The largest scale pilot to date of teaching EIM to practising physicians across 17 Latin American countries

– Written by Carolina Paez, Vanessa Collazos and John Duperly, Colombia and Felipe Lobelo, USA

The Exercise is Medicine® (EIM) global initiative was launched in 2007 in response to a global call to promote physical activity (PA) and combat the growing levels of sedentary behaviour. Physical inactivity is responsible for about 5 million deaths worldwide or 9% of the total global premature mortality due to major non-communicable diseases (NCDs)¹. Accordingly, international agencies like the World Health Organization (WHO), the United Nations and the World Economic Forum, together with the Centers for Disease Control and Prevention (CDC) have vouched for promoting PA as a major global strategy to halt the rising health burden and costs associated with NCDs^2-5.

EIM was designed by the American College of Sports Medicine (ACSM) to promote PA at different societal levels, with a special emphasis in healthcare settings. EIM invites physicians and other healthcare professionals (HCPs) to include PA as a vital sign in every patient visit and to deliver effective and personalised PA counselling and prescription⁶. EIM’s organisational structure consists of a Global Center, seven EIM Regional Centers (North America, Latin America, Europe, Africa, Southeast Asia, China, Russia and Australasia) and several National Centers (NCs) within each region⁷.

EIM IN LATIN AMERICA

In 2009, the Colombian National Center (EIM Colombia) introduced the EIM initiative to foster local schemes that promote PA. The official launch was held a year later at the XXII Colombian Congress of Cardiology and Cardiovascular Surgery, gathering a network of local and international leaders eager to promote PA throughout Latin America. Among the participants were the government’s health and research authorities (Ministry of Health, Colciencias), a leading academic institution (Los Andes University), scientific associations (Colombian Association of Medical Schools – ASCOFAME), Colombian Society of Cardiology and Cardiovascular Surgery, private industry (The Coca-Cola Company, International Life Sciences Institute, Polar, AstraZeneca), media representatives, PA experts and civil servants.

The WHO recommends that strategies for the promotion of PA should be multi-sectorial and multi-disciplinary to enhance its impact in society⁸. Accordingly, EIM Colombia invited representatives from five sectors (scientific associations, academia, the public sector, private industry and the media) to embody the NC committee. In 2013, the EIM Regional Center for Latin America (EIM Latam) was established with the support of academic leaders from the region who accepted the challenge to replicate this structure and create NCs in their respective nations (Figure 1).

EIM Latam initially placed great emphasis on continuing medical and HCPs education, among other strategies. Healthcare settings constitute a key scenario for PA promotion because the available resources and workforce facilitate the delivery of effective PA counselling and interventions for individuals of a variety of health statuses⁶. This paper describes the details and impact of the Exercise Prescription course, a continuing education programme with a multi-sectorial structure, implemented in 17 Latin American countries (Argentina, Aruba, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Mexico, Nicaragua, Paraguay, Peru, the Dominican Republic, Uruguay and Venezuela).

THE EXERCISE PRESCRIPTION COURSE

The Exercise Prescription course (EPc) aims to provide continuing exercise education tailored to physicians and other HCPs, delivering the fundamentals of exercise prescription and encouraging participants to be role models and become active themselves (Figure 2). The course is delivered as an in-person, 1-day (8 hours) workshop, with both lectures and practical sessions. This original structure has remained mostly unchanged since its creation, with only some details being optimised to offer a transformative personal experience rather than just an ordinary academic update (Table 1).

EIM Latam uses the ‘train the trainer’ model, targeting practicing physicians (general practitioners, primary care physicians and sub-specialists) who are key actors in the promotion of PA and healthy behaviours⁹. For instance, Colombia has twice as many doctors as nurses, and patient care in the region is mainly based on physicians’ criteria and management¹⁰. Hence, doctors are in a unique position to positively lead PA promotion strategies in society and healthcare settings¹¹. Other HCPs – such as nurses, nutritionists, physical therapists and psychologists, among others, have an important role within the strategies aimed at increasing patients’ PA levels. Therefore, other HCPs have been invited to participate in the physicians’ course, strengthening the referral system aligned with EIM Latam and the EIM global solution. Also, their feedback has been crucial to the improvement of the programme.

