An initiative to implement a triage and referral system to make exercise and rehabilitation referrals standard of care in oncology.

BACKGROUND: Clinical guidelines suggest that patients should be referred to exercise while undergoing cancer treatment. Oncology clinicians report being supportive of exercise referrals but not having the time to make referrals. Toward the goal of making exercise referrals standard of care, we implemented and evaluated a novel clinical workflow. METHODS: For this QI project, a rehabilitation navigator was inserted in chemotherapy infusion clinics. Patients were offered a validated electronic triage survey. Exercise or rehabilitation recommendations were communicated to patients during a brief counseling visit by the rehabilitation navigator. The implementation approach was guided by the EPIS framework. Acceptability and feasibility were assessed. RESULTS: Initial meetings with nursing and cancer center leadership ensured buy-in (exploration). The education of medical assistants contributed to the adoption of the triage process (preparation). Audit and feedback ensured leadership was aware of medical assistants' performance (implementation). 100% of medical assistants participated in implementing the triage tool. A total of 587 patients visited the infusion clinics during the 6-month period when this QI project was conducted. Of these, 501 (85.3%) were offered the triage survey and 391 (78%) completed the survey (acceptability). A total of 176 (45%) of triaged patients accepted a referral to exercise or rehabilitation interventions (feasibility). CONCLUSIONS: Implementation of a validated triage tool by medical assistants and brief counseling by a rehabilitation navigator resulted in 45% of infusion patients accepting a referral to exercise or rehabilitation. The triage process showed promise for making exercise referrals standard of care for patients undergoing cancer treatment.

Screening and socioeconomic associations of dyslipidemia in young adults.

BACKGROUND: The Southern region of the United States is home to substantial populations with obesity, dyslipidemia, and hypertriglyceridemia, while also housing a large percentage of America's minority, rural, and low socioeconomic status (SES) peoples. Adult-onset cardiovascular disease (CVD) research may be informed by investigating associations(s) between late adolescent demographic variables and lipid values. Our objective was to investigate lipid parameter associations with college-age socioeconomic status, which may improve age-specific screening algorithms for management or prevention of adult-onset CVD. METHODS: Using an Analysis of Variance test and a general linear model, associations between gender, race/ethnicity, SES, and athletic participation on lipid parameters (VLDL-C, LDL-C, TG, TC, and HDL-C) were analyzed in 4423 private liberal arts college students enrolled in freshman-level wellness courses at Furman University in Greenville, SC. Comparative data were collected from an age-matched sample (National Health and Nutrition Examination Survey: NHANES 2003-2016). Our main outcomes were statistically significant relationships between any lipid values (TC, HDL-C, LDL-C, TG) and any demographic variables (gender, SES, ethnicity, athlete status). RESULTS: Males demonstrated lower TC and LDL-C, and higher HDL-C values. HDL-C was highest in athletes. African-American students demonstrated healthier VLDL-C, TG, and HDL-C values. With similar distributions, the age-matched NHANES comparison group showed unhealthier values in nearly all categories. CONCLUSIONS: College students may have better lipid health than the general population. African-Americans may have seemingly healthier lipid values than age-matched individuals independent of athletic or college enrollment which has already been demonstrated in other studies. Future research should include SES relationships in lipid screening paradigms along with other appropriate risk factors for cardiovascular disease. Based on our comparative data, pediatric health providers and researchers may consider education as a potential protective factor against poor lipid health when considering lipid screening protocols for students.

Call to Action on Making Physical Activity Assessment and Prescription a Medical Standard of Care.

The U.S. population is plagued by physical inactivity, lack of cardiorespiratory fitness, and sedentary lifestyles, all of which are strongly associated with the emerging epidemic of chronic disease. The time is right to incorporate physical activity assessment and promotion into health care in a manner that engages clinicians and patients. In April 2015, the American College of Sports Medicine and Kaiser Permanente convened a joint consensus meeting of subject matter experts from stakeholder organizations to discuss the development and implementation of a physical activity vital sign (PAVS) to be obtained and recorded at every medical visit for every patient. This statement represents a summary of the discussion, recommendations, and next steps developed during the consensus meeting. Foremost, it is a "call to action" for current and future clinicians and the health care community to implement a PAVS in daily practice with every patient.

