CHAPTER 21
Preventive Health Care and Screening
KEY POINTS
1 Preventive health services that encompass screening and counseling for a broad range
of health behaviors and risks are important components of general obstetric and
gynecologic care.
2 Traditional gynecologic care—including cervical cytology testing, pelvic and breast
screening examinations, and the provision of contraceptive services—is considered
primary preventive care.
11283 Routine health care assessments for healthy women include a medical history,
physical examination, routine and indicated laboratory studies, assessment and
counseling regarding healthy behaviors, and relevant interventions, taking into
account the leading causes of morbidity and mortality within different age groups.
4 Through the Women’s Preventive Services Initiative (WPSI), the American College
of Obstetricians and Gynecologists (ACOG) is coordinating with the U.S.
Department of Health and Human Services (HHS) to develop and update
recommendations for women’s preventive health services.
5 Obesity, smoking, and alcohol abuse are preventable problems that have a major
impact on long-term health; assessment, counseling, and referral for these health
risks is a component of periodic health assessment and primary care.
[1] Although obstetrician-gynecologists are specialists in caring for women
during pregnancy and adeptly manage abnormal gynecologic conditions,
they also have a traditional role of providing primary and preventive care to
women, particularly for women of reproductive age. Preventive health
services that encompass screening and counseling for a broad range of health
behaviors and risks are important components of general obstetric and
gynecologic care. The obstetrician-gynecologist often serves as a woman’s point
of entry into the health care system, her primary care clinician, and a source of
continuity of care (1).
Primary care emphasizes health maintenance, preventive services, early
detection of disease, and availability and continuity of care. Women often regard
their gynecologist as their primary care provider; indeed, many women of
reproductive age have no other physician. Obstetrician-gynecologists estimated
that at least one-third of their nonpregnant patients rely on them for primary care
(2). [2] As primary care physicians, obstetrician-gynecologists provide
ongoing care for women through all stages of their lives—from the
reproductive age to postmenopause. Many services provided as part of
traditional gynecologic care, including cervical cytology testing, pelvic and
breast screening examinations, and the provision of contraceptive services,
are considered primary preventive care. Some gynecologists include screening
for certain medical conditions, such as hypertension, diabetes mellitus, and
thyroid disease, and management of those conditions in the absence of
complications, as a routine part of their practices.
Some traditional aspects of gynecologic practice, such as family planning and
preconception counseling, are recognized as key Healthy People 2020 goals (3).
Culturally appropriate evidence- and competency-based clinical guidelines are
lacking in the United States, and preventing unintended pregnancies remains an
elusive goal (4). Preventive medical services encompass screening and counseling
1129for a broad range of health behaviors and risks, including sexual practices;
prevention of sexually transmitted diseases (STDs); the use of tobacco, alcohol,
and other drugs; diet; and exercise.
While promoting preventive health care can lead to significant improvements
in the overall health, it remains a challenging task for many physicians, as they
must prioritize which of the numerous preventive services to recommend and
incorporate into everyday practice. Preventive care is often provided in
conjunction with an entire team of clinicians, including other specialists,
subspecialists, and allied health professionals. In general, the approach to
promoting preventive health care in clinical practice is to tailor services to
individual patients based upon the age, lifestyle habits, medical and family
history, and other risk factors.
Effectively communicating and explaining the relevant recommendations and
the harms of inappropriate screening are equally important and crucial to the
provision of preventive health. In a population-based cohort study, the existence
of a patient’s connection to a physician was more closely associated with the
receipt of various levels of preventive care, than race or ethnicity (5). A team
approach that extends beyond reliance on the clinician and incorporates all staff
of an office system to facilitate reminders and provide patient information can be
a very successful strategy for the timely delivery of quality preventive care
services.
GYNECOLOGIST AS A PRIMARY CARE PROVIDER
The obstetrician-gynecologist frequently serves as a primary medical resource for
women and their families, providing information, [3] guidance, and referrals
when appropriate. Routine health care assessments for healthy women are
based on age groups and risk factors. Health guidance takes into account the
leading causes of morbidity and mortality within different age groups. Patient
counseling and education require an ability to assess individual needs, assess
stages of readiness for change, and use good communication skills, including
motivational interviewing to encourage behavioral changes and ongoing care (6).
