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Health Promotion and Wellness

  • Naomi ParrellaEmail author
  • Kara Vormittag
Living reference work entry

Latest version View entry history

Abstract

The evidence shows that health and well-being are affected and created by a combination of physical activity, nutrition, and rest. Family physicians can directly impact all of these components by educating and guiding patients regarding healthy lifestyle choices. With appropriate nutrition, physical activity, and rest, bodily function is optimized, and health and well-being of patients and communities are improved. In addition, tobacco cessation has been shown repeatedly to directly improve morbidity and mortality. While we know that health outcomes are also heavily affected by socio-demographic factors, this chapter is focused on patient lifestyle choices.

Keywords

Physical Activity Waist Circumference Sedentary Behavior Motivational Interview Physical Activity Guideline 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

The evidence shows that health and well-being are affected and created by a combination of physical activity, nutrition, and rest. Family physicians can directly impact all of these components by educating and guiding patients regarding healthy lifestyle choices. With appropriate nutrition, physical activity, and rest, bodily function is optimized, and health and well-being of patients and communities are improved. In addition, tobacco cessation has been shown repeatedly to directly improve morbidity and mortality. While we know that health outcomes are also heavily affected by socio-demographic factors, this chapter is focused on patient lifestyle choices.

Lifestyle Choices and Risk of Disease

Individual and familial risk of disease throughout the lifespan can be modified positively or negatively by lifestyle choices and behavior patterns. Preventable diseases account for 60 % of all non-communicable disease deaths. The main causes of preventable disease and death are related to poor lifestyle choices, especially physical inactivity, unhealthy diet, and tobacco and alcohol abuse [1]. This chapter will focus on tobacco cessation, activity, and nutrition to promote health and well-being in the United States and reduce the burden of preventable disease.

Physical Activity

Regular physical activity (PA) is associated with enhanced health and reduced risk of all-cause mortality [2]. Research shows that a low level of physical activity exposes an individual to a greater risk of dying than does smoking, obesity, hypertension, or high cholesterol. Regular physical activity can [3]:
  • Reduce mortality and risk of recurrent breast cancer by approximately 50 %

  • Lower the risk of colon cancer by over 60 %

  • Reduce the risk of developing Alzheimer’s disease by 40 %

  • Reduce the incidence of heart disease and high blood pressure by 40 %

  • Lower the risk of stroke by 27 %

  • Lower the risk of developing type 2 diabetes by 58 %

  • Be twice as effective in treating type 2 diabetes than the standard insulin prescription

  • Can decrease depression as effectively as Prozac or behavioral therapy

  • In an elementary school setting, regular physical activity can decrease discipline incidents involving violence by 59 % and decrease out of school suspensions by 67 %

Physical Activity Guidelines for Pregnancy

Most studies show the overwhelming benefits of physical activity to the maternal-fetal unit. Physical activity has a role in chronic disease prevention for both mother and offspring [4]. Obesity is the most common chronic disease of pregnancy and affects mother and child negatively [5]. Maternal BMI increases in pregnancy correlate with the odds of an overweight child. Excessive gestational weight is associated with higher likelihood of the child becoming overweight. Exercise during pregnancy reduces the likelihood of excessive weight gain. A vast majority of women who exercise during pregnancy continue to exercise after birth, and parental physical activity correlates positively with the physical activity of their offspring [5].

ACOG recommends that, in the absence of either medical or obstetric complications, pregnant women should exercise at a moderate level for 30 min or more per day on most, if not all, days of the week [4]. Weight-bearing and non-weight-bearing exercises are likely to be safe during pregnancy. However, physically active women with a history of or risk for preterm labor or fetal growth restriction should be advised to reduce her activity in the second and third trimesters [6]. Physical Activity Readiness Medical Examination (PARmed-X) for pregnancy can assist in evaluations of medical problems that may require special considerations in pregnant patients. For a full list of absolute and relative contraindications, see the ACOG statement or the ACSM Exercise Prescription and Testing guidelines [6].

Physical Activity Guidelines for Children and Adolescents

Physical activity declines with age, while time spent in sedentary activities steadily increases [5]. Childrens’ physical activity is closely linked to time spent in front of a screen (e.g., television, computer, cellphone). As screen time increases, vigorous activity declines and BMI increases. The American Academy of Pediatrics (AAP) recommends that children have 60 min of vigorous activity per day, which may be accumulated over the course of a day in smaller increments [5]. Activity should be of moderate intensity and include a wide variety of activities – sports, recreation, transportation, chores, work, planned exercise, and school-based physical education classes. These activities should preferably be unstructured and fun.