Using lifestyle medicine in U.S. health care to treat obesity: too many bariatric surgeries?

More than one-third of Americans are classified as obese. Many clinicians perform bariatric surgery (BSx) when it is said that lifestyle intervention failed. However, BSx is medically complex, with extremely variable success, certain failures, major complications, and sometimes death. Although many studies declare BSx as more effective for producing weight loss than nonsurgical lifestyle management, these conclusions are flawed when lifestyle management between cohorts are not identical. Lifestyle behavior change is essential to success for both surgical and nonsurgical weight loss, as over 50% of BSx patients regain weight without lifestyle modification. Indeed, programs that include self-reward and reinforcement are extremely effective. It is therefore possible that successful BSx is simply an intrinsic reward for an intensive change in lifestyle behavior. Accounting for the costs and risks associated with BSx, providing state and federal resources for lifestyle behavior change programs could provide a key opportunity for the war against obesity.

Assessing preschool children's physical activity: how many days of accelerometry measurement.

The purpose of this study was to determine the minimum number of days of accelerometry required to estimate accurately MVPA and total PA in 3- to 5-year-old children. The study examined these metrics for all days, weekdays, and in-school activities. Study participants were 204 children attending 22 preschools who wore accelerometers for at least 6 hr per day for up to 12 days during most waking hours. The primary analysis considered the intraclass correlation coefficient (ICC) for each metric to estimate the number of days required to attain a specified reliability. The ICC estimates are 0.81 for MVPA-all days, 0.78 for total PA-all days, 0.83 for MVPA weekdays, 0.80 for total PA-weekdays, 0.81 for in-school MVPA, and 0.84 for in-school total PA. We recommend a full seven days of measurement whenever possible, but researchers can achieve acceptable reliability with fewer days, as indicated by the Spearman-Brown prophecy: 3-4 days for any weekday measure and 5-6 days for the all-days measures.

The Feasibility and Efficacy of a Virtual Reality Tandem Cycling Program for Persons with Parkinson's Disease and Their Care Partners.

INTRODUCTION: Persons with Parkinson's disease (PwPD) suffer from motor and non-motor symptoms which significantly affect their quality of life (QoL), and the QoL of their care partners (CP). Tandem cycling reduces PwPD motor symptoms; however, no studies have examined other benefits or included PwPD CP. We conducted an 8-week community virtual reality (VR) tandem cycling intervention to assess the feasibility and efficacy for PwPD and their CP (i.e., PD dyads). We hypothesized that dyadic tandem cycling would improve (1) PwPD motor and non-motor symptoms and (2) dimensions of PD dyads' QoL and physiologic health. METHODS: Ten PD dyads were recruited to complete 8 weeks of progressive intensity, bi-weekly tandem cycling. At pre- and post-testing, PwPD were assessed using the Movement Disorder Society-Unified Parkinson's Disease Rating Scale-III (MDS-UPDRS-III), functional gait assessment (FGA), and 10-m gait speed test. PD dyads also completed emotional and cognitive status questionnaires [e.g., Geriatric Depression Scale-Short Form (GDS-SF)], and wore BodyGuard 2 heart rate (HR) monitors for 48 h to assess surrogate measures of heart rate variability. Statistical analyses were conducted using Student's t tests with significance set at p ≤ 0.05. RESULTS: Eight PD dyads and one PwPD completed the intervention. Retention of PwPD (90%) and CP (80%) was adequate, and PD dyad adherence ranged from 91.67 to 97.91%. PwPD demonstrated significant clinical improvements in MDS-UPDRS-III scores (- 7.38, p < 0.01), FGA scores (+ 3.50, p < 0.01), and 10-m gait speed times (+ 0.27 m/s, p < 0.01), in addition to significant self-reported improvements in mobility (- 13.61, p = 0.02), fatigue (- 5.99, p = 0.02), and social participation (+ 4.69, p < 0.01). CP depressive symptoms significantly decreased (- 0.88, p = 0.02), and PD dyads shared a significant increase in root mean square of the successive differences (RMSSD; p = 0.04). CONCLUSION: Our pilot study demonstrated feasibility and multiple areas of efficacy supporting further investigation of community VR tandem cycling as a therapeutic intervention for PD dyads.

