Physical Activity Counseling

Am Fam Physician. 2008 Apr 15;77(8):1129-1136.

  Patient information: See related handout on physical activity, written by the authors of this article.

This version of the article includes supplemental content.

Every year in the United States, at least 250,000 deaths are attributed to lack of physical activity. Because of the health benefits of physical activity, national guidelines recommend participation in 30 minutes of accumulated moderate-intensity physical activity such as walking fast on five or more days of the week. However, most Americans fail to achieve this goal and report that their physicians have not counseled them to increase physical activity. Because 84 percent of Americans consult a physician each year, even brief physician counseling that leads to modest activity changes could affect the population's health. Some physicians report that they do not deliver physical activity counseling because of limitations in time, reimbursement, knowledge, confidence, and practical tools. The five A's (Assess, Advise, Agree, Assist, Arrange) model can help physicians deliver brief, individually tailored physical activity messages to patients.

Physical inactivity leads to at least 250,000 deaths annually in the United States,1 and more than one half of Americans fail to meet recommended physical activity levels.2 Regular physical activity decreases total mortality rates as well as the incidence and mortality of cardiovascular disease, diabetes, and some cancers.3,4 Physical activity improves mental health and control of diabetes, hypertension, and lipid levels; prevents osteoporosis; and, especially in older patients, sustains mobility, reduces disability, and decreases the risk of falls.3,4

The Centers for Disease Control and Prevention, American College of Sports Medicine, U.S. Surgeon General, and American College of Preventive Medicine recommend that adults participate in at least 30 minutes of accumulated moderate-intensity physical activity (i.e., walking fast [3 to 4 miles per hour] or the equivalent) on five or more days of the week.35 The following are key principles for physical activity: (1) the more activity the better, (2) accumulated time is more important than intensity, (3) activity can be accumulated in 10-minute increments,35 and (4) lifestyle activities (e.g., substituting walking or biking for short car rides, using a push rather than a riding lawn mower) are more likely to be sustained than structured activities (e.g., exercising at a gym).6

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

Adults should participate in at least 30 minutes of accumulated moderate-intensity physical activity (e.g., walking fast) on five or more days of the week.

B

35

Recommendation based on systematic reviews of evidence from observational studies; quality, quantity, and consistency of the evidence are strong.

Physicians should counsel patients to meet recommended levels of physical activity.

C

5, 89, 12

Recommendation based on RCTs of varying quality and with short follow-up periods.

Physicians should use the five A's (Assess, Advise, Agree, Assist, Arrange) model when counseling patients about physical activity.

C

8, 12

Recommendation based on theory, observational studies, and RCTs of physical activity and smoking cessation counseling.

Expert advice is conflicting about medical clearance before patients with risk factors initiate exercise programs.

C

35, 2325

ACC and AHA: Exercise stress testing should be performed before high-risk patients initiate vigorous physical activity.23

ACSM: Exercise stress testing should be preformed before high-risk patients initiate physical activity.24

CDC, ACPM, and U.S. Surgeon General: Most patients can participate in moderate physical activity without medical clearance.35

USPSTF: Insufficient evidence to recommend for or against exercise stress testing.25


RCT = randomized controlled trial; ACC = American College of Cardiology; AHA = American Heart Association; ACSM = American College of Sports Medicine; CDC = Centers for Disease Control and Prevention; ACPM = American College of Preventive Medicine; USPSTF = U.S. Preventive Services Task Force.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1063 or http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

Adults should participate in at least 30 minutes of accumulated moderate-intensity physical activity (e.g., walking fast) on five or more days of the week.

B

35

Recommendation based on systematic reviews of evidence from observational studies; quality, quantity, and consistency of the evidence are strong.

Physicians should counsel patients to meet recommended levels of physical activity.

C

5, 89, 12

Recommendation based on RCTs of varying quality and with short follow-up periods.

Physicians should use the five A's (Assess, Advise, Agree, Assist, Arrange) model when counseling patients about physical activity.

C

8, 12

Recommendation based on theory, observational studies, and RCTs of physical activity and smoking cessation counseling.