Age-specific physical activity considerations [5]:
  • Infants and Toddlers – Provide opportunities for safe play activity and movement.

  • Preschool (4–6 years) – Focus on fun, playful, and safe activities and movement. Encourage activities that emphasize exploration and experimentation, and begin motor learning such as running, kicking, catching, and throwing a ball. Preschoolers can tolerate walking longer distances. Establish walking as a habit and option for transportation.

  • Elementary School-Aged Children (6–9 years) – Encourage play to develop motor skills, visual tracking, and balance. Consider organized sports with the focus on enjoyment.

  • Middle School-Aged Children (10–12 years) – Encourage play, movement, and sports. Supervised weight training, emphasizing proper technique with small weights and high repetitions may begin. Avoid heavy weights and max lifts. Additionally, certain types of Olympic-style weightlifts should be avoided, including squat lifts, clean and jerk or dead lifts.

  • Adolescents – This is a critical age for promotion of lifetime physical activity. Encourage organized sports, other traditional forms of exercise, or exercise with friends and peer group.

Physical Activity Guidelines for Adults

A brief summary of American College of Sports Medicine (ACSM) PA recommendations and Physical Activity Guidelines for Americans is included here: [1, 7].

Cardiorespiratory Exercise

  • Adults should get at least 150 min of moderate-intensity exercise per week.

  • Exercise recommendations can be met through 30–60 min of moderate-intensity exercise (5 days per week) or 20–60 min of vigorous-intensity exercise (3 days per week).

  • One continuous session and multiple shorter sessions (of at least 10 min) are both acceptable to accumulate desired amounts of daily exercise.

  • Gradual progression of exercise time, frequency, and intensity is recommended for best adherence and least injury risk.

  • People unable to meet these minimums can still benefit from some activity.

Resistance Exercise

  • Adults should train each major muscle group 2 or 3 days each week using a variety of exercises and equipment.

Flexibility Exercise

  • Adults should do flexibility exercises at least 2 or 3 days each week to improve range of motion.

Neuromotor Exercise

  • Neuromotor exercise (sometimes called “functional fitness training”) is recommended for 2 or 3 days per week. Neuromotor exercises develop motor skills. They work a precise group of muscles that are used to perform a learnt act and improve balance, coordination, gait, and agility. Examples of activities that incorporate neuromotor exercises are yoga and thai chi.

Physical Activity Guidelines for Older Adults

The structural and functional decline, overall decrease in physical activity, and increase in chronic disease that accompanies human aging can all be limited by physical activity [8]. Older adults are defined as those older than 65 years or adults between 50 and 64 years who have chronic conditions or functional limitations. Recommendations for older adults are similar to those for adults, with a few special considerations [8]:
  • Patients who are deconditioned, functionally limited or with chronic conditions that may affect their ability to be active, should start with low intensity and duration.

  • Activities that do not impose excessive orthopedic stress like walking, stationary bike, or aquatic exercise should be considered.

  • For flexibility, static stretches are encouraged versus multiple options for others.

  • Neuromotor exercises should focus is on progressive balance improvement.

Physical Activity Assessment and Counseling Tools

Many resources are available to family physicians to help incorporate regular counseling into patient visits. These resources and tools should be used in conjunction with behavior change counseling, motivational interviewing, and the five A’s (Ask, Advise, Assess, Assist, Arrange). The “Five A’s” is a convenient approach to physical activity counseling in clinical practice and reviewed in depth later in this chapter.

Physical Activity Assessment and Counseling for Children and Adolescents

Assess what the child AND parents do for physical activity. There is no clinically validated office tool to assess physical activity in children. The physical activity vital sign (PAVS) may be used starting at age 13. PACE+ is a validated tool that may be used in adolescents [9].

PAVS for adolescents:
  1. 1.

    How many days in the past week have you participated in physical activity where your heart was beating faster and your breathing was harder than normal?

     
  2. 2.

    How many days in a typical week do you participate in activity like this?

     
Other questions used to assess physical activity in younger children:
  • How many days of physical education do you participate in at school in a week?

  • How many days in a week do you run, bike, swim, or play a sport for 1 h?

  • On average, how many hours each day to you spend in front of a screen, either TV or computer, outside of school?