Design and implementation of a clinic-to-community, physical activity health promotion model for healthcare providers.

Due to the worldwide burden of noncommunicable disease, the American College of Sports Medicine (ACSM) launched a global health awareness initiative in 2007 called Exercise is Medicine® (EIM®) to create awareness in healthcare providers in promoting physical activity to their patients. To transition awareness into action, Exercise is Medicine Greenville® (EIMG®) launched in 2016 through a first-of-its-kind partnership between a medical school, large healthcare system, and community organization to comprehensively integrate physical activity as a primary prevention strategy into their health system. The EIMG® model connects patients referred by their healthcare provider due to diagnosis of a physical inactivity and/or noncommunicable disease to community partners who provide evidence-based physical activity programs as a population health management strategy. The EIMG® program is inclusive of all patients referred and provides an "open door policy" through the YMCA scholarship fund. Through 2019, 210 patients completed the program (>60% graduation rate). Patients receiving usual care by their healthcare provider decreased body weight (p < 0.001) and systolic blood pressure (p = 0.042). Patients receiving usual care by their healthcare provider who were referred with hypertension decreased body weight (p = 0.001), and both systolic and diastolic blood pressure (p < 0.001). Graduating patients were highly satisfied with the program and program personnel (>4 on a 5-point Likert scale). Aligning healthcare and community partners to implement a clinic-to-community model for patients with noncommunicable disease may be a beneficial population health promotion strategy. Future efforts will be to refine the referral process, scale the model, and continue to inform national health promotion strategies.

Effect of sprint interval training on circulatory function during exercise in sedentary, overweight/obese women.

Very high-intensity, low-volume, sprint interval training (SIT) increases muscle oxidative capacity and may increase maximal oxygen uptake ([Formula: see text]), but whether circulatory function is improved, and whether SIT is feasible in overweight/obese women is unknown. To examine the effects of SIT on [Formula: see text] and circulatory function in sedentary, overweight/obese women. Twenty-eight women with BMI > 25 were randomly assigned to SIT or control (CON) groups. One week before pre-testing, subjects were familarized to [Formula: see text] testing and the workload that elicited 50% [Formula: see text] was calculated. Pre- and post-intervention, circulatory function was measured at 50% of the pre-intervention [Formula: see text], and a GXT was performed to determine [Formula: see text]. During the intervention, SIT training was given for 3 days/week for 4 weeks. Training consisted of 4-7, 30-s sprints on a stationary cycle (5% body mass as resistance) with 4 min active recovery between sprints. CON maintained baseline physical activity. Post-intervention, heart rate (HR) was significantly lower and stroke volume (SV) significantly higher in SIT (-8.1 and 11.4%, respectively; P < 0.05) during cycling at 50% [Formula: see text]; changes in CON were not significant (3 and -4%, respectively). Changes in cardiac output ([Formula: see text]) and arteriovenous oxygen content difference [(a - v)O(2) diff] were not significantly different for SIT or CON. The increase in [Formula: see text] by SIT was significantly greater than by CON (12 vs. -1%). Changes by SIT and CON in HR(max) (-1 vs. -1%) were not significantly different. Four weeks of SIT improve circulatory function during submaximal exercise and increases [Formula: see text] in sedentary, overweight/obese women.

