Physical inactivity is a global health burden. Promoting physical activity in primary care through physical activity counseling is an effective intervention. This article provides an overview of and perspectives on physical activity counseling in primary care. The identification of physical inactivity as a health problem may increase the awareness of physical inactivity among patients and primary care providers, which will lead to an action plan. The contents of physical activity counseling should be based on evidence-based recommendations. Safety issues should be evaluated appropriately to optimize the utilization of primary care services. Physical activity counseling methods should be “tailored” for an individual using appropriate counseling methods and setting-specific resources. Multilevel barriers to physical activity counseling in primary care (i.e., healthcare providers, patients, and systems) must be addressed. Setting-specific strategies to overcome these barriers should be implemented to maximize the effectiveness of physical activity counseling in primary care.
Physical inactivity or insufficient physical activity is a global health issue. According to the Global Burden of Disease Study 2017, physical inactivity caused more than 1 million deaths, and the mortality rate increased 22% compared with that documented in 2007 [
Primary care systems have several effects on population health: better accessibility and quality of care; reduction in unnecessary specialty care; early management of health problems; health promotion; and disease prevention [
Promoting physical activity in primary care can convert one out of 12 sedentary people to become physically active [
“Physical activity” can be defined as any bodily movement produced by skeletal muscles that results in energy expenditure, which includes physical activity during work, traveling, and leisure time [
PAC is a component of promoting physical activity in primary care. Stoutenberg et al. [
A single standard of PAC practice in primary care is lacking. A “tailored” practice for a particular setting is necessary. This article provides an overview of and perspectives on PAC in primary care.
According to a global analysis from 2001 to 2016, the prevalence of physical inactivity was 27.5%, and it was higher among high-income countries (36.8%) than in low-income countries (16.2%) [
“Physical inactivity” can be defined as “performing insufficient amounts of moderate- and vigorous-intensity activity” or “an insufficient physical activity level to meet present physical activity recommendations [
In primary care, a recommended aerobic level is considered as a cut-off point between being “physically inactive” and “physically active.” According to “exercise is medicine” guidelines, the “dose” of physical activity can be assessed based on two questions: (1) “on average, how many days per week do you engage in moderate-to-strenuous (vigorous) exercise?”; and (2) “on average, how many minutes do you engage in exercise at this level [
Listing physical inactivity as a health problem could increase the awareness of primary care providers. Creating a list of active and current/previous diagnoses relevant to patient care [
PAC requires specific knowledge and skills. In addition, it should be tailored for each individual and each primary care setting. The sections below detail essential considerations to adapt for primary care. PAC for specific diseases is beyond the scope of this article.
A time-based recommendation for physical activity has been used widely. That is, 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity is set as an indicator for “being physically active.” This time-based indicator has been cited in research [
There are some changes in the recent guideline. The Physical Activity Guidelines for Americans (second edition) recommend that “adults should do at least 150 minutes to 300 minutes a week of moderate-intensity, or 75 minutes to 150 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity [
These guidelines also include recommendations for different age groups and health conditions [
A step-based recommendation for physical activity is an alternative approach. Walking 10,000 steps every day is recommended to reduce health risks and improve metabolic outcomes [
Physical activity and exercise can increase injury risks, from musculoskeletal injuries to sudden cardiac arrest [
To avoid the risks of injuries and fatal cardiac events, health screening before undertaking physical exercise may be necessary for some people. A well-known preparticipation health-screening tool is the Physical Activity Readiness Questionnaire (PAR-Q) and You, which consists of seven simple questions to appraise one’s ability to become more physically active. One or more positive answers on the PAR-Q requires that a physician be consulted for a physical activity clearance [
New tools based on evidence-based consensus are being developed to support the preparticipation screening for physical activity [
The preparticipation health-screening process set by the American College of Sports Medicine in 2015 is another example. This guideline aims to reduce the excessive number of physician referrals, while exercise is safe for most people [
PAC methods vary according to theories, interventions, and providers. The term PAC is used interchangeably with “physical activity consultation.” A systematic review on the content and competency of PAC by Breckon and colleagues revealed diverse theories and interventions, such as the transtheoretical model, social cognitive theory, brief negotiation, and motivational interviewing [
The 5As (Assess, Advise, Agree, Assist, and Arrange) framework is another commonly used method to counsel about physical activity [
These processes require topic-based knowledge and communication skills. Primary care providers advise their patients to participate in physical activity based on the recommendations for physical activity, but 150 minutes per week of moderate-intensity aerobic physical activity is the general information provided. According to the transtheoretical model (stages of change), this information may be sufficient for a physically active person who is at the action or maintenance stage but must be translated and placed in an action plan for those in precontemplation, contemplation, or preparation stages [
The frequency, intensity, time, and type (FITT) principle is used widely for PAC [
Frequency represents the number of sessions of physical activity or exercise per week. According to the guidelines for adults, aerobic activities should be spread throughout the week so that at least 150–300 minutes per week of moderate-intensity physical activity is accumulated [
Intensity is the rate of energy expenditure (i.e., how hard a person works to carry out an activity). Most guidelines focus on moderate- to vigorous-intensity activity. The intensity of physical activity is vital for discussions of participation in physical activity. Nevertheless, this component is, sometimes, neglected by counselors [
Time refers to the duration of an activity session. Previously, the guidelines suggested a 10-minute bout of aerobic physical activity [
The type of physical activity is defined by the characteristics and goals of the activity.
