Background Diabetes has been associated with increased COVID-19-related mortality, but the association between modifiable risk factors, including hyperglycaemia and obesity, and COVID-19-related mortality among people with diabetes is unclear. We assessed associations between risk factors and COVID-19-related mortality in people with type 1 and type 2 diabetes. Methods We did a population-based cohort study of people with diagnosed diabetes who were registered with a general practice in England. National population data on people with type 1 and type 2 diabetes collated by the National Diabetes Audit were linked to mortality records collated by the Office for National Statistics from Jan 2, 2017, to May 11, 2020. We identified the weekly number of deaths in people with type 1 and type 2 diabetes during the first 19 weeks of 2020 and calculated the percentage change from the mean number of deaths for the corresponding weeks in 2017, 2018, and 2019. The associations between risk factors (including sex, age, ethnicity, socioeconomic deprivation, HbA 1c , renal impairment [from estimated glomerular filtration rate (eGFR)], BMI, tobacco smoking status, and cardiovascular comorbidities) and COVID-19-related mortality (defined as International Classification of Diseases, version 10, code U07.1 or U07.2 as a primary or secondary cause of death) between Feb 16 and May 11, 2020, were investigated by use of Cox proportional hazards models. Findings Weekly death registrations in the first 19 weeks of 2020 exceeded the corresponding 3-year weekly averages for 2017–19 by 672 (50·9%) in people with type 1 diabetes and 16 071 (64·3%) in people with type 2 diabetes. Between Feb 16 and May 11, 2020, among 264 390 people with type 1 diabetes and 2 874 020 people with type 2 diabetes, 1604 people with type 1 diabetes and 36 291 people with type 2 diabetes died from all causes. Of these total deaths, 464 in people with type 1 diabetes and 10 525 in people with type 2 diabetes were defined as COVID-19 related, of which 289 (62·3%) and 5833 (55·4%), respectively, occurred in people with a history of cardiovascular disease or with renal impairment (eGFR <60 mL/min per 1·73 m 2 ). Male sex, older age, renal impairment, non-white ethnicity, socioeconomic deprivation, and previous stroke and heart failure were associated with increased COVID-19-related mortality in both type 1 and type 2 diabetes. Compared with people with an HbA 1c of 48–53 mmol/mol (6·5–7·0%), people with an HbA 1c of 86 mmol/mol (10·0%) or higher had increased COVID-19-related mortality (hazard ratio [HR] 2·23 [95% CI 1·50–3·30, p<0·0001] in type 1 diabetes and 1·61 [1·47–1·77, p<0·0001] in type 2 diabetes). In addition, in people with type 2 diabetes, COVID-19-related mortality was significantly higher in those with an HbA 1c of 59 mmol/mol (7·6%) or higher tha...

Background Although diabetes has been associated with COVID-19-related mortality, the absolute and relative risks for type 1 and type 2 diabetes are unknown. We assessed the independent effects of diabetes status, by type, on in-hospital death in England in patients with COVID-19 during the period from March 1 to May 11, 2020. Methods We did a whole-population study assessing risks of in-hospital death with COVID-19 between March 1 and May 11, 2020. We included all individuals registered with a general practice in England who were alive on Feb 16, 2020. We used multivariable logistic regression to examine the effect of diabetes status, by type, on in-hospital death with COVID-19, adjusting for demographic factors and cardiovascular comorbidities. Because of the absence of data on total numbers of people infected with COVID-19 during the observation period, we calculated mortality rates for the population as a whole, rather than the population who were infected. Findings Of the 61 414 470 individuals who were alive and registered with a general practice on Feb 16, 2020, 263 830 (0·4%) had a recorded diagnosis of type 1 diabetes, 2 864 670 (4·7%) had a diagnosis of type 2 diabetes, 41 750 (0·1%) had other types of diabetes, and 58 244 220 (94·8%) had no diabetes. 23 698 in-hospital COVID-19-related deaths occurred during the study period. A third occurred in people with diabetes: 7434 (31·4%) in people with type 2 diabetes, 364 (1·5%) in those with type 1 diabetes, and 69 (0·3%) in people with other types of diabetes. Unadjusted mortality rates per 100 000 people over the 72-day period were 27 (95% CI 27–28) for those without diabetes, 138 (124–153) for those with type 1 diabetes, and 260 (254–265) for those with type 2 diabetes. Adjusted for age, sex, deprivation, ethnicity, and geographical region, compared with people without diabetes, the odds ratios (ORs) for in-hospital COVID-19-related death were 3·51 (95% CI 3·16–3·90) in people with type 1 diabetes and 2·03 (1·97–2·09) in people with type 2 diabetes. These effects were attenuated to ORs of 2·86 (2·58–3·18) for type 1 diabetes and 1·80 (1·75–1·86) for type 2 diabetes when also adjusted for previous hospital admissions with coronary heart disease, cerebrovascular disease, or heart failure. Interpretation The results of this nationwide analysis in England show that type 1 and type 2 diabetes were both independently associated with a significant increased odds of in-hospital death with COVID-19. Funding None.

