Physical Inactivity Crisis & the COVID-19 Pandemic: Time is Now to Implement Exercise as Medicine in Medical School Teaching

Nathan McLaughlin, BS1, Trevor Takami, BS1, and Cindy Lin, MD, FASCM1,2,3
1 University of Washington School of Medicine, Seattle, WA 98195, USA
2 Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA 98195, USA
3 The Sports Institute, University of Washington Medical Center, Seattle, WA 98195, USA

ABSTRACT

Although there is robust evidence that physical activity (PA) is integral in preventing and managing chronic diseases, 80% of American adults do not meet the US Physical Activity Guidelines for exercise and 66% of American children are physically inactive every day. Clinicians are critical in assessing and prescribing PA for patients; however, less than half of patients reported being counselled on PA in a 12-month period. A PA focus is even more crucial due to COVID-19, as it creates new barriers to PA and individuals with chronic medical conditions are most vulnerable. Now is the time to address population health by educating medical students that exercise is medicine. 

We suspect the main issue is the lack of exercise as medicine education in medical training, with more than half of students receiving no formal education on exercise and physicians frequently citing decreased knowledge as a barrier to discussing PA with patients. Evidence suggests education improves provider’s comfort prescribing exercise to their patients. We argue that PA education is imminently needed considering COVID-19 further contributes to sedentary lifestyles (e.g., gym/school closures, working from home). There are both current and downstream effects of the pandemic and with PA education, clinicians can mitigate the physical inactivity crisis.

We propose three recommendations for addressing PA in medicine: 1) implement PA education into required medical school curriculums, 2) create resources for patients who have significant barriers to PA and, 3) promote medical student wellness to increase the likelihood that they discuss PA with patients.

As medical students, many of us are entering back into the clinical setting after months off due to the COVID-19 pandemic. At this point, everyone’s life has been affected by COVID-19 in some way. Upon speaking with patients shortly after returning to clerkships, one of the themes I noticed was how their exercise routines have been interrupted. For example, a patient with abdominal pain, who stated that prior to COVID-19 he was an avid swimmer but has not been able to swim since his community pool has closed. Or another, who was experiencing heart palpitations, said that he would go to the gym daily after work because he enjoys weight training, but now does not exercise because he does not have weights at home. As a student, I had previously felt ill equipped to address exercise plans with patients, and now with life being changed, supporting patients in staying physically active will be even more challenging and important than ever.

Physical activity (PA) is well known to be both effective in the management and prevention of chronic disease and can boost immune function [1,2,3,4]. PA is often considered the “polypill” of disease, improving cardiorespiratory fitness and muscular strength, which are directly related to the function of many other bodily systems [2,5].

In this article, we outline how COVID-19 is disrupting lifestyles and PA, and why this is both an immediate and long-term danger for the general public. Then, we discuss how education on “exercise as medicine” is severely lacking in medical education, and how this translates into physicians lacking confidence to address PA with patients. Finally, we propose long term solutions to better incorporate PA into medical school curriculums, with there being evidence to suggest that this will increase confidence and willingness to promote and prescribe PA routines.

Although it is well known that exercise has countless benefits, 80% of American adults do not meet the US Physical Activity Guidelines for exercise and 66% of American children are physically inactive every day [6]. In terms of healthcare costs, physical inactivity accounts for $117 billion annually of US health care expenditures [7]. Multiple government and public health initiatives have tried to address physical inactivity (e.g., Healthy People 2020, Exercise is Medicine, US National Physical Activity Plan). Exercise guidance and prescription have had a therapeutic role in medical settings such as in cardiac rehabilitation and physical therapy. However, its use in primary care settings to promote well-being and prevention is not universal [8]. A contributing factor is the knowledge deficit among healthcare providers (HCPs) and needing more practice in effective counseling techniques [8,9]. Less than 40% of HCPs report regularly discussing exercise with their patients [10].

Although clinicians recognize PA as an important health intervention, they often do not feel confident in counseling and prescribing PA to patients. Studies show that the lack of confidence often comes from minimal teaching in medical education with only 58% of surveyed deans/directors indicating their medical graduates were competent in conducting a patient evaluation for approving that patient to begin an exercise program, and further only 10% said their students could design an exercise prescription [11]. Only 6% of medical programs reported that their school provided a core course addressing the American College of Sports Medicine Guidelines for Exercise Testing and Prescription [11]. Notably, medical students spend more time on subjects, such as pharmacology, compared to PA, even though drug therapies for chronic diseases have known adverse side effects, whereas PA generally has less [1].