A team approach to care is frequently helpful, utilizing the expertise of medical
colleagues, such as nurses; advanced practice nurses, including nurse midwives
and nurse practitioners; health educators; other allied health professionals, such as
dieticians or physical therapists; relevant social services; and other physician
specialists. All clinicians, regardless of the extent of their training, have
limitations to their knowledge and skills and should seek consultation at
appropriate times for the benefit of their patients in providing reproductive and
nonreproductive care.
1130The National Ambulatory Medical Care Survey (NAMCS), conducted by the
Centers for Disease Control and Prevention’s (CDC) National Center for Health
Statistics is an annual nationally representative survey of visits to nonfederal
office-based patient care physicians. It defines obstetrician-gynecologists among
primary care providers, as opposed to medical or surgical subspecialists (7). In
2012, it was estimated that there were 929 million physician office visits. The
visit rate for women aged 18 to 64 years (321 visits per 100 women) was 57%
higher than the rate for men aged 18 to 64 years (204 per 100 men) (8).
Women’s needs for primary care vary across their lifespan. One survey of
women’s satisfaction with primary care found that women in their early
reproductive years (ages 18 to 34) were more satisfied with care coordination and
comprehensiveness when their regular provider was a reproductive health
specialist, primarily an obstetrician-gynecologist physician as compared to a
generalist, a generalist clinician plus an obstetrician-gynecologist, or no regular
provider (9). The scope of services provided by obstetrician-gynecologists varies
from one practice or clinician to another and may include more or fewer aspects
of well-woman and reproductive health care. It is important to establish with each
patient whether she has another primary care clinician, and who will be providing
which primary care and preventive health services (1). In 2014, routine prenatal
and gynecologic examinations were among the leading principal reasons for care
(7).
When asked to characterize the nature of an office or clinic visit, obstetriciangynecologists may or may not identify themselves as primary care providers,
depending on a number of variables (10). Those variables may include the
patient’s age, pregnancy status, whether it is a new versus a return visit,
diagnoses, insurance or referral status, and geographic practice region.
APPROACHES TO PREVENTIVE CARE
In health care, the focus is shifting from disease to prevention. Preventive care—
including reproductive life planning, optimization of nutrition and exercise,
screening for and management of chronic diseases, immunizations, management
of infectious diseases, and attention to psychological and behavioral health—
contributes to women’s overall health. Efforts are under way to promote effective
screening measures that can have a beneficial effect on public and individual
health.
To ensure that women of all ages receive appropriate preventive health
screenings, health care providers and patients need uniform, established
guidelines for recommended preventive services for women.
The Institute of Medicine’s July 2011 report noted a perceived lack of
1131transparency in the derivation of certain clinical practice recommendations and in
managing conflicts of interest (11). Variations in the guidelines’ development
processes were felt to be a fundamental cause of the lack of consistent guidelines
across specialties and groups, such as the American College of Obstetricians and
Gynecologists (ACOG), National Comprehensive Cancer Network (NCCN) and
U.S. Preventive Services Task Force (USPSTF). These discrepancies were
thought to contribute to provider uncertainty and patient confusion.
In 2016, in response to this concern over inconsistent recommendations,
ACOG launched the Women’s Preventive Services Initiative (WPSI). [4]
Through a 5-year cooperative agreement with the U.S. Department of Health
and Human Services (HHS), Health Resources and Services Administration
(HRSA), ACOG will coordinate the WPSI effort to develop, review, update
and disseminate recommendations for women’s preventive health care
services. WPSI aims to promote thorough consideration of the best available
evidence, ensure transparency and minimize the impact of individual bias, and
conflicts of interest.
An advisory panel consisting of representatives from the ACOG, American
Academy of Family Physicians (AAFP), the American College of Physicians
(ACP), and the National Association of Nurse Practitioners in Women’s Health
(NPWH) oversees the initiative. Representatives from many medical specialty
societies and national health professional organizations listed in Table 21-1
constitute the Multidisciplinary Steering Committee (MSC).