Counsel parents to be role models for their children and involve the whole family in physical activity. Also, parents should limit screen time to 2 h daily.

Physical Activity Assessment and Counseling for Adults

The adult PAVS consists of two questions:
  1. 1.

    On average, how many days per week do you engage in moderate to strenuous exercise like a brisk walk?

     
  2. 2.

    On average, how many minutes do you engage in exercise at this level?

     

These two screening questions will provide you with a snapshot of whether your patients are meeting the current PA guidelines of 150 min of moderate intensity physical activity each week. By repeating the assessment of PAVS at every clinic visit, you will be able to track changes in their physical activity levels over time.

In addition to PAVS, there are several validated tools that are designed to facilitate physical activity assessment in adults [3, 10]. These tools evaluate readiness to change, self efficacy, medical contraindications, and other aspects of physical activity. They are available online and include the PAAT, PARmed-X, PAR-Q, and RAPA [10]. They vary greatly in length and content and can be utilized based on physician and patient needs. The most comprehensive guide for PA risk assessment is ACSM’s Guidelines for Exercise Testing and Prescription [11]. A useful algorithm based on ACSM guidelines is available for free online as part of the Exercise is Medicine – Healthcare Providers’ Action Guide [3].

Sedentary Behavior

Sedentary behavior – sitting for long periods of time – as distinct from simple inactivity has been shown to be a health risk in itself. Meeting the guidelines for exercise does not make up for a sedentary lifestyle [8]. High non-exercise physical activity (NEPA) defined as physical activity that is engaged in to accomplish daily activities, such as gardening or cleaning, is associated with a number of positive health markers, including more preferable waist circumference, HDL cholesterol, and triglycerides. Additionally the prevalence of metabolic syndrome is lower in those with higher NEPA in non-exercising AND regularly exercising individuals. Lastly, high NEPA has been associated with a lower risk of CVD events and all-cause mortality [12]. It is important to discuss sedentary behavior and encourage more non-exercise physical activity. For example, substituting walking or biking for short car rides, or using a push mower instead of a riding mower can be very helpful. Additionally, these lifestyle activities are more likely to be sustained than structured activities such as exercising in a gym [10].

Exercise Prescription

For most healthy adults, the simplest prescription is to recommend an increase in activity in daily routines to prevent a sedentary lifestyle and to provide a goal of achieving 150 min of moderate intensity physical activity each week. It is important that a written physical activity prescription be provided. Written prescriptions are an effective means of motivating patients to be more physically active [3].

Consider a physical activity referral to a fitness professional if it is felt that additional instruction or structure is needed. Identifying other community programs may help to personalize recommendations. Numerous mobile technologies exist for promoting, tracking, and advancing physical activity. These include apps, websites, and individual devices.

Nutrition

Nutrition is the intake, digestion, and absorption of nutrients that provide energy and determine the structure and metabolic functions of the human body. With proper nutrition, the body and mind are more resilient and able to develop, respond, and adapt to the environment. The challenge for family physicians has been to determine which of the various nutrition recommendations are appropriate to guide patients to promote health and well-being. This section is focused on evidence-based nutrition counseling for the general population with the goals of promoting health and well-being.

Low fat diets have failed a large portion of the US population. By decreasing the high density caloric intake of fats in the American diet, it was assumed that daily caloric intake would decrease. However, since the initiation of the “low fat” dietary recommendations, the explosion of overweight and obesity, metabolic syndrome, Type II diabetes, sleep apnea, and other weight-related health issues have sky-rocketed to levels never seen before. Individual caloric intake was not decreased by cutting fat, instead the proportion of calories changed to a diet with higher intake of calories from sugar [13] and other refined carbohydrates.

Unlike fat, which is satiating, consuming excessive sugar stimulates appetite, triggers cravings for more sugar, and promotes the development of central obesity and insulin resistance. With excessive circulating insulin, the body continues to produce and enlarge ever more adipose cells, mainly around the waist. To maintain this metabolically active excess adipose tissue, once again, the appetite is stimulated to support energy needs. This vicious cycle accelerates as insulin resistance develops further.

One promising approach to improving health with nutrition is the Mediterranean style diet , which is similar to diets found in the areas of the world where more people experience longevity and healthy aging [14]. These diets are not exactly defined but consist of mainly plant-based foods including vegetables, fruit and nuts, whole grains and legumes, moderate poultry and fish, olive oil in place of butter, margarine or cream, reduced simple carbohydrates, and minimal red meat and processed foods [15].

