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OBJECTIVE Sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA) reduce body weight and improve cardiometabolic health, but their effect on physical activity is unknown. RESEARCH DESIGN AND METHODS We pooled data (n = 148) from three randomized trials to investigate the effect of empagliflozin (SGLT2i) and liraglutide (GLP-1RA), in comparison with sitagliptin (dipeptidyl peptidase 4 inhibitor) and dietary therapies, on accelerometer-assessed physical activity. RESULTS Liraglutide (mean −1,144 steps/day; 95% CI −2,069 to −220), empagliflozin (−1,132 steps/day; −1,739, −524), and sitagliptin (−852 steps/day; −1,625, −78) resulted in reduced total daily physical activity after 6 months (P < 0.01 vs. control). Moderate- to vigorous-intensity physical activity was also reduced. Dietary interventions led to no change or an increase in physical activity. CONCLUSIONS The initiation of all glucose-lowering therapies was associated with reduced physical activity, warranting further investigation.

High physical activity levels during wake are beneficial for health, while high movement levels during sleep are detrimental to health. Our aim was to compare the associations of accelerometer-assessed physical activity and sleep disruption with adiposity and fitness using standardized and individualized wake and sleep windows. People (N = 609) with type 2 diabetes wore an accelerometer for up to 8 days. Waist circumference, body fat percentage, Short Physical Performance Battery (SPPB) test score, sit-to-stands, and resting heart rate were assessed. Physical activity was assessed via the average acceleration and intensity distribution (intensity gradient) over standardized (most active 16 continuous hours (M16h)) and individualized wake windows. Sleep disruption was assessed via the average acceleration over standardized (least active 8 continuous hours (L8h)) and individualized sleep windows. Average acceleration and intensity distribution during the wake window were beneficially associated with adiposity and fitness, while average acceleration during the sleep window was detrimentally associated with adiposity and fitness. Point estimates for the associations were slightly stronger for the standardized than for individualized wake/sleep windows. In conclusion, standardized wake and sleep windows may have stronger associations with health due to capturing variations in sleep durations across individuals, while individualized windows represent a purer measure of wake/sleep behaviors.

Type 2 diabetes (T2D) confers a high risk of heart failure frequently with evidence of cardiovascular structural and functional abnormalities before symptom onset. The effects of remission of T2D on cardiovascular structure and function are unknown. The impact of the remission of T2D, beyond weight loss and glycaemia, on cardiovascular structure and function and exercise capacity is described. Adults with T2D without cardiovascular disease underwent multimodality cardiovascular imaging, cardiopulmonary exercise testing and cardiometabolic profiling. T2D remission cases (Glycated hemoglobin (HbA1c) < 6.5% without glucose-lowering therapy, ≥3 months) were propensity score matched 1:4 based on age, sex, ethnicity and time of exposure to those with active T2D (n = 100) with the nearest-neighbour method and 1:1 with non-T2D controls (n = 25). T2D remission was associated with a lower leptin–adiponectin ratio, hepatic steatosis and triglycerides, a trend towards greater exercise capacity and significantly lower minute ventilation/carbon dioxide production (VE/VCO2 slope) vs. active T2D (27.74 ± 3.95 vs. 30.52 ± 5.46, p < 0.0025). Evidence of concentric remodeling remained in T2D remission vs. controls (left ventricular mass/volume ratio 0.88 ± 0.10 vs. 0.80 ± 0.10, p < 0.025). T2D remission is associated with an improved metabolic risk profile and ventilatory response to exercise without concomitant improvements in cardiovascular structure or function. There is a requirement for continued attention to risk factor control for this important patient population.

OBJECTIVE: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1RA) reduce body weight and improve cardiometabolic health, but their effect on physical activity is unknown. RESEARCH DESIGN AND METHODS. We pooled data (n = 148) from three randomised trials to investigate the effect of empagliflozin (SGLT2i) and liraglutide (GLP-1RA), in comparison to sitagliptin (dipeptidyl peptidase 4 inhibitor) and dietary therapies on accelerometer-assessed physical activity. RESULTS: Liraglutide (-1144 steps/day; 95% CI -2069, -220), empagliflozin (-1132 steps/day; -1739, -524) and sitagliptin (-852 steps/day; -1625, -78) resulted in reduced total daily physical activity after 6 months (p< 0.01 vs. control). Moderate-to-vigorous intensity physical activity was also reduced. Dietary interventions led to no change or an increase in physical activity. CONCLUSIONS: The initiation of all glucose lowering therapies was associated with reduced physical activity, warranting further investigation.

Background Type 2 diabetes, which contributes 90% of all cases of diabetes mellitus is now mostly managed in the primary care settings in the UK and other advanced health care systems. The UK National Health Service as a whole could potentially benefit if more patients were managed in primary care settings since primary care‐based care is likely to be more cost‐effective. We initially compared eight larger general practices (Enhanced practices) in Leicester, UK with neighbouring smaller practices (Core practices) matched for comparable demographic characteristics. Even though this initial study did not find any statistically significant differences in terms of clinical outcomes there was trend in favour of the enhanced practices. In this current study, we conducted a cost comparison of enhanced practice model of diabetes care, to standard care delivered in the core practices. Methods Data and information were combined from a number of sources and a cost comparison evaluation was carried out in WinBUGs. A probabilistic approach was taken, to allow uncertainty to be included around analysis parameters where appropriate. The analysis evaluated a straight-forward cost comparison of enhanced versus standard care. Results The cost per person with diabetes per year was £255 (95% CrI 175, 380) in the core practices and £173 (95% CrI 96, 291) in the enhanced practices, resulting in an annual cost saving of –£83 (95% CrI -148, -28) per patient. If the enhanced model of diabetes care were delivered across all the practices in the UK, the cost would be £575,100,000 (95% CrI 320,700,000, 970,700,000), resulting in an annual cost saving of -276,200,000 (95% CrI -495,400,000, -94,480,000). Conclusion A cost comparison analysis of our larger enhanced primary care based diabetes service confirms significant cost saving, probably driven by economies of scale. These benefits could be multiplied manifold if the service was implemented nationally.