Moreover, COVID-19 has recently become a worldwide public health issue and has presented many challenges for the general population. As of September 19, 2020, the World Health Organization has reported over 28 million cases and 911,000 deaths globally, and approximately 6 million cases and 190,000 deaths in the US [12]. Various public health entities have initiated quarantine and/or stay-at-home orders, which have globally restricted activity. These orders disrupt exercise routines, increase sedentary time, and lead to unhealthy eating habits [3,4,5]. The existing physical inactivity crisis is compounded by the fact that individuals with medical conditions associated with inactive lifestyles, including heart disease, diabetes, and obesity, are more likely to be hospitalized due to COVID-19 and have higher rates of morbidity and mortality [4,13,14].

Lifestyle and PA Changes with COVID-19

COVID-19 has disrupted several aspects of daily life, including how people stay physically active. A study by a company called “Evidation,” shows that PA – measured by step count – is down 48% nationally [15]. These changes likely act as a result of closed gyms, community centers, public parks, and closure of places where many go to walk like malls. COVID-19 has also led to decreased participation in team sports and group exercise programming. Recent articles have mentioned increases in use of streaming services and video games. For example, Twitch, the video game streaming platform, reported video game streaming up 12-24% coinciding with the COVID-19 pandemic, ultimately suggesting an increase in sedentary behavior [16,17].

Unfortunately, COVID-19 has led to increases in unemployment, likely forcing families to experience economic hardship, potentially leading increases in sedentary behavior.  As of June 2020, the national unemployment rate was 11.1% [18]. It is also well known that lower socioeconomic status has been correlated with lower PA upon retirement, further exacerbating rates of physical inactivity among the general public [19,20,21]. 

Increases in sedentary behavior also occur in those who are still working, as working from home is becoming required for many businesses [22]. With more people working from home, commutes are essentially eliminated, and those who can afford it are getting grocery and food deliveries, leading to an overall decreased mobility [23]. Nutritional habits may have also changed because of financial resource limitation, reduced availability of foods, limited access to food caused by restricted store hours, and a switch to more easily accessible, processed and shelf-stable foods [4]. These population level changes may lead to an increase in all-cause mortality, and increased risk of many chronic diseases, including obesity. This is also true for our youth, with school closures and a lack of organized sports during this time. Notably, studies show increased youth weight gain over the summer months, the months commonly associated with being out of school [24].

Further, many people have reported mental health being significantly affected during the COVID-19 pandemic with 1 in 3 Americans reporting that quarantine and social distancing is having a serious impact on their mental health [14]. This is likely due in part to an increase in various stressors including concerns about finances, fear of infection, inadequate supplies, inaccurate information, stigma, and frustration [7,14]. Studies have also shown in older individuals that social isolation is associated with lower PA levels and loneliness in adults has been shown to be an independent risk factor for physical inactivity and increases the likelihood that PA will discontinue over time [25,26]. COVID-19 has indeed created drastic lifestyle changes for an already sedentary population, further compounding the health risk factors of physical inactivity. 

Exercise Prescription and Social Determinants of Health

The COVID-19 pandemic also underscores well known social determinants of health with people of color and minority communities, especially native, black, and Hispanic groups disproportionately affected by COVID-19 [27]. There are various reasons for this, including work environment, front line work, and housing conditions pointing to the issue of systemic racism that exists in our society [28]. Home environment is also important to consider, as physical isolation is a form of protection that may be not possible for many people due to living conditions. Also, certain marginalized groups, such as black and brown communities, may be less likely to hold jobs that permit working from home, such as grocery clerks, transit workers, and hospital staff, among others. Further, communities of Hispanic and black ancestry may have poorer health outcomes and higher COVID-19 death rates likely because these communities receive poorer care through lack of testing and less access to healthcare, as well as facing higher rates of diabetes, hypertension, and heart disease due to systemic racism issues. These trends are also true for children who are Hispanic or black, and these observed disparities might be related to the higher prevalence of underlying conditions among hospitalized Hispanic and black children compared with those among white children [29].

