Education for Health

ORIGINAL RESEARCH ARTICLE
Year
: 2016  |  Volume : 29  |  Issue : 3  |  Page : 203--209

Institutionalized physical activity curriculum benefits of medical students in Colombia


Gustavo Tovar1, Gabriel López1, Milcíades Ibáñez2, Ricardo Alvarado2, Felipe Lobelo3, John Duperly4,  
1 Department of Research, Physical Activity and Human Development Research Group, School of Medicine and Health Sciences, University of Rosario, Bogotá, Colombia
2 Department of Research, Clinical Research Group, School of Medicine and Health Sciences, University of Rosario, Bogotá, Colombia
3 Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
4 Department of Social Medicine, Medical School, University of the Andes, Fundación Santa Fé, Bogotá, Colombia

Correspondence Address:
Gustavo Tovar
University of Rosario, Department of Research, Carrera 24, No. 63C-69, Bogotá
Colombia

Abstract

Background: Health authorities internationally have recommended implementing physical activity and exercise for health training programs within the curriculum of medical schools. The purpose of this evaluation was to determine the changes in physical fitness and health (Fitnessgram criteria) of a sports medicine and physical activity course implemented for 3rd year students in a private medical school in Bogotá, Colombia. Methods: Intervention was targeted to 13 medical student cohorts. Cardiovascular endurance (20 m shuttle run test), speed (20 m sprint), strength (push-ups and curl-ups in 30 s), and flexibility (sit and reach) were evaluated at the beginning and end of the school semester. It was a 54 semester-hour intervention (3 h/week), with 37 h (69%) of directed group-based physical exercise. Results: Five hundred and twenty-four students were evaluated with an average age of 20 ± 1.4 years; 341 (65.1%) were women. In all the fitness tests for men and women, a significant increase was found. The prevalence of a healthy cardiorespiratory capacity went from 47.8% to 89.1% in women (P < 0.001) and from 54.6% to 83.1% in men (P < 0.001). Body mass index and weight increased in both sexes. Discussion: The results of the current study showed that a 54 h physical activity course within the medicine curriculum had a positive impact on health-related fitness indicators in Colombian medical students.



How to cite this article:
Tovar G, López G, Ibáñez M, Alvarado R, Lobelo F, Duperly J. Institutionalized physical activity curriculum benefits of medical students in Colombia.Educ Health 2016;29:203-209


How to cite this URL:
Tovar G, López G, Ibáñez M, Alvarado R, Lobelo F, Duperly J. Institutionalized physical activity curriculum benefits of medical students in Colombia. Educ Health [serial online] 2016 [cited 2021 Oct 19 ];29:203-209
Available from: https://www.educationforhealth.net/text.asp?2016/29/3/203/204212


Full Text

 Background



Physical activity is one of the essential elements for preventing noncommunicable diseases,[1] including cardiovascular diseases,[2] diabetes,[3] chronic obstructive pulmonary disease (COPD), and cancer.[4] The World Health Organization (WHO) Global Status Report on Noncommunicable diseases 2010showed that noncommunicable diseases are the primary cause of death worldwide. More than 36 million people died from noncommunicable diseases in 2008, mainly from cardiovascular diseases (48%), cancers (21%), chronic respiratory diseases (12%), and diabetes (3%), and over 80% of the mortality burden from these diseases occurs in low-to-middle-income countries.[5],[6] In Colombia in 2008, 134,500 people died from these causes (66% of total mortality) according to the WHO figures. In Colombia, strategies based on the use of physical activity as a tool to control and prevent these diseases have been scarce.[7] This is reflected in the growing rate of sedentarism: close to 46.5% of Colombian adults between the ages of 18 and 64 years are sedentary, similar to the worldwide figures.[8]

Health professionals, particularly physicians, play an important role in motivating and committing their patients to seek an active lifestyle with healthy living habits.[9],[10] In Colombia, 72% are general practitioners and only 28% are specialists. General practitioners are the entry point for patients into the health system and those from whom patients initially seek care. However, it is well known that general practitioners have limited knowledge of this subject, little training and little time during the medical visit, reasons that may explain why physicians less often council on physical activity than on other healthy behaviors.[11],[12],[13],[14] Therefore, training medical students in subjects related to physical activity and healthy living habits should be included in undergraduate studies.[11],[14],[15] In addition, it has been shown that medical students with better health habits have a greater probability of increasing the quantity and quality of physical activity recommendations given to their patients.[16] In order to promote physical activity, physicians must be an example for their patients, performing and internalizing physical activity and healthy living habits.[10],[17],[18] However, the inclusion of these subjects in the curriculum is low and often not given the importance they deserve. In the United States, 87% of the 102 surveyed medical schools do not offer any type of preparation in subjects related to physical activity, and 76% do not intend to include it in the curriculum in the next few years.[11] Worldwide, we know that subjects related to physical activity have only been included in specializations such as family medicine and internal medicine.[11]

