Royal College of General Practitioners - Online Learning Environment

Intermittent fasting (IF) is a pattern of eating whereby the person undertakes a regular (usually daily) fast of at least 16 hours. In light of National Obesity Awareness Week in January or in keeping with New Year’s resolutions, patients may seek advice on weight loss from their GP and opinions on the efficacy of certain diets. This blog will discuss some of the evidence around fasting for weight loss and management of type 2 diabetes (T2D) and other cardiovascular risk factors.  

Ingested food is stored in the body as liver glycogen and as fat, the process of lipogenesis being mediated by insulin. Energy is provided by glycogenolysis, however after around 12 hours of fasting, hepatic glycogen becomes depleted and adipose tissue lipolysis begins to occur. A recent NEJM review article suggested that ‘intermittent  fasting  elicits  evolutionarily  conserved,  adaptive  cellular  responses  that  are  integrated  between  and  within  organs  in  a  manner  that  improves  glucose  regulation,  increases  stress  resistance,  and  sup-presses inflammation”¹

For patients, we can explain that across our evolution we not always had access to three meals a day, and that after about 8 to 12 hours the body enters a ‘fat burning’ phase.

There are many ways to fast, with the most basic being a fast of at least 16 continuous hours in every 24. To get results in terms of weight loss or increased health benefits, the fasts should ideally be done on a daily basis. Two popular IF methods are as follows:

• 16:8 – Fast for 16 hours and eat all meals within an 8 hour window. This typically means skipping breakfast and eating two meals a day.

• 20:4 – Fast for 20 hours and eat all meals within a 4 hour window. This would involve eating one meal or having two smaller meals a day.

 A relatively short fast of 16 hours can be incorporated as part of daily life. The ‘intermittent’ nature of IF is that the fasting is flexible and at the convenience of the individual – the number of fasts per day and the exact hours of fasting can be altered if needed e.g. to allow the patient to eat normally at a social event.

Alternative methods include the 5:2 diet, which includes eating a balanced diet for 5 days out of the week and only consuming 500 calories for the remaining 2 days. Whilst this has been shown as an effective method for weight loss, it differs from intermittent fasting as it involves reducing calorie intake instead of not eating at all. 

There is evidence to suggest that IF may reduce the need for prescribed insulin in patients with diabetes².

IF is a relatively new concept, with some studies being small and of short duration; longer and larger studies are needed. Some examples of the evidence around IF are given below:

• A 2014 crossover study of 54 patients with T2D found that the group which ate only two meals per day, had better outcomes than those who ate the same calories spread out over six smaller meals. The group eating only two meals per day had a greater reduction in BMI, waist circumference and fasting plasma glucose³.

• A 2015 literature review of 15 studies found that various types of fasting reduced weight and improved lipid profiles and called for further research, with greater information about food intake so as to differentiate between the benefits of fasting and the benefits of calorie restriction⁴

• A 2019 study randomised 88 obese women into four groups (control, calorie restriction and IF with or without calorie restriction). All food was measured and provided by the study. Those who fasted for 24 hours three times a week lost more weight than those who simply restricted their calories, even though the calorie intake of the two groups was identical. The fasting group also had lower lipids and fat mass than the calorie restriction group⁵.

• A 2019 study of 15 men who limited their food intake to nine hours in each 24 hour period, whilst wearing a continuous glucose monitor, were found to have improved glucose tolerance and fasting triglycerides during the fasting period compared to the control period⁶.
• Another 2019 study followed 19 participants with metabolic syndrome who limited their dietary intake to a 10 hour period for 12 weeks. There were significant reductions in BMI, waist circumference, LDL cholesterol and blood pressure⁷.

It seems that IF therefore has the potential to be beneficial for patients with T2D and metabolic syndrome; it may be the case that educating patients on the benefits of IF can help in the management of T2D and reduce the need for pharmacological interventions⁸.

IF is a relatively new concept in relation to T2D so there are no official guidelines for healthcare professionals on how to manage a diabetic patient who wishes to do try it. As with any kind of fast, it is not recommended for pregnant/breastfeeding women or for children.