Background In patients with type 2 diabetes, hyperglycaemia is an independent risk factor for COVID-19-related mortality. Associations between pre-infection prescription for glucose-lowering drugs and COVID-19-related mortality in people with type 2 diabetes have been postulated but only investigated in small studies and limited to a few agents. We investigated whether there are associations between prescription of different classes of glucose-lowering drugs and risk of COVID-19-related mortality in people with type 2 diabetes. MethodsThis was a nationwide observational cohort study done with data from the National Diabetes Audit for people with type 2 diabetes and registered with a general practice in England since 2003. Cox regression was used to estimate the hazard ratio (HR) of COVID-19-related mortality in people prescribed each class of glucose-lowering drug, with covariate adjustment with a propensity score to address confounding by demographic, socioeconomic, and clinical factors. Findings Among the 2 851 465 people with type 2 diabetes included in our analyses, 13 479 (0•5%) COVID-19-related deaths occurred during the study period (Feb 16 to Aug 31, 2020), corresponding to a rate of 8•9 per 1000 person-years (95% CI 8•7-9•0). The adjusted HR associated with recorded versus no recorded prescription was 0•77 (95% CI 0•73-0•81) for metformin and 1•42 (1•35-1•49) for insulin. Adjusted HRs for prescription of other individual classes of glucose-lowering treatment were as follows: 0•75 (0•48-1•17) for meglitinides, 0•82 (0•74-0•91) for SGLT2 inhibitors, 0•94 (0•82-1•07) for thiazolidinediones, 0•94 (0•89-0•99) for sulfonylureas, 0•94 (0•83-1•07) for GLP-1 receptor agonists, 1•07 (1•01-1•13) for DPP-4 inhibitors, and 1•26 (0•76-2•09) for α-glucosidase inhibitors.Interpretation Our results provide evidence of associations between prescription of some glucose-lowering drugs and COVID-19-related mortality, although the differences in risk are small and these findings are likely to be due to confounding by indication, in view of the use of different drug classes at different stages of type 2 diabetes disease progression. In the context of the COVID-19 pandemic, there is no clear indication to change prescribing of glucoselowering drugs in people with type 2 diabetes. Funding None.

Aim To estimate the healthcare costs of diabetic foot disease in England. Methods Patient‐level data sets at a national and local level, and evidence from clinical studies, were used to estimate the annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014–2015. Results The cost of health care for ulceration and amputation in diabetes in 2014–2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration. Conclusions Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one‐third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries.

To assess weight and HbA 1c changes in the Healthier You: National Health Service Diabetes Prevention Programme (NHS DPP), the largest DPP globally to achieve universal population coverage. RESEARCH DESIGN AND METHODS A service evaluation assessed intervention effectiveness for adults with nondiabetic hyperglycemia (HbA 1c 42-47 mmol/mol [6.0-6.4%] or fasting plasma glucose 5.5-6.9 mmol/L) between program launch in June 2016 and December 2018, using prospectively collected, national service-level data in England.

Background: Our aim was to identify and compare modifiable risk factors associated with adverse pregnancy outcomes in women with type 1 and type 2 diabetes and to identify effective maternity clinics. Methods:We included 17,375 pregnancies in 15,290 women with diabetes in a populationbased cohort study across 172 maternity clinics in England, Wales and the Isle of Man.Obstetric complications (preterm delivery, large birthweight) and adverse pregnancy outcomes (congenital anomaly, stillbirth, neonatal death) were obtained for pregnancies completed between 01 January 2014 and 31 December 2018. We assessed associations between modifiable (glycaemia, obesity, clinic) and non-modifiable risk factors (age, deprivation, ethnicity) with pregnancy outcomes.Results: Of 17,375 pregnancies, 8,690 (50.0%) were in women with type 1 and 8,685 (50.0%) in women with type 2 diabetes. The rates of preterm delivery (42.5% type 1, 23.4% type 2), and large birthweight (52.2% type 1, 26.2% type 2) were higher in type 1 diabetes (p<0.001).The prevalence of congenital anomaly (44.8/1000 type 1, 40.5/1000 type 2; p=0.175), and stillbirth (10.4/1000 type 1, 13.5/1000 type 2; p=0.072) did not differ but neonatal death rates (7.4/1000 type 1, 11.2/1000 type 2; p=0.013) were higher in type 2 diabetes. Independent risk factors for perinatal death were third trimester HbA1c > 48mmol/mol (OR 3.06, 95% CI 2.16 to 4.33), living in the highest deprivation quintile (OR 2.29 95% CI 1.16 to 4.52) and having type 2 diabetes (OR 1.65 95% CI 1.18 to 2.31). Variations in glycaemia and large birthweight were associated with maternal characteristics (diabetes duration, deprivation, BMI) without substantial differences between clinics.Interpretation: Our data highlight persistent adverse pregnancy outcomes in type 1 and type 2 diabetes. Maternal glycaemia and obesity are the key modifiable risk factors. No clinics were achieving appreciably better outcomes, suggesting that healthcare system changes are needed

We have proposed, tentatively, a panel of outcome measures which could be deployed in community-based, lifestyle intervention studies. The evidence base for selection of measurement domains is less well developed in some areas e.g. social wellbeing (where the definition of the concept itself remains elusive) and this has implications for the identification of appropriate tools. Although we have developed this panel as potential outcomes for intervention studies, we recognise that broader agreement on the concept of the HAP and on tools for its measurement could have wider utility and e.g. could facilitate comparisons of healthy ageing across diverse study designs and populations.

This study used event-related potentials to explore whether mind wandering (task-unrelated thought, or TUT) emerges through general problems in distraction, deficits of task-relevant processing (the executive-function view), or a general reduction in attention to external events regardless of their relevance (the decoupling hypothesis). Twenty-five participants performed a visual oddball task, in which they were required to differentiate between a rare target stimulus (to measure task-relevant processes), a rare novel stimulus (to measure distractor processing), and a frequent nontarget stimulus. TUT was measured immediately following task performance using a validated retrospective measure. High levels of TUT were associated with a reduction in cortical processing of task-relevant events and distractor stimuli. These data contradict the suggestion that mind wandering is associated with distraction problems or specific deficits in task-relevant processes. Instead, the data are consistent with the decoupling hypothesis: that TUT dampens the processing of sensory information irrespective of that information's task relevance.