|PHYSICIAN ENCOUNTERS/COUNSELING||PATIENTS MEETING PHYSICAL ACTIVITY RECOMMENDATIONS|
|1. Do you have a doctor whom you see for regular health care?|
|2. In a usual year, how often do you see your doctor?|
|Once a year or less||1.41||1.02-1.95|
|Twice a year or more||Ref|
|3. Have you been advised within the last year by a doctor to exercise more?|
|Of those advised to exercise more (n=402):
4. Has your doctor helped you to develop a plan to increase exercise?
|5. Has your doctor followed up with you at subsequent visits to see how you increased exercise?|
|aOR, adjusted odds ratio; CI, confidence interval; Ref, reference group.|
|*Adjusted for sex, age, educational attainment, and baseline physical activity.|
The final cohort consisted of 1141 adults (TABLE 2). Those who did not respond to the follow-up survey were significantly more likely to be younger (P<.001), have less than a high school education (P<.001), and have an annual household combined income <$25,000 (P<.001). Those completing the follow-up survey were more likely to have a doctor for regular care (P<.001), although they saw their doctor, on average, significantly less per year than nonrespondents (P<.001).
Ninety percent of the cohort sample reported having a doctor whom they saw for regular care. Within the last year, 35% had been advised by their doctor to exercise more. Of those who had been so advised, 34% received help from their physician in developing a plan to increase exercise, and 46% were queried at subsequent visits as to how they were progressing with their exercise program.
After adjusting for age, sex, education, and baseline physical activity, we found that those who had a doctor for regular care were 54% more likely to be physically active than those who reported not having a doctor for regular care (aOR=1.54; 95% CI, 1.04-2.28). If the advising physician also developed a plan with the patient to increase exercise, there was nearly a 2-fold increase in physical activity compared with those who received only advice to exercise more (aOR=1.93; 95% CI, 1.19-3.15). If the physician followed up with the exercise plan at subsequent visits, the likelihood of physical activity increased further (aOR=2.84; 95% CI, 1.78-4.53) compared with those who did not receive follow-up from the physician.
Results of stratified analysis by BMI status are shown in TABLE 3. Individuals at normal weight were significantly more likely to be physically active if they had a physician for regular care (aOR=2.76; 95% CI, 1.49-5.13). Overweight adults (BMI 25-29.9 kg/m2) who had been advised by their physician to exercise more were significantly more likely to attain recommended levels of physical activity if their doctor helped develop an exercise plan than were those given more general advice about exercise (aOR=4.99; 95% CI, 1.69-14.73). Overweight individuals who received further counseling with follow-up inquiries were 5.64 times more likely to be physically active (95% CI, 2.10-15.17). A physician-developed exercise plan did not appreciably improve physical activity in obese adults (BMI ≥30 kg/m2); however, benefit in this group was demonstrated when physicians prescribed and followed up with the exercise plan (aOR=2.13; 95% CI, 1.10-4.12). Stratified analysis by income status provided no clear pattern (data not shown).
|PHYSICIAN ENCOUNTERS/COUNSELING||PATIENTS MEETING PHYSICAL ACTIVITY RECOMMENDATIONS* (aOR [95% CI])|
|NORMAL (BMI<25)||OVERWEIGHT (BMI 25-29.9)||OBESE (BMI ≥30)|
|Has seen a doctor for regular care||2.76 (1.49-5.13)||1.08 (0.51-2.29)||1.34 (0.62-2.91)|
|In a usual year, has seen a doctor ≤1 time||1.98 (1.13-3.47)||0.95 (0.54-1.68)||0.95 (0.47-1.92)|
|Has been advised to exercise more||1.02 (0.56-1.85)||0.75 (0.46-1.25)||0.77 (0.46-1.31)|
|Doctor helped develop a plan to exercise more||0.69 (0.22-2.18)||4.99 (1.69-14.73)||1.76 (0.87-3.56)|
|Doctor followed up on plan to exercise more||2.59 (0.80-8.36)||5.64 (2.10-15.17)||2.13 (1.10-4.12)|
|aOR, adjusted odds ratio; BMI, body-mass index; CI, confidence interval.|
|*Adjusted for sex, age, educational attainment, and baseline physical activity.|
Findings from our analyses support the need for more detailed and more frequent exercise counseling (including follow-up) by rural primary care physicians. In our study, physicians’ counsel was most effective when presented as a plan or prescription that was followed up with periodic inquiries. Patients’ initiation and maintenance of physical activity were significantly associated with physicians’ follow-up of exercise plans. Those who were merely “advised” to exercise more were less likely to meet physical activity recommendations. This illustrates the importance of detailed physician counseling over simple advice to exercise more.