Effects of 6 weeks of quercetin supplementation on energy, fatigue, and sleep in ROTC cadets.

PURPOSE: To investigate the effects of 6 weeks of quercetin supplementation on energy, fatigue, and sleep quality in young persons conducting military physical training. METHODS: Using a randomized, double-blind, repeated-measures, placebo-controlled design, 58 healthy, moderately trained men and women were assigned to quercetin group and placebo group. Energy, fatigue, and sleep quality were evaluated before, in the middle, at the end, and 2 weeks following 42 to 54 days of supplementation with 1 g/day of quercetin in a soft chew or a placebo. RESULTS: Changes in energy and fatigue, assessed by the Profile of Mood States-Brief and the Mental and Physical State Energy and Fatigue Scales, and changes in sleep quality, measured by the Pittsburgh Sleep Quality Index were not significantly different (p > 0.05) in quercetin and placebo groups. CONCLUSION: Six weeks of quercetin supplementation in young persons conducting military physical training does not influence energy, fatigue, or sleep quality.

Medical Education Transformation: Lifestyle Medicine in Undergraduate and Graduate Medical Education, Fellowship, and Continuing Medical Education.

A gaping void of adequate lifestyle medicine (LM) training exists across the medical education continuum. The American College of Lifestyle Medicine's (ACLM's) undergraduate medical education (UME) Task Force champions the need for widespread integration of LM curriculum in UME by sharing ideas for catalyzing success, lessons learned, and publishing standards and competencies to facilitate curriculum reform. When it comes to graduate medical education and fellowship, the ACLM and American Board of Lifestyle Medicine have made great strides in filling the void, developing both Educational and Experiential Pathways through which physicians may become certified LM Physicians or LM Specialists (LMSs). The Lifestyle Medicine Residency Curriculum meets the Educational Pathway requirements and prepares resident graduates for the LM Physician board certification. LMS is the second tier of LM certification that demonstrates expertise in disease reversal. The LMS Fellowship is an Educational Pathway intent on American Board of Medical Specialties recognition of LM as a new subspecialty in the near future. Finally, continuing medical education and maintenance of certification equip physicians with LM training to support knowledge, application, and certification in LM.

Exercise Counseling in Pregnancy: Do Women Perceive Receiving the Information They Need?

The American College of Obstetricians and Gynecologists recommends that women exercise throughout pregnancy unless they have a condition-related contraindication. This study's purpose was to determine if pregnant women perceive receiving exercise counseling by their providers with details of frequency, intensity, type, and time (FITT principle). Women in 2 postpartum care units of a large health care system were invited to complete a voluntary, anonymous survey regarding whether they received exercise counseling during their prenatal care. Survey results were descriptively reported, stratified by demographic variables, and analyzed using Fisher's exact tests. Of 224 postpartum women surveyed, 130 (58.0%) perceived receiving exercise counseling during pregnancy; 119 (91.5%) did not recall receiving counseling on exercise frequency. Though 165 (73.6%) exercised before becoming pregnant, 64 (38.8%) ceased exercise during pregnancy. Eighty-eight (39.3%) received advice from other sources/non-health care professionals. Privately insured women reported receiving exercise counseling at a higher rate (70.1%) than those on Medicaid (44.8%) or uninsured (40.0%; P = .004). A disproportionate number of pregnant women perceived not receiving adequate prenatal exercise counseling or received incomplete counseling. Women at a socioeconomic disadvantage may be vulnerable. As social determinants of health, structural barriers, and socioeconomic status likely contribute, women may benefit from more targeted inclusive and equitable messaging.

Undergraduate Medical Education: Lifestyle Medicine Curriculum Implementation Standards.