Recommendations presented by the WPSI follow the criteria specified by the
National Academies of Sciences, Engineering and Medicine (formerly the
Institute of Medicine). Topics considered by the WPSI focus on specific evidence
gaps and new recommendations not covered by existing recommendations from
the USPSTF, the American Academy of Pediatrics (AAP) Bright Futures
Initiatives for infants, children, and adolescents, and the CDC’s Advisory
Committee on Immunization Practices (ACIP).
Table 21-1 Women’s Preventive Services Initiative 2016 Multidisciplinary Steering
Committee Participating Organizations
American Academy of Family
Physicians
American Osteopathic Association
American College of Obstetricians and
Gynecologists
American Psychiatric Association
American College of Physicians American Geriatrics Society
National Association of Nurse Association of Reproductive Health
1132Practitioners in Women’s Health Professionals
Academy of Women’s Health Association of Women’s Health,
Obstetric and Neonatal Nurses
American Academy of Pediatrics National Comprehensive Cancer
Network
American Academy of Physician
Assistants
National Medical Association
American Cancer Society Association of Maternal and Child
Health Programs
American College of Nurse-Midwives National Partnership for Women and
Families
American College of Preventive
Medicine
National Women’s Law Center
American College of Radiology Patient Representative
Source: Women’s Preventive Services Initiative. Final recommendations: preventive
services for women. In: Recommendations for preventive services for women. Final report
to the U.S. Department of Health and Human Services, Health Resources & Services
Administration, December 2016. Washington, DC: American College of Obstetricians and
Gynecologists; 2017:8.
Reviews and updates of the evidence for each topic under consideration were
carefully undertaken. The scope of updates was based on Populations,
Interventions, Comparators, Outcomes, Timing and Setting/Study Design
(PICOTS) format. Searches were conducted in Ovid MEDLINE, the Cochrane
Central Register of Controlled Trials, the Cochrane Database of Systematic
Reviews, and PsycINFO. Studies conducted in settings applicable to the United
States were particularly targeted. Recommendations were adopted only if 75%
agreement was reached by the Multispecialty Steering Committee. In general,
recommendations apply to the general population of women in the United States
at average risk for the conditions addressed.
One of the research gaps includes lack of sufficient evidence for tailoring many
of the recommendations to the specific needs of racial and ethnic minority women
and underserved populations.
Guidelines for Primary and Preventive Care
1133The initial evaluation of a patient involves a complete history, physical
examination, routine and indicated laboratory studies, evaluation and counseling,
appropriate immunizations, and relevant interventions. Risk factors should be
identified and arrangements should be made for continuing care or referral, as
needed.
In its first year, the WPSI updated nine topics (12).
In the subsequent 4 years, various subcommittees will be tasked with
developing recommendations on one to two topics each year. The WPSI
preventive services recommendations are presented in a single website,
http://www.WomensPreventiveHealth.org. Recommendations will be reviewed
for currency and accuracy at least every 24 months after submission to and
adoption by HRSA.
Guide to Clinical Preventive Services
The USPSTF was commissioned in 1984 as a 20-member nongovernmental panel
of experts in primary care medicine, epidemiology, and public health. The
USPSTF, comprising primary care providers, now includes nonfederal experts in
prevention and evidence-based medicine (such as internists, pediatricians, family
physicians, gynecologist-obstetricians, nurses, and health behavior specialists);
the task force conducts and publishes scientific evidence reviews on a variety of
preventive health services with administrative and research support from the
Agency for Health Care Research and Quality (AHRQ). Initial and subsequent
reviews and recommendations are being revised and periodically released on the
website sponsored by the AHRQ (13). The charge to the panel was to develop
recommendations for the appropriate use of preventive interventions based on a
systematic review of evidence of clinical effectiveness. The panel was asked to
rigorously evaluate clinical research to assess the merits of preventive measures,
including screening tests, counseling, immunizations, and medications.