Thus, we feel that improving education around the best known “poly-pill” (i.e., exercise) for healthcare providers is well-timed. More education and confidence around exercise prescription for physicians means improved outcomes for many chronic diseases in the general population, including those experiencing systemic oppression. More individualized exercise and PA as prescribed by physicians may lead to improved cardiorespiratory function and may lessen the severity of COVID-19 infections, further protecting these populations.

Benefits of physical activity during the COVID-19 pandemic

How does PA play a part in benefiting the population during a pandemic? There is a growing amount of research surrounding optimizing immune system function and PA, and some evidence suggests exercise may lessen the severity of COVID-19 symptoms [7]. PA may enhance immune response to prevent upper respiratory tract infections and augment immune competency [30]. PA may also improve antibody production and interact with antioxidant enzymes (such as extracellular superoxide dismutase) and help improve acute respiratory distress syndrome [31,32,33]. Mechanisms behind these pathways are still being discovered. However, this demonstrates the importance of PA to improve physical conditioning to prevent severe COVID-19 infections, and overall, habitual exercise improves immune regulation and generally reduces illness risk [34].

PA also reduces the risk of common chronic medical conditions which, as shown by CDC’s COVID-NET, have been seen in over 90% of hospitalized patients with COVID-19 [1,35,36].  Individuals infected with COVID-19 are much more likely to be hospitalized and have poorer health outcomes if one or more chronic disease diagnoses are present [35]. The evidence linking a significantly increased risk for chronic disease if a person is physically inactive is well established. Cardiovascular (CV) disease had the highest prevalence among diseases that put patients at higher risk of worse COVID-19 disease, and CV disease risk is greatly increased with sedentary behavior [35]. This highlights the importance of PA for reducing the risk of severe COVID-19. 

This introduces the idea of prehabilitation regarding COVID-19 [34]. Prehabilitation is aimed at creating interventions to improve patients’ health before a physiologic stressor, such as coronavirus, so they can better handle the stress if it presents [34]. Prehabilitation may have the greatest positive effect on vulnerable groups (e.g., elderly patients) with multiple medical conditions by supporting overall physiologic function, and therefore immune function [7,34]. Thus, PA becomes especially important for older people during quarantine to improve cardiorespiratory fitness, which is directly related to the function of the respiratory, circulatory, muscular, nervous, and skeletal systems, as well as endocrine and immune systems [5].  

Exercise can also decrease the activity of the nervous system, decreasing the body’s reaction to stress, and may help with anxiety of the pandemic, improving mental health outcomes for those who are stressed [37,38,39]. In fact, exercise may be as effective as antidepressants in reducing symptoms of mild-to-moderate depression [37]. Specifically, evidence suggests that walking, particularly outdoors, can aid in the prevention and treatment of depression and anxiety [40]. Adults 60 years and older with higher PA levels showed a 21% reduction in risk for depression compared to those with lower PA levels [41].  

Medical schools lack education on exercise as medicine

Medical schools continue to graduate the next generation of doctors during COVID-19 and the current physical inactivity crisis. However, education on PA, PA as disease therapeutic and prevention, and exercise prescription is largely missing from medical schools and residency programs. In 2013, more than half of physicians trained in the US in 2013 did not receive formal education in PA and may, therefore, be ill prepared to assist their patients in a manner consistent with current health initiatives [42]. 

There is also a lack of confidence in medical trainees to make effective recommendations [11,43]. In a 2010 survey of 500 trainees and attending physicians at a major teaching hospital, only 13.7% of trainees and 17.3% of attending physicians reported that they had received appropriate training regarding counseling on exercise, and less than 40% of the trainees engaged in any counseling regarding exercise or nutrition with their patients [9].

These trends are not isolated to the United States and are reflected elsewhere in the world. A study of final year UK medical students suggested a substantial portion underestimated the risk of physical inactivity and did not know the physical guidelines. Physical inactivity was incorrectly perceived to be the least important risk factor to global mortality, and only 52% stated they felt adequately trained to give PA advice to the general public [44]. Another study of family medicine residents in Canada felt the need to be better trained in exercise prescription, with 14.9% perceiving their education on exercise prescription to be adequate and 91% desired more training [45].