Lifestyle medicine (LM) is an emerging specialty that is gaining momentum and support from around the world. The American Medical Association passed a resolution to support incorporating LM curricula in medical schools in 2017. Since then, the American College of Lifestyle Medicine Undergraduate Medical Education Task Force has created a framework for incorporating LM into medical school curricula. This article provides competencies for medical school LM curriculum implementation and illustrates how they relate to the Association of American Medical College's Core Entrustable Professional Activities and the LM Certification Competencies from the American Board of Lifestyle Medicine. Finally, standards are presented for how medical schools may receive certification for integrating LM into their curriculum and how medical students can work toward becoming board certified in LM through an educational pathway.

Effects of six weeks of quercetin supplementation on physical performance in ROTC cadets.

OBJECTIVE: To investigate the effects of 6 weeks of quercetin supplementation on physical performance during military physical training. METHODS: Using a randomized, double-blind, repeated-measures, placebo-controlled design, 58 healthy, moderately trained men and women were randomly assigned to quercetin (Q) or placebo (P) groups. Peak oxygen uptake (VO(2peak)) during maximal effort uphill treadmill running and four physical performance measures (Army Physical Fitness Test, [APFT], Baumgartner Modified Pull-Up Test [BMPU], Wingate Anaerobic Test [WanT], and a 36.6-m sprint) were evaluated before and after 42-54 days of supplementation with 1 g/d of quercetin with vitamins and other substances in a soft chew or placebo chew. RESULTS: Pretreatment-to-posttreatment changes in VO(2peak) and physical performance were not significantly different (p > 0.05) in Q and P. CONCLUSIONS: Six weeks of dietary quercetin supplementation in moderately trained individuals conducting military physical training did not improve VO(2peak) or performance on the APFT, BMPU, WAnT, and 36.6-m sprint.

Exercise Is Medicine.

There is overwhelming evidence in the scientific and medical literature that physical inactivity is a major public health problem with a wide array of harmful effects. Over 50% of health status can be attributed to unhealthy behaviors with smoking, diet, and physical inactivity as the main contributors. Exercise has been used in both the treatment and prevention of a variety of chronic conditions such as heart disease, pulmonary disease, diabetes, and obesity. While the negative effects of physical inactivity are widely known, there is a gap between what physicians tell their patients and exercise compliance. Exercise is Medicine was established in 2007 by the American College of Sports Medicine to inform and educate physicians and other health care providers about exercise as well as bridge the widening gap between health care and health fitness. Physicians have many competing demands at the point of care, which often translates into limited time spent counseling patients. The consistent message from all health care providers to their patients should be to start or to continue a regular exercise program. Exercise is Medicine is a solution that enables physicians to support their patients in implementing exercise as part of their disease prevention and treatment strategies.

Effect of intensity of resistance exercise on postprandial lipemia.

The purpose of this study is to determine whether moderate-intensity resistance exercise (MOD) lowers postprandial lipemia (PPL) as much as high-intensity resistance exercise (HI) of equal work. Ten healthy men performed three trials, each conducted over 2 days. On day 1 of each treatment, they either did not exercise (CON), performed 3 sets of 16 repetitions of 10 exercises at 50% of 8 repetitions maximum (MOD), or performed 3 sets of 8 repetitions of 10 exercises at 100% of 8 repetitions maximum (HI). On the morning of day 2 at 15.5 h postexercise, participants ate a high-fat meal. Venous blood samples were collected, and metabolic rate was measured at rest and 3 h postprandial. HI reduced fasting triglyceride (TG) and TG area under the curve (AUC) (36%, P = 0.011 and 35%, P = 0.014) compared with CON. MOD tended to reduce fasting TG and TG AUC (21%, P = 0.054 and 26%, P = 0.052) compared with CON, but MOD and HI did not differ in fasting TG or TG AUC. Incremental TG AUC did not differ among treatments. MOD and HI did not change resting metabolic rate. HI increased fat oxidation at rest (21%, P = 0.021) and at 3 h postprandial (39%, P = 0.009) relative to CON. MOD tended to increase fat oxidation at rest (18%, P = 0.060) relative to CON. Fat oxidation and metabolic rate did not differ in MOD and HI. MOD and HI increased the fasting quantitative insulin-sensitivity check index (4%, P = 0.001 and P = 0.004) relative to CON. As MOD and HI resulted in similar reductions in PPL and increases in fat oxidation, resistance exercise intensity does not influence PPL.