The task force uses systematic reviews of the evidence on specific topics in
clinical prevention that serve as the scientific basis for recommendations. The
task force reviews the evidence, estimates the magnitude of benefits and harms,
reaches consensus about the net benefit of a given preventive service, and issues a
recommendation that is assigned a grade from “A” (recommends; net benefit
substantial), to “B” (recommends; net benefit moderate), “C” (recommends;
selectively), “D” (recommends; against), “I” (insufficient evidence to recommend
for or against) (Table 21-3). The grading system includes suggestions for
practice, recommending that the service should be provided, discouraged, or that
the uncertainty about the balance of benefits versus harms should be discussed.
The task force evaluates services based on age, gender, and risk factors for
disease, making recommendations about which preventive services should be
1134included in routine primary care for which populations. Primary preventive
measures are those that involve intervention before the disease develops, such as
quitting smoking, increasing physical activity, eating a healthy diet, quitting
alcohol and other drug use, using seat belts and receiving immunizations.
Secondary preventive measures are those used to identify and treat asymptomatic
persons who have risk factors or preclinical disease but in whom the disease itself
has not become clinically apparent. Examples of secondary preventive measures
are well known in gynecology, such as screening mammography and cervical
cytology testing.
Table 21-2 Women’s Preventive Services Initiative Clinical Recommendations 2016
Topic Recommendation
Breast cancer
screening for
average-risk
women
• Initiate mammography screening no earlier than age 40 and no later
than age 50. Screening mammography should occur at least
biennially and as frequently as annually. Screening should
continue through at least age 74 and age alone should not be the
basis to discontinue screening.
Breastfeeding
services and
supplies
• Recommends comprehensive lactation support services (including
lactation counseling, education and breastfeeding equipment, and
supplies) during the antenatal, perinatal, and postpartum periods.
• Access to double electric breast pumps should be based on
optimization of breastfeeding, and not predicated on prior failure
of a manual pump.
Screening for
cervical
cancer
• Recommends cervical cancer screening for average-risk women
aged 21 to 65 years.
• Recommends screening with cytology alone every 3 years for
women aged 21 to 29 years.
• Recommends screening with cytology and human papillomavirus
every 5 years or cytology alone every 3 years for women aged 30
to 65.
• Cervical cancer screening is not recommended for women younger
than 21 years or those older than 65 with adequate prior screening.
Adequate prior negative screening is defined as three consecutive
negative cytology results or two consecutive negative cotest results
within the previous 10 years with the most recent test within the
past 5 years.
Contraception • Recommends the full range of female-controlled U.S. FDA-
1135approved contraceptive methods, effective family planning
practices, and sterilization procedures be available as part of
contraceptive care.
• Recommends timely authorization of contraceptives.
• Emphasizes patient-centered decision making and allows for
discussion of full range of contraceptive options.
Screening for
gestational
diabetes
mellitus
• Recommends screening pregnant women for gestational diabetes
mellitus after 24 weeks of gestation (preferably between 24 and 28
weeks of gestation).
• Recommends screening with a 50-g oral glucose challenge test
(followed by a 100-g 3-hour glucose tolerance test if results on the
initial glucose challenge test are abnormal).
Screening for
HIV infection
• Recommends prevention education and risk assessment for HIV
infection in adolescents and women at least annually throughout
the lifespan.
• Recommends all women be tested at least once during their
lifetime.
• Screening for HIV is recommended for all pregnant women upon
initiation of prenatal care.
• Rapid HIV testing is recommended for pregnant women who
present in active labor with an undocumented HIV status.
• Risk factors for HIV infection in women include, but are not
limited to: being an active injection drug user; having unprotected
vaginal or anal intercourse; having multiple sexual partners;
initiating a new sexual relationship; having sexual partners who are
HIV-infected, bisexual, or injection drug users; exchanging sex for
drugs or money; being a victim of sex trafficking; being
incarcerated (currently or previously); and having other sexually
transmitted infections (STIs).
Screening for
interpersonal
and domestic
violence
• Recommends screening adolescents and women for interpersonal
and domestic violence, at least annually.
• Interpersonal and domestic violence includes physical violence,
sexual violence, stalking and psychological aggression (including
coercion), reproductive coercion, neglect and the threat of
violence, abuse, or both.