To investigate the relationship between fibro-inflammatory biomarkers and cardiovascular structure/function in people with Type 2 Diabetes (T2D) compared to healthy controls and the effect of two lifestyle interventions in T2D.Data were derived from the DIASTOLIC randomised controlled trial (RCT) and includes a comparison between those with T2D and the matched healthy volunteers recruited at baseline. Adults with T2D without cardiovascular disease (CVD) were randomized to a 12-week intervention either: (1) exercise training, (2) a low-energy (∼810 kcal/day) meal-replacement plan (MRP) or (3) standard care. Principal Component and Fisher's linear discriminant analysis were used to investigate the relationships between MRI acquired cardiovascular outcomes and fibro-inflammatory biomarkers in cases versus controls and pre- and post-intervention in T2D.At baseline, 83 people with T2D (mean age 50.5 ± 6.4; 58% male) and 36 healthy controls (mean age 48.6 ± 6.2; 53% male) were compared and 76 people with T2D completed the RCT for pre- post-analysis. Compared to healthy controls, subjects with T2D had adverse cardiovascular remodelling and a fibro-inflammatory profile (20 differentially expressed biomarkers). The 3D data visualisations showed almost complete separation between healthy controls and those with T2D, and a marked shift towards healthy controls following the MRP (15 biomarkers significantly changed) but not exercise training.Fibro-inflammatory pathways and cardiovascular structure/function are adversely altered before the onset of symptomatic CVD in middle-aged adults with T2D. The MRP improved the fibro-inflammatory profile of people with T2D towards a more healthy status. Long-term studies are required to assess whether these changes lead to continued reverse cardiac remodelling and prevent CVD.

Background Type 2 diabetes (T2D) and hypertension commonly coexist and are associated with subclinical myocardial structural and functional changes. We sought to determine the association between blood pressure (BP) and left ventricular (LV) remodeling, systolic/diastolic function, and coronary microvascular function, among individuals with T2D without prevalent cardiovascular disease. Methods Participants with T2D and age-, sex-, and ethnicity-matched controls underwent comprehensive cardiovascular phenotyping including fasting bloods, transthoracic echocardiography, cardiovascular magnetic resonance imaging with quantitative adenosine stress/rest perfusion, and office and 24-h ambulatory BP monitoring. Multivariable linear regression was performed to determine independent associations between BP and imaging markers of remodeling and function in T2D. Results Individuals with T2D (n = 205, mean age 63 ± 7 years) and controls (n = 40, mean age 61 ± 8 years) were recruited. Mean 24-h systolic BP, but not office BP, was significantly greater among those with T2D compared to controls (128.8 ± 11.7 vs 123.0 ± 13.1 mmHg, p = 0.006). Those with T2D had concentric LV remodeling (mass/volume 0.91 ± 0.15 vs 0.82 ± 0.11 g/mL, p Conclusion 24-h ambulatory systolic BP, but not office BP, is independently associated with cardiac remodeling, coronary microvascular dysfunction, and diastolic dysfunction among asymptomatic individuals with T2D. (Clinical trial registration. URL: https://clinicaltrials.gov/ct2/show/NCT03132129 Unique identifier: NCT03132129).

Introduction: This study examined the equivalency of sleep estimates from Axivity, GENEActiv, and ActiGraph accelerometers worn on the nondominant and dominant wrists and with and without using a sleep log to guide the algorithm. Methods: 47 young adults wore an Axivity, GENEActiv, and ActiGraph accelerometer continuously on both wrists for 4–7 days. Sleep time, sleep window, sleep efficiency, sleep onset, and wake time were produced using the open-source software (GGIR). For each outcome, agreement between accelerometer brands, dominant and nondominant wrists, and with and without use of a sleep log, was examined using pairwise 95% equivalence tests (±10% equivalence zone) and intraclass correlation coefficients (ICCs), with 95% confidence intervals and limits of agreement. Results: All sleep outcomes were within a 10% equivalence zone irrespective of brand, wrist, or use of a sleep log. ICCs were poor to good for sleep time (ICCs ≥ .66) and sleep window (ICCs ≥ .56). Most ICCs were good to excellent for sleep efficiency (ICCs ≥ .73), sleep onset (ICCs ≥ .88), and wake time (ICCs ≥ .87). There were low levels of mean bias; however, there were wide 95% limits of agreement for sleep time, sleep window, sleep onset, and wake time outcomes. Sleep time (up to 25 min) and sleep window (up to 29 min) outcomes were higher when use of the sleep log was not used. Conclusion: The present findings suggest that sleep outcomes from the Axivity, GENEActiv, and ActiGraph, when analyzed identically, are comparable across studies with different accelerometer brands and wear protocols at a group level. However, caution is advised when comparing studies that differ on sleep log availability.

Background/aims Obstructive sleep apnoea is a public health problem that remains under recognised. Despite obstructive sleep apnoea being associated with the incidence and progression of heart failure, clinician awareness is lacking within and across clinical specialities. This study aimed to evaluate heart failure clinicians' knowledge, attitudes and clinical practice in the diagnosis and treatment of obstructive sleep apnoea. Methods This study used a web-based, cross-sectional survey, using the modified Obstructive Sleep Apnoea Knowledge and Attitudes questionnaire among heart failure clinicians in the UK. Results The survey was completed by 102 heart failure clinicians. Out of a possible score of 37, the median knowledge scores were 29 (78%; interquartile range 26–31), 26 (70%; interquartile range 22–28) and 18 (49%; interquartile range 16.5–23.5) for doctors, nurses and pharmacists, respectively. The majority of doctors and nurses felt that obstructive sleep apnoea was important; however, confidence in the identification and management of obstructive sleep apnoea was low across all three groups of clinicians. Conclusions There is a knowledge deficit regarding the diagnosis and treatment of obstructive sleep apnoea among heart failure clinicians.