Including Lifestyle Medicine in Medical Education: Rationale for American College of Preventive Medicine/American Medical Association Resolution 959.

Introduced by the American College of Preventive Medicine and released by the American Medical Association House of Delegates in 2017, Resolution 959 (I-17) supports policies and mechanisms that incentivize and/or provide funding for the inclusion of lifestyle medicine education and social determinants of health in undergraduate, graduate and continuing medical education. Resolution 959 was passed to help address the current healthcare costs of lifestyle-related, noncommunicable chronic diseases that exert a devastating economic burden on the U.S. healthcare system. Approximately 86% of $2.9 trillion is spent annually on obesity, cardiovascular disease, type 2 diabetes, and some cancers, with very poor return on investment for health outcomes. Lifestyle medicine provides an evidence-based solution to the noncommunicable chronic disease epidemic; however, medical education in lifestyle medicine is minimal to nonexistent. This paper provides the case for healthcare innovation to include lifestyle medicine in the prevention and treatment of noncommunicable chronic diseases. Our medical education system recommendation is to provide lifestyle medicine training for prevention and treatment of noncommunicable chronic diseases. Exemplar lifestyle medicine schools are showcased and guidance for reform is highlighted that can be used to aid lifestyle medicine integration across the medical school education continuum. With a transformation of curriculum and development of new policies to support a focus on lifestyle medicine education in medical education across the continuum, a new healthcare model could be successful against noncommunicable chronic diseases and U.S. citizen wellness could become a reality.

Design and Implementation of a Lifestyle Medicine Curriculum in Undergraduate Medical Education.

While scientific evidence demonstrates conclusive associations between unhealthy lifestyle behaviors and increased morbidity and mortality related to noncommunicable chronic diseases (NCDs), most physicians are not formally taught the root causes of NCDs nor how to counsel patients regarding their lifestyle behaviors for disease prevention and treatment. Since its inception in 2012, the University of South Carolina School of Medicine Greenville has designed, developed, and implemented an innovative, formalized lifestyle medicine curriculum to provide required undergraduate medical student training with a graduating program-level goal to "Deliver total health care using lifestyle medicine to prevent and treat morbidity and mortality related to chronic diseases." The process was guided by the Association of American Medical Colleges' Core Entrustable Professional Activities (required for graduates entering residency) and aimed to satisfy the Quadruple Aim components of better outcomes, lower cost, improved patient experience, and improved physician experience. Four essential instructional design phases, Analysis, Design, Development, and Evaluation, were used as systematic steps to create and deploy the curriculum. This article describes the evidence-based approach used and offers guidance to other undergraduate medical schools that may wish to implement lifestyle medicine training to improve physicians' medical knowledge and clinical skills for optimum health care.

Advancing Nutrition Education, Training, and Research for Medical Students, Residents, Fellows, Attending Physicians, and Other Clinicians: Building Competencies and Interdisciplinary Coordination.

Nutrition plays an important role in health promotion and disease prevention and treatment across the lifespan. Physicians and other healthcare professionals are expected to counsel patients about nutrition, but recent surveys report minimal to no improvements in medical nutrition education in US medical schools. A workshop sponsored by the National Heart, Lung, and Blood Institute addressed this gap in knowledge by convening experts in clinical and academic health professional schools. Representatives from the National Board of Medical Examiners, the Accreditation Council for Graduate Medical Education, the Liaison Committee on Medical Education, and the American Society for Nutrition provided relevant presentations. Reported is an overview of lessons learned from nutrition education efforts in medical schools and health professional schools including interprofessional domains and competency-based nutrition education. Proposed is a framework for coordinating activities of various entities using a public-private partnership platform. Recommendations for nutrition research and accreditation are provided.