• Risk factors for interpersonal and domestic violence include but are
not limited to pregnancy; younger and older age; increased stress;
lesbian, gay, bisexual, transgender, and queer (or questioning)
1136status; dependency; drug and alcohol misuse former or current
military service; and living in an institutional setting.
• Minimum screening intervals are unknown.
Counseling
for STIs
• Recommends directed behavioral counseling by a health care
provider or other appropriately trained individual for sexually
active adolescent and adult women at an increased risk for STIs.
• Risk factors include age younger than 25; a recent history of an
STI; a new sex partner; multiple partners; a partner with concurrent
partners; a partner with an STI; and lack of or inconsistent condom
use.
Well-woman
preventive
visits
• Recommends that women receive at least one preventive visit per
year beginning in adolescence and continuing across the lifespan.
Source: Women’s Preventive Services Initiative. Final recommendations: preventive
services for women. In: Recommendations for preventive services for women. Final report
to the U.S. Department of Health and Human Services, Health Resources & Services
Administration, December 2016. Washington, DC: American College of Obstetricians and
Gynecologists; 2017:17–23.
The USPSTF has recognized that for certain issues in medicine, evidence from
randomized controlled trials (RCT) are lacking and that it is necessary to consider
evidence from other study designs. Nevertheless, even when incorporating
evidence from non-RCT studies, insufficient evidence remains a limitation. As
clinicians do not have the luxury of waiting for certain evidence, the USPSTF
acknowledges the importance of four different “domains” when making clinical
decisions about prevention. The four domains pertinent to the decision-making
process are the preventable burden of suffering from a particular condition,
potential harm of an intervention, monetary and opportunity costs of a particular
service, and current practice landscape (15).
Table 21-3 U.S. Preventive Services Task Force Ratings
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations
according to one of five classifications (A, B, C, D, I) reflecting the strength of
evidence and magnitude of the net benefit (benefits minus harms). The USPSTF
changed its grade definitions based on a change in methods in May 2007 and again in
July 2012, when it updated the definition of and suggestions for practice for the grade
C recommendation (14).
Grade Definition Suggestions for Practice
1137A The USPSTF recommends the service.
There is high certainty that the net
benefit is substantial.
Offer or provide this service
B The USPSTF recommends the service.
There is high certainty that the net
benefit is moderate or there is
moderate certainty that the net benefit
is moderate to substantial.
Offer or provide this service
C The USPSTF recommends selectively
offering or providing the service to
individual patients based on
professional judgment and patient
preferences. There is at least moderate
certainty that the net benefit is small.
Offer or provide this service
for selected patients depending
on individual circumstances
D The USPSTF recommends against the
service. There is moderate or high
certainty that the service has no net
benefit or that the harms outweigh the
benefits.
Discourage the use of this
service
IS
tatement
The USPSTF concludes that the
current evidence is insufficient to
assess the balance of benefits and
harms of the service. Evidence is
lacking, of poor quality, or conflicting,
and the balance of benefits and harms
cannot be determined.
Read the clinical
considerations section of the
USPSTF Recommendation
Statement. If the service is
offered, patients should
understand the uncertainty
about the balance of benefits
and harms.
International efforts to categorize the effectiveness of treatments include the
Cochrane Library, which produces and disseminates high-quality systematic
reviews of health care interventions. Their reviews and abstracts are published
monthly and are available online and on DVDs by subscription (16). The
Cochrane Library provides searchable databases online and through institutional
purchase of licenses. Evidence-based guidelines are published in journals
available in print and online by discipline (i.e., medicine, mental health, and
nursing).
Counseling for Health Maintenance
During periodic assessments, patients should be counseled about preventive care
1138based on their age and risk factors. [5] Obesity, smoking, and alcohol abuse are
associated with preventable problems that can have major long-term impacts
on health. Patients should be counseled about smoking cessation and moderation
in alcohol use and directed to appropriate community resources as necessary.
Positive health behaviors, such as eating a healthy diet and engaging in regular
exercise, should be reinforced. Adjustments may be necessary based on the
presence of risk factors and the woman’s current lifestyle and condition. Efforts
should focus on weight control, cardiovascular fitness, and reduction of risk
factors associated with cardiovascular disease and diabetes (6).