Education on exercise as medicine may give confidence to providers

This section was meant to offer a perspective that education on “exercise as medicine” may give providers the confidence they need to discuss and prescribe exercise. However, the research available is rather sparse, which speaks to the relative lack of focus on exercise as medicine during medical training. The few studies found, however, were telling. A study in 2017, involving a 4.5 week course in geriatric medicine with exposure to therapy programs including visits to a community-based exercise class where medical students interview older adults, there was a significant increase in the students’ perception of the importance of exercise for elderly people. Perceived competence in prescribing exercise also increased significantly after this geriatric course [46]. Other preliminary data from a University of Massachusetts Medical School exercise medicine elective showed an increased level of confidence after completing coursework [47]. A 2004 study at Harvard Medical School showed a significant increase in self-reported confidence advising family and friends about exercise, assessing patient exercise, and changing patient exercise after students took a preventative medicine and nutrition course which included one week on exercise [48].  

Future Directions

The combination of COVID-19 and the current physical inactivity crisis has forced us to think about how we can best prioritize the health of the public, and here we outline recommendations to promote PA in the clinical setting. 

(1) We must increase or institute education on “exercise as medicine” in required medical school curriculums. One way this could be accomplished is by building on resources that already exist, such as the Exercise is Medicine (EIM) global health initiative through by American College of Sports Medicine (ACSM), which aims to make PA assessment and promotion a standard in clinical care. EIM encourages physicians to include PA when designing treatment plans and to refer patients to evidence-based exercise programs and qualified exercise professionals [49]. There are several guidelines for providers on how to work with your patients and exercise prescription. The Action Guide includes motivational interviewing tactics and examples of exercise prescription. However, this organization does not have content targeted specifically toward medical students. EIM could expand programming/coursework into all medical schools, drastically increasing the amount of education provided for students. Education could also be facilitated through musculoskeletal teaching blocks taught by sports medicine/exercise specialists to offer expertise on exercise prescription for common chronic conditions. This dissemination of knowledge could also be addressed through training modules in the didactic or clinical phase of medical school and include case scenarios or simulation training.  By further enhancing the education of our new medical practitioners on exercise prescription, patients are more likely to incorporate regular PA into their daily lives.

(2) We must improve PA awareness and the accessibility of resources in the community. Awareness around PA can be improved in the outpatient clinical setting by establishing PA and fitness as a vital sign and may improve the issue that PA is sub-optimally addressed in most clinical encounters [50].  This is currently done at the University of Washington (UW), led by Cindy Lin, MD, FACSM, by integrating a standardized and simple two question “exercise as vital sign screener” in the EPIC electronic medical record [51].  UW medical assistants are now asking these questions as part of the usual heart rate and blood pressure vital sign intake. The American Heart Association states that routine PA assessment in clinical settings is imperative for prevention and management of chronic disease, including CV disease. Best practices involve assessing PA at patient check-ins when vital signs are administered, or as part of the rooming process [52].  Another study showed that systematically collecting exercise information during outpatient settings in the form of a vital sign may be associated with significant changes in exercise related clinical outcomes [53]. We can also improve the accessibility of local resources for our patients, an example of this being Exercise Rx. Exercise Rx through The Sports Institute at UW Medicine offers clinicians and patients alike the ability to view and access a variety of low cost, free, and local programs, parks, websites, and online workout plans [54]. 

(3) We must continue to promote individual wellness and PA for students in medical schools and physicians across the globe. The reason for this is not only to support the mental health and well-being of students while journeying through a challenging educational experience, but also because there is evidence that health care providers who are more physically active are more likely to educate patients on PA [55]. If the medical community fosters an environment of PA promotion and movement for its HCPs, it is likely such principles may be dispersed to the physicians’ patients. 

CONCLUSION

The COVID-19 pandemic has created concerns regarding social isolation, stay-at-home orders, and the closures of gyms and other recreational areas, exacerbating population level sedentary behaviors. Prior to COVID-19, most of the world was already not meeting activity recommendations, even though exercise is known for its countless preventative and therapeutic benefits for a multitude of diseases. Regular PA and exercise may help improve outcomes for COVID-19 patients and prepare us for future pandemics. With the future unknowns of continued isolation and stay-at-home orders, this calls for changes in medical education such as those proposed in this paper. New clinicians need to build expertise on PA and exercise as an individualized medical therapy and have access to the tools and resources to help patients be successful.

