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Review Article

Exercise Is Medicine® on Campus during COVID-19: Necessary Adaptations and Continuing Importance

Stanford, Kathleen1; Pomeroy, Alexander1; Bates, Lauren C.1; Tamminga, Kyle2; Chai, Thevy2; Moore, Justin B.3; Brookey, Lindsay4; Stoner, Lee1

Author Information
Translational Journal of the ACSM: Fall 2020 - Volume 5 - Issue 12 - e000157
doi: 10.1249/TJX.0000000000000157
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Abstract

INTRODUCTION

Globally, more than 280 college campuses participate in the Exercise Is Medicine® On-Campus (EIM-OC) initiative. EIM-OC was created by the American College of Sports Medicine (ACSM) to connect college medical providers with exercise providers to promote physical activity (PA) among students. At the University of North Carolina at Chapel Hill (UNC), PA has been incorporated as a vital sign within the campus health medical system. Should the patient not meet the recommended levels of PA, the provider refers the patient to the UNC EIM-OC team. The UNC EIM-OC initiative began in fall 2016, but not until spring 2020 was the initiative fully operational and awarded “gold status” by the ACSM. However, just as UNC EIM-OC was running smoothly, COVID-19 reached America (1,2). The pandemic has resulted in campus closures and social distancing measures to control virus transmission (3) and many challenges to EIM-OC at UNC and elsewhere. This commentary reports on (i) the continuing importance of EIM-OC during COVID-19, (ii) COVID-related adaptations to UNC EIM-OC, and (iii) EIM-OC recommendations for the upcoming school year.

COLLEGE STUDENT ACTIVITY BEHAVIORS PRE- AND POST-COVID-19

Adequate PA for adults is defined as meeting PA guidelines: 150 min of moderate-intensity exercise or 75 min of vigorous exercise per week (1). Meeting these guidelines is strongly associated with decreased cardiometabolic disease risk (4) as well as decreased risk of mental illnesses, including depression and anxiety (5,6). In addition, sedentary behavior (7) is a biologically novel cardiometabolic disease risk factor (8), which has also been associated with poor mental health (9). Of concern, before COVID-19, only 19% of students met PA guidelines. They sat at least 6.4 h·d−1 (10), and 61% reported feeling overwhelming anxiety in the past 12 months (1).

On March 12, 2020, UNC implemented plans to mitigate the spread of COVID-19 (11), including transition to remote instruction and the closure of many campus facilities (12). These closures and social distancing measures reduced access to recreation and fitness opportunities for students and placed additional stressors on them, including social isolation, daily schedule disruption, sudden changes in housing, financial difficulties, and family illness from the virus (13,14). Although college student-specific data are not available, according to an international survey, walking and PA has decreased after COVID-19 (15), and sedentary behaviors have increased (13). Further, anxiety has increased in college students since the COVID-19 pandemic began (14).

UNC EIM-OC ADAPTATIONS IN RESPONSE TO COVID-19

With many students returning to classes on a virtual or hybrid (remote and in-person) basis, this fall, sedentary behaviors are likely to increase. Further, the social distance measures will continue to impede access to PA opportunities. Considering that many students will continue to access Campus Health and that meeting PA guidelines while minimizing sedentary behavior can affect both physical and mental health, EIM-OC can and should continue to play an important role during COVID-19.

PARTNERSHIPS AND COMMUNICATION

The most important contribution to the success of UNC EIM-OC is the development and maintenance with partners across and beyond campus, including the Department of Sport and Exercise Science, Campus Health, Campus Recreation, and an EIM-OC undergraduate club (Table 1). To maintain these partnerships, at least once per month, members of the UNC EIM-OC team, typically graduate students, would provide Campus Health providers with literature pertaining to the importance of PA and sedentary behavior reduction, as well as provide education about the UNC EIM-OC referral process. The communication would be delivered via one-on-one visits, group presentations, or e-mail listservs. In addition, UNC EIM-OC graduate students hosted a monthly “Walk with the Providers,” a stroll featuring discussions about new PA literature, its relevance to exercise prescription, and ways to implement in the routines of students, all while providers took part in light PA themselves. The regular communication, and particularly walks, served to foster familiarity between EIM-OC’s consulting team and Campus Health Staff to encourage providers to refer patients to EIM’s services. After the onset of COVID-19, to ensure the UNC EIM-OC team could regularly communicate with medical providers, an online newsletter was developed (https://exerciseismedicineunc.wordpress.com/). This weekly newsletter summarizes PA and sedentary behavior literature, and it serves as an addendum to the virtual presentations that have replaced in-person presentations.