Nutrition
Patients should be given general nutritional information and referred to other
professionals if they have special needs (6). Assessment of the patient’s body
mass index (BMI) = weight (in kilograms) divided by height (in meters) squared
(kilograms per square meter) will give valuable information about the patient’s
nutritional status. Tables and apps (applications) to calculate BMI are available in
print and electronic resources. Patients who are 20% above or below the normal
range require evaluation and counseling and should be assessed for systemic
disease or an eating disorder. From 2013 to 2014, the overall age-adjusted
prevalence of obesity was 40.4% (95% CI; 37.6%–43.3%) among adult women
(17). In 2017, all states had more than 20% of adults with obesity. The South had
the highest prevalence of obesity (32.4%), followed by the Midwest (32.3%), the
Northeast (27.7%) and the West (26.1%) (18). Overweight and obesity
substantially increase the risk of morbidity from hypertension, dyslipidemia, type
2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis,
sleep apnea, and cancers of the endometrium, breast, and colon (19).
Central obesity—measured as the waist-to-hip ratio—is an independent risk
factor for disease. Women with a waist circumference greater than 35 in are at
higher risk of diabetes, dyslipidemia, hypertension, and cardiovascular disease
(20). Metabolic syndrome is a complication of obesity that, while somewhat
variably defined, includes a clustering of atherogenic dyslipidemia, elevated
blood pressure, elevated plasma glucose, and abdominal obesity and confers an
increased risk for cardiovascular disease and diabetes (21). One-third to one-half
of premenopausal women with polycystic ovarian syndrome (PCOS) meet the
criteria for metabolic syndrome (22).
1139FIGURE 21-1 MyPlate icon. This is a new communications initiative based on the 2010
Dietary Guidelines for Americans, replacing the Food Pyramid. It is designed to remind
Americans to eat healthfully, and illustrates the five food groups using a familiar mealtime
visual of a place setting. (From the U.S. Department of Agriculture,
http://www.choosemyplate.gov)
Every 5 years, the U.S. Department of Agriculture (USDA) and (HHS) jointly
publish a report containing nutritional and dietary information and guidelines for
the general public, with the 2015–2020 Dietary Guidelines for Americans being
the most current edition (23). The guidelines provide evidence-based food and
beverage recommendations for Americans aged 2 years and older with aims to
promote health, prevent chronic disease, and help people reach and maintain a
healthy weight. The Dietary Guidelines recommend including a variety of
vegetables, fruits, grains, fat-free or low-fat dairy, a variety of proteins and oils as
1140part of a healthy eating pattern. The MyPlate symbol is a useful tool to bring
together the key elements of healthy eating patterns, translating the Dietary
Guidelines into key consumer messages that are used in educational materials for
the public (Fig. 21-1) (23). The guidelines include recommendations to balance
food and physical activity and stay within daily calorie requirements.
Fiber content of the diet is being studied for its potential role in the prevention
of several disorders, particularly colon cancer. It is recommended that the average
diet for adult women contain 22 to 28 g of fiber per day (23). Whole-grain foods
and vegetables, citrus fruits, and some legumes, are high in fiber and are
emphasized in the guidelines for healthy foods.
Adequate calcium intake is important in the prevention of osteoporosis. A
postmenopausal woman should ingest 1,200 mg per day. Adolescents require
1,300 mg per day. Because it may be difficult to ingest an adequate amount of
calcium daily in an average diet, supplements may be required.
The U.S. Public Health Service has recommended that women of reproductive
age who are capable of becoming pregnant take supplemental folic acid (0.4 mg
daily) to help prevent neural tube defects in their infants. Surveys indicate that in
2007, 40% of women of childbearing age consumed a supplement, a percentage
that is only half of the Healthy people 2010 objective of 80% (24). Women who
are contemplating pregnancy should be counseled about the risk of fetal neural
tube defects and the role of folic acid supplementation in their prevention prior to
conception (25).
