Developing an intervention to support dietary change for shift workers living with type 2 diabetes: A stakeholder consultation

Shift workers, compared to day workers, are more likely to be diagnosed with type 2 diabetes (T2D). Currently, there is no tailored programme of dietary support available to either shift workers living with T2D or employers.


| INTRODUCTION
A third of working-age adults in the UK are estimated to be living with a chronic condition. 1This is in parallel with an ageing population that is moving public health priorities towards the promotion of extended healthy working lives. 2 Promoting health and well-being in specific occupational groups may pose more of a challenge, for example, occupations that involve shift work (i.e., working outside standard hours of 7. A.M. to 7. P.M).Shift work requires the alteration of diet, sleep, and social habits to fit with an atypical work schedule that is often out of sync with health and well-being services.Shift work exposure, specifically rotating and night work, is associated with an increased risk of developing type 2 diabetes (T2D). 3In the UK 27% of the workforce is engaged in some form of shift work. 4The Health Survey for England reported that shift workers compared to day workers, were more likely to be living with obesity and have more than one longstanding illness including T2D. 5 There is limited research investigating the health of shift workers with T2D.However, a previous study suggested higher glycated haemoglobin (HbA1c) levels in night workers compared to day workers. 6Diet is an important first-line strategy in the management of T2D 7 and there is good evidence to support the association between shift work and an unhealthy dietary pattern. 8While workplace interventions have been shown to improve diet and other health outcomes 9 shift workers tend to engage less with workplace initiatives 10 and are less likely to seek support for diabetes. 11There is an urgent need to develop interventions to support shift workers to improve dietary intakes, and this is particularly important for shift workers diagnosed with T2D who already have an elevated risk of cardiovascular disease (CVD).
Currently, there is no tailored programme of dietary support available to either shift workers living with T2D or employers.Including end users and key stakeholders at the intervention development stage is vital to maximising the likely acceptability, feasibility and in turn effectiveness of new interventions