Greater adherence to Mediterranean style diets have been shown to reduce cardiovascular mortality [16]; decrease risk of cancer incidence and mortality [17]; decrease risk of cerebrovascular disease [18] and the metabolic syndrome [19]; and reduce cognitive decline and dementia [20] with aging. In fact, greater adherence to the Mediterranean style diet has been found to result in longer leukocyte telomere lengths which have been linked to healthy aging and longevity [21, 22].

Some tools to assess dietary quality include food frequency questionnaires (these are fast, inexpensive, and easy to use), 1–7 day food logs (these are more accurate, but require patients prepare ahead of appointment. This may be easier with smartphone apps like MyFitnessPal), and 24 h dietary recall (quick interview during office visit). There is a validated 14 point screening tool to assess adherence to Mediterranean style diet [15]. Also, the simple act of requesting a food log improves eating behavior(s) by developing a greater awareness of what is consumed. Logging food and drink intake can be done easily with smartphone apps and online resources. These can also be used to log physical activity and sleep.

Using a nutrition assessment tool, family physicians or staff can counsel patients appropriately towards a Mediterranean style diet by offering one or two dietary recommendations at a time.
  1. 1.

    Limit sugar: Work towards limiting or eliminating sweetened food and drink in the diet. Recommend avoidance of sugar sweetened beverages. Educate patients that 100 % fruit juice is NOT equivalent to a serving of fruit.

     
  2. 2.

    Fluids: Most liquids should consist of water, unsweetened tea, coffee, dairy or dairy alternative with calcium. Wine (up to one glass for women and up to two glasses for men) may be included as appropriate.

     
  3. 3.

    Vegetables: Work towards daily consumption of leafy greens and increased quantity and variety of colors of vegetables to ensure adequate supply of the various nutrients and phytochemicals necessary for disease prevention and health promotion [23].

     
  4. 4.

    Grains: Suggest replacement of processed grains with whole grains. Grain may be replaced entirely with more vegetables. This strategy improves insulin resistance, blood sugar control, and triglyceride levels [24, 25].

     
  5. 5.

    Protein: Include plant-based protein sources (nuts and legumes) and animal protein sources such as eggs, seafood, poultry, and wild game. Limit commercially raised red meat.

     
  6. 6.

    Fats: Recommend avoiding trans-fatty acids and switching to naturally occurring fats and olive oil.

     
  7. 7.

    Probiotics can be recommended for health promoting benefits [26].

     
  8. 8.

    Non-nutritive sweeteners: Despite much controversy, there are no clear evidence that these FDA-approved sweeteners are harmful. There are acceptable daily intake (ADI) levels for each of the seven FDA-approved non-nutritive sweeteners (acesulfame K, aspartame, neotame, saccharin, sucralose; and food products such as luo han guo fruit extract, stevia) [27].

     
  9. 9.

    Individual patients have different needs. Referral to a registered dietician is recommended for patients with complicated medical issues or needs. For example, the Dietary Approach to Stop Hypertension (DASH) diet may benefit those with hypertension and lower carbohydrate diets may benefit those with metabolic syndrome or type II diabetes. This diet has been found to be more effective than low fat diets in reducing cardiovascular risk factors [28].

     
  10. 10.

    Recommend sitting down to eat meals and connecting with others. Regular relaxing breaks spaced throughout the day improve well-being [29].

     

Evidence and Common Areas of Concern

Fats

Trans-fats are primarily found in artificially hydrogenated fats such as margarine and shortening and should be avoided due to adverse effects on lipid panels and cardiovascular health. Rather than decreasing saturated fat in the diet, modification of dietary fat leads to cardiovascular benefit [30]. Recommend switching fats from red meats and sugar-laden foods to fats from fish, avocado, nuts, and nut oils (i.e., coconut or olive oil).

Fiber

Dietary fiber is found in whole grains, vegetables, legumes, and fruit. Dietary fiber from grains, vegetables, and legumes is inversely related to deaths from cardiovascular disease, cancer, infectious and respiratory disease in both men and women. This is not true for fruit fiber however. Encouraging high fiber food choices may reduce the risk of premature death [31]. There is no upper limit of recommended fiber intake, although as a practical matter, excess intestinal gas may be experienced by those who increase their fiber intake quickly. The recommended total daily fiber intake is 14 g fiber per 1000 kcal ingested [32].