Over 80% of normal-weight individuals, who comprised more than 40% of the sample, reported that their physician had not suggested they exercise more. There are many possible explanations for these reports. Rural populations are relatively isolated and slow to adopt changes. Thus patients may be unaware of new recommendations for physical activity and their significant benefit for disease prevention, and therefore unlikely to discuss such matters with their physician. Physicians also may perceive normal-weight individuals as healthy regardless of their actual health behaviors. On the other hand, 1 study showed that patients with disease risk factors (eg, high cholesterol, elevated BMI) were more likely to be counseled on preventive health behaviors.37
With overweight patients, who are at increased risk of developing chronic diseases, physician counseling strengthened their resolve significantly. Overweight individuals who received directives from their physician (a plan to increase exercise and subsequent follow-up) were 5½ times more likely to be physically active than those who received less counseling.
Obese patients did not receive counseling as often as overweight patients, or benefit from it as much when given, perhaps due to the presence of comorbidities. However, many studies show that regardless of BMI status, physical activity reduces all-cause mortality.38-41
Interestingly, our results showed that seeing a doctor less than once a year was associated with increases in physical activity. Patients who see their physician once a year may be going for annual wellness exams, providing more opportunity to discuss health behavior.
Overall, patients are counseled less often/thoroughly than needed. Our findings agree with those of a previous statewide study that used Missouri BRFSS data to assess the extent to which overweight or physically inactive people received advice from their physicians concerning these risk factors.42 Although most Missouri residents who were overweight or inactive reported seeing their physician within the past year, less than half said their doctors advised them to alter their risk behavior(s).42 Our findings are also consistent with a recent nationwide study by Ma and colleagues that focused on adults with obesity, diabetes, or other related conditions.43 Participants from across the United States reported receiving counseling for physical activity in <30% of visits to private physician offices and hospital outpatient departments.43
Our study was unique in that it examined a tri-state sample of the nation’s rural population for both evidence and effectiveness of physician counseling. It is one of very few studies using a longitudinal design, strengthening the associations found. Causality is limited, however, due to the multifaceted design of the intervention program from which the data were obtained. Future research should evaluate varying degrees of physician counseling and other indirect measures of its impact.
Our observational cohort design and the large, randomly selected sample resulted in fewer limitations than were seen with previous similar studies. However, our study had several limitations.
Recall bias may be present. We assessed counseling with patient memory alone; we made no attempts to interview physicians or audit charts.
Self-reported height and weight data tend to underestimate the prevalence of obesity.44,45 Resultant misclassification of overweight subjects as being at normal weight could have skewed the stratified analysis.
The external validity of the physician-counseling questions we used has not been formally confirmed. Given the demographics of the analytic sample (ie, mostly female, white, low income), it would be appropriate to generalize our findings only to similar, rural populations.
Primary care physicians—rural or urban—are no doubt aware of the health risks associated with physical inactivity. However, the barriers physicians face in counseling at-risk patients overwhelm most efforts. These barriers include lack of time, inadequate provider counseling skills and training, perceived ineffectiveness and nonadherence, patient comorbidities, and lack of organizational support and reimbursement.46-48
Intervention programs and tools have been developed to help health care providers overcome time, skill, and training barriers. These programs, available even to rural providers, have proven effective.49,50 (Go to www.paceproject.org/Home.html and click on “Projects” to learn about the PACE program.) However, application of such skills and tools may be more successful if training is incorporated into medical school curricula and residency training programs rather than through CME endeavors.49 This would require medical institutions and organizations to prioritize the direct link between healthy lifestyle behaviors and disease prevention and the vital role physicians play in underscoring this link.
Finally, health care policy makers and systems must be persuaded to address the lack of organizational support and reimbursement that prevents physicians from counseling at-risk patients on unhealthy lifestyle behaviors. Responsible payers and providers should aggressively explore low-cost ways to promote physical activity and weight loss in primary care settings, to stem the tide of obesity-related chronic diseases. At the local level, physicians can team up to support policies that may enhance preventive counseling efforts2—increasing access to places for activity, encouraging physical activity programming in communities, schools, and organizations, and physical environment enhancements such as safe sidewalks, adequate lighting, and improved zoning.44,51,44,52
We thank the communities that are participating in the ongoing intervention study. For their assistance in data collection, we thank the Department of Health Management and Informatics, Behavioral Risk Research Unit at the University of Missouri, Columbia.
This study was funded through the National Institutes of Health grant NIDDK #5 R18 DK061706 and the Centers for Disease Control and Prevention contract U48/CCU710806 (Centers for Research and Demonstration of Health Promotion and Disease Prevention). Human subjects approval was obtained from the Saint Louis University Institutional Review Board.
The authors reported no potential conflict of interest relevant to this article.
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Correspondence Sarah L. Lovegreen, MPH, Prevention Research Center and Department of Community Health, Saint Louis University School of Public Health, 3545 Lafayette Ave., Salus Center, Suite 300, St. Louis, MO 63146; slove email@example.com.
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