Expert advice is conflicting about medical clearance before patients with risk factors initiate exercise programs.

C

35, 2325

ACC and AHA: Exercise stress testing should be performed before high-risk patients initiate vigorous physical activity.23

ACSM: Exercise stress testing should be preformed before high-risk patients initiate physical activity.24

CDC, ACPM, and U.S. Surgeon General: Most patients can participate in moderate physical activity without medical clearance.35

USPSTF: Insufficient evidence to recommend for or against exercise stress testing.25


RCT = randomized controlled trial; ACC = American College of Cardiology; AHA = American Heart Association; ACSM = American College of Sports Medicine; CDC = Centers for Disease Control and Prevention; ACPM = American College of Preventive Medicine; USPSTF = U.S. Preventive Services Task Force.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1063 or http://www.aafp.org/afpsort.xml.

Evidence

Although physical activity clearly improves health,3,4 the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence that physician counseling leads to sustained changes in patient behavior.7 Nevertheless, in many patients, physician advice is associated with short-term increases in physical activity.79 In one study, the number of patients who improved their physical activity level increased by 50 percent after receiving physician advice.10

Each year, 84 percent of Americans consult a physician, with an average of 2.1 visits each.11 Because primary care physicians can potentially reach many patients, the cumulative health impact of even modestly effective physician interventions may surpass that of other interventions.5,8,12 Tailored counseling that incorporates shared decision making, a written prescription, printed supportive materials, and follow-up has been shown to increase the likelihood of success.5,9,12 Recognizing and addressing barriers to physical activity counseling is also essential.

Studies show that family physicians spend one and one half to three minutes providing health education and counseling during a typical visit.8,13 Barriers to physical activity counseling include limited time; reimbursement problems; lack of practical tools; and insufficient physician knowledge, skills, and confidence that patients will change their behaviors.8,9

Physical Activity Counseling

The five A's (Assess, Advise, Agree, Assist, Arrange) model, which has been shown to be effective for smoking cessation counseling, is a convenient approach to physical activity counseling in clinical practice8,12  (Table 1). See online Figures A and B for illustrative cases describing patient-oriented physical activity counseling.

Table 1

The Five A's Model for Helping Patients Change Physical Activity Behavior

Assess

Assess current physical activity (type, frequency, intensity, and duration); contraindications to physical activity; the patient's readiness for change; patient-oriented benefits; social support; willingness to help others; self-efficacy (the patient's self-confidence that he or she can change behavior)

See Table 2 for tools to facilitate the physical activity assessment

Advise

Provide a structured, individually tailored counseling message; the national recommendation for physical activity is at least 30 minutes of accumulated moderate-intensity physical activity (i.e., walking fast [3 to 4 miles per hour] or the equivalent) on five or more days of the week

Deliver a structured counseling message based on the patient's stage of change (see Table 3)

National recommendations + patient-oriented benefits + social support + helping others + agree on next steps + assist with printed materials and self-monitoring tools + arrange follow-up and referrals

Agree

Initiate shared decision making based on the patient's stage of change

Precontemplation stage (the patient is not ready for change): ask the patient if you can talk about physical activity in the future

Contemplation stage (the patient is thinking about changing): discuss the next steps

Preparation stage (the patient intends to change soon): help the patient make a plan and set a start date

Action/maintenance stage (the patient is meeting goals): congratulate the patient; ask if the patient is ready to start another healthy behavior

Assist

Provide the patient with a written prescription; printed support materials; self-monitoring tools (e.g., pedometer, calendar); or Internet-based resources (see accompanying patient handout)

Arrange

Schedule a follow-up visit

Provide telephone or e-mail reminders (e.g., have a staff member call or e-mail the patient on the start date of the behavior change) and Internet-based counseling

Refer the patient for additional assistance (e.g., physical activity counseling from a dietitian; physical therapy if the patient is deconditioned, injured, or has a condition that affects physical activity [arthritis, back pain]; community-based programs)

Table 1   The Five A's Model for Helping Patients Change Physical Activity Behavior