Aims/hypothesis Early-onset adult type 2 diabetes (diagnosed between ages 18 and 39 years) is increasingly prevalent and associated with poor long-term outcomes. We hypothesised that individuals with early-onset adult type 2 diabetes were underrepresented in the prominent research trials that underpin type 2 diabetes management guidelines. Methods We reviewed the mean age of the study populations recruited to 90 prominent trials in type 2 diabetes, including 37 cardio-renal outcomes trials across a range of pharmacological, non-pharmacological and multifactorial interventions, 28 trials from the phase III programmes of three representative glucose-lowering therapies used routinely in clinical practice (empagliflozin, liraglutide and sitagliptin) and 25 prominent trials of diabetes self-management education and support or intensive lifestyle interventions (diet or supervised exercise training). We then estimated the number of individuals within these trials who were aged between 18 and 39 years. Results Across all 90 trials, the mean age of 268,978 participants was 63 years (range 51–69 years in individual trials). In 73 trials (81%), Conclusions/interpretation Guidelines for early-onset adult type 2 diabetes are extrapolated predominantly from evidence in older individuals. Strategies to support the participation of individuals with early-onset adult type 2 diabetes in future research are imperative to ensure guidelines for these high-risk individuals are evidence-based.

OBJECTIVE To confirm the presence of subclinical cardiovascular dysfunction in working-age adults with type 2 diabetes (T2D) and determine whether this is improved by a low-energy meal replacement diet (MRP) or exercise training. RESEARCH DESIGN AND METHODS This article reports on a prospective, randomized, open-label, blinded end point trial with nested case-control study. Asymptomatic younger adults with T2D were randomized 1:1:1 to a 12-week intervention of 1) routine care, 2) supervised aerobic exercise training, or 3) a low-energy (∼810 kcal/day) MRP. Participants underwent echocardiography, cardiopulmonary exercise testing, and cardiac magnetic resonance (CMR) at baseline and 12 weeks. The primary outcome was change in left ventricular (LV) peak early diastolic strain rate (PEDSR) as measured by CMR. Healthy volunteers were enrolled for baseline case-control comparison. RESULTS Eighty-seven participants with T2D (age 51 ± 7 years, HbA1c 7.3 ± 1.1%) and 36 matched control participants were included. At baseline, those with T2D had evidence of diastolic dysfunction (PEDSR 1.01 ± 0.19 vs. 1.10 ± 0.16 s−1, P = 0.02) compared with control participants. Seventy-six participants with T2D completed the trial (30 routine care, 22 exercise, and 24 MRP). The MRP arm lost 13 kg in weight and had improved blood pressure, glycemia, LV mass/volume, and aortic stiffness. The exercise arm had negligible weight loss but increased exercise capacity. PEDSR increased in the exercise arm versus routine care (β = 0.132, P = 0.002) but did not improve with the MRP (β = 0.016, P = 0.731). CONCLUSIONS In asymptomatic working-age adults with T2D, exercise training improved diastolic function. Despite beneficial effects of weight loss on glycemic control, concentric LV remodeling, and aortic stiffness, a low-energy MRP did not improve diastolic function.

Aims: To examine the independent associations between relative protein intake (g kg−1 day 1) and markers of physical function in those with type 2 diabetes, while also comparing with current guidelines for protein intake. Methods: This analysis reports data from the ongoing Chronotype of Patients with Type 2 Diabetes and Effect on Glycaemic Control (CODEC) study. Functional assessments included: Short Physical Performance Battery (SPPB), 60 s sit-to-stand (STS-60), 4-m gait speed, time to rise from a chair (×5) and handgrip strength. Participants also completed a self-reported 4 day diet diary. Regression analyses assessed whether relative protein intake was associated with markers of physical function. Interaction terms assessed whether the associations were modified by sex, age, HbA1c or body mass index (BMI). Results413 participants were included (mean ± SD:age = 65.0 ± 7.7 years, 33% female, BMI = 30.6 ± 5.1 kg/m2). The average total protein intake was 0.88 ± 0.31 g kg⁻¹ day⁻¹ . 33% of individuals failed to meet the reference nutrient intake for the United Kingdom (≥0.75 g kg⁻¹ day⁻¹ ), and 87% for European recommendations (≥1.2 g kg⁻¹ day⁻¹ ). After adjustment, each 0.5 g/kg of protein intake was associated with an 18.9% (95% CI: 2.3, 35.5) higher SPPB score, 22.7% (1.1, 44.3) more repetitions in STS-60, 21.1% (4.5, 37.7) faster gait speed and 33.2% (16.9, 49.5) lower chair rise time. There were no associations with handgrip strength or any interactions. Conclusions: Relative protein intake was positively associated with physical function outcomes, even after consideration of total energy intake. As a number of individuals were below the current guidelines, protein intake may be a modifiable factor of importance for people with type 2 diabetes. Refereed/Peer-reviewed

Introduction: Type 2 diabetes (T2D) confers a higher relative risk of heart failure in women than men. Women also have a greater prevalence of heart failure with preserved ejection fraction (HFpEF), linked to microvascular dysfunction. We hypothesize that sex-specific differences are present in the pathophysiological alterations of myocardial structure, function, and perfusion associated with T2D. Methods: Cross-sectional case-control study. Participants underwent comprehensive cardiac phenotyping with echocardiography and cardiac magnetic resonance with adenosine stress/rest perfusion. Global myocardial perfusion was derived as a mean of three short axis slices. Image analysis was performed by two observers blinded to all participant information. Statistical analysis was performed with independent-sample T-tests or Mann-Whitney test. Results: Individuals with T2D (n=287, 41% female) were compared with age-matched controls (n=87, 41% female). Women with T2D were more obese than men (body mass index 35.7±7.2 vs 32.4±5.3 kg/m 2 , p Conclusions: In asymptomatic people with T2D, women have increased LV mass index and lower myocardial perfusion reserve than men, driven primarily by increased resting perfusion. These findings support the growing evidence that microvascular dysfunction partly explains the greater risk of HFpEF in women with T2D.