RCGP members can find out more about using diet to manage Type 2 diabetes by accessing our eLearning course on ‘Type 2 diabetes and the low GI diet’. Non-members can pay £25 to access this course.

The following resources are free to both members and non-members:

• ‘Five Minutes to Change your Practice’ screencast on Updated management of type 2 diabetes in adults
• EKU Journal watch item on Effects of intermittent fasting on health, aging, and disease

RCGP members can also benefit from free access to the following resources on Type 2 diabetes:

• EKU17: Diabetes in Adults, Children & Young People (Type 1 & 2)
• EKU18: Type 2 Diabetes in Adults: Management
• EKU Screencast: Type 2 diabetes in adults: management

References

1 De Cabo, R., & Mattson, M. P. (2019). Effects of Intermittent Fasting on Health, Aging, and Disease. New England Journal of Medicine, 381(26), 2541–2551. doi:10.1056/nejmra1905136

² Diabetes UK,  2019. About Type 2 diabetes. [Online] Available at: https://www.diabetes.org.uk/Type-2-diabetes

³ Kahleova H, Belinova L, Malinska H, et al. Eating two larger meals a day (breakfast and lunch) is more effective than six smaller meals in a reduced-energy regimen for patients with type 2 diabetes: a randomised crossover study [published correction appears in Diabetologia. 2015 Jan;58(1):205]. Diabetologia. 2014;57(8):1552–1560. doi:10.1007/s00125-014-3253-5

⁴ Grant M. Tinsley, Paul M. La Bounty, Effects of intermittent fasting on body composition and clinical health markers in humans, Nutrition Reviews, Volume 73, Issue 10, October 2015, Pages 661–674,

⁵Hutchison A.T. et. al., 2019. Effects of Intermittent Versus Continuous Energy Intakes on Insulin Sensitivity and Metabolic Risk in Women with Overweight. Obesity (Silver Spring). 2019 Jan;27(1):50-58

⁶Hutchison A.T., et. al., 2019. Time-Restricted Feeding Improves Glucose Tolerance in Men at Risk for Type 2 Diabetes: A Randomized Crossover Trial. Obesity (Silver Spring). 2019 May;27(5):724-732. Available at https://www.ncbi.nlm.nih.gov/pubmed/31002478

⁷Wilkinson M.J. et. al., 2019. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2019 Dec 2. pii: S1550-4131(19)30611-4. Available at https://www.sciencedirect.com/science/article/pii/S1550413119306114

⁸ Firmly S., et al., 2018. Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/

Many thanks to Dr Rachel Hudson and Dr Claudia Camden-Smith for their help with producing this blog. 

Stress is a problem

Being a GP can be an extremely varied and rewarding career, but the pressure of dealing with an ever-increasing number of patients every day can take its toll.  It’s estimated that GPs in England alone provide first contact care to more than 1.2 million patients per day¹. Many practices struggle with staffing levels, meaning that some GPs are taking on even larger list sizes than before.

According to the Ninth National GP Worklife Survey² of 2195 GPs, the average reported working week was 41.8 hours, which has stayed consistent since 2008. Nine out of ten GPs reported experiencing considerable or high pressure from increasing workloads, amongst other stressors such as paperwork and having insufficient time in the working day to do their jobs. The 2015 Commonwealth Fund International Survey of Primary Care Physicians found that GPs in the UK had the highest levels of stress out of the 10 nations surveyed³

A GP’s personal life can also be affected. The GMC’s 2018 report on ‘The state of medical education and practice in the UK’ found that 72% of younger GPs feel that their work-life balance has deteriorated as a result of their stress at work. The report also found that one out of four doctors had considered leaving the medical profession at least every month. One of the most alarming findings was that two out of every 100 doctors said that they had to take a leave of absence due to stress for at least one month in the last year⁴.

With many GPs regularly fearing that they can’t cope in their current roles, it’s not surprising that burnout is increasing. The BMA’s 2019 report on ‘Caring for the mental health of the medical workforce’ found that a total of 88% of GP partners and 85% of sessional GPs face a 'high' or 'very high' risk of burnout⁵.  Regional reports from the RCGP found that a proportion of GPs feel so stressed that they are unable to cope. The figures for this were 31% in Wales⁶, 37% in Scotland⁷ and 32% in Northern Ireland⁸.