In 1999, the Rosario University in Colombia began an experiential program based on physical activity and exercise, which facilitated comprehension of these subjects and focused on individual health care and the practice of healthy living habits. This program seeks to improve the quality of knowledge on this subject and the experience of the students so that they will be able to apply it to their patients.[11]

The purpose of the present study is to describe the program and its educational methodology and to determine its short-term impact on students' health-related physical fitness indicators by evaluating medical students' physical fitness before and after the program.

 Methods



This is a longitudinal, before and after study of the semester-long Sports Medicine and Physical Activity Program at the School of Medicine and Health Sciences in the Rosario University, a fully-accredited Internationally Recognized Medical School [19] in Bogota, Colombia.

Program description

The Sports Medicine and Physical Activity Program has functioned at the university since 1999, in the beginning offered as an elective course. It was widely accepted and in 2001, the course was institutionalized for all 5th semester medical students, making up 10% of the total internal medicine curriculum academic load. Beginning in 2007, this course was included as an independent, required course within the medical school curriculum, with a 4-month length as part of the 5th semester curriculum.

Practice-based classes

At the beginning of each semester, individual physical tests were carried out with students within four groups based on their performance on the cardiovascular test. The assignment of training loads for the individuals (intensity, frequency, and duration) is adjusted for each group to optimize the training results in the greatest number of subjects while at the same time diminishing the associated risks. A soccer field, basketball court, track, and a small gymnasium located at the university and basic implements for group-based fitness classes were used (elastic bands, ropes, plastic tubes, etc.). Motivational strategies were used such as play, some competition, and awarding academic points for physical accomplishments. The same fitness instructor has led with the course since its establishment, guaranteeing the stability of the training implementation.

Theory-based classes

Theory classes begin with a lecture on scientific evidence which supports the benefits of physical activity for all areas of human health. Likewise, students are shown the results of their own health indicators, taken from the physical tests and a preparticipation questionnaire on health status and performance of physical activity, to diminish the risk of the tests and exercise. The course's medical instructor then highlights the prevalence of smoking, overweight, and physical inactivity in the cohort, and their cardiovascular endurance results, indicating how many have healthy criteria in each indicator.[20] In this lecture, the professor has them reflect on their own performance compared to what is considered a healthy state. Two other lectures are focused on the physiological changes which occur with training (fitness physiology). In a third one, the elements of exercise prescription are taught (mode, duration, frequency, intensity, progression, and calorie burning) and a fourth teaches how to carry out medical evaluations on individuals who wish to practice a sport or who wish to enter an exercise program. Likewise, a strength training workshop is carried out at the gymnasium of the Centro de Medición de la Actividad Física (Physical Activity Measurement Center). The academic activity concludes with presentations by the students regarding the usefulness of exercise in various chronic pathologies (coronary diseases, diabetes, hypertension, COPD, rheumatoid arthritis, obesity, and osteoporosis) with an exercise prescription for fictional patients having each pathology. At the end of the course, health-related fitness indicators are once again measured with a presentation showing group results classified by test, sex, and performance categories, making the program an important pedagogical tool where the student can evaluate the impact of exercise on his/her health and physical fitness.

Logistics

The course meets 3 h a week (Tuesday and Friday), for a total of 54 h each academic semester. These hours are distributed as follows: 37 (69%) directed group-based physical exercise; 8 (15%) theory; and the remaining time is used for activities such as orientation, results' feedback, and physical tests. The course is taught by a physician specialized in sports medicine and a physical trainer with experience in managing groups.