Introduction: The accumulation of excess epicardial adipose tissue (EAT) is associated with the onset of specific heart failure phenotypes. Subsets of adipocytes in EAT produce an inflammatory secretome which alters the extracellular matrix of the epicardium and impairs myocardial contractility. Lipid-laden adipocytes have a low computed tomography (CT) attenuation and can be readily identified using cardiac CT. Objective: This study sought to identify the clinical and biomarker determinants of low attenuation EAT in participants with Type 2 diabetes (T2D) at risk of heart failure. Methods: Participants with T2D and non-diabetic controls were prospectively recruited to an observational multi-modality cardiovascular imaging study. Deep learning analytics (QFAT, Cedars-Sinai) measured EAT volume and CT attenuation from cardiac CT datasets. Adipose tissue with CT attenuation values of -90 to -190 Hounsfield Units (HU) were classified as low attenuation EAT regions. Comparison was made with anthropometric and blood biomarkers to evaluate determinants of low attenuation EAT. Results: Type 2 diabetic (n=151, median age 64 (59, 69) years, 65% male) and non-diabetic individuals (n=39, median age 59 (54, 66.5) years, 59% male) were recruited. Total EAT volume indexed to body surface area was 1.6-fold higher in diabetics (62.4 (49.1, 77.7) cm 3 /m 2 vs 38.8 (29.6, 51.9) cm 3 /m 2 , p 2 = 0.2003, p Conclusions: In patients with T2D, indexed EAT volumes are 1.6-fold higher with a lower mean CT attenuation. Age, white ethnicity and waist circumference are associated with low attenuation EAT. Prospective studies are required to determine whether interventions to reduce low attenuation EAT will prevent the onset of heart failure.

Aerobic exercise training and low energy diets have been shown to improve left ventricular remodelling and diastolic function in adults with type 2 diabetes (T2D), albeit with differential effects. The impact of these lifestyle interventions on left atrial (LA) function, however, has not previously been reported. The DIASTOLIC study was a prospective, randomised, open-label, blind endpoint trial, in which 90 people with obesity and T2D and no prevalent cardiovascular disease were randomised to a 12-week intervention of: (i) routine care, (ii) aerobic exercise training, or (iii) low energy (≈ 810 kcal/day) meal replacement plan (MRP). Cardiac magnetic resonance (CMR) imaging was performed pre- and post-intervention. Image analysis included LA volumes (LAV), emptying fraction (LAEF), and LA strain (LAS) corresponding to LA reservoir (LAS-r), conduit (LAS-cd), and booster pump (LAS-bp) function. 73 participants with T2D (mean age 50 ± 6 years, 62% male, body mass index (BMI) 36.1 ± 5.3 kg/m2) completed the trial and had analysable LA images. There was no significant change in CMR measured LA volumetric function (LAV/LAEF) in any group. The routine care group showed no significant change in BMI or LAS. In the MRP group, there were significant reductions in BMI (4.5 kg/m2) and a significant increase in LAS-r and LAS-bp (29.9 ± 7.0 to 32.3 ± 7.0%, p = 0.036 and 14.6 ± 5.3 to 17.2 ± 3.7%, p = 0.034). The exercise group showed a small reduction in BMI (0.49 kg/m2), with no significant change in LAS. Compared to routine care, weight loss via a 12-week MRP, led to improvements in LA filling and contractile function in adults with T2D and obesity. However, these within-group changes were not statistically significant on between-group comparison. ClinicalTrials.gov Identifier: NCT02590822.

Introduction Left atrial (LA) strain has been shown to be an independent predictor of cardiovascular events in many conditions and superior to conventional measures of LA function (LA volumes and emptying fraction). The effects of low-energy diet or exercise on cardiovascular function in younger adults with type 2 diabetes (DIASTOLIC) study has previously demonstrated an improvement in left ventricle peak early diastolic strain rate in response to aerobic exercise in patients with type-2 diabetes (T2D). However, the effect of lifestyle intervention on LA function, assessed by cardiac magnetic resonance (CMR) imaging, is unknown. Methods The DIASTOLIC study was a prospective, randomised, open-label, blind endpoint trial, that randomised 90 obese participants with T2D (aged 18–65 years) to a 12-week intervention of: (i) routine care, (ii) aerobic exercise training, or (iii) low energy (≈810kcal/day) meal replacement plan (MRP). CMR was performed at baseline and week-12. Images were analysed using Medis v3.1. LA strain (LAS) was assessed using Feature Tracking (QStrain v2.0), corresponding to LA reservoir (LAS-r), conduit (LAS-cd), and booster pump (LAS-bp) using 4- and 2-chamber standard steady-state free precession cine images, and average values calculated. LA emptying fraction (LAEF) was calculated using biplane area-length method (QMass v8.1) for total, passive and active EF. Results 73 participants with T2D completed the trial and had analysable LA images (28 routine care, 22 exercise and 23 MRP). There was no significant change in CMR measured standard LA volumetric function (LAV/LAEF) and echocardiogram measured LV filling pressures (E/e') in any groups. The routine care arm showed no significant change in body mass index (BMI) or LAS (see Table). In the MRP group, there were significant reductions in BMI (4.8 kg/m2), mean systolic blood pressure (SBP) (13mmHg), and a significant increase in LAS-r and LAS-bp (29.9±7.0 to 32.3±7.0,p=0.036 and 14.6±5.3 to 17.2±3.7,p=0.034). The exercise arm showed a small reduction in BMI (0.8kg/m2), with no significant change in BP or LAS. Conclusion There was significant improvement in LAS post-lifestyle intervention in young adults with T2D, despite no change in volumetric measurements. MRP led to weight loss and improved SBP, with associated improved LA filling and contraction. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute for Health Research (NIHR) a career development fellowship.