The EPc has been structured to create a personal experience from beginning to end. The purpose is to avoid boredom and keep the mind and body active throughout the day, maximising participation and strengthening the learning process. Its overall structure is distributed as follows: the morning block includes the first two lectures with a short break between them and a fitness assessment workshop. At lunchtime, participants are invited to enjoy a carefully selected meal during an interactive nutrition workshop. The afternoon block includes the third lecture, the final exam and a Q&A and networking session.

Registration, introduction and initial exam

First, EPc staff welcome and register participants as they arrive from 7.00 am, handing them printed materials and a CD containing resources and references used during the lectures. Then, the course co-ordinator briefly explains the programme and activities that will take place during the day, the first of which is the pre-course exam used only to establish a baseline of participants’ knowledge in exercise prescription.

After the exam, physicians are asked to fill out a brief validated self-reported survey regarding demographics, health status, PA habits (short version of the International PA Questionnaire), frequency of assessing and prescribing PA to their patients and self-efficacy related to PA practices. Then, all participants are asked to choose a partner to role-play doctor and patient interchangeably throughout the activities, so that by the end of the course, each participant will assess, test and give an exercise prescription to his or her colleague.

First lecture: health benefits and risks associated with PA

A historical approach is taken to review the evidence behind the physiological benefits of PA, the risks associated with different intensities of exercise and the role of PA as a strategy to prevent and manage disease. At this time, the speaker invites participants to identify the specific benefits that they and their patient (partner) can get from engaging in regular PA. After the lecture, participants take a break to have a healthy snack and each pair is provided with a heart rate monitor (Polar®) and a set of instruments to be used during the fitness assessment workshop.

Second lecture: screening and risk stratification

Different cardiovascular and fitness screening methods are presented here, from easy-to-use international questionnaires to more sophisticated scales and tests. Physicians learn how to establish a baseline of the patient’s current fitness level and identify risk factors for cardiovascular events during exercise, among other potential health issues (musculoskeletal injuries). The speaker also introduces motivation and readiness to change assessment tools. Participants are asked to make an assessment of their patient’s (partner) cardiovascular risk level and readiness to change status using the questionnaires and scales provided.

Health and fitness assessment workshop

The goal of this activity is to allow participants apply the health and fitness assessment tools by performing each other’s fitness evaluation. The workshop includes objective measurement of health and metabolic indicators (blood pressure, resting heart rate and blood glucose); body composition indicators (body weight, height, body fat percentage and abdominal circumference); and fitness components such as cardiorespiratory fitness level (6-Minute Walk test), core and upper body strength (abdominals and push-up tests, and a handgrip dynamometer) and flexibility (modified version of the sit and reach test). Trained staff are placed at different measurement stations to assist participants during the activity.

Nutrition workshop

Good nutrition is essential to health maintenance, adequate body performance and recovery from exercise. Thus, the course includes a dynamic nutrition workshop in which participants enjoy a three-course meal (entrée, main course and dessert) carefully selected by the nutritionist leading the activity. The nutritionist challenges participants to calculate the calories of each element of the meal and moderates a conversation around the common issues, myths and questions around the strategies to improve nutrition habits.

Third lecture: general principles of exercise prescription

The FITT principles of exercise prescription are the axis of this lecture. The speaker gives practical recommendations for exercise progression, hydration, physical recovery and injury prevention. According to the region, culturally adapted and relevant strategies are proposed to facilitate the adoption of exercise. At this point, participants complete the exercise prescription for their patient according to the previous health and fitness assessment.

Final exam

Participants take the individual, written, multiple-choice final exam and only those who score 80% or higher obtain the EIM/ACSM certification in Exercise Prescription. Currently, only physicians can get the prescription certification, whereas other HCPs are given a certificate of participation.

Q&A, networking session and certificate ceremony

As the exam is scored, a Q&A session is held to address the course contents or clinical practice issues. Also, representatives from local community programmes on PA, private industry (gyms, fitness technology, etc.), media and academia are introduced to the audience to encourage local collaboration (referral system). Also, participants are asked to anonymously complete a satisfaction survey, which contains items on the lectures, the speakers, the applicability and utility of theoretical and practical components, and general logistics. Finally, each participant is awarded with either the EIM/ACSM Exercise Prescription Certification or the certificate of participation.

