Illustrative Case 1 Patient characteristics History Hypertension treated with a diuretic and lisinopril (Prinivil) Hypothyroidism treated with levothyroxine Irregular periods, some hot flashes The patient is concerned because her mother, a smoker, began menopause at 47 years of age and had a myocardial infarction at 51 years of age The patient does not work outside of the home, and she homeschools her teenage daughter; her husband is an engineer Physical examination Body mass index is 28 kg per m2 ; blood pressure is 118/72 mm Hg No abnormal findings Physical activity counseling approach, based on the five A’s model Assess (using the Physical Activity Assessment Tool; Figure 1) Current physical activity: patient has been walking for 20 minutes, two days per week for several months (underactive) Contraindications: none for moderate physical activity Readiness for physical activity: patient is thinking about increasing physical activity (contemplation) Patient-oriented benefits: more energy, weight control, lower risk of heart disease Social support: daughter could do dishes so that the patient would have time for physical activity Helping others: husband needs physical activity; the patient could ask him to walk and go dancing with her Self-efficacy: patient is somewhat confident that she can increase physical activity Advise Praise the patient’s current physical activity Provide the patient with the recommended physical activity level (30 minutes of moderate-intensity physical activity on five or more days of the week) Emphasize physical activity’s role in weight control, reducing stress, and looking good Agree Ask the patient if she would agree to increasing her physical activity Tell the patient to call the office if she has chest pain or light-headedness during physical activity Assist Give the patient a written prescription and print materials for assistance Recommend that the patient track her physical activity with a pedometer or calendar Arrange Schedule a follow-up visit Refer the patient to Web sites for more information about physical activity, to a dietitian, and for telephone counseling (if available) Possible dialogue “I’m glad to see you are walking several times a week. However, everyone needs at least 30 minutes of moderate-intensity physical activity, like walking fast, on at least five days of the week. This will help you control your weight, cope with stress better, and look and feel your best. Why don’t you ask your daughter to do the dishes so you have time to get more activity? Your husband could use more physical activity to help control his blood pressure, so why don’t you ask him to go walking with you and take you dancing more often? Is that something you think you can do? If the patient agrees: “That sounds like a plan. Here’s a prescription for physical activity; it’s as important as the medication prescriptions I’ve given you today.” Give the patient printed supportive materials and self-monitoring tools: “Please look over these materials. Let’s schedule a follow-up visit, and I’ll ask how you’re doing then.” Online Figure A. Illustrative case of physical activity counseling for a 46-year-old woman presenting at an initial visit to establish primary care. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests. 2 American Family Physician www.aafp.org/afp Volume 77, Number 8 April 15, 2008 Illustrative Case 2 Patient characteristics History Hypertension and hyperlipidemia, which are being treated with medications, and benign postural vertigo Left ventricular hypertrophy and mild diastolic dysfunction shown on a recent echocardiogram The patient is taking medications for hypertension The patient is able to carry groceries without difficulty Physical examination Body mass index is 22 kg per m2 ; blood pressure is 115/80 mm Hg Remainder of examination is unremarkable Physical activity counseling approach, based on the five A’s model Assess (using the Physical Activity Assessment Tool; Figure 1) Current physical activity: gardening 10 to 20 minutes, seven days per week (underactive) Contraindications: the patient becomes dizzy if she rises suddenly or tilts her head back too far; she usually has no symptoms with physical activity; her vertigo and cardiac conditions are well controlled; relative contraindication for vigorous physical activity, but she should be able to do symptom-limited, moderate physical activity Readiness for physical activity: patient intends to become more active in the next six months (prepreparation) Patient-oriented benefits: improved health, lower cholesterol, and lower risk of heart disease Social support: none Helping others: husband needs more physical activity; she can ask him to participate with her Self-efficacy: patient is fairly confident that she can increase physical activity Advise Provide the patient with the recommended physical activity level (30 minutes of symptom-limited, moderate-intensity physical activity on five or more days of the week) Emphasize physical activity’s role in lowering blood pressure and cholesterol and in protecting her heart Recommend that she ask her husband to participate with her Agree Work with the patient to set a start date for physical activity Tell the patient to call the office if she has chest pain, shortness of breath, or light-headedness during physical activity Assist Give the patient a written prescription and print materials for assistance Recommend that the patient track her physical activity with a pedometer or calendar Arrange Schedule a follow-up visit Refer the patient to Web sites for more information about physical activity, consider physical therapy for conditioning, reevaluate and consider cardiac rehabilitation if symptoms develop during moderate physical activity Possible dialogue “I’m glad that you are interested in increasing your physical activity; it’s one of the best things you can do to improve your health. Everyone needs at least 30 minutes of moderate-intensity physical activity, like walking fast, on at least five days of the week. This will help lower your blood pressure and cholesterol and protect your heart. The gardening you are doing counts as physical activity, but more activity would be better. I’d encourage you not to do anything that makes you dizzy and to stop and call my office if you have light-headedness, chest pain, or shortness of breath.” If the patient agrees: “Do you think you can get your husband to take up gardening, too, or is there another type of physical activity, like walking, that you would enjoy doing together? If he increases his activity, it will lower his heart disease risk as much as when a smoker stops smoking.” Give the patient printed supportive materials and self-monitoring tools: “Please look over these materials. Let’s schedule a follow-up visit, and I’ll ask how you’re doing then.” Online Figure B. Illustrative case of physical activity counseling for a 69-year-old female retired schoolteacher, presenting for a primary care visit, who would like to increase her physical activity, but is unsure if it is safe to do so. April 15, 2008 Volume 77, Number 8 www.aafp.org/afp American Family Physician 3 Physical Activity Calendar Monthly goal: Day Minutes Month Year Write in the month and the corresponding dates in the spaces provided. Then record your type and minutes of activity for each day. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Weekly totals Weekly goals Days Minutes Weekly goals Days Minutes Weekly goals Days Minutes Weekly goals Days Minutes Monthly totals Online Figure C. Calendar for self-monitoring of physical activity. Figure courtesy of Rebecca A. Meriwether, MD, MPH.