Aims Self-compassion is a modifiable characteristic, linked with psychological well being and intrinsic motivation to engage in positive health behaviours. We aimed to explore levels of self-compassion in individuals with type 2 diabetes (T2DM) and their association with levels of depression, diabetes-related distress and glycaemic control. Methods A cross-sectional study in 176 patients with T2DM in Leicester, UK, using three self-report questionnaires: the Self Compassion Scale (SCS); Patient Health Questionnaire (PHQ-9), and Diabetes Distress Scale (DDS-17). Demographic data, medical history and blood samples were collected. Results Majority of participants were male (n=120, 68.2%), with median [IQR] age and HbA1c of 66 [60, 71] years and 7.3 [6.7, 8.0] %, respectively. Multivariable analysis adjusting for age, gender, ethnicity and diabetes duration revealed significant association of all three scores with HbA1c: per one standard deviation increase of each score, a -0.16% reduction in HbA1c for SCS (p=0.027), 0.21% increase for PHQ-9 (p=0.012) and 0.33% increase for DDS-17 (p Conclusions Higher levels of self-compassion and lower levels of depressive symptoms were associated with significantly better long-term diabetes control. These results reinforce the importance of emphasis on psychological parameters, including self-compassion, in the multi-disciplinary management of T2DM. We identify this as a potential area for intervention in UK practice.

IntroductionLow self-compassion and poor sleep quality have been identified as potential key predictors of distress in type 2 diabetes (T2D). This study investigated relationships between sleep behaviors (sleep duration, social jetlag and daytime sleepiness), diabetes-related distress (DRD) and self-compassion in people with T2D.Research design and methodsThis cross-sectional study used data from 467 people with T2D derived from self-report questionnaires, accelerometer-assessed sleep measures and demographic information (clinicaltrials.gov registration: NCT02973412). All participants had a diagnosis of T2D and no comorbid sleep disorder (excluding obstructive sleep apnea). Hierarchical multiple regression and mediation analysis were used to quantify relationships between self-compassion, sleep variables and DRD.ResultsSignificant predictors of DRD included two negative subscales of the Self-Compassion Scale (SCS), and daytime sleepiness. The ‘overidentified’ and ‘isolation’ SCS subscales were particularly important in predicting distress. Daytime sleepiness also partially mediated the influence of self-compassion on DRD, potentially through self-care around sleep.ConclusionsDaytime sleepiness and negative self-compassion have clear associations with DRD for people with T2D. The specific negative subscale outcomes suggest that strengthening individuals’ ability to mindfully notice thoughts and experiences without becoming enmeshed in them, and reducing a sense of separateness and difference, might be key therapeutic targets for improving well-being in T2D. Psychological interventions should include approaches focused on reducing negative self-compassion and improving sleep behavior. Equally, reducing DRD may carry beneficial outcomes for sleep and self-compassion. Further work is however crucial to establish causation and long-term impact, and for development of relevant clinical resources.

Background Diabetes Self-Management Education and Support (DSMES) programmes are vital for type 2 diabetes mellitus (T2DM) management. However, they are limited in Sub-Saharan Africa (SSA). To address this gap, a DSMES, namedEXTEND was developed in Lilongwe (Malawi) and Maputo (Mozambique). This qualitative study aimed to explore factors that influence the implementation of DSMES in these settings. Methods The Socio-ecological model was applied to explore factors influencing the implementation of DSMES in SSA. Data was analysed using the Framework method and constant comparative techniques. Sixty-six people participated in the study: people with T2DM who participated in the EXTEND programme; healthcare professionals (HCPs), EXTEND educators, EXTEND trainers, and stakeholders. Results Our findings indicate that there is a need to develop an integrated and dedicated diabetes services in SSA healthcare systems, incorporating culturally adapted DSMES and tailored diabetes training to all professions involved in diabetes management. Traditional media and the involvement of community leaders were proposed as important elements to help engage and promote DSMES programmes in local communities. During the design and implementation of DSMES, it is important to consider individual and societal barriers to self-care. Conclusion Findings from this study suggest that multi-faceted factors play a significant role to the implementation of DSMES programmes in LICs. In the future, EXTEND could be incorporated in the development of diabetes training and dedicated diabetes services in SSA healthcare systems, acting as an educational tool for both people with T2DM and HCPs. This project was supported by the Medical Research Council GCRF NCDs Foundation Awards 2016 Development Pathway Funding.

While limited evidence suggests that longer sleep durations can improve metabolic health in habitual short sleepers, there is no consensus on how sustained sleep extension can be achieved. A total of 18 men (mean [SD] age 41 [ 9] years), who were overweight/obese (mean [SD] body mass index 30 [3] kg/m2 ) and short sleepers at increased risk of type 2 diabetes were randomised to a 6-week sleep-extension programme based on cognitive behavioural principles (n = 10) or a control (n = 8) group. The primary outcome was 6-week change in actigraphic total sleep time (TST). Fasting plasma insulin, insulin resistance (Homeostatic Model Assessment for Insulin Resistance [HOMA-IR]), blood pressure, appetite-related hormones from a mixed-meal tolerance test, and continuous glucose levels were also measured. Baseline to 6-week change in TST was greater in the sleep-extension group, at 79 (95% confidence interval [CI] 68.90, 88.05) versus 6 (95% CI -4.43, 16.99) min. Change in the sleep-extension and control groups respectively also showed: lower fasting insulin (-11.03 [95% CI -22.70, 0.65] versus 7.07 [95% CI -4.60, 18.74] pmol/L); lower systolic (-11.09 [95% CI -17.49, -4.69] versus 0.76 [95% CI -5.64, 7.15] mmHg) and diastolic blood pressure (-12.16 [95% CI -17.74, -6.59] versus 1.38 [95% CI -4.19, 6.96] mmHg); lower mean amplitude of glucose excursions (0.34 [95% CI -0.57, -0.12] versus 0.05 [95% CI -0.20, 0.30] mmol/L); lower fasting peptide YY levels (-18.25 [95%CI -41.90, 5.41] versus 21.88 [95% CI -1.78, 45.53] pg/ml), and improved HOMA-IR (-0.51 [95% CI -0.98, -0.03] versus 0.28 [95% CI -0.20, 0.76]). Our protocol increased TST and improved markers of metabolic health in male overweight/obese short sleepers.