View Table

Table 1

The Five A's Model for Helping Patients Change Physical Activity Behavior

Assess

Assess current physical activity (type, frequency, intensity, and duration); contraindications to physical activity; the patient's readiness for change; patient-oriented benefits; social support; willingness to help others; self-efficacy (the patient's self-confidence that he or she can change behavior)

See Table 2 for tools to facilitate the physical activity assessment

Advise

Provide a structured, individually tailored counseling message; the national recommendation for physical activity is at least 30 minutes of accumulated moderate-intensity physical activity (i.e., walking fast [3 to 4 miles per hour] or the equivalent) on five or more days of the week

Deliver a structured counseling message based on the patient's stage of change (see Table 3)

National recommendations + patient-oriented benefits + social support + helping others + agree on next steps + assist with printed materials and self-monitoring tools + arrange follow-up and referrals

Agree

Initiate shared decision making based on the patient's stage of change

Precontemplation stage (the patient is not ready for change): ask the patient if you can talk about physical activity in the future

Contemplation stage (the patient is thinking about changing): discuss the next steps

Preparation stage (the patient intends to change soon): help the patient make a plan and set a start date

Action/maintenance stage (the patient is meeting goals): congratulate the patient; ask if the patient is ready to start another healthy behavior

Assist

Provide the patient with a written prescription; printed support materials; self-monitoring tools (e.g., pedometer, calendar); or Internet-based resources (see accompanying patient handout)

Arrange

Schedule a follow-up visit

Provide telephone or e-mail reminders (e.g., have a staff member call or e-mail the patient on the start date of the behavior change) and Internet-based counseling

Refer the patient for additional assistance (e.g., physical activity counseling from a dietitian; physical therapy if the patient is deconditioned, injured, or has a condition that affects physical activity [arthritis, back pain]; community-based programs)

ASSESS

Calculating a patient's current physical activity is complex. Eliciting the frequency, intensity, and duration of physical activity from patients is important in determining if the patient meets minimum recommendations.35 The physician may also need to elicit the types of physical activity the patient participates in to determine intensity and to tailor recommendations to patient preferences.

Psychosocial factors such as readiness for change, social support, and self-efficacy (i.e., the patient's self-confidence that he or she can change behavior) must be assessed.9,12,14,15 Physicians are also encouraged to assess the patient's willingness to help family or friends increase physical activity, because some patients may be motivated to increase their own activity to help others. Finally, the physician must determine if there are medical conditions that require diagnostic evaluation or modified management before the patient can safely initiate or increase physical activity.

Several tools have been designed to facilitate physical activity assessment (Table 2).1621 The Physical Activity Assessment Tool (PAAT; Figure 1) is a validated instrument designed to help primary care physicians assess patients quickly; reserve time for counseling; and develop individually tailored, structured counseling messages.17

Table 2

Tools for Assessing Physical Activity

Tool Description Web site

Brief physical activity assessment tool16

Assesses current physical activity

PAAT (see Figure 1)17

Assesses current physical activity, potential contraindications, physical activity readiness, patient-oriented benefits, social support, willingness to help others, and self-effectiveness (the patient's self-confidence that he or she can change behavior); available in English and Spanish

PACE, PACE+18,19

Assesses current physical activity and physical activity readiness; PACE+, which is the electronic version, also assesses diet

http://www.sandiegochi.com/pace_written_materials.html

PARmed-X

Assists in the evaluation of medical problems that may require special consideration before initiation of physical activity

http://www.csep.ca/communities/c574/files/hidden/pdfs/parmedx.pdf

PARmed-X for Pregnancy

Assists in advising pregnant women about physical activity

http://www.csep.ca/communities/c574/files/hidden/pdfs/parmed-xpreg.pdf

PAR-Q and You20

Self-assessment to determine the need for consulting a physician before initiating or increasing physical activity; includes Canada's Physical Activity Guide to Healthy Active Living

http://www.csep.ca/communities/c574/files/hidden/pdfs/par-q.pdf

RAPA21

Assesses current physical activity in older adults; available in English, Spanish, and Vietnamese

http://depts.washington.edu/hprc/publications/rapa.htm


PAAT = Physical Activity Assessment Tool; PACE = Patient-Centered Assessment and Counseling for Exercise and Nutrition; PARmed-X = Physical Activity Readiness Medical Examination; PAR-Q = Physical Activity Readiness Questionnaire; RAPA = Rapid Assessment of Physical Activity.