REFERENCE

  1. Pedersen, B.K., Saltin, B. (2015). Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal of Medicine & Science in Sports, 25 (S3). doi: https://doi-org.offcampus.lib.washington.edu/10.1111/sms.12581 

  2. Fiuza-Luces C., Garatachea, N., Berger, N.A., Lucia, A. Exercise is the Real Polypill. Physiology, 28(5), 330-358. doi: 10.1152/physiol.00019.2013

  3. Chen, P., Mao, L., Nassis, G.P., Harmer, P., Ainsworth, B., & Li, F. (2020). Coronavirus disease (COVID-19): The need to maintain regular physical activity while taking precautions. Journal of Sport and Health Science, 9, 103-104.

  4. Mattioli, A.V., Puviani, M.B., Nasi, M., & Farinetti, A. (2020). COVID-19 pandemic: The effects of quarantine on cardiovascular risk. European Journal of Clinical Nutrition. doi: https://doi.org/10.1038/s41430-020-0646-z

  5. Jiménez-Pavón, D., Carbonell-Baeza, A., & Lavie, C.J. (2020). Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: Special focus in older people. Progress in Cardiovascular Diseases. doi: https://doi.org/10.1016/j.pcad.2020.03.009

  6. US Department of Health & Human Services, President’s Council on Sports, Fitness, & Nutrition (2017). Facts & Statistics Physical Activity. Retrieved from: https://www.hhs.gov/fitness/resource-center/facts-and-statistics/index.html#footnote-1

  7. Ding, D., Lawson, K.D., Kolbe-Alexander, T.L., Finkelstein, E.A., Katzmarzyk, P.T., . . ., Pratt, M. (2016). The economic burden of physical inactivity: A global analysis of major non-communicable diseases. Lancet, 388(10051):1311-1324.

  8. Walsh, J.M., Swangard, D.M., Davis, T., & McPhee, S.J. (1999). Exercise counseling by primary care physicians in the era of managed care. American Journal of Preventive Medicine, 16(4), 307-313. doi: 10.1016/s0749-3797(99)00021-5

  9. Hill, L.L., Nichols, J., Wing D., Waalen J., Friedman E. (2015). Training on Exercise is Medicine Within an Integrative Medicine Curriculum. American Journal of Preventive Medicine. 49(5 Supple 3):S278-84. doi: 10.1016/j.amepre.2015.08.018

  10. Barnes, P.M. Schoenborn, CA. (2012). Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional.  NCHS Data Brief. (86):1-8.  Retrieved from: https://pubmed.ncbi.nlm.nih.gov/22617014/

  11. Connaughton A.V., Weiler R.M., Connaughton D.P. (2001). Graduating medical students’ exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Health People 2010. Public Health Rep. 116(3):226-234. doi: 10.1016/S0033-3549(04)50038-9

  12. World Health Organization. (2020, May 28). WHO Coronavirus Disease (COVID-19) Dashboard. Retrieved from: https://covid19.who.int

  13. Hall, G., Laddu, D.R., Phillips, S.A., Lavie, C.J., & Arena, R. (2020). A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another? Progress in Cardiovascular Disease.

  14. Carter, S.J., Baranauskas, M.N., & Fly, A.D. (2020). Considerations for obesity, vitamin D, and physical activity amidst the COVID-19 pandemic. Obesity. doi:10.1002/oby.22838

  15. Evidation. (2020, April 15). COVID-19 Pulse: Delivering regular insights on the pandemic from a 150,000+ person connected cohort. Evidation. https://evidation.com/news/covid-19-pulse-first-data-evidation/

  16. Bellanger, C. (2020, March 20). New Study from Upfluence Finds COVID-19 Lockdown Restrictions Resulted in a 24% Viewership Increase on Live-Streaming Platform. Upfluence. https://www.upfluence.com/press-release/new-study-from-upfluence-finds-covid-19-lockdown-restrictions-resulted-in-a-24-viewership-increase-on-live-streaming-platform-twitch

  17. Beech, M. (2020, March 25). COVID-19 Pushes Up Internet Use 70% And Streaming More Than 12%, First Figures Reveal. Forbes. https://www.forbes.com/sites/markbeech/2020/03/25/covid-19-pushes-up-internet-use-70-streaming-more-than-12-first-figures-reveal/#7b9104da3104

  18. Duffin, E. (2020). U.S. unemployment rate: seasonally adjusted June 2020. Statista. https://www.statista.com/statistics/273909/seasonally-adjusted-monthly-unemployment-rate-in-the-us/

  19. Chung, S., Domino M.E., Stearns S.C., Popkin B.M. (2009). Retirement and physical activity: analyses by occupation and wealth. American Journal of Preventive Medicine. 36(5): 422-8. doi: 10/1016/j.amepre.2009.01.026.