A MULTI-SECTORIAL CONTINUING EDUCATION PROGRAMME

The EPc has evolved to become a multi-sectorial collaboration between five sectors (the public sector, academia, scientific societies, private industry and the media) to strengthen PA promotion strategies in the healthcare system and the community. EIM Latam has worked across the region to facilitate local and international collaborations to provide sustainability to the programme in each country. Initially, EIM Latam allocated resources to deliver the first course in each country, but every NC was thereafter responsible for creating and maintaining collaborations that would keep supporting the execution of the course in their area. For this reason, the institutions, companies and programmes that support and collaborate with the EPc can vary from country to country, some examples can be found in the EIM Latam Report of Activities 2010-2013¹².

Public sector

Integrating primary care services with local, community-based PA programmes is a main goal of the EIM initiative. Therefore, EIM Latam invites representatives of national and local PA programmes to join the course to facilitate networking between them and participants. In Colombia, for example, the National Programme of Healthy Lifestyles and Habits (HEVS, in Spanish) has been a constant support, strengthening the referral system between practitioners and local PA promotion programmes. Some of their staff also support the execution of the fitness assessment workshop. Finally, HEVS representatives explain how the programmes work and how patients can access them, which serves as an important guide to physicians that work with communities of middle- to low-socioeconomic status that often lack access to PA facilities and programmes.

Private industry

Sponsorship and financial support are the main channels of collaboration with private industry. The course fee is around $150 USD per participant, including materials and lunch, but the alliance with private industry allows the EIM team to deliver the course at no cost for participants, facilitating access for physicians regardless of their socioeconomic status. More than one company or institution can sponsor a single course at a time. Some of the companies that have supported the implementation of the course in the region are: The Coca-Cola Company, International Life Sciences Institute, Polar, AstraZeneca, Merck Sharp & Dohme, Novo Nordisk and Abbott Laboratories. The financial support received by a company is entirely assigned to the execution of each sponsored course, covering costs from venues and meals, to educational materials, registration processes and speaker fees, among other costs specific to individual events. On the other hand, private industries also collaborate by facilitating essential material and tools for the fitness assessment workshop (heart rate monitors, exercise mats etc.) and by supporting different activities with their own staff (physical trainers).

Academia

The support of academic institutions has been a cornerstone for the development and execution of the course in Latin America. For example, Los Andes University nested the EIM initiative from the very beginning and was an important platform for the pilot versions of the EPc. Likewise, research projects such as Healthy Doc – Healthy Patient in Colombia served as introduction channels for EIM into the local and regional academic community. Other important universities have promoted the EPc and EIM activities and many others have adapted the resources and guidelines to their own health-related curriculum, broadening the impact of EIM in the region. Academic endorsement of the EIM initiative is important in Latin America because it enhances the programme’s legitimacy, increasing trust and openness from society and the different sectors involved.

Besides scholarly endorsement, academic institutions also support different processes of the course, like facilitating the call to participation, sponsoring staff enrolment, facilitating venues to deliver the course and providing content updates to the course lectures that are relevant and culturally appropriate.

Scientific associations

Much of the massive participation of physicians is achieved in collaboration with national and international scientific associations. The pre-course registration is enhanced when physicians receive an invitation through the representatives or communication channels of these associations due to the pre-established relationship. Additionally, scientific associations can sponsor an entire course for its members, which entails a higher commitment from their part to guarantee a ‘full house’ and cover all or most of the associated costs.

Additionally, scientific associations organise national and international conferences to which EIM Latam has been invited to give keynotes and lectures on the work of EIM in the region, as well as the benefits of PA and its role in primary care settings. Some scientific associations have included the EPc as a full day or shorter version pre-conference workshop. These venues serve as a platform to reach a bigger audience and to create a database of those interested in future local EIM activities.

