Applicability of time-restricted eating for the prevention of lifestyle-dependent diseases in a working population: results of a pilot study in a pre-post design.

Background: The ongoing epidemic of lifestyle-dependent diseases in industrialized countries threatens to overtax the health and social systems of these nations. New approaches beyond the usual therapeutic and preventive measures which have been applied so far must be tested. A paradigm shift with regard to nutrition and associated illness is overdue. Time-restricted eating (TRE) offers a low-threshold and easy-to-implement lifestyle change which may have what it takes for broad, population-wide applicability and a widely diversified range of possible effects. In this pilot study, we examine the feasibility and adherence of TRE in healthy adult employees. Methods: Pre-post design study with healthy volunteers from the staff of Ulm University and Ulm University Hospital. Participants were asked to reduce their daily eating time to 8-9 hours for three months. Surrounding the eating time, they were allowed drinks other than water for 12 hours, and water for the rest of the day. Anthropometric measurements were taken by trained staff, and blood samples were taken at baseline and follow-up. Pre- and post-data on lifestyle, health and health-related quality of life (HRQoL, recorded with the Visual Analog Scale (VAS) of the EuroQol 5-Dimension (EQ-5D)), and attitudes towards TRE were collected in questionnaires. During the course of the study, timing of the first and the last meal, as well as sleep duration and quality, were assessed in diaries. Primary outcome was the percentage of days with achievement of the fasting goal out of the total number of days recorded per participant. Results: Sixty-three participants (aged 47.8±10.5 years, 86% female) were recruited and started the intervention immediately after the baseline assessment. Two persons dropped out while all others finished the study. Ratings of compatibility of TRE with professional activities were good in 78% of participants, neither good nor difficult in 3%, and 18% reported to have encountered some difficulties. On average, the fasting target was reached on 72.2±18.9% of the recorded days. After three months of TRE, participants showed moderate reductions in weight (-1.3±2.3 kg, p≤0.001) and waist circumference (-1.7±3.2 cm, p≤0.001). HRQoL increased significantly by 5.8±12.4 (p=0.008) points between baseline and follow-up. Conclusion: TRE is feasible and well accepted, even in regularly employed persons, and may improve HRQoL. TRE may help to reduce obesity and abdominal obesity in adult working people, thereby preventing lifestyle-dependent diseases; however, volunteers need more guidance to increase effects.

Developing a seminar curriculum for the Competence Center for General Practice in Baden-Wuerttemberg - a progress report.

Aim: The seminar program of the KWBW Verbundweiterbildungplus® is offered by the Competence Center for Postgraduate Medical Education in Baden-Württemberg (KWBW) for physicians specializing in general practice (GP trainees). Attendance is a voluntary one comprised of 48 curricular units of 45 minutes each per GP trainee. This seminar program is meant to be attended in parallel to the postgraduate medical education in clinic or practice. The intention behind this project was to develop objectives, topics and a feasible structure for a seminar curriculum while taking time and financial constraints into account. Method: The Kern cycle was applied in an open, modified nominal group consensus technique in the form of an iterative process. Participating were 17 experts from the departments of general practice at the universities in Freiburg, Heidelberg, Tuebingen and Ulm, plus a pediatrician. Results: The main objective was defined as empowering GP trainees to independently provide high-quality primary care, including in rural areas. A basic curriculum was defined based on relevant frameworks, such as the 2018 Model Regulation for Postgraduate Medical Training (Musterweiterbildungsordnung/MWBO) and the Competency-based Curriculum General Practice (KCA). Overall, the seminar curriculum has 62 basic modules with 2 curricular units each (e.g. Basic Principles of General Practice, Chest Pain, Billing) and another 58 two-unit modules on variable topics (e.g. digitalization, travel medicine) adding up to 240 (124+116) curricular units. A blueprint with a rotation schedule for all of the teaching sites in Baden-Württemberg allows regular attendance by n=400 GP trainees over a period of five years, with individual variability in terms of program length. Conclusion: The model entails a five-year, flexible program to accompany the postgraduate medical education in general practice which can also be implemented in multicenter programs and those with high enrollments. The model's focus is on acquisition of core competencies for general practice. Despite the current shift to eLearning seminars due to SARS-CoV, the program's implementation is being continued, constantly evaluated, and used to further develop the KWBW Verbundweiterbildungplus® program.

Didactic qualification of teaching staff in primary care medicine - a position paper of the Primary Care Committee of the Society for Medical Education.