Sodium

According to the Institute of Medicine, evidence supporting the recommendations for strictly limiting dietary sodium seems to be weak or nonexistent for many medical issues [33]. While there is some evidence that salt restriction may lead to increased insulin resistance and cardiovascular mortality [34], the data are conflicting. There are also data that suggest that the risk of death and cardiovascular events are lower when sodium consumption is maintained between 3–6 g daily [35].

Calcium and Vitamin D

There exists an inverse association between 25-hydroxyvitamin D levels and all cause mortality in primary prevention cohort studies. Vitamin D3 supplementation (but not Vitamin D2) reduced all cause mortality by 11 % [36]. There is inconsistent evidence to support vitamin D and calcium supplementation for improved health outcomes related to pregnancy, bone or cardiovascular health, incidence of cancer, immune function, all-cause mortality or vitamin D status in the general population [37].

Multivitamins

Links between vitamin supplementation and cardiovascular disease are also complex. Multivitamins alone have not consistently been shown to improve cardiovascular outcomes or to reduce mortality risk. The United States Preventive Services Task Force (USPSTF) recommends against the use of beta carotene or Vitamin E supplementation for primary prevention of cardiovascular disease or cancer [38, 39].

Fish Oil

No trials examining fish oil with endpoints of vascular events or mortality were identified. Clinically significant lower triglyceride levels and VLDL were noted in trials with mean omega-3 poly-unsaturated fatty acid (PUFA) doses of 3.5 g/day. No significant changes in total or HDL cholesterol, HbA1c, fasting glucose, fasting insulin, or body weight were observed. No adverse effects of the intervention were reported [40].

Iron

Iron deficiency is the most common nutritional deficiency and leading cause of anemia in the USA and the world. People at high risk for iron deficiency anemia include infants and children after 6 months old, unless they are breast feeding or drinking iron fortified formula, people who restrict some food groups from their diets, women with heavy menstrual periods, and pregnant or breastfeeding women. Among children with iron deficiency, decreased motor and brain development as well as poor health and even death can be prevented with appropriate iron supplementation and education to avoid overconsumption of cow’s milk, which limits iron absorption.

Nutrition Recommendations for Special Populations

Vegan

Vegans do not consume any animal products and are at risk of developing Vitamin B12 deficiency. Counseling about Vitamin B12 supplements or fortified cereals or beverages is needed. Consultation with a registered dietician should be considered.

Vegetarian

When planned well, vegetarian diets may provide complete nutrition for individuals of all ages. Vegetarian patients may want to ensure adequate calcium, iron, zinc, and vitamins D and B12 with the guidance of a registered dietician. Vegetarian meal planning assistance is also available through the American Dietetic Association at http://www.eatright.org/.

Pediatrics

Water and dairy or dairy equivalent containing calcium and vitamin D are the only beverages children need. For children under 2 years old, dietary fat should not be restricted. Recommend introducing and re-introducing a variety of colorful vegetables, proteins, whole grains, and whole fruit to picky eaters as their tastes are constantly developing. Minimizing or eliminating sugar sweetened beverages and foods will help prevent obesity.

Geriatrics

Older adults require adequate protein combined with physical activity to limit sarcopenia which can increase frailty and contribute to the development of metabolic disorders [41].

Mind-Body Connection and Resiliency

The mind-body connection to health and healthcare costs is well established. Stress, poor lifestyle choices, and disease symptoms often coexist and if not managed, exacerbate each other. Mind-body therapies act through the common factor of increasing nitric oxide which elicits the relaxation response (RR) and stimulates the body’s endogenous stress management responses. These include adaptive changes to gene expression and neurobiological signaling that seem to promote health and resiliency [29]. The RR effectively treats stress and reduces symptom severity in chronic disease, increases positive lifestyle behaviors, and improves many mental health symptoms [42]. The RR has been described as a hypo-metabolic state with decreased sympathetic tone, [29] resulting in lower heart rate, blood pressure, respiratory rate, and oxygen consumption and increased heart rate variability. At the cellular level, the RR positively affects gene expression related to mitochondrial metabolism, insulin secretion, telomere maintenance, and inflammatory pathways [43]. Of the multiple mind-body techniques that elicit the RR, meditation, yoga, and tai chi are reviewed below.

