44: Evidence-Based Behavioral Practice

CASE ILLUSTRATION 1

A 43-year-old man presents for a preventive care visit. He has not had any preventive care in over 5 years but at an urgent care visit 4 months ago he was told he had high blood pressure. His past medical history is remarkable only for mild eczema. He is married, has two children, and works as an attorney. He says his work is sometimes stressful but denies a depressed mood or loss of interest in leisure activities. He has no difficulty sleeping. He recently cut back to about five cigarettes per day and has three to four alcoholic drinks almost every night. He does not exercise regularly, but walks about 5 minutes twice a day to the train. He does not follow any particular diet: breakfast is usually coffee and toast; lunch is fast food or a deli sandwich; he snacks on cookies or pastries at work. His wife cooks “healthy food” sometimes and they order from restaurants frequently. On physical examination his weight is 207 lbs with a body mass index of 29.7 kg/m². An average of three office blood pressures is 139/88 mm Hg. The rest of the examination is normal except for an eczematous rash on his arms. As you prescribe triamcinolone cream for his rash, you consider how best to counsel him about behavior change. The list of changes you think would be beneficial include: (1) stopping smoking; (2) reducing total calories; (3) following a diet low in sodium and high in vegetables, fruits, whole grains, and nonfat dairy products; (4) reducing saturated fat in his diet; (5) reducing alcohol use to no more than two drinks per day; and (6) increasing the amount of moderate-intensity physical activity he does by an additional 90–120 minutes each week.