Having teaching staff with didactic qualifications in university teaching leads to a measurable improvement in academic skills among students. Previous recommendations on the type and scope of medical didactic qualification measures primarily apply to teaching staff at university and in-patient settings. The situation of primary care medicine, which often employs external lecturers and whose teaching takes place to a considerable extent in decentralized training facilities (teaching practices) is not adequately addressed. Taking into account a survey on the status quo at higher education institutions for General Practice in Germany, recommendations for minimum standards are made, based on national and international recommendations on the content and scope of medical didactic qualification measures. These recommendations include preliminary work by the Personnel and Organizational Development in Teaching (POiL) Committee of the Society for Medical Education (GMA), the MedicalTeachingNetwork (MDN), the Society of University Teaching Staff in General Medicine (GHA) as well as the experiences of the committee members, who hail from the field of general medicine, internal medicine and pediatrics amongst others.

Adherence to Time-Restricted Feeding and Impact on Abdominal Obesity in Primary Care Patients: Results of a Pilot Study in a Pre-Post Design.

The epidemic of lifestyle-dependent diseases and the failure of previous interventions to combat the main causes demand an alternative approach. Abdominal obesity is associated with most of these diseases and is a good target for therapeutic and preventive measures. Time-restricted feeding (TRF) offers a low-threshold, easy-to-implement lifestyle-modification concept with promising results from animal testing. Here, we describe a pilot study of TRF with abdominally obese participants (waist-to-height ratio, WHtR ≥0.5) in a general practitioner's office. Participants (n = 40, aged 49.1 ± 12.4, 31 females) were asked to restrict their daily eating time to 8-9 hours in order to prolong their overnight fasting period to 15-16 hours. Questionnaires, anthropometrics, and blood samples were used at baseline and at follow-up. After three months of TRF, participants had reached the fasting target, on average, on 85.5 ± 15.2% of all days recorded. Waist circumference (WC) was reduced by -5.3 ± 3.1cm (p < 0.001), and three participants reached a WHtR <0.5. HbA1c was diminished by -1.4 ± 3.5 mmol/mol (p = 0.003). TRF may be an easily understandable and readily adoptable lifestyle change with the potential to reduce abdominal obesity and lower the risk for cardiometabolic diseases. Further well-designed studies are necessary to investigate the applicability and usefulness of TRF for public health.

Recommendations for undergraduate training in the primary care sector--position paper of the GMA-Primary Care Committee.

During their studies to become medical professionals, all students are obliged to become familiar with various aspects of primary care. The aim is to provide all students with a high quality training which ensures the best possible cooperation across all sectors of the medical system. Primary care comprises the primary use of the medical service by an unfiltered set of patients as well as continued patient care--including home-care. This position paper was developed together with representatives of the German Society of University Teachers of General Practice (GHA), the German Society for Ambulatory General Paediatrics (DGAAP), the German Society of General Practice and Family Medicine (DEGAM) and the German Society for Internal Medicine (DGIM). It includes recommendations for teaching in the field of primary care in four different types of internships such as preclinical work experience ("Hospitation"), 4-week clinical traineeships of a casual nature ("Famulatur") and 2-week courses of structured and assessed clinical training ("Blockpraktikum") as well as a broad-based 4-month elective clinical placement in the final year (known as a practical year, "PJ"). The recommendations encompass structural and process criteria for internships in different general practices. In addition, for the first time recommendations for teaching on campus--in the fields of general medicine, paediatrics, numerous cross-sectional areas and other clinical fields, but also for clinical skills training--are set down here. In this position paper the intention is to demonstrate the possible ways in which more aspects of primary care could be integrated into undergraduate medical training.

[Drug therapy in primary care in the light of discount contracts to health insurers--a patient survey]. / Die medikamentöse Therapie in der hausärzt- lichen Versorgung unter dem Aspekt der Rabattverträge der Krankenkassen--Patientensurvey.

BACKGROUND: Since April 1, 2007 pharmacists in Germany are obligated by law to dispense products from particular manufacturers with whom the health insurance funds have entered into discount agreements. Only by ticking the relevant tick box ("Aut Idem") on the prescription form can the prescriber insist on a drug of a specific company. METHODOLOGY: A standardized questionnaire was designed and piloted in a small group and adapted accordingly. By means of this questionnaire patients were asked about their experiences with drug discount contracts. RESULTS: 226 patients participated in this study. 75% of the participants had knowledge of these contracts. 64.6% of the patients were concerned about substitute drugs. 32.1% took no longer the drugs regularly, and 21.2% indicated that they were confused by the changed packaging of medicinal drugs. 79.5% of the participants wanted to keep their old, familiar drug, and 53.7% of the participants insisted on receiving their familiar medication against the prescriber's prescription. DISCUSSION: The survey shows that patients feel irritated by their medication and that medication errors occur. In addition, GPs and pharmacists must inform patients about the discount contracts (substitution). Many participants wanted to keep or insist on their familiar medication and compliance and physician-patient-relationship could be compromised. CONCLUSION: This intervention by the health insurance funds interferes with the medical treatment of patients. Such far-reaching changes in medication might lead to life-threatening situations.