Information from references 16 through 21.

Table 2   Tools for Assessing Physical Activity

View Table

Table 2

Tools for Assessing Physical Activity

Tool Description Web site

Brief physical activity assessment tool16

Assesses current physical activity

PAAT (see Figure 1)17

Assesses current physical activity, potential contraindications, physical activity readiness, patient-oriented benefits, social support, willingness to help others, and self-effectiveness (the patient's self-confidence that he or she can change behavior); available in English and Spanish

PACE, PACE+18,19

Assesses current physical activity and physical activity readiness; PACE+, which is the electronic version, also assesses diet

http://www.sandiegochi.com/pace_written_materials.html

PARmed-X

Assists in the evaluation of medical problems that may require special consideration before initiation of physical activity

http://www.csep.ca/communities/c574/files/hidden/pdfs/parmedx.pdf

PARmed-X for Pregnancy

Assists in advising pregnant women about physical activity

http://www.csep.ca/communities/c574/files/hidden/pdfs/parmed-xpreg.pdf

PAR-Q and You20

Self-assessment to determine the need for consulting a physician before initiating or increasing physical activity; includes Canada's Physical Activity Guide to Healthy Active Living

http://www.csep.ca/communities/c574/files/hidden/pdfs/par-q.pdf

RAPA21

Assesses current physical activity in older adults; available in English, Spanish, and Vietnamese

http://depts.washington.edu/hprc/publications/rapa.htm


PAAT = Physical Activity Assessment Tool; PACE = Patient-Centered Assessment and Counseling for Exercise and Nutrition; PARmed-X = Physical Activity Readiness Medical Examination; PAR-Q = Physical Activity Readiness Questionnaire; RAPA = Rapid Assessment of Physical Activity.

Information from references 16 through 21.

Physical Activity Assessment Tool

Figure 1.

Tool for assessing patients' physical activity.

Figure courtesy of Rebecca A. Meriwether, MD, MPH.

View Large

Physical Activity Assessment Tool

 Download in PDF format


Figure 1.

Tool for assessing patients' physical activity.

Figure courtesy of Rebecca A. Meriwether, MD, MPH.

Physical Activity Assessment Tool

 Download in PDF format


Figure 1.

Tool for assessing patients' physical activity.

Figure courtesy of Rebecca A. Meriwether, MD, MPH.

ADVISE

The following information may be helpful when advising patients about physical activity:

  • Epidemiologic evidence and clinical trials show significant health benefits with 30 minutes of moderate-intensity physical activity on five or more days of the week or with 20 minutes of vigorous activity on three or more days of the week.

  • Physical activity duration appears to be more important than intensity.

  • Ten-minute increments of moderate-intensity physical activity provides health benefits.3,4

  • No more than two days should elapse between episodes of physical activity because metabolic rate and insulin sensitivity return to baseline three days after a single episode.22

  • The greatest health benefits are likely to accrue when inactive persons begin even modest amounts of regular activity.35

  • Strength and flexibility training further enhance health and well-being, but should not replace movement or aerobic activity.4

Several organizations have issued guidelines for medical clearance before vigorous activity, although they provide conflicting advice.35,2325 The USPSTF states that there is insufficient evidence to recommend for or against exercise stress testing before recommending physical activity.25 In general, symptom-limited, moderate physical activity can be safely recommended unless patients are unstable or have certain uncontrolled medical conditions.35

Musculoskeletal injuries occur in one fourth to one half of adults who become active.26 Serious adverse events such as sudden cardiac death and myocardial infarction are rare, occurring in one out of 1.6 million episodes of vigorous physical activity.27

ASSIST: PROCESSES OF CHANGE

Changing health behaviors is difficult.14 Evidence suggests that repeated counseling and shared decision making encourage change. Counseling that is patient-centered and nonjudgmental, respects patient autonomy, incorporates patient preferences and motivations, and uses processes of change is more likely to be successful.28

Counseling should be tailored to the individual patient's stage of change (Table 39,14). Physicians who care for several family members may also facilitate social support, motivation, and helping others.