Student study population

The study population was composed of medical students enrolled in the Sports Medicine and Physical Activity course during their 5th semester. Thirteen student cohorts were taken during 6½ years. Those students with any inability to perform physical activity, or who had a risk factor detected and diagnosed by the Sports Medicine and Physical Activity Medical specialist, were excluded from the study. The study was approved by the Ethics Committee of the Escuela de Medicina y Ciencias de la Salud (Medical and Health Sciences School) of the university, and all students signed a consent form prior to participating in the study.

Measurements

At the beginning and end of the semester, the following physical tests were performed to evaluate the students' physical fitness and the impact of the program.

Body composition

Body weight was measured in kilograms (kg) and the percentage of fat by bioelectrical impedance using a Tanita 2001 T-TB scale. In addition to the body fat percentage, the body fat weight was calculated in kilograms (kg) before and after the program. Height was measured with a measuring tape attached to the wall, in meters (m). The body mass index (BMI) was calculated by dividing weight in kilograms by height in meters squared (kg/m 2). Measurement tools were calibrated before every assessment according to international guidelines.[21]

Aerobic capacity

Cardiorespiratory fitness, in terms of VO2 peak, was estimated using the progressive aerobic cardiovascular endurance run (PACER) test. This test expresses the individual's aerobic capacity according to the number of stages finished, beginning with stage one, running at 8 km/h, and increasing speed to 9 km/h in the second stage. From the second stage onward, speed is increased by 0.5 km/h for each minute. The last stage completed by the student is used for the result analysis.[20] The VO2 peak was calculated indirectly using Léger and Lambert test: VO2 peak (ml/kg/min) = 31025 + 3238 × speed − 3248 × age + 0.1536 × speed × age.[22]

Heart rate (HR) was taken at different times during PACER using a cardiac monitor. The HRpeak was recorded by the monitor immediately at the end of the test. Likewise, this parameter was recorded at min 1 following the end of the test. The recovery HR was found using the difference between the HRpeak and the HR at min 1. The ratio of distance covered/HRpeak was calculated as the indicator of physical performance.[23]

Speed

The 20 m sprint test was used, which measures the time in seconds taken by the student to run a distance of 20 m, beginning from a standing position with both feet behind a starting line and ending when one of the feet crosses the finish line.

Abdominal strength (curl-up)

This physical quality was evaluated using the maximum number of curl-ups performed in 30 s (knees bent and feet completely flat on the floor and held by a partner, with hands behind the base of the neck).[24]

Upper body strength (push-up)

Upper body strength was evaluated using the maximum number of elbow flexion extensions in 30 s (face down, and women resting on their knees).[24]

Flexibility

Flexibility was evaluated using the “Sit and Reach” test.[20]

The previous measurements were used to analyze whether or not the students fulfilled the following healthy criteria.

BMI: <25 kg/m 2 for both sexes [8]Body fat percentage: <21% for men and <34% for womenAerobic capacity: Surpassing Stage 7, which is approximately equal to a VO2 peak >42 ml/kg/min, for men, and surpassing Stage 4, which is approximately equal to a VO2 peak >37.8 ml/kg/min, for women [20]Flexibility: To reach at least 27 cm in men and 34 cm in women.[20]

Statistical analysis

The data were entered and processed using the IBM SPSS Statistics V22.0 of the USA. The description of categorical or qualitative variables was carried out using absolute and relative frequency distributions expressed in percentages and, for the quantitative ones, using measures of central tendency (average and median) and dispersion (range and standard deviation). Prior to this, the normality of the fitness variables before and after the program was evaluated using Kolmogorov–Smirnov and Shapìro–Wilk tests. The nonparametric Wilcoxon test for repeated measurements was used to evaluate the changes in physical characteristics between before and after the physical activity and health course. The tests were evaluated to a 5% (P < 0.05) and 1% (P < 0.01) significance level.

 Results



Out of 603 total students, 524 (87%) were evaluated (183 men [34.9%] and 341 women [65.1%]), with an average age of 20 ± 1.4 years, from a total of 13 yearly student cohorts who took this course. [Table 1] shows the changes in physical fitness. Significant positive changes were found in abdominal strength, aerobic capacity, flexibility, upper body strength, and speed following the intervention, both in men and women (P < 0.001). These changes were consistent when analyzed by stratification according to the intervention groups classified following the first cardiovascular test (P < 0.001).{Table 1}

The BMI and weight anthropometric parameters increased in a statistically significant way in both sexes. Body fat percentage and body fat weight also increased in both sexes, but the increase was only statistically significant in women [Table 2]. The proportion of students who maintained or increased their body fat weight was 63.5% for women and 57.2% for men.{Table 2}