Meditation, tai chi, yoga, and sleep are some of the ways to obtain the health benefits of stress reduction by inducing the relaxation response. Meditation has repeatedly been shown to be effective in decreasing stress in otherwise healthy individuals [44, 45, 46]. Mindfulness meditation has been shown to result in positive changes in the brain and immune function [47]. There is evidence that mindfulness meditation programs may alleviate anxiety, depression, and pain, and they may reduce stress, distress, and improve quality of life in those patients with chronic disease or mental health diseases [29, 45, 46]. Also, in the pediatric population, among children 6–18 years old, sitting meditation was effective in improving physiologic (improved systolic blood pressure, cardiac output, urinary sodium excretion, and endothelial vasodilation function) parameters, as well as psychosocial and behavioral conditions [48].

Mind-body movement programs such as tai chi and yoga appear to have physiological and psychosocial benefits [49, 50]. Tai chi has been shown to promote balance control, flexibility, and cardiovascular fitness in older patients with chronic conditions [50]. In addition, adequate sleep is essential to rest and resiliency. Inadequate sleep leads to a range of health problems and is addressed elsewhere in this text.

Identifying Disease Risks: Weight, Waist Circumference and Body Mass Index (BMI) Screening

Regular physical activity levels, weight, waist circumference, and BMI can be objective measures of overall health risk over time. In addition to physical activity assessment, patients of all ages can be screened for overall health risk assessment with simple measures of height, weight, and waist circumference. Using height and weight, BMI can be calculated to screen for underweight, overweight, and obesity which are linked with increased risks for adverse health outcomes in all ages [51].

Body mass index (BMI) is calculated as weight (kg)/height2 (m2). Abnormal BMI, excessive weight loss, or weight gain at any age can be associated with negative health outcomes at all ages. Excess weight is a risk factor for many types of cancer.

Definitions of underweight, overweight, and obesity depend on BMI and differ in pediatrics and adults. In children, BMI percentiles are used for assessment from 2 years old and older: these are based on the age and sex of the child. Underweight is defined as those with a BMI <5th percentile, overweight, as having a BMI between the 85–95 percentiles, and obesity as a BMI >95th percentile for age and sex [52]. In adults, the definitions are based on weight and height. Underweight is considered to be a BMI <18.5, the BMI classified as overweight is between 25 and 29.9 and obesity is a BMI greater than 30, with morbid obesity defined as a BMI ≥40. In postmenopausal women and older adults, being overweight is less strongly correlated with mortality than it is in younger age groups [53].

An equally important risk factor assessment in adults is the waist circumference . Although the traditional measurements were defined as men >40 in. (102 cm) or women >35 in. (88 cm), it is now recognized that different ethnic groups have different waist circumference measurements at which elevated cardiometabolic risk occurs. The waist circumference is measured using a tape at the level of the top of the iliac crest.

Monitoring a patient’s weight, BMI, and waist circumference is a relatively simple way of monitoring for increased disease risks in the outpatient office. In the pediatric population, the child’s weight and BMI percentile is expected to follow a similar curve if he/she is getting adequate nutrition and growing appropriately. Appropriate weight assessment and management at all ages is important in optimizing health.

In pediatrics, the height and weight should be measured and monitored for unhealthy trends during every routine pediatric wellness visit with specific screening for risk of overweight and obesity beginning at 2 years old [52]. Though specific screening frequency guidelines do not exist for adults, it is recommended to obtain a waist circumference and BMI at routine chronic disease follow up visits and/or during annual exams in order to recognize unhealthy weight trends and to provide earlier interventions that may be more effective in promoting health.

Tobacco Cessation

Tobacco use is a modifiable risk factor responsible for disease and deaths from cancer and cardiovascular and pulmonary diseases. There is no evidence that any form of tobacco use is safe. Cessation should be addressed with all patients who use tobacco in any form [54]. The “Five A’s” framework was developed to allow physicians to incorporate smoking cessation counseling into practice [54]. It is described below.

There are medication and non-medication options to assist patients with smoking cessation. Medication options include nicotine replacement, varenicline, and buproprion [54]. Nicotine replacements (gum, inhaler, lozenge, patch, nasal spray) increase the chances of quitting successfully by 50–70 %. They usually need to be titrated based on the amount the patient smokes. Varenicline is a nicotine receptor agonist. It reduces cravings and withdrawal symptoms while blocking the binding of smoked nicotine. It increases the chances of quitting by two- to threefold. Buproprion doubles the odds of smoking cessation when compared to placebo.