Table 3

Counseling Approach to Physical Activity Based on the Stages of Change

Stage Approach Recommendations

Precontemplation (patient is not ready to change behavior)

Offer nonjudgmental advice, express intention to revisit the topic in the future

Tell the patient, “As your physician, it's my responsibility to recommend that you get at least 30 minutes of moderate-intensity physical activity, such as walking fast on at least five days of the week; I hope you don't mind if I ask you about physical activity in the future”

Contemplation (patient is thinking about changing behavior)

Increase the “pros” of changing

Emphasize benefits that the patient cares about Associate the benefits with increased physical activity Suggest that the patient help someone he or she cares about get physically active for health (to increase self-motivation)

Preparation (patient intends to change behavior in the next six months and is taking steps toward becoming more active)

Decrease the “cons” of changing

Help the patient overcome barriers Make a plan for the patient to start changing behavior Suggest that the patient help someone he or she cares about get physically active for health

Action/maintenance (patient has met the recommended physical activity goals for more than one month [action] or more than six months [maintenance])

Congratulate and reinforce the patient's behavior change

Tell the patient, “Congratulations, you are doing one of the most important things you can for your health” Reinforce the benefits by asking the patient to consider other activities he or she enjoys for variety Have the patient plan for times when it might be more difficult to be physically active (e.g., vacations, travel, holidays) If the patient has a lapse, encourage the patient to start the plan again as soon as possible Suggest that the patient help someone he or she cares about get physically active for health


Information from references 9 and 14.

Table 3   Counseling Approach to Physical Activity Based on the Stages of Change

View Table

Table 3

Counseling Approach to Physical Activity Based on the Stages of Change

Stage Approach Recommendations

Precontemplation (patient is not ready to change behavior)

Offer nonjudgmental advice, express intention to revisit the topic in the future

Tell the patient, “As your physician, it's my responsibility to recommend that you get at least 30 minutes of moderate-intensity physical activity, such as walking fast on at least five days of the week; I hope you don't mind if I ask you about physical activity in the future”

Contemplation (patient is thinking about changing behavior)

Increase the “pros” of changing

Emphasize benefits that the patient cares about Associate the benefits with increased physical activity Suggest that the patient help someone he or she cares about get physically active for health (to increase self-motivation)

Preparation (patient intends to change behavior in the next six months and is taking steps toward becoming more active)

Decrease the “cons” of changing

Help the patient overcome barriers Make a plan for the patient to start changing behavior Suggest that the patient help someone he or she cares about get physically active for health

Action/maintenance (patient has met the recommended physical activity goals for more than one month [action] or more than six months [maintenance])

Congratulate and reinforce the patient's behavior change

Tell the patient, “Congratulations, you are doing one of the most important things you can for your health” Reinforce the benefits by asking the patient to consider other activities he or she enjoys for variety Have the patient plan for times when it might be more difficult to be physically active (e.g., vacations, travel, holidays) If the patient has a lapse, encourage the patient to start the plan again as soon as possible Suggest that the patient help someone he or she cares about get physically active for health


Information from references 9 and 14.

AGREE

Initially setting high goals is a more effective approach to increasing physical activity than setting a series of incrementally increasing goals.29 With shared decision making and active listening, the physician can determine what steps the patient is willing to take to increase physical activity and can endorse the patient's plans, if appropriate. Understanding the best steps for each stage can help physicians facilitate change while maintaining reasonable expectations.14

ASSIST: INTERVENTIONS

Printed materials that support verbal counseling messages and written prescriptions appear to increase the effectiveness of health behavior interventions.5 Writing a prescription for exercise duration and intensity (e.g., 30 minutes of accumulated moderate-intensity physical activity on five or more days of the week) and that supports lifestyle activities is easier for a patient to follow than an exercise prescription based on heart rate.36 Self-monitoring tools, such as calendars (see online Figure C) or pedometers may also enhance behavior change and adherence.30