[Table 3] shows the changes in the measured cardiovascular parameters by gender, showing a significant decrease in HRpeak and HR at the first minute, both in men as well as in women, following the intervention. The recovery HR at the 1st min decreased significantly in women (P = 0.012). The improvement in test performance efficiency was significant in both sexes.{Table 3}

The analysis of the number of individuals with healthy ranges according to international criteria showed a significant increase (P < 0.001) in aerobic capacity and flexibility for both sexes [Figure 1]. In men, there was an increased number of individuals with healthy body fat percentage criteria although this difference was not significant.{Figure 1}

 Discussion



In a world where noncommunicable chronic diseases steadily increase and cause 36 million deaths per year (world health), the training of health professionals in physical activity and exercise prescription is essential to promote the use of this tool for preventing and treating these pathologies.[25],[26] Physicians are professionals who should be familiar with the benefits of physical activity, carrying it out and internalizing it in their lives so that they can then adequately recommend it to their patients.[27],[28],[29] Nevertheless, only 12 of the 102 medical schools include physical activity education courses within their curriculum, and in only six of these have an important place within the curriculum, with an average of 5 h during the first 2 years of the study and an average of 6 h in the final 2 years.[11],[30] Our medical school has implemented an independent and required course, with 54 scheduled hours in the 3rd year.

Although the intervention period was relatively short, students showed significant changes in the measured fitness variables, both in men and women, in all the intervention groups, increasing the number of individuals who achieve a healthy status according to the extensive evidence linking improved functional capacity, muscular strength, and cardiovascular performance levels with health.[4] One factor that might have influenced the results is that the students received a grade according to their performance on the tests and the improvement of the same. Therefore, they might have had a greater motivation to perform better on the final test. However, the analysis of maximum HR showed that performance was maximal in both measurements of the cardiovascular test, being close to 194 beats/min for both sexes, in accord with the theoretical estimates for this age group.[31]

The HR analysis showed an important improvement in motor performance efficiency by the significant increase in the ratio of HRpeak and distance covered, a physiological variable that implies a large number of cardiovascular, neuromuscular, and endocrine adaptations in response to physical training, which positively impacts health.[23],[32] In women, there was a significant increase in vagal activity seen in the improvement in HR recovery at the first minute, which is considered to be an additional benefit due to its relationship to a decrease in general mortality.[33],[34]

With regard to the anthropometric variables, an increase in weight, BMI, and total body fat content in the students could be expected, according to previous findings in medical students in Colombia.[35],[36] In addition, in our National Survey of Nutritional Status ENSIN 2010, in the group of 18–22 years, the average weight is higher, i.e., 0.56 kg each year in women and 0.84 kg in men,[8] and in international prospective studies, it can be seen that the general population increases between 0.4 and 0.9 kg/year.[37] Further, the program is not focused on weight reduction and does not control the students' diet, and the length of the intervention with physical activity was short, only 180 min/week and noncontinuous. However, it was interesting to note that 36.5% of women and 42.8% of men decreased their body fat weight, with a greater impact on male adiposity, a sex difference that has been obtained in other studies.[38],[39] In this study, the same set of students were taken as the control group, assessed at two different times, but we are planning to use an independent control group for future comparisons.

The mandatory nature of the course, as opposed to elective or selective educational interventions, allows most medical students to be exposed, not only those who already have an interest in physical activity. This increases the probability that the message will ultimately reach the patients of all these future physicians,[16],[40] thus cooperating with public health by providing education and the possibility of physical activity behaviors to the least active people who are at the greatest risk of morbidity and mortality.[41]

We anticipate that as students experience how to train the various fitness components, their own progress, the benefits of fitness, and improve their knowledge regarding exercise, (how to train it and thereby how to prescribe it), with the support of some theoretical classes that explain the achievements from a physiological perspective, they will be more likely to include physical activity in their own lives, prescribe it to their patients,[36],[42] and serve as better role models for their patients. This should be evaluated in a later study when these students are practicing professionals.

The findings of the current study show that a 54 h physical activity course within the medicine curriculum had a positive impact on health-related fitness indicators of students.

Acknowledgments

The authors thank University of Rosario for the support given to the Sports Medicine and Physical Activity course from which this study is derived.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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