Media

Raising public awareness about the benefits of PA is key to complement the strategies implemented within the healthcare community. Media coverage of EIM activities can enable patients to start a conversation about PA with their doctors and encourage other institutions and companies to join the growing network of stakeholders that support promotion of PA in the region.

Media involvement can be grouped into traditional media coverage and the social media phenomenon. Media agencies, newspapers and even TV channels have interviewed EIM leaders and covered various EIM activities, including local implementation of the EPc. Some EIM NCs have created their own social media profiles to promote direct conversations with their audiences, encourage sharing of experiences, research projects or local activities and promote an online community for professionals and institutions interested in the promotion of PA. Platforms like Twitter, Flickr, Youtube and Facebook have been key elements in documenting and creating a visual history of EIM Latam’s activities (https://youtu.be/h3sblXWpFDU; https://www.flickr.com/photos/johnduperly/albums).

EIM LATAM SCALED UP

The leadership of the Regional Center’s Director, the programme’s Co-ordinator and the NCs frame the successful advancement of EIM Latam. The Regional Center held periodic meetings (at least annually) with NCs to support and follow-up the programme’s development in the region. The 1st EIM Latam meeting took place during the 4th World Congress on EIM and the 60th Annual Meeting of the American College of Sports Medicine in May 2013, in Indianapolis, USA. The 2nd EIM Latam meeting was held during the VIII Conference of the Latin American Society of Internal Medicine (SOLAMI) and the XII Internal Medicine Conference of Paraguay in August 2013, in Asunción, Paraguay. The 3rd EIM Latam meeting and the first training workshop for speakers was held in Bogotá, Colombia at the beginning of 2014. At this special meeting the most important leaders in the region shared their experiences implementing EIM in their countries, addressing the factors that either facilitated or limited it. The 4th, 5th and 6th EIM Latam meetings were held in May 2014, May 2015 and May 2016 during the World Congresses on EIM and the Annual Meetings of the ACSM in the USA (Orlando, San Diego and Boston, respectively).

New needs arise: more speakers and more courses for the region

The successful implementation of the EPc in Colombia favoured the demand of the course in the region. As the EIM Latam team worked to deliver the course in more than one place at a time, it was evident that a bigger network of speakers and leaders was needed in the region to ensure that the programme grew while maintaining high standards.

Following the ‘train the trainer’ model, the first speakers’ training workshop was launched at the 3rd EIM Latam meeting, held in Bogotá. Two representatives of each Latin American country and major cities of Colombia (mostly physicians and academics specialised in internal medicine and sports medicine) were invited to receive training as future speakers for the EPc. These leaders were chosen for their high academic level, their professional recognition in their country and their experience in promoting exercise. Additionally, participation in at least two EPc and holding the EIM/ACSM Exercise Prescription certificate were prerequisites to qualify for the speakers’ training workshop. The training was based on the EPc manual of procedures, a document containing detailed instructions to effectively accomplish the academic and logistic standards of the course (Appendix 1, available in the PDF version of this paper at www.aspetar.com/journal).

In total, 31 physicians from 15 member countries plus 25 Colombian doctors from 11 cities were accredited by EIM Latam as speakers and replicators of the EPc. Through the training workshop and the regional meeting, EIM Latam sought the standardisation of the courses implemented across the region and allowed for networking between the leaders, strengthening their ties of co-operation.

Permanent assessment of National Centers by EIM Latam

The EIM Latam Co-ordinator played a key role in scaling up EIM in the region between 2013 and 2015. EIM Latam defined the profile and job description for a national or regional Programme Co-ordinator, with a suggested fee of $1,000 USD per month for every NC. The position for the regional and Colombian Co-ordinator was filled by a health professional with postgraduate studies in public health.

The specific tasks of the EIM Latam Co-ordinator included:

• Support the launch of NC.
• Standardise the EPc processes.
• Provide follow-up of activities implemented by each NC.

The Co-ordinator provided face-to-face support during the first year of operation, mainly focusing on the EIM Latam manual of procedures, including monitoring the planning and execution of the course, the execution of logistical-academic (application of questionnaires and exams) and logistical-administrative (venue, materials etc.) items and the subsequent collection and registry of data. The EIM Latam Co-ordinator also validated and registered, in physical and electronic format, the activities implemented by each country.