ARRANGE

Finally, the physician should arrange for a follow-up visit and refer the patient to specialists for additional assistance, if the patient is receptive and assistance is available. Patient self-efficacy and social support are strong predictors of successful behavior change.12

Follow-up enables physicians to provide ongoing support and maintenance.5 When feasible, telephone or e-mail follow-up may also be effective.31 Electronic- and chart-based reminders should be used when possible to maximize repeated physical activity counseling, encouragement, and reinforcement at subsequent visits.32

Telephone counseling has been shown to enhance initiation of and adherence to physical activity.31 Telephone counseling services may be available through insurance company case managers, from nurses, or from health care educators.8 Individually tailored, Internet-based counseling (see accompanying patient handout) and self-monitoring also appear to be effective for some patients.31

Some dietitians incorporate physical activity counseling into nutritional services, and some communities offer classes to assist persons in adopting and maintaining healthier behaviors. Physical therapists can help deconditioned adults and those with chronic musculoskeletal problems improve strength, balance, and flexibility before beginning independent physical activity.

Structured Counseling Message

Using a structured counseling message based on patient answers to the PAAT and incorporating the other elements mentioned in this article can be delivered in the one and one half to three minutes devoted to health education and promotion in a typical primary care visit. The message should include the following: national physical activity recommendations, social support, helping others, printed materials and self-monitoring tools, agreement on next steps, and arrangement of follow-up and referrals.

The Authors

REBECCA A. MERIWETHER, MD, MPH, is an associate professor of family and preventive medicine at the University of South Carolina School of Medicine, Columbia. She received her medical degree from the Medical College of Georgia, Augusta, and completed a family medicine residency at the Mountain Area Health Education Foundation, Asheville, N.C.

JEFFREY A. LEE, MD, MPH, is an occupational and urgent care physician at Gundersen Lutheran Medical Center, LaCrosse, Wis. He received his medical degree from the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Md., and completed a preventive medicine residency at the University of South Carolina School of Medicine.

AUGUSTA SCHROEDER LAFLEUR, MD, MPH, practices emergency medicine in Lafayette, La. She received her medical degree from Tulane University School of Medicine, New Orleans, La., and completed a family practice residency at Louisiana State University School of Medicine, Lafayette.

PAMELA WISEMAN, MD, is an assistant professor of family and community medicine and director of the Family Medicine Clerkship Program at Tulane University School of Medicine. She received her medical degree from the University of Virginia School of Medicine, Charlottesville, and completed a family medicine residency at the University of Missouri–Columbia School of Medicine.

Address correspondence to Rebecca A. Meriwether, MD, MPH, University of South Carolina School of Medicine, Dept. of Family and Preventive Medicine, 3209 Colonial Dr., Columbia, SC 29203 (e-mail: rebecca.meriwether@sc.edu). Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Booth FW, Gordon SE, Carlson CJ, Hamilton MT. Waging war on modern chronic diseases: primary prevention through exercise biology. J Appl Physiol. 2000;88(2):774–787.

2. Centers for Disease Control and Prevention. Adult participation in recommended levels of physical activity—United States, 2001 and 2003. MMWR Morb Mortal Wkly Rep. 2005;54(47):1208–1212.

3. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273(5):402–407.

4. U.S. Department of Health and Human Services. Physical activity and health: a report of the surgeon general. 1996. http://www.cdc.gov/nccdphp/sgr/sgr.htm. Accessed October 19, 2007.

5. Jacobson DM, Strohecker L, Compton MT, Katz DL. Physical activity counseling in the adult primary care setting: position statement of the American College of Preventive Medicine. Am J Prev Med. 2005;29(2):158–162.

6. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW III, Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardio-respiratory fitness: a randomized trial. JAMA. 1999;281(4):327–334.

7. Eden KB, Orleans CT, Mulrow CD, Pender NJ, Teutsch SM. Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137(3):208–215.