Alcohol
Alcoholic beverages, if consumed, should be done so in moderation—up to one
drink per day for women (23). A simple device called the T-ACE questionnaire
(Tolerance; been Annoyed by criticism of drinking; felt need to Cut down; need
for Eye-opener) can be used to elicit information about alcohol use and identify
problem drinkers (26). Women should be questioned in a nonjudgmental fashion
about their alcohol use and directed to counseling services as required.
Exercise
Exercise can help control or prevent hypertension, diabetes mellitus,
hypercholesterolemia, and cardiovascular disease and helps to promote the overall
good health, psychological well-being, and a healthy body weight. Moderate
exercise along with calcium supplementation can help retard bone loss in
postmenopausal women. Physical activity, adequate nutrition, and good health are
necessary for bone health (27). Exercise helps promote weight loss, strength and
fitness, and stress reduction. Federal exercise guidelines from the HHS note that
“regular physical activity reduces the risk of many adverse health outcomes; some
1141physical activity is better than none; for most health outcomes, additional benefits
occur as the amount of physical activity increases through higher intensity,
greater frequency, and/or longer duration; most health benefits occur with at least
150 minutes (2 hours and 30 minutes) a week of moderate-intensity physical
activity, such as brisk walking. Additional benefits occur with more physical
activity; both aerobic (endurance) and muscle-strengthening (resistance) physical
activity are beneficial; health benefits occur for children and adolescents, young
and middle-aged adults, older adults, and those in every studied racial and ethnic
groups; the health benefits of physical activity occur for people with disabilities;
and the benefits of physical activity far outweigh the possibility of adverse
outcomes” (28). Cardiovascular conditioning, stretching exercises for flexibility,
resistance exercises, or calisthenics for muscle strength and endurance are
recommended for most people. Older adults (65 years and older) should do
exercises that maintain or improve balance if they are at risk of falling and should
determine their level of effort for physical activity relative to their level of fitness
(23). Factors that should be considered in establishing an exercise program
include medical limitations, such as obesity or arthritis, and careful selection of
activities that promote health and enhance compliance (1).
Cardiovascular fitness can be evaluated by measurement of heart rate during
exercise. As conditioning improves, the heart rate stabilizes at a fixed level. The
heart rate at which conditioning will develop is called the target heart rate (1). The
American Heart Association recommends calculation of maximum heart rate
using the formula 220 - age. Target heart rate should range from 50% to 70% for
moderate exercise and 70% to 85% for strenuous exercise (29). A 2010 study
examined the definition of a normal heart rate response to exercise stress testing
in women and noted that the traditional male-based calculation of target heart rate
may not be appropriate for women (30). The alternative formula for target heart
rate, based on this research, is 206 - (patient’s age × 0.88).
Smoking Cessation
Smoking is a major cause of preventable illness, and every opportunity should be
taken to encourage patients who smoke to quit. Patient education about the
benefits of smoking cessation, clear advice to quit smoking, and physician
support improve smoking cessation rates, although 95% of smokers who
successfully quit do so on their own. Self-help materials are available from the
National Cancer Institute, and community-based support groups and local
chapters of the American Cancer Society and the American Lung Association.
The combination of counseling and medication (nicotine and non-nicotine
options) is more effective than either used alone, and Clinical Practice Guidelines
on treating tobacco use, and dependence from the HHS provide recommendations
1142(31).
The “5 As”—Ask, Advise, Assess, Assist, and Arrange—are designed to be used
with smokers who are willing to quit (32). The Ask component involves
systematically identifying all tobacco users at every visit. It is important that the
advice given to urge tobacco users to quit is clear, strong, and personalized. Next,
providers should assess a patient’s willingness to quit and provide assistance if
applicable or provide an intervention to increase future quit attempts. In 2015, the
USPSTF released evidence-based recommendations for behavioral and
pharmacologic interventions to help people quit smoking. Patient-centered
outcomes research strongly supports the use of behavioral interventions alone or
in combination with pharmacotherapy. All pregnant women who smoke should
receive behavioral interventions (33). Relapse prevention is important, with
congratulations for any successes and encouragement to remain abstinent.
Patients who use tobacco but are unwilling to quit at the time of the visit should
be treated with the “5 Rs” motivational intervention: Relevance, Risks, Rewards,
Roadblocks, and Repetition (31).
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