TABLE 1 - Summary of Changes in Communication with Campus Health that Have Occurred in Response to COVID-19.
Process before March 2020 Change Consideration
Communications with Campus Health Providers
Scientific literature delivered via in-person presentations Weekly newsletter translates latest studies into concise summaries Social distancing; wider audience able to consume evidenced-based recommendations
Monthly in-person meeting Monthly virtual meeting Social distancing; flexible scheduling allows more team members to join meeting
Consultation Process
In-person meetings Meetings over Zoom Social distancing
Location of participant not asked Ask for location of participant; resources adapted accordingly Remote learning
Group fitness class recommendations Group fitness through virtual classes and fitness applications; outdoor, distanced workouts recommended UNC Campus Recreation indoor facilities closed; gym closures in North Carolina; outdoor workouts can be done safely in groups
In-person personal training Virtual meetings with personal trainers on Zoom Gym closures in North Carolina
Sedentary behavior reduction not discussed Strategies for breaking-up prolonged sitting Increases in sedentary behaviors

REFERRAL PROCESS

This UNC EIM-OC referral process has been developed and refined through research conducted by the UNC EIM-OC team. For example, between January 2018 and May 2018, we distributed 550 surveys throughout Campus Health to determine interest in receiving PA information and to better understand how to administer the referrals process. Four hundred and nine students (74%) completed the survey (key results presented in Fig. 1), with 58% stating that they would like to receive PA guidance and 41% preferring a referral to a trained exercise professional (16). Subsequently, a trial was implemented in Counseling and Psychological Services to further refine the process currently in use.

Figure 1
Figure 1:
Example results from a survey conducted with 409 students in 2018.

A simplified version of the UNC EIM-OC referral process is depicted in Fig. 2. Fortunately, this process did not require further adaptation after COVID-19. The process begins at Campus Health Services. To assess PA guideline fulfillment, students are asked the following: (i) “How many days per week do you usually exercise?” and (ii) “How long do you exercise each session?” on their medical questionnaire. If the provider believes the patient would benefit from adding PA into their prescription, they contact EIM-OC’s physician liaison, who forwards the participant information to the UNC EIM-OC team using a secure online network. The network also contains the UNC EIM-OC user manual and promotion, education, and consultation materials, i.e., consultation script, prescription pad, and presentations.

Figure 2
Figure 2:
Traditional model of how students interact with EIM and their partners. Campus Health identifies students who are not meeting PA guidelines. Subsequently, UNC EIM-OC representatives engage with the student in a one-on-one meeting, recommending the use of local, on-campus programs and affordable online workouts.

CHANGES IN CONSULTATION MEETINGS

A standardized script, based on motivational-based interviewing and social cognitive theory, is used to guide the consultation. Before COVID-19, a member of the UNC EIM-OC team would either meet with the participant during office hours held at Campus Health or arrange an in-person meeting (e.g., at a coffee shop) via e-mail (16). After COVID-19, the consultations are delivered virtually using the Zoom platform. The participant is provided with exercise prescription using the UNC EIM-OC prescription pad. In addition, a second consultation is arranged. Before COVID-19, the UNC EIM-OC sent an e-mail to the participant after 4 wk to arrange the second consultation and provide further counseling, if needed. After COVID-19, the second visit is arranged during the initial consultation. This change has drastically decreased loss-to-follow-up rates, from essentially nil follow-ups to 100% follow-up adherence.

Fig. 3 illustrates a pre-COVID-19 PA general resource sheet handed out to participants during the initial consultation. This is complemented with a tailored and goal-specific resource sheet, as exemplified in Fig. 4. Before COVID-19, the use of UNC Campus Recreation facilities (e.g., group fitness classes, personal training, swimming, weights lifting, and/or cardio equipment access) was heavily referenced. However, since the onset of COVID-19, providing cohesive and personalized PA recommendations has been challenging after the reduction in campus recreation facilities and students moving away from campus. As summarized in Table 2, UNC EIM-OC’s standard recommendations evolved to fit the reduction in resources and government ordinances on social gatherings. For example, the participants are now asked about their current location so that the team can provide recommendations for that environment. In addition, the team has taken advantage of the increased prevalence of online, streamed, or on-demand applications (17). Given the overwhelming number of options available, many of which may lack repute, the UNC EIM-OC team researched suitable free or affordable PA online applications, cardio applications (e.g., Peloton’s cycle and Charge Running’s jogging programs), yoga applications (e.g., DownDog or YouTube practitioners), and resistance training applications (e.g., Les Mills On Demand). The online applications compliment adaptations made by Campus Recreation to ensure their continued ability to serve the community. Online platforms such as Facebook and YouTube Live have allowed group fitness classes to continue, whereas Zoom permits small group training sessions with more personalized encouragement and feedback. In addition, fitness challenges by Campus Recreation were established on fitness apps (e.g., Strava) with prizes to create competition and engagement among UNC students.