The FITT principle is emphasized to target the epidemic of physical inactivity. However, the enjoyment of individuals should be considered as an additional component to overwhelm the high prevalence of physical inactivity [
In primary care, PAC can be conducted solely by physicians or allied health professionals, or in combination. Physician-only counseling can be completed in a single consultation. Nonetheless, there is no guarantee that patients will change their behavior. A multidisciplinary approach could utilize the credibility of primary care physicians and their underlying relationship with their patients for PAC and offer referrals to allied health professionals for specialized management [
Moreover, exercise-referral schemes have been implemented to achieve higher yields on physical activity participation. In the United Kingdom, for example, exercise-referral schemes have been enacted in primary care since the 1990s for supervised exercise conducted in non-clinical environments or public leisure facilities [
Lack of knowledge or training in PAC can be a barrier. Training in PAC is sparse in undergraduate medical education and postgraduate primary care training [
Insufficient time, resources, and social support are regarded as patient-based barriers [
Time constraints are a major barrier to PAC, as documented by studies in various settings [
To overcome the barriers to PAC, different approaches in primary care are necessary. Primary care providers should be trained to counsel about physical activity. Training in physical activity is associated with greater confidence in discussing physical activity and exercise with patients [
Communicating with patients to change their behavior is a challenging task. Primary care providers should give tailored information to patients. Writing a prescription for physical activity or exercise can improve and facilitate PAC and increase the levels of physical activity [
At organizational and policy levels, primary care settings should focus on physical activity and healthy lifestyles as part of organizational culture. For example, the UK campaign “making every contact count” encourages healthcare providers to maximize the opportunity within routine healthcare interactions for a brief discussion on health and wellbeing [
PAC in primary care is a practical intervention to deal with the pandemic of physical inactivity and NCDs. Physical inactivity should be addressed as a health problem to increase awareness among patients and primary care providers, which should lead to an action plan. PAC contents should be evidence-based and tailored for an individual using appropriate counseling methods and setting-specific resources. The primary care setting should identify the barriers to PAC (healthcare providers, patients, systemic). Moreover, strategies to overcome such barriers should be implemented.
No potential conflict of interest relevant to this article was reported.
This work was supported in part by the new strategic research (P2P) project within Walailak University, Thasala, Thailand.
The authors thank Aekthawat Watthanachon and Atchara Aidwang for their support.
Intensity of physical activity
Intensity | Aerobic activity |
Muscle-strengthening activity | ||
---|---|---|---|---|
%HRmax | Talk test (comfortable conversation) | Compendium of physical activities | ||
Sedentary | <50 | Possible | ≤1.5 METs | |
- Sitting, playing traditional video game, computer game (1 MET) | ||||
Light | 50–63 | Possible | <3 METs | 40%–50% of 1 RM |
- Watering plants (2.5 METs) | ||||
- Walking to and from an outhouse (2.5 METs) | ||||
Moderate | 64–76 | Possible | 3–5.9 METs | 60%–70% of 1 RM |
- Walking a dog (3 METs) | ||||
- Walking at 3.5 mph briskly on a firm surface (4.3 METs) | ||||
Vigorous | 77–93 | Not likely possible | 6–8.8 METs | ≥80% of 1 RM |
- Race walking (6.5 METs) | ||||
- Walking at 4.0 mph very briskly on a level, firm surface (6.8 METs) | ||||
- Jogging (general) (7.0 METs) | ||||
Very hard to maximum | >93 | Not possible | ≥8.8 METs | |
- Running a marathon (13.3 METs) |
The compendium of physical activities is a list of physical activities quantifying the energy cost as MET values (1 MET=3.5 mL/kg/min of oxygen uptake).
%HRmax, percent of maximum heart rate (HRmax=220−age); MET, metabolic equivalent; 1 RM, one-time repetition maximum (the heaviest weight a person can lift once).
Types of physical activity
Type | Explanation |
---|---|
Aerobic activity | Uses the large muscles for a sustained amount of time to improve cardiorespiratory fitness (also called “endurance” or “cardio activity”). |
Muscle-strengthening activity | Increases the strength, power, endurance, and mass of skeletal muscles. |
Bone-strengthening activity | Creates a force on bones, which stimulates their strength and growth. |
Balance activity | Improves the ability to resist forces that cause falls. |
Multicomponent physical activity | Combines more than one type of physical activity (i.e., aerobic, muscle-strengthening, and balance). |