Non-medication options include complementary and alternative therapies including acupuncture and hypnotherapy which are not supported by evidence. Exercise is useful and literature supports the use of internet-based interventions and telephone quit lines [54].

E-cigarettes were introduced in the United States in 2007. These operate with a small heating element that creates a water vapor that can be inhaled. There are still many concerns regarding their use and at this time, their safety is unknown [55].

Promoting Adoption of Healthy Behaviors

In order to have a successful intervention in a busy office practice, it is important to be aware of evidence-based treatment options and then to have an effective and practical method to facilitate behavior change, improve treatment compliance, and support successful adoption of healthy lifestyle choices.

Understanding that many patients already have ideas about what they “should be doing” for health, and that patients will only respond to information and suggestions for which they are ready, physicians will be more effective in promoting healthy behavior changes using the “Stages of Change (SOC),” model and appreciate that the patient must progress through each stage in sequence to be successful. Two tools that family physicians can use to facilitate this progress include motivational interviewing (MI) [56] and the 5 A’s [57] (see Table 1).
Table 1

Counseling for behavior change incorporating Stages of Change and Motivational Interviewing (Adapted from [56, 59])

Stages of change

Patient status

Physician action: motivational interviewing

Precontemplation

No interest, unaware

Assess awareness, help develop awareness, plant the seed, offer hope

Contemplation

Longest stage

Aware of risk. Ambivalent: wants to change “but” may not believe it is possible or may not know how

Identify ambivalence (“I should start exercising but I have no time.”)

Listen for change talk:

Desire (“I wish I ate healthier,” “I want to start exercising.”)

Ability (“I could eat healthier if…,” “I might be able to start exercising if…”)

Reasons (“I would probably feel better if I started eating healthier,” “I want to be able to run around with my grandkids.”)

Need (“I should plan ahead and make my lunches,” “I have to find a place to walk during lunch.”)

Commitment (“I am going to take a 10 min walk three times a week,” “I plan to bring my lunch to work every day.”)

Taking steps (“Last week, I brought my own lunch 4 days, and I started walking with a coworker during lunch on those days.”)

Help patient progress in his/her discussion

Ask permission (“Would you like to talk about quitting smoking?)

Offer choices (“We can discuss some of the ways to quit smoking: “cold turkey,” nicotine patches, nicotine gum, or medications.”)

Share others’ success stories that the patient will be able to identify with and visualize for him/herself

Preparation

Change planned within next 6 months

Patient hopeful and inspired

Continue to encourage change talk (“I could eat a salad for lunch most days”)

Focus on eliciting patient’s positive consequences after change (“I could go on a cruise with the money I save if I quit smoking.”)

Action

Change made within past 6 months

Resisting return to old habits

Elicit patient’s sense of satisfaction and pride (“My clothes fit better and my friends are asking me what I am doing!”)

Provide recognition and positive support (“You must feel so proud of your success.”)

Maintenance

Avoid triggers

Positive reinforcement. Enthusiasm. Watch for signs of relapse

5 A’s

The Five A’s construct – Assess, Advise, Agree, Assist, and Arrange, adapted from tobacco cessation interventions in clinical care – provides a structured strategy for many different types of behavioral counseling intervention [57].
  • Ask – Address the behavior change agenda

  • Advise – Provide personalized information on benefits of change

  • Assess – Address previous attempts, and identify barriers and readiness for change

  • Assist – Strategize to overcome barriers, and match advice to stage of change

  • Arrange – Arrange follow-up, and inquire about behavior and readiness for change

  • Agree* – Shared decision making with a plan that physician and patient mutually agree upon

  • *Some models omit “Ask” and incorporate that information in “Assess.” Agree is then added as the fifth “A.”

A successful visit means moving forward through the SOC in the appropriate sequence, not necessarily immediately adopting the new lifestyle habit. The physician can use brief moments through multiple visits to help the patients’ progress through predictable stages and toward the ultimate desired behavior change [57, 58, 59] (see Table 1).

Patient health and well-being are strongly impacted by healthy lifestyle choices, including avoidance of tobacco, increased physical activity, improved nutrition, and adequate rest. By counseling and encouraging patients and their families and advocating for tobacco control and other measures to improve health, physicians can have large-scale impacts on populations and improve both individual and public health outcomes.

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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Department of Family & Preventive MedicineRosalind Franklin University of Medicine and ScienceNorth ChicagoUSA
  2. 2.Department of Family MedicineAdvocate Lutheran General HospitalPark RidgeUSA

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