Figure 3
Figure 3:
The UNC EIM-OC PA resource sheet handed out to participants before remote consultations.
Figure 4
Figure 4:
The UNC EIM-OC PA resource sheet e-mailed to participants after virtual consultations, tailored to their interview.
TABLE 2 - Summary of Changes among Consult Recommendations that Occurred in March 2020.
Recommendations before March 2020 Change Consideration
Cardiovascular Training
Use of Campus Recreation facilities’ cardio machines Facebook Live and Zoom classes hosted by Campus Recreation; Strava social challenges; Cycle, run, HIIT, and power-walk classes from Peloton, Charge Running, Les Mills On Demand RPM, DownDog apps.
Outdoor classes hosted by Campus Recreation, private fitness companies (e.g., Camp Gladiator)
Gym closures in North Carolina
Campus Recreation group fitness classes: HIIT, cycle fitness, Zumba, kickboxing, HeelFit classes (in-person). Social distancing; outdoor group workouts can be done safely
Swimming walk-ins at on-campus aquatic centers Appointments needed to reserve lanes Social distancing
Strength Training
Use of weight machines, barbells, and dumbbells at Campus Recreation facilities Facebook Live classes hosted by Campus Recreation; Peloton strength classes, Les Mills On Demand, BodyPump workouts Gym closures in North Carolina
Campus Recreation group fitness classes: Pilates, intensity, lift classes (in-person) Gym closures in North Carolina
Outdoor Fitness
Recommendation for parks and trails local to UNC Investigated open parks and trails close to the participant’s location, which may be away from Chapel Hill, NC.
Carolina Adventure’s hiking expeditions, rock climbing workshops, stand-up paddling boarding trips
Many parks and trails closed during stay-at-home ordinances; remote classes mean participants may be not be local to UNC
Hiking, rock climbing, and other outdoor fitness Social distancing can be maintained in many outdoor venues
Use of AllTrails and RGreenway to locate local trailheads and download maps No change Social distancing can be maintained in many outdoor venues
Joining intramural or pick-up sports teams, clubs No longer recommending most sports Social distancing

Since the adoption of virtual consultations, referrals at UNC have not only continued but have increased in number. Between March 1, 2020, and August 24, 2020, the UNC EIM-OC team received 39 referrals, or ~7 referrals per month. Before COVID, the team received approximately one referral per month. Reasons for the increase in referrals may include the ease of meeting online, the flexibility in scheduling, and the omission of a commute. In addition, a virtual meeting may be less intimidating than in-person meetings (18), and as a result of social restrictions, there may be an increased desire to interact with people (19). Because of the success of this method, UNC EIM-OC will continue to offer virtual meetings as a consultation option beyond COVID-19.

RECOMMENDATIONS FOR EIM-OC IN THE FALL SEMESTER

Orienting UNC EIM-OC participants to available PA resources will be a priority this fall. Returning students will likely be disoriented and overwhelmed and will likely experience a high degree of psychological stress. The students will either not physically return to campus or return to an unfamiliar campus environment. Integrating PA into their daily routine can help students manage the stressful nature of the academic semester. The authors recommend other EIM-OC chapters identify resources local to the participant’s location, such as trails, and compliment with virtual options, including Campus Recreation’s fitness classes. EIM-OC may play a critical role this semester by helping students start or reestablish an exercise routine when they return to campus by connecting them with the resources and planning they need to achieve their goals—all while maintaining safe social distancing practices.

CONCLUSION

The UNC EIM-OC team has adapted to COVID-19 challenges by transitioning to a virtual platform while maintaining relationships with partners across campus. The team has also become familiarized with new PA resources in accordance with COVID-19-related restrictions to continue to serve UNC students. Furthermore, these adaptations may have improved the success of EIM-OC because referral numbers and follow-up appointments have significantly increased since March 2020 at the onset of the pandemic. Consult appointments will continue to take place virtually, low-cost or no-cost PA resources on online or app-based platforms will remain a cornerstone of the participant resource sheet, and follow-up appointments will be made at the initial consultation for lowering loss-to-follow-up cases.

EIM-OC, for UNC and beyond, can play an important role through the course of the COVID-19 pandemic in helping to maintain the physical and mental health of college students.

The authors declare that they have no conflict of interest. The views of this article do not constitute endorsement from the ACSM.

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