Purpose Volumetric liver fat fraction (VLFF) measurements were made using the HepaFat-Scan® technique at 1.5T and 3T to determine the agreement between the measurements obtained at the two fields. Methods Sixty patients with type 2 diabetes (67% male, mean age 50.92 ± 6.56yrs) and thirty healthy volunteers (50% male, mean age 48.63 ± 6.32yrs) were scanned on 1.5T Aera and 3T Skyra (Siemens, Erlangen, Germany) MRI scanners on the same day using the HepaFat-Scan® gradient echo protocol with modification of echo times for 3T (TEs 2.38, 4.76, 7.14 ms at 1.5T and 1.2, 2.4, 3.6 ms at 3T). The 3T analyses were performed independently of the 1.5T analyses by a different analyst, blinded from the 1.5T results. Data were analysed for agreement and bias using Bland-Altman methods and intraclass correlation coefficients (ICC). A second cohort of 17 participants underwent interstudy repeatability assessment of VLFF measured by HepaFat-Scan® at 3T. Results A small, but statistically significant mean bias of 0.48% was observed between 3T and 1.5T with 95% limits of agreement -2.2% to 3.2% VLFF. The ICC for agreement between field strengths was 0.983 (95% CI 0.972–0.989). In the repeatability cohort studied at 3T the repeatability coefficient was 4.2%. The ICC for agreement was 0.971 (95% CI 0.921–0.989). Conclusion There is minimal bias and excellent agreement between the measures of VLFF using the HepaFat-Scan® at 1.5 and 3T. The test retest repeatability coefficient at 3T is comparable to the 95% limits of agreement between 1.5T and 3T suggesting that measurements can be made interchangeably between field strengths.

Objective: People with T2D have increased risk of heart failure, with fibro-inflammatory pathways implicated in the pathogenesis. This secondary analysis assessed the relationship between multiple fibro-inflammatory biomarkers and cardiovascular (CV) structure and function in patients with T2D and asymptomatic nondiabetic controls and the impact of two lifestyle interventions, exercise training or meal replacement plan (MRP). Methods: Data was derived from a randomised controlled trial (RCT), including a nested case-control study. Adults with T2D and no CV disease were randomized (1:1:1) to a 12-week intervention of 1) supervised aerobic exercise training, 2) a low-energy (∼810 kcal/day) MRP or 3) standard care. Fasting bloods for fibro-inflammatory biomarkers and cardiac MRI (CMR) were undertaken pre- and post-intervention. Principal component analysis (PCA) was performed to visualise this multivariate dataset in a 3D space to understand the relationship between CMR outcomes of interest (e.g., cardiac geometry, systolic and diastolic function), key demographic variables (age, sex, ethnicity and smoking status) and the fibro-inflammatory biomarkers (total of 68 variables) between cases and controls and pre-post intervention. Results: At baseline 36 controls and 83 T2D were compared of which 76 participants completed the RCT. People with T2D had an adverse fibro-inflammatory profile compared to controls’. The PCA 3D-visulisation containing demographics, biomarkers and CMR data shows almost complete separation between controls and those with T2D. Following MRP there was a marked shift in the PCA but not for the exercise intervention. Conclusion: Alterations in fibro-inflammatory pathways impact CV structure and function before the onset of symptomatic heart failure in people with T2D. The MRP improved this fibro-inflammatory profile but not exercise. Longer term studies are required to determine whether the MRP can reduce symptomatic heart failure. Disclosure E. M. Brady: Other Relationship; Self; Bristol Myers Squibb Pharmaceutical company. E. Mirkes: None. K. Parke: None. G. S. Gulsin: None. L. Athithan: None. J. Henson: None. T. Yates: None. M. J. Davies: Advisory Panel; Self; Boehringer Ingelheim International GmbH, Boehringer Ingelheim Limited (UK), Eli Lilly and Company, Lexicon Pharmaceuticals, Inc., Novo Nordisk A/S, Sanofi, Other Relationship; Self; AstraZeneca, NIHR Leicester Biomedical Research Centre, Novo Nordisk, Speaker's Bureau; Self; Astra Zeneca Pharma India Ltd, Boehringer Ingelheim (China), Boehringer Ingelheim (Philippines), Inc., Boehringer Ingelheim International GmbH, Boehringer Ingelheim Limited (UK), Boehringer Ingelheim Saudi Arabia Trading, Boehringer Ingelheim Singapore Pte. Ltd, Boehringer Ingelheim Sp. Z o. o., Eli Lilly and Company, Napp Pharmaceuticals, Novo Nordisk, Novo Nordisk A/S, S. C. Sanofi Romania SRL, Sanofi K. K. G. P. Mccann: None. P. Kanagala: None. L. Ng: None. Funding National Institute for Health Research (CDF2014-07-045 to G.P.M.)