Recognising the signs of stress and burnout

Even though GPs are expected to recognise the signs in their patients, they may not always realise that they are stressed themselves. It’s easy to plough on with day-to-day tasks and to become consumed with work, so the tell-tale signs such as irritability, poor sleep and increased alcohol use may be missed. The NHS website page on stress includes lists of the physical, mental and behavioural symptoms that may be overlooked.

The NHS Practitioner Health Programme (PHP) was launched in 2008, with the addition of the NHS General Practitioner Health Service (GPH) in 2017. These services aim to provide support to practitioners who are struggling with mental health or addiction problems, so that they can find help before these issues escalate further. According to the PHP’s report on their first 10 years of service, around half of all PHP patients are GPs. Between 2008 and 2018, over 5000 doctors presented to PHP and 83.5% of these were due to mental health problems. For GPs specifically, this figure rises to 88%, with 10% presenting with addiction problems. The remaining 2% is classified as ‘other’¹. In general, NHS staff have higher sickness rates than the rest of the economy. The latest sickness absence reports, from NHS digital, show that the sickness rate is now at 4.23% in England. From the sicknesses reported, 27.1% of Full Time Equivalent (FTE) days were lost due to anxiety, stress, depression or other psychiatric illnesses⁹.

Dealing with stress

Resilience is mentioned a lot in relation to managing stress. It can be defined as “the ability to adapt and succeed in the face of adversity and stress”. A resilient person can maintain their wellbeing and continue moving forward when they are tested by life’s difficulties. Being resilient doesn’t come naturally to everyone and can be something to develop over time. The Chartered Institute of Personnel and Development have produced ‘Developing resilience: a guide for practitioners’  which contains evidence-based guidance. NHS England also looks at resilience from a clinician’s point of view and summarises the 'Eight principles for being a resilient doctor' which are set out by the Australian Medical Association. These principles focus on the changes that can be made in everyday life to help with developing resilience.

Taking time to improve wellbeing can be a good stress-reliever. The New Economics Foundation (NEF) outlines ‘Five ways to wellbeing’, These consist of:

• Connect – Make time for family and friends. Build relationships with colleagues and neighbours. Become part of your local community.
• Take notice – Think about what matters to you most and take time to appreciate it. Be aware of your feelings and emotions. Try meditation and mindfulness.
• Keep learning – Try something new and embrace new experiences. Learning a new skill can boost your confidence and create an escape from stressors.
• Be active – Think about which physical activity you enjoy and that suits you. Regular exercise is associated with lower rates of depression and anxiety and helps to slow down age-related cognitive decline.
• Give – Do something nice for a friend or stranger or volunteer your time to the community. Feeling part of a wider community can be rewarding and build connections with those around you.

In order to ensure the wellbeing of doctors in their workplace, the GMC outline an ‘ABC of doctors’ core needs’. When these needs are met, it’s suggested that people are more motivated and have better overall health and wellbeing. Even if one of the needs is not met, it can have a negative impact on a doctor’s wellbeing and motivation. The following needs are taken from the GMC’s ‘Caring for doctors Caring for patients’ report¹⁰

• Autonomy or control – the need to have control over our work lives, and to act consistently with our work and life values.
• Belonging – the need to be connected to, cared for, and caring of others around us in the workplace and to feel valued, respected and supported.
• Competence – the need to experience effectiveness and deliver valued outcomes, such as high-quality care.

The RCGP recognises that being a GP is one of the most difficult jobs in medicine. As the first point of contact for most patients, a GP sees an average of 41 patients per day¹¹. The RCGP’s ‘Fit for the Future’ campaign is the College’s vision for the future of general practice. It covers the changing role of the GP, the tools and skills needed to fulfil this role and the vision of an expanding general practice workforce. This campaign outlines the ways that primary care can adapt to ever-changing health needs and ultimately help to relieve the dangerous levels of stress that GPs currently face.

Further information about the ‘Fit for the Future’ campaign can be found on the RCGP website.

