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.

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.

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.

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.

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.

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.

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.

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.

Lifestyle Medicine Education Collaborative (LMEd): "Champions of Change" Medical School Leaders Workshop.

The Lifestyle Medicine Education Collaborative (LMEd) hosted the "Champions of Change" Medical School Leaders workshop at the 2017 American College of Lifestyle Medicine annual conference. Presentations focused on the following: (1) accelerating adoption and implementation of lifestyle medicine (LM) education in medical schools through collaboration and action networks that produce positive results, (2) showcasing medical school champions and their work in LM education leadership, and (3) helping participants create a roadmap for how to engage with LMEd and implement LM education in their own medical school.

Advancing Lifestyle Medicine Education in Undergraduate Medical School Curricula Through the Lifestyle Medicine Education Collaborative (LMEd).

Physicians are uniquely positioned to stem the tide of the world's top lifestyle-related diseases; however, most are not trained to provide effective patient care. The Lifestyle Medicine Education Collaborative (LMEd) has a plan that is a comprehensive and sustainable approach to policies, programs, and initiatives to increase graduating US medical students' knowledge and application of lifestyle medicine. LMEd's strategic plan is to (1) provide high-quality curricular material; (2) solicit support of medical school deans, critical administration, and faculty; (3) influence federal and state policy; (4) develop and conduct assessment; and (5) support medical students as lifestyle medicine champions. Accomplishments to date include (1) collaboration with Association of American Medical Colleges' MedEdPORTAL for the curation of a LM Collection; (2) creation of a network of >350 members, 80 medical schools including 33 hospitals/clinics; 1:1 mentoring sessions >70 medical school faculty/administration; and (4) establishment of a relationship with the National Board of Medical Examiner's Customized Assessment Services to create a subject test in lifestyle medicine. National awareness is being increased through webinars and hosting the first-annual LMEd Summit in October 2016. LMEd strives to alter the health care landscape by enhancing physician competency in lifestyle-related disease and value-based care and affecting the health of populations.

Advancing health promotion through massage therapy practice: A cross-sectional survey study.

The human resources needed to provide health promotion services to improve health behaviors in populations are currently limited. Health promotion and education is included in the definition of massage therapy, and many within the massage therapy profession understand that health promotion and education are a part of massage therapy practice. However, the amounts and types of health promotion activities in massage therapy practice have not been thoroughly explored. The objective of this study was to investigate the current attitudes, practices, and barriers toward providing health promotion in a national sample of practicing massage therapists. A descriptive cross-sectional survey disseminated May to August 2016 to practicing massage therapists in the United States. The majority (90.2%) of the 182 participants agree or strongly agree that it is important for massage therapists to provide health promotion. Therapists with less favorable attitudes about providing health promotion reported more barriers to providing the messages to their patients. Barriers to providing health promotion included a lack of guidelines, knowledge, and skills. Training and guidelines for massage therapists regarding health promotion would be a reasonable next step for future research development. Utilizing massage therapists as health promoters may provide opportunities to deliver more prevention messages to patients which may impact public health.

'Recover quicker, train harder, and increase flexibility': massage therapy for elite paracyclists, a mixed-methods study.

OBJECTIVES: Massage therapy (MT) enhances recovery by reducing pain and fatigue in able-bodied endurance athletes. In athletes with disabilities, no studies have examined similar MT outcomes, yet participation in sport has increased by >1000 athletes from 1996 to 2016 Olympic games. We examined the effect of MT on pain, sleep, stress, function and performance goals on the bike, as well as quality of life off the bike, in elite paracycling athletes. METHODS: This is a quasi-experimental, convergent, parallel, mixed-methods design study of one team, with nine paracycling participants, in years 2015 and 2016. One-hour MT sessions were scheduled one time per week for 4 weeks, and then every other week for the duration of the time the athlete was on the team and/or in the study. Closed and open-ended survey questions investigating athlete goals, stress, sleep, pain and muscle tightness were gathered pre and post each MT session, and every 6 months for health-related quality of life. Quantitative analysis timepoints include baseline, 4-6 months of intervention and final visit. Additional qualitative data were derived from therapists' treatment notes, exit surveys, and follow-up emails from the athletes and therapists. RESULTS: Significant improvement was found for sleep and muscle tightness; quantitative results were reinforced by athlete comments indicating MT assisted in their recovery while in training. There were no improvements in dimensions measuring quality of life; qualitative comments from athletes suggest reasons for lack of improvement. CONCLUSION: This real-world study provides new information to support MT for recovery in elite paracyclists.

Cardiac Structure and Function in Elite Para-cyclists with Spinal Cord Injury.