The diagnosis of type 2 diabetes (T2D) in younger adults, an increasingly common public health issue, is associated with a higher risk of cardiovascular complications and mortality, which may be due to a more adverse cardiovascular risk profile in individuals diagnosed at a younger age.To investigate the association between age at diagnosis and the cardiovascular risk profile in adults with T2D.A pooled dataset was used, comprised of data from five previous studies of adults with T2D, including 1409 participants of whom 196 were diagnosed with T2D under the age of 40 years. Anthropometric and blood biomarker measurements included body weight, body mass index (BMI), waist circumference, body fat percentage, glycaemic control (HbA1c), lipid profile and blood pressure. Univariable and multivariable linear regression models, adjusted for diabetes duration, sex, ethnicity and smoking status, were used to investigate the association between age at diagnosis and each cardiovascular risk factor.A higher proportion of participants diagnosed with T2D under the age of 40 were female, current smokers and treated with glucose-lowering medications, compared to participants diagnosed later in life. Participants diagnosed with T2D under the age of 40 also had higher body weight, BMI, waist circumference and body fat percentage, in addition to a more adverse lipid profile, compared to participants diagnosed at an older age. Modelling results showed that each one year reduction in age at diagnosis was significantly associated with 0.67 kg higher body weight [95% confidence interval (CI): 0.52-0.82 kg], 0.18 kg/mThe diagnosis of T2D earlier in life is associated with a worse cardiovascular risk factor profile, compared to those diagnosed later in life.

AIMS 'Chronotype' describes an individual's sleep-wake schedule, and can be classified into morning, intermediate or evening types. Evening chronotype has been widely associated with increased cardiometabolic risk and mortality in people with type 2 diabetes. We explored associations between chronotype and markers of well-being in people with type 2 diabetes. METHODS Participants of the 'Chronotype of Patients with Type 2 Diabetes and Effect on Glycaemic Control' (CODEC) observational study completed questionnaires to determine chronotype (Morningness-Eveningness Questionnaire, MEQ) and concurrent measures of well-being (Diabetes-related Distress scale, Patient Health Questionnaire-9 to measure depression, and Self-Compassion Scale), as a secondary endpoint of the study. Adjusted generalised linear models were used to compare well-being between chronotype subgroups in this cohort. RESULTS Of the 808 individuals included in the CODEC study, from convenience sampling, 476 individuals completed the psychosocial questionnaire substudy. Of these, 67% (n = 321) were male, and 86% (n = 408) were white European. From the MEQ, 24% (n = 114) were morning chronotype, 24% (n = 113) were evening and 52% (n = 249) were intermediate chronotype. Diabetes-related distress was significantly higher in evening chronotypes (exponentiated adjusted coefficient = 1.18 (CI: 1.05-1.32)), compared to morning (padjusted = 0.005) and intermediate chronotypes (padjusted = 0.039). Similarly, depression was significantly higher in evening chronotypes (exponentiated adjusted coefficient = 1.84 (CI: 1.28-2.65)) compared to morning (padjusted = 0.001) and intermediate chronotypes (padjusted = 0.016). DISCUSSION Evening chronotype in people with type 2 diabetes may be associated with higher levels of diabetes-related distress and depression. These findings warrant further investigation to establish causality and evidence-based interventions that negate the effects of evening chronotype in people with type 2 diabetes.

Diabetes mellitus represents a global health concern affecting 463 million adults and is projected to rapidly rise to 700 million people by 2045. Amongst those with type 2 diabetes (T2D), there are recognised differences in the impact of the disease on different sex and ethnic groups. The relative risk of cardiovascular complications between individuals with and without T2D is higher in females than males. People of South Asian heritage are two to four times more likely to develop T2D than white people, but conversely not more likely to experience cardiovascular complications. Differences in the pathophysiological responses in these groups may identify potential areas for intervention beyond glycaemic control. In this review, we highlight key differences of diabetes-associated cardiovascular complications by sex and ethnic background, with a particular emphasis on South Asians. Evidence assessing therapeutic efficacy of new glucose lowering drugs in minority groups is limited and many major cardiovascular outcomes trials do not report ethnic specific data. Conversely, lifestyle intervention and bariatric surgery appear to have similar benefits regardless of sex and ethnic groups. We encourage future studies with better representation of women and ethnic minorities that will provide valuable data to allow better risk stratification and tailored prevention and management strategies to improve cardiovascular outcomes in T2D.

Aims: Restrictions during the COVID-19 crisis will have impacted on opportunities to be active. We aimed to (a) quantify the impact of COVID-19 restrictions on accelerometer-assessed physical activity and sleep in people with type 2 diabetes and (b) identify predictors of physical activity during COVID-19 restrictions. Methods: Participants were from the UK Chronotype of Patients with type 2 diabetes and Effect on Glycaemic Control (CODEC) observational study. Participants wore an accelerometer on their wrist for 8 days before and during COVID-19 restrictions. Accelerometer outcomes included the following: overall physical activity, moderate-to-vigorous physical activity (MVPA), time spent inactive, days/week with ≥30-minute continuous MVPA and sleep. Predictors of change in physical activity taken pre-COVID included the following: age, sex, ethnicity, body mass index (BMI), socio-economic status and medical history. Results: In all, 165 participants (age (mean±S.D = 64.2 ± 8.3 years, BMI=31.4 ± 5.4 kg/m2, 45% women) were included. During restrictions, overall physical activity was lower by 1.7 mg (~800 steps/day) and inactive time 21.9 minutes/day higher, but time in MVPA and sleep did not statistically significantly change. In contrast, the percentage of people with ≥1 day/week with ≥30-minute continuous MVPA was higher (34% cf. 24%). Consistent predictors of lower physical activity and/or higher inactive time were higher BMI and/or being a woman. Being older and/or from ethnic minorities groups was associated with higher inactive time. Conclusions: Overall physical activity, but not MVPA, was lower in adults with type 2 diabetes during COVID-19 restrictions. Women and individuals who were heavier, older, inactive and/or from ethnic minority groups were most at risk of lower physical activity during restrictions Refereed/Peer-reviewed