EIM LATAM INDICATORS

Course coverage and participants

Between 2011 and 2015, 140 courses were delivered in 42 cities in 13 Latin American countries. In total, 4854 physicians and other HCPs were trained (Table 2). Table 3 and Table 4 illustrate the distribution of physicians’ specialties and other HCPs profiles represented on these courses.

Physicians’ demographic characteristics

A recent EIM Latam study reported characteristics of a subsample (n=1044) of the courses implemented in Latin America between 2014 and 2015¹³. According to the study, participants were 50.3% female and the mean age was 40 years (40.5 ± 10.7). Only 31% of physicians complied with both aerobic and resistance PA recommendations for health and 51% of participants were either overweight or obese (body mass index >25 kg/m²). Regarding clinical practice, 78% of doctors reported to evaluate their patient’s PA levels and 84% to provide counselling. Moreover, more than 90% of doctors agreed with the statements “physicians are responsible for promoting adequate PA levels” and “I will be able to provide more credible and effective counselling if I stay fit”. Agreement with the statement “I am effective in helping my patients to be physically active” was somewhat lower at 73%.

Short-term impact on participants’ knowledge

The same study evaluated the knowledge gained by course participants, showing a significant improvement in the final exam score (from 67% in pre-course exam to 82% in final exam; p <0.001). Primary care practitioners such as family medicine and internal medicine specialists showed the most improvement. Factors such as following PA recommendations and male gender were associated with a higher score in the pre-course exam and factors such as low perception of health and age >40 years were associated with lower score in the final exam when adjusted by specialty.

Satisfaction of the course and evaluation of speakers

Table 5 details the results of the satisfaction survey using a 5-point Likert-scale. Overall, most participants were highly satisfied with the logistics and the academic and practical components of the course. The satisfaction levels increased annually even during critical periods of time, such as when each NC started to independently deliver courses (2011 to 2012) and when EIM Latam was scaled up (2013 to 2014). Participants also evaluated the speakers’ performance with high scores (Table 6). Overall, speakers’ characteristics were graded 4.8 or higher in 2014 and 2015.

CHALLENGES FOR THE FUTURE

Sustainability

The EPc is a high-quality continuing education programme that has been highly rated by participants across the region. However, EIM Latam and each NC faces a sustainability issue regarding the capacity of hiring a Programme Co-ordinator and the continuous implementation of the course as it is structured, without losing the high standards achieved so far.

Until now, the collaboration with different sponsors has allowed EIM Latam to offer the course at no cost for participants. However, it is difficult for EIM leaders to ensure funding as political, commercial and scientific interests change over time. Lack of sufficient sponsorship and funding threatens the sustainability of the course and the alternative of charging a course fee can become an important financial barrier, limiting the range of HCPs that EIM Latam will be able to reach.

Internet-based version

EIM leaders from the Global Center and Regional Centers, as well as many participants, have suggested that the course is adapted to an online version in order to facilitate its delivery to a broader audience at a lower cost. Internet-based models are gaining increased popularity among medical education programmes, but a low-cost online course can hardly replicate the in-person experience that the EPc provides. The entire design of the current course aims at transforming the lives and views of every participant, giving them the opportunity practice and learn with the best speakers in the region. Similarly, the networking between local PA programmes, institutions, companies and HCPs is enhanced through the personal interaction between participants and EIM supporting partners.

Exercise prescription course for other HCPs

Representatives from other HCPs associations such as nurses, physical therapists, nutritionists, among others, have asked for adapted versions of the EPc for their professional community. The EIM Latam team is challenged to allocate human and financial resources to develop these. Leaders from the other HCP communities are constantly invited to collaborate with the Regional Center, help shape the proposals and find funding options.

CONCLUSION

The Exercise Prescription course is a multi-sectorial strategy to promote PA counselling and prescription in primary healthcare settings. The course has been widely accepted and highly rated by participants and healthcare leaders in the region. Its success can be attributed to the collaborative work between representatives from five sectors across the region: academia, scientific societies, the public sector, private industry and the media. Participants don’t just gain basic knowledge and skills in exercise assessment and prescription, but also join a growing network of professionals and institutions that want to promote the benefits of PA in disease prevention and management. However, sustainability challenges and scaling capacity need to be addressed for the benefit of the healthcare community and their patients.