8. Eakin EG, Smith BJ, Bauman AE. Evaluating the population health impact of physical activity interventions in primary care—are we asking the right questions? J Phys Activ Health. 2005;2(2):197–215.

9. Meriwether RA, Wilcox S, Parra-Medina D. Physical activity interventions in clinical settings. Curr Cardiovasc Risk Reports. 2007;1(3):237–246.

10. Kreuter MW, Chheda SG, Bull FC. How does physician advice influence patient behavior? Evidence for a priming effect. Arch Fam Med. 2000;9(5):426–433.

11. U.S. Department of Health and Human Services. Health, United States, 2005, with chartbook on trends in the health of Americans. http://www.cdc.gov/nchs/data/hus/hus05.pdf#088. Accessed August 2, 2007.

12. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267–284.

13. Stange KC, Woolf SH, Gjeltema K. One minute for prevention: the power of leveraging to fulfill the promise of health behavior counseling. Am J Prev Med. 2002;22(4):320–323.

14. Prochaska JO, Velicer WF, Rossi JS, et al. Stages of change and decisional balance for 12 problem behaviors. Health Psychol. 1994;13(1):39–46.

15. Calfas KJ, Sallis JF, Oldenburg B, Ffrench M. Mediators of change in physical activity following an intervention in primary care: PACE. Prev Med. 1997;26(3):297–304.

16. Marshall AL, Smith BJ, Bauman AE, Kaur S. Reliability and validity of a brief physical activity assessment for use by family doctors. Br J Sports Med. 2005;39(5):294–297.

17. Meriwether RA, McMahon PM, Islam N, Steinmann WC. Physical activity assessment: validation of a clinical assessment tool. Am J Prev Med. 2006;31(6):484–491.

18. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med. 1996;25(3):225–233.

19. Calfas KJ, Sallis JF, Zabinski MF, et al. Preliminary evaluation of a multicomponent program for nutrition and physical activity change in primary care: PACE+ for adults. Prev Med. 2002;34(2):153–161.

20. Thomas S, Reading J, Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Can J Sport Sci. 1992;17(4):338–345.

21. Topolski TD, LoGerfo J, Patrick DL, Williams B, Walwick J, Patrick MB. The Rapid Assessment of Physical Activity (RAPA) among older adults. Prev Chronic Dis. 2006;3(4):A118.

22. King DS, Baldus PJ, Sharp RL, Kesl LD, Feltmeyer TL, Riddle MS. Time course for exercise-induced alterations in insulin action and glucose tolerance in middle-aged people. J Appl Physiol. 1995;78(1):17–22.

23. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106(14):1883–1892.

24. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 7th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2005.

25. U.S. Preventive Services Task Force. Screening for coronary heart disease. February 2004. http://www.ahrq.gov/clinic/uspstf/uspsacad.htm. Accessed August 2, 2007.

26. Hootman JM, Macera CA, Ainsworth BE, Addy CL, Martin M, Blair SN. Epidemiology of musculoskeletal injuries among sedentary and physically active adults [published correction appears in Med Sci Sorts Exerc. 2003;35(1):183]. Med Sci Sports Exerc. 2002;34(5):838–844.

27. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355–1361.

28. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic Illness: the chronic care model, part 2. JAMA. 2002;288(15):1909–1914.

29. Locke EA, Latham GP. Building a practically useful theory of goal setting and task motivation. A 35-year odyssey. Am Psychol. 2002;57(9):705–717.

30. Tudor-Locke CE, Myers AM, Bell RC, Harris SB, Wilson Rodger N. Preliminary outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type 2 diabetes. Patient Educ Couns. 2002;47(1):23–28.

31. Marcus BH, Nigg CR, Riebe D, Forsyth LH. Interactive communication strategies: implications for population-based physical activity promotion. Am J Prev Med. 2000;19(2):121–126.

32. Hulscher ME, Wensing M, van Der Weijden T, Grol R. Interventions to implement prevention in primary care. Cochrane Database Syst Rev. 2001;(1):CD000362.


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