Aims The primary aim was to evaluate the effectiveness of a model integrating diabetes services across primary, secondary and community care (Transformation model). The secondary aim was to understand whether changes resulted from the model. Methods The model was implemented In Leicester, Leicestershire and Rutland (UK) across three clinical commissioning groups, the acute trust and accompanying stakeholders. One clinical commissioning group (Leicester City) implemented the entire model and was the primary evaluation population. A quasi-experimental interrupted time series design was employed. The primary outcome was number of Type 2 diabetes-related bed-days per 1000 patients. Results In the primary population, the mean number of Type 2 diabetes-related bed-days per 1000 patients was increasing before model implementation by 0.33/month (95% confidence interval: -0.07, 0.72), whereas it was decreasing after implementation by a mean value of -0.14/month (-0.33, 0.06); a statistically significant difference (p = 0.04). Secondary analyses showed: nationally, there was no significant change between the pre- and post-periods so it is unlikely that large secular change drove the improvement; the other two Leicestershire clinical commissioning groups saw improvement or stability; underlying processes worked as hypothesised overall; diabetes biomedical markers deteriorated in the primary care population suggesting a change in case-mix due to moving some patients out of secondary care. Conclusions Given that the initial aim was to shift services from secondary to primary care without causing harm, an improvement is better than expected. This observational evaluation cannot show conclusively that improvements were due to the Transformation model, but secondary analyses support this.

Background: There is a high prevalence of asymptomatic (American Heart Association Stage B) heart failure (SBHF) in people with type 2 diabetes (T2D). We aimed to identify associations between clinical characteristics and markers of SBHF in adults with T2D, which may allow therapeutic interventions prior to symptom onset. Methods: Adults with T2D from a multi-ethnic population with no prevalent cardiovascular disease [ n = 247, age 52 ± 12 years, glycated haemoglobin A1c (HbA1c) 7.4 ± 1.1% (57 ± 12 mmol/mol), duration of diabetes 61 (32, 120) months] underwent echocardiography and adenosine stress perfusion cardiovascular magnetic resonance imaging. Multivariable linear regression analyses were performed to identify independent associations between clinical characteristics and markers of SBHF. Results: In a series of multivariable linear regression models containing age, sex, ethnicity, smoking history, number of glucose-lowering agents, systolic blood pressure (BP) duration of diabetes, body mass index (BMI), HbA1c, serum creatinine, and low-density lipoprotein (LDL)-cholesterol, independent associations with: left ventricular mass:volume were age (β = 0.024), number of glucose-lowering agents (β = 0.022) and systolic BP (β = 0.027); global longitudinal strain were never smoking (β = −1.196), systolic BP (β = 0.328), and BMI (β = −0.348); myocardial perfusion reserve were age (β = −0.364) and male sex (β = 0.458); and aortic distensibility were age (β = −0.629) and systolic BP (β = −0.348). HbA1c was not independently associated with any marker of SBHF. Conclusions: In asymptomatic adults with T2D, age, systolic BP, BMI, and smoking history, but not glycaemic control, are the major determinants of SBHF. Given BP and BMI are modifiable, these may be important targets to reduce the development of symptomatic heart failure.

Background: Type 2 diabetes (T2D) is increasing in young people. Reporting on the processes used when developing prevention interventions is needed. We present the development of a family-based interactive lifestyle intervention for adolescents with risk factors for T2D in the future. Method: A multidisciplinary team in the UK site led the intervention development process with sites in Portugal, Greece, Germany and Spain. Potential programme topics and underpinning theory were gathered from literature and stakeholders. A theoretical framework based on self-efficacy theory and the COM-B (capability, opportunity, motivation, behaviour) model was developed. Sessions and supporting resources were developed and refined via two iterative cycles of session and resource piloting, feedback, reflection and refinement. Decision on delivery and content were made by stakeholders (young people, teachers, parents, paediatricians) and all sites. Materials were translated to local languages. Site-specific adaptations to the language, content and supporting resources were made. Results: The &ldquo, PRE-STARt&rdquo, programme is eight 90-min interactive sessions with supporting curriculum and resources. Iterative development work provided valuable feedback on programme content and delivery. Conclusion: Reporting on the intervention development process, which includes stakeholder input, could yield a flexible approach for use in this emerging &lsquo, at risk&rsquo, groups and their families.

Background The determinants of exercise capacity in people with type 2 diabetes (T2D), a group at high risk of heart failure, are unknown. Purpose To assess the relationship between subclinical cardiovascular dysfunction and peak VO2 in adults with T2D. Methods We enrolled asymptomatic adults with T2D and no prevalent cardiovascular disease. Matched controls were recruited for comparison. Subjects underwent echocardiography, cardiopulmonary exercise testing and adenosine stress cardiac MRI. Multivariable linear regression analysis was undertaken to identify independent associations between measures of cardiovascular structure and function and peak VO2 (Figure 1). Results 247 adults with T2D (age 52±12y, 55% males, A1c 7.4±1.1%) and 78 controls were included. Subjects with T2D had increased concentric LV remodelling (LV mass/volume 0.84±0.14 vs. 0.76±0.11g/mL, p Conclusions In asymptomatic people with T2D, aortic stiffening, diastolic filling, and myocardial perfusion reserve are key determinants of peak VO2, independent of age, sex, ethnicity, smoking status, or blood pressure. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): National Institute for Health Research - Career Development Fellowship (G P McCann, CDF-2014-07-045). British Heart Foundation - Clinical Research Training Fellowship (G S Gulsin)

We aim to rapidly assess public attitudes to attending hospital across the UK for research purposes and clinical appointments, and attitudes to vaccine research using an online survey and online focus groups. Online surveys offer a rapid and, during a global pandemic, safe way of collecting information about public opinion. However, they are flawed in relying on self-report, and subject to abuse by means of multiple responses from one person or even merely random responses. Sampling methods associated with online surveys require opt-in so respondents are likely to be motivated, and specifically interested in research. Thus the methodology will attract a 'warm' audience when discussing questions about research as is standard in public involvement.Online focus groups with public involvement volunteers will also experience similar issues with generalisability. All online methodologies will exclude those without access to the online world.