CHaPTeR6. REGULAR EXERCISE 153 in the decision-making process. The primary need is for the clinician to spend time with patients communicating about regular exercise, recognizing bstacles to success, and equipping patients with the tools to overcome them Risk Assessment The clinician should assess patient before recommending a regular exercise program. Some will need a full medical examination(see subsequent text). Many otherwise healthy patients will not. According to the USPSTF, neither a resting electrocardiogram nor an exercise stress test provides information helpful in reducing the risk of an adverse outcome from regular exercise among asymptomatic persons. Although the USPSTF does not endorse them, these tests may be clinically indicated for men older than 40 years with two or more risk factors for coronary artery disease other than sedentary lifestyle. Coronary artery disease risk factors include elevated serum cholesterol, history of cigarette smoking, hypertension, diabetes,or a family history of early-onset coronary artery disease Furthermore, the clinician should conduct a thorough clinical evaluation of patients for whom regular exercise presents a definite risk, before advising these patients to start exercising. These high-risk patients may have a history of one or more of the following diseases or conditions Previous myocardial infarction Exertional chest pain or pressure, or severe shortness of breath Pulmonary disease, especially chronic obstructive pulmonary disease Bone, joint or other musculoskeletal diseases or other limitations These conditions are not necessarily contraindications to regular exercise but each patient's risk must be assessed on an individual basis Patients for whom regular exercise presents a possible risk may have a history of one or more of the following di Iscascs or co Hypertension Cigarette smoking Elevated serum cholesterol Prescription medication used on a regular basis Abuse of drugs or alcohol Any other chronic illness, such as diabetes Family history of heart disease Overweight in excess of 20 lb Current sedentary lifestyle Regular exercise is very useful in the management of a number of these diseases and conditions (3). For example, regular physical activity has been shown to reduce the rate of progression of diabetes by more than 50%(11) In fact, regular exercise may be a pivotal force in changing the natural