Virtual patients for assessing medical students--important aspects when considering the introduction of a new assessment format.

BACKGROUND: A case-based online assessment tool has been accomplished at the University of Ulm by simulating consultations with virtual patients in General Practice setting. After a successful pilot study, more data on validity were needed as one important step when considering introducing this assessment format to replace the regular written course exam. METHODS: Five distinct sources of validity evidence are addressed: content, response process, internal structure, relationship to other variables and consequences. An examination simulation was conducted including all students (147) of the General Practice course, scores of three virtual patient cases compared with the written course exam and data gathered regarding usability, acceptance, content and structural characteristics, and consequences. RESULTS: All five aspects were supported by collected data. Correlation to the written exam was moderate with r = 0.36, correlation between the cases higher with r = 0.50-0.56. CONCLUSION: Although a direct comparison of written course exams and dealing with virtual patients is difficult in many aspects and the study setting as an exam simulation caused confounders, this new assessment format is supported by many aspects of validity evidence. Solving virtual clinical scenarios addresses other abilities, skills and knowledge than traditional written exams and since "assessment drives learning" it could have positive implications on teaching and learning alike.

Faculty development in general practice in Germany: experiences, evaluations, perspectives.

From 1999 to 2001, the German Society of General Practice and Family Medicine (DEGAM) pioneered a faculty development programme to help general practitioners (GPs) interested in an academic career to develop their skills in teaching, primary care, quality assurance and research. The programme involves five weekend-training sessions over 18 months and applies a learner-centred approach. Participants choose the learning formats and switch between the roles of learners, teachers, chair persons and programme organizers. This article evaluates the acceptability and feasibility of the programme. Data were collected over a two-year period from the 16 participants who completed the first training programme. The evaluation involved a focus group, telephone interviews and email questionnaires. Participants appreciated the learner centred format of the programme and gained new teaching and research skills. They also learned to better assess and critically reflect on their professional work as GPs and reported improved academic 'survival skills' due to collaborative networks with colleagues. The faculty development programme proved advantageous for the personal and professional development of the participating GPs. It constitutes a promising tool for the further development of General Practice as an academic discipline that is still in the process of establishing itself at medical schools in Germany.

[A complex process: decision-making in general practice: 117 structured case analyses]. / Die hausärztliche Entscheidungsfindung--Ein komplexer Vorgang: Qualitative Analyse von 117 Patientenkasuistiken.

BACKGROUND: A variety of factors seem to play a role in decision-making in general practice. To describe the complexity of this process a vague symptom with a broad spectrum of possible causes and outcomes was chosen: dizziness. Aim of this study was to provide a conceptual framework to describe and assess the complex reasoning process of general practitioners. METHODS: 22 GPs were interviewed about the patients seeking help for dizziness. The semi-structured focussed interviews were qualitatively analysed by consensus method. RESULTS: By 117 structured case analyses factors with influence on the decision-making process were identified and assigned to 7 different domains. Concepts described in literature were found as well as less well-known or even not accepted motives. CONCLUSIONS: Influenced by a variety of parameters, the decision-making process in general practice is complex. It is necessary to be aware of them to be able to deal with them.

A comparison of different strategies to collect standard gamble utilities.

OBJECTIVE: The authors performed a methodological comparison of the usual standard gamble with methods that could also be used in mailed questionnaires. METHODS: Ninety-two diabetic patients valued diabetes-related health states twice. In face-to-face interviews, the authors used an iterative standard gamble (ISG) in which the probabilities were varied in a ping-pong manner and a self-completion method (SC) with top-down titration as search procedure (SC-TD) in 2 independent subsamples of 46 patients. Three months later, all patients received a mailed questionnaire in which the authors used the self-completion method with bottom-up (SCBU) and SC-TD as search procedures. RESULTS: ISG and SCTD showed feasibility and consistency in the interviews. The ISG resulted in significantly higher utilities than the SC-TD. Two thirds of the mailed questionnaires provided useful results indicating some problems of feasibility. Utilities measured by SC-BU and SC-TD did not differ significantly showing procedural invariance. Further, patients indicated ambivalence when given the choice not to definitely state their preferences. CONCLUSIONS: The results show that different strategies to collect standard gamble utilities can yield different results. Compared with the usually applied ISG, the SC method is feasible in interviews and provides a consistent alternative that is less costly when used in mailed questionnaires, although its practicability has to be improved in this later setting.