  20. Puciato, D., Rozpara M., Mynarski W., Olesniewicz P., Markiewicz-Patkowska J., Debska M. (2018). Physical Activity of Working-Age People in View of Their Income Status. Biomed Research International. v.2018. doi: 10.1155/2018/8298527

  21. Farrell, L., Hollingsworth, B., Propper, C., Shields, M.A. (2014). The socioeconomic gradient in physical inactivity: Evidence from one million adults in England. Social Science & Medicine. 123:55-63. doi: 10.1016/j.socscimed.2014.10.039

  22. Lister, K. (2020). Work-At-Home After Covid-19 – Our Forecast. Global Workplace Analytics. https://globalworkplaceanalytics.com/work-at-home-after-covid-19-our-forecast

  23. Saint-Maurice, P.F., Troiano R.P., Bassett Jr, D.R. (2020). Association of Daily Step Count and Step Intensity With Mortality Among US Adults. JAMA. 323(12): 1151-1160. doi:10.1001/jama.2020.1382

  24. Baranowski, T., O’Connor, T., Baranowski, J. (2014). School Year Versus Summer Difference in Child Weight Gain: A Narrative Review. Childhood Obesity. 10(1):18-24. doi: 10.1089/chi.2013.0116.

  25. Schrempft, S., Jackowska, M., Hamer, M., Steptoe, A. 2019. Associations between social isolation, loneliness, and objective physical activity in older men and women. BMC Public Health. 19: 74. doi: 10.1186/s12889-019-6424-y

  26. Hawkley, L. C., Thisted, R. A., & Cacioppo, J. T. (2009). Loneliness predicts reduced physical activity: Cross-sectional & longitudinal analyses. Health Psychology, 28(3), 354–363. doi:10.1037/a0014400

  27. Centers for Disease Control and Prevention. (2020, June 25). COVID-19 in Racial and Ethnic Minority Groups| CDC. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html

  28. University of Pennsylvania. (2020, May 27). COVID-19’s assault on black and brown communities. Medical Xpress. https://medicalxpress.com/news/2020-05-covid-assault-black-brown.html

  29. Centers for Disease Control and Prevention. (2020). Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with Laboratory-Confirmed COVID-19 – COVID-NET, 14 States, March-July 25, 2020. Morbidity and Mortality Weekly Report. 69.

  30. Martin, S.A., Pence, B.D., Woods, J.A. (2009). Exercise and Respiratory Tract Viral Infections. Exercise and sports sciences reviews. 37(4):157-164. doi:10.1097/JES.0b013e3181b7b57b

  31. Nieman, D., Wentz, L. (2019). The compelling link between physical activity and the body’s defense system. Journal of Sport and Health Science. 8(3):201-217. doi:10.1016/j.jshs.2018.09.009

  32. Schuler, P.B., Leblanc, P.A., Marzilli, T.S. (2003). Effect of physical activity on the production of specific antibody in response to the 1998-99 influenza virus vaccine in older adults. Journal of Sports Medicine and Physical Fitness. 43(3):404.

  33. Woods, J.A. et al. (2009). Cardiovascular exercise training extends influenza vaccine seroprotection in sedentary older adults: the immune function intervention trial. Journal of American Geriatrics Society. 57(12):2183-91. doi: 10.1111/j.1532-5415.2009.02563.x

  34. Silver JK.  Prehabilitation could save lives in a pandemic. The British Medical Journal. Published April 6, 2020.  Accessed May 28, 2020. Retrieved from https://pubmed.ncbi.nlm.nih.gov/32253187/

  35. Emami, A., Javanmardi, F., Akbari, A. (2020). Prevalence of Underlying Diseases in Hospitalized Patients with COVID-19: a Systemic Review and Meta-Analysis.  Archives of Academic Emergency Medicine. 8(1):e35. 

  36. Centers for Disease Control and Prevention. (2020). Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 – COVID-NET, 14 States, March 1-30, 2020. Morbidity and Mortality Weekly Report. 69 (15);458-464.

  37. Robins, L.M.,  Hill, K.D.,  Finch, C.F., Clemson, L., & Haines, T. (2018). The association between physical activity and social isolation in community-dwelling older adults. Aging & Mental Health. 22(2), 175-182.