PURPOSE: We sought to explore the association between the spinal cord injury (SCI) level on the cardiac structure and the function observed in elite para-cyclists. METHODS: Cross-sectional echocardiographic data from 44 elite SCI hand cyclists (39.8 ± 9 yr, 68% male/32% female) stratified by the level of SCI (cervical, N = 9; T1-T5, N = 10; below T5, N = 25) and 19 non-SCI blind/visually impaired (BVI) tandem cyclists (32.4 ± 7 yr, 58% male/42% female) were analyzed before the initiation of international competition. RESULTS: Compared with non-SCI BVI cyclists, cervical SCI para-cyclists were observed with lower indexed left ventricular (LV) mass (99.6 ± 12 vs 125 ± 20 g·m, P = 0.01), posterior wall thickness (4.5 ± 0.3 vs 5.8 ± 0.7 mm·m, P < 0.001), interventricular septal wall thickness (4.8 ± 0.5 vs 5.7 ± 0.7 mm·m; P = 0.03), and left atrial volume (21 ± 3.5 vs 28 ± 7 mL·m; P = 0.02). In multivariable analyses, cervical SCI was independently associated with decreased LV wall thickness [interventricular septum (ß = -0.67, P = 0.01), posterior wall (ß = -0.98, P = 0.001)], decreased LV mass (ß = -21, P < 0.001), and decreased left atrial volume index (ß = -6.9, P = 0.001) compared with other levels of SCI and non-SCI BVI cyclists. There were no differences in ventricular function among any of the athlete groups. CONCLUSION: Compared with para-cyclists with lower levels of SCI, the athletes with cervical SCI demonstrate attenuated cardiac size and concentric LV hypertrophy.

Physical activity training in US medical schools: Preparing future physicians to engage in primary prevention.

BACKGROUND: Medical professionals serve as influential sources of information and guidance for their patients. Medical school may be an opportune time to provide future physicians with training in physical activity (PA) so that it can be more effectively addressed in clinical practice. METHODS: To assess the inclusion and amount of PA training in US medical school curricula, we attempted to conduct structured interviews with the program directors of the 171 accredited US medical education programs in the spring of 2013. RESULTS: Seventy-four schools (allopathic, n = 64; osteopathic, n = 10) completed the structured interviews. Fifty-eight programs (78.4%) reported having PA training included as a part of their curriculum. Thirty-five (61.4%) and 25 (43.9%) programs included instruction on national aerobic and strength training guidelines, respectively. Thirty-one programs (56.4%) felt that they offered a sufficient level of PA-related training for their students to successfully counsel their patients in the future. Over the 4 years of medical school, an average of 8.1 (± 9.8) h of mandatory PA training was offered. CONCLUSION: Though many medical schools report providing some level of PA content, the time dedicated for this training is still low in comparison to other topics, such as nutrition education, which are featured more prominently. New and innovative ideas are needed for the integration of more, higher quality PA training for our next generation of medical practitioners.

A Standardized, Evidence-Based Massage Therapy Program for Decentralized Elite Paracyclists: Creating the Model.

BACKGROUND AND PURPOSE: Evidence suggests that para-athletes are injured more often than able-bodied athletes. The benefits of massage therapy for these disabled athletes are yet to be explored. This paper documents the process followed for creating a massage program for elite paracycling athletes with the goal to assess effects on recovery, rest, performance, and quality of life both on and off the bike. SETTING: Massage therapists' private practices throughout the United States. PARTICIPANTS: A United States Paracycling team consisting of 9 elite athletes: 2 spinal cord injury, 2 lower limb amputation, 1 upper limb amputation, 1 transverse myelitis, 1 stroke, 1 traumatic brain injury, and 1 visually impaired. DESIGN: The process used to develop a massage therapy program for para-cyclists included meetings with athletes, coaching staff, team exercise physiologist, and sports massage therapists; peer-reviewed literature was also consulted to address specific health conditions of para-athletes. RESULTS: Team leadership and athletes identified needs for quicker recovery, better rest, and improved performance in elite paracyclists. This information was used to generate a conceptual model for massage protocols, and led to creation of the intake and exit questionnaires to assess patient health status and recovery. Forms also were created for a general health intake, therapist information, and a therapist's SOAAP notes. DISCUSSION: The conceptual model and questionnaires developed herein will help to operationalize an exploratory study investigating the feasibility of implementing a standardized massage therapy program for a decentralized elite paracycling team.

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.

Cardiorespiratory fitness, waist circumference, and alanine aminotransferase in youth.

PURPOSE: Nonalcoholic fatty liver disease (NAFLD) is considered the liver component of the metabolic syndrome and is strongly associated with cardiometabolic diseases. In adults, cardiorespiratory fitness (CRF) is inversely associated with alanine aminotransferase (ALT), a blood biomarker for NAFLD. However, information regarding these associations is scarce for youth. The objective of this study is to examine associations between CRF, waist circumference, and ALT in youth. METHODS: Data were obtained from youth (n = 2844, 12-19 yr) in the National Health and Nutrition Examination Survey 2001-2004. CRF was dichotomized into youth FITNESSGRAM categories of "low" and "adequate" CRF. Logistic and quantile regression were used for a comprehensive analysis of associations, and variables with previously reported associations with ALT were a priori included in the models. RESULTS: Results from logistic regression suggested that youth with low CRF had 1.5 times the odds of having an ALT >30 than youth with adequate CRF, although the association was not statistically significant (P = 0.09). However, quantile regression demonstrated that youth with low CRF had statistically significantly higher ALT (+1.04, +1.05, and +2.57 U·L) at the upper end of the ALT distribution (80th, 85th, and 90th percentiles, respectively) than youth with adequate CRF. For every 1-cm increase in waist circumference, the odds of having an ALT >30 increased by 1.06 (P < 0.001), and the strength of this association increased across the ALT distribution. CONCLUSIONS: Future studies should examine whether interventions to improve CRF can decrease hepatic fat and liver enzyme concentrations in youth with ALT ≥80th percentile or in youth diagnosed with NAFLD.