients. They showed that providers who were trained in behavioral and motivational weight-control counseling skills and who were also given patient materials for use in their practice were nearly twice as likely to counsel patients for weight loss as compared with providers who were unskilled in counseling patients for obesity. PACE is a structured counseling program for physical activity that health-care providers can use in a primary-care setting to encourage patients to become more physically active. The program uses the Stages of Change theory to identify patients by their readiness to become physically active and provides counseling for patients using strategies based on social cognitive theory. PACE has been shown effective in increasing physical activity levels among healthy patients. Further, PACE has been shown to have high acceptance among health-care providers as a method for counseling patients to increase their physical activity levels. We thank Dr. Karen Calfas from the PACE project for her review and helpful comments of the manuscript. Similar patient-centered counseling tools are available from the PACE project for nutrition and focus on dietary fat, fruit and vegetable intake, and caloric balance. Readers interested in additional information are referred to the PACE website (http:www.paceproject.org).

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