Getting help

For any GPs who are struggling with the pressures of their role or showing signs of stress or burnout, the following resources may help:

• NHS GP Health service – Confidential service for GPs and GP trainees in England. It can help with issues relating to mental health, including stress or depression, or addiction problems. It’s provided by health professionals with expertise in addressing the issues concerning doctors. The BMA also have a support service that is open to the whole of the UK.
• Online cognitive behavioural therapy (CBT) – This can be accessed via your local ‘Improving Access to Psychological Therapies’ scheme in England. In Scotland, there are online self-help resources available on ‘Moodjuice’.  The ‘Living Life to the Full’ website also contains many online CBT resources that are available throughout the UK.
• The Balint Society – The society aims to help all health and social care professionals in the UK better understand the emotional content of their patient relationships. As a member of the Balint Society you can join a ‘Balint group’, which is a gathering for members to discuss particularly difficult patient cases confidentially in a safe space.
• Mentoring – Becoming a mentor or mentee provides an opportunity to develop professionally and discuss any work-based issues. In either role, mentoring can be a great way to get further insights in to your own working situation, whilst having an impartial sounding board for any difficulties experienced in your role.  You can find out more about The Faculty of Medical Leadership and Management (FMLM) mentoring scheme. You can also contact your local RCGP Faculty to see if any local mentorship schemes are available. Further mentoring resources can be found on the BMA website.
• Mental health apps – A range of different apps that can help with anxiety, self-harm and exploring mindfulness are listed on the NHS website.
• Big White Wall – This website offers a support network, resources for self-management and live therapy via text, audio or secure video. It is accessible, for free, to UK serving personnel, veterans and their families, and some UK Universities and colleges. It is also available in some locations via the NHS. Eligibility can be checked via their website.
• The RCGP provides support and advice on GP wellbeing and mental health.
• A list of further support services that are specifically aimed at GPs in England can be found on the NHS website. If you are registered with GP Online, you can also access a list of support organisations on their website.

References

¹  NHS Practitioner Health Service. 2018. The Wounded Healer: Report on the First 10 Years of Practitioner Health Service. [Online]. Available from: http://php.nhs.uk/wp-content/uploads/sites/26/2018/10/PHP-report-web.pdf

²  Policy Research Unit in Commissioning and the Healthcare System. 2017. Ninth National GP Worklife Survey. [Online]. Available from: http://dudleylmc.org/oldsite/archived/www.mrsite.co.uk/usersitesv22/dudleylmc.org/wwwroot/USERIMAGES/Ninth-National-GP-Worklife-Survey.pdf

³  The Commonwealth Fund. 2015. 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. [Online]. Available from: https://www.commonwealthfund.org/publications/surveys/2015/dec/2015-commonwealth-fund-international-survey-primary-care-physicians

⁴  General Medical Council. 2018. The state of medical education and practice in the UK. [Online]. Available from: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/the-state-of-medical-education-and-practice-in-the-uk

⁵  British Medical Association. 2019. Caring for the mental health of the medical workforce. [Online].

⁶  Royal College of General Practitioners Wales. 2018. Transforming general practice: Building a profession fit for the future. [Online].

⁷  Royal College of General Practitioners Scotland. 2019. From the Frontline. The Changing landscape of Scottish general practice. [Online]. Available from: https://www.rcgp.org.uk/getmedia/6a6e4f92-1110-4c84-8ce9-589a8f4eeb48/RCGP-scotland-frontline-june-2019.pdf

⁸  Royal College of General Practitioners Northern Ireland. 2019. Royal College of General Practitioners Northern Ireland GPs Survey. [Online]. Available from: https://www.comresglobal.com/wp-content/uploads/2019/11/RCGP_ComRes_Northern-Ireland-GPs-Survey_Wave-4_Tables.pdf

⁹  NHS Digital. 2019. NHS Sickness Absence Rates, July 2019, Provisional Statistics. [Online]. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-sickness-absence-rates/july-2019-provisional-statistics

¹⁰  General Medical Council. 2019. Caring for doctors Caring for patients. [Online]. Available from:  https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf     

¹¹  Pulse. 2018. GPs have almost twice the safe number of patient contacts a day. [Online]. Available from: http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/gps-have-almost-twice-the-safe-number-of-patient-contacts-a-day/20035863.article