Carolina Paez F.T.Esp., M.P.H.

Research Associate

School of Medicine, Universidad de los Andes

Bogotá, Colombia

Vanessa Collazos M.D.

Clerkship Co-ordinator - Lecturer Medicine

School of Health Sciences

Pontificia Universidad Javeriana Cali

Cali, Colombia

John Duperly M.D., Ph.D.

Associate Professor

School of Medicine

Universidad de los Andes

Bogotá, Colombia

Director, Institute of Exercise Medicine

Fundación Santa Fe de Bogotá

Bogotá, Colombia

Felipe Lobelo, M.D., Ph.D., F.A.H.A.
Associate Professor, Hubert Department of Global Health
Director, Exercise is Medicine Global Research and Collaboration Center
Rollins School of Public Health, Emory University

Atlanta, USA

Contact: john.duperly@ama.com.co

References

1. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. The Lancet 2012; 380:219-229.
2. World Economic Forum. Charter for Healthy Living. Geneva: World Economic Forum 2013. Available from: http://www3.weforum.org/docs/WEF_HE_HealthyLiving_Charter_2013.pdf [Accessed February 2017].
3. World Health Organization. Physical Inactivity: A Global Public Health Problem. Available from: http://who.int/dietphysicalactivity/factsheet_inactivity/en/ [Accessed February 2017].
4. UNESCO. Revised International Charter of Physical Education, Physical Activity and Sport 2015. Available from: http://portal.unesco.org/en/ev.php-URL_ID=13150&URL_DO=DO_TOPIC&URL_SECTION=201.html [Accessed February 2017].
5. US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington DC: USDHHS; 2008. Availible from: https://health.gov/paguidelines/guidelines/ [Accessed February 2017].
6. Lobelo F, Steinacker JM, Duperly J, Hutber A. Physical activity promotion in health care settings: the "Exercise is Medicine" Global Health Initiative perspective. Schweiz Z Med Traumatol 2014; 62:42-45.
7. Lobelo F, Stoutenberg M, Hutber A. The Exercise is Medicine Global Health Initiative: a 2014 update. Br J Sports Med 2014; 48:1627-1633.
8. World Health Organization. 2008-2013 Action plan for the global strategy for the prevention and control of noncommunicable diseases. Geneva: World Health Organization 2009. Available from: http://apps.who.int/iris/bitstream/10665/44009/ 1/9789241597418_eng.pdf [Accessed February 2017].
9. Orfaly RA, Frances JC, Campbell P, Whittemore B, Joly B, Koh H. Train-the-trainer as an educational model in public health preparedness. J Public Health Manag Pract 2005: Suppl:S123-127.
10. Ministerio de Salud y Protección Social. [Density of human resources in health in Colombia 2011]. Available from: https://www.minsalud.gov.co/salud/Documents/Observatorio%20Talento%20Humano%20en%20Salud/Estad%C3%ADsticas%20b%C3%A1sicas%20sobre%20el%20programa%20de%20becas%20cr%C3%A9dito%20y%20la%20densidad%20de%20THS.pdf. [Accessed February 2017].
11. Duperly J, Collazos V, Paez C, Donado C, Pratt M, Lobelo F. “Exercise is Medicine” in Latin America: training health care professionals in physical activity prescription. Schweiz Z Med Traumatol2014; 62:38-41.
12. Duperly J, Donado C, Páez C. Exercise is Medicine, Centro Regional para América Latina. In: Collazos V, ed. Reporte de Actividades 2010-2013, 1st ed. Bogotá, Colombia: Exercise Is Medicine Latin America 2013.
13. Arciniegas Calle MC, Lobelo F, Jimenez MA, Paez DC, Cortes S, de Lima A et al. One-day workshop-based training improves physical activity prescription knowledge in Latin American physicians: a pre-test post-test study. BMC Public Health 2016; 16:1224.