  38. Anderson, E., Shivakumar, G. (2013). Effects of Exercise and Physical Activity on Anxiety. Front Psychiatry. 4:27. doi: 10.3389/fpsyt.2013.00027

  39. Mueller, P. (2007). Exercise training and sympathetic nervous system activity: evidence for physical activity dependent neural plasticity. Clin Exp Pharmacol Physiol. 34 (4):377-84. doi: 10.1111/j.1440-1681.2007.04590.x

  40. Kelly, P., Williamson, C., Niven, A.G., Hunter, R., Mutrie, N., & Richards, J. (2018). Walking on sunshine: Scoping review of the evidence for walking and mental health. British Journal of Sports Medicine, 52, 800-806. doi: 10.1136/bjsports-2017-098827

  41. Cunningham, C., O' Sullivan, R., Caserotti, P., & Tully, M. (2019). Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses. Scandinavian Journal of Medicine & Science in Sports, 30(5), 816-827.

  42. Cardinal, B., Park, E., Kim, M., Cardinal, M. (2015). If Exercise is Medicine, Where is Exercise in Medicine. Review of U.S. Medical Education Curricula for Physical Activity – Related Content. Journal of Physical Activity and Health. 12(9): 1336-43. doi: 10.1123/jpah.2014-0316

  43. Oregon State University. (2015). Exercise largely absent from US medical school curriculum, study shows. Science Daily. Retrieved from www.sciencedaily.com/releases/2015/03/150331145142.htm

  44. Dunlop, M., Murray, A.D. (2013). Major limitations in knowledge of physical activity guidelines among UK medical students revealed: implications for the undergraduate medical curriculum. British Journal of Sports Medicine. 47 (11). doi: 10.1136/bjsports-2012-091891

  45. Solmundson, K., Koehle, M., McKenzie, D. (2016). Are we adequately preparing the next generation of physicians to prescribe exercise as prevention and treatment? Residents express the desire for more training in exercise prescription. Canadian Medical Education Journal. 7(2): e79-e96. 

  46. Jadczak, A., Tam, K., Yu, S., Visvanathan, R. (2017). Medical students’ perceptions of the importance of exercise and their perceived competence in prescribing exercise to older people. Australasian journal on ageing. 36(3):E7-E13. doi: 10.1111/ajag.12412

  47. Mastrocala, M. (2018, July 2). Doctors Aren’t Educating Patients About Exercise Because We Never Teach Our Doctors. Op-Med. https://opmed.doximity.com/articles/doctors-aren-t-educating-patients-about-exercise-because-we-never-teach-our-doctors-9094be78-6f6b-4bba- 99ff-7e96f7b951df?_csrf_attempted=yes

  48. Conroy, M.B., Delichatsios, H.K., Hafler, J.P., Rigotti, N.A. (2004). Impact of a preventive medicine and nutrition curriculum for medical students. American Journal of Preventive Medicine. 27(1): 77-80. doi:10.1016/j.amepre.2004.03.009

  49. Exercise is Medicine. American College of Sports Medicine. https://www.exerciseismedicine.org/support_page.php/health-care-providers/

  50. Sallis, R., Baggish, A., Franklin, B., Whitehead, J. (2016). The Call for a Physical Activity Vital Sign in Clinical Practice. The American Journal of Medicine. 129:9. doi:10.1016/j.amjmed.2016.05.005

  51. Pellegrini, C.A. (2018, August). August 2018 Newsletter. UW Medicine. https://depts.washington.edu/uwmedptn/press/1187/

  52. Lobelo, F., Young, D.R., Sallis, R., Garber, M.D., Billinger, S.A., . . . Joy, E.A. (2018). Routine assessment and promotion of physical activity in healthcare settings: A scientific statement from the American Heart Association. Circulation, 137(18), e495-e522. doi:  10.1161/CIR.0000000000000559.

  53. Grant, R.W., Schmittdiel, J.A., Neugebauer, R.S., Urratsu, C.S., & Sternfeld, B. (2014). Exercise as a vital sign: A quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels. Journal of Internal Medicine, 29(2), 341-348.

  54. Exercise Rx. The Sports Institute. https://thesportsinstitute.com/exercise-rx/

  55. Lobelo, F., Garcia de Quevedo, I. (2016). The Evidence in Support of Physicians and Health Care Providers as Physical Activity Role Models. American Journal of Lifestyle Medicine. 10(1): 36-52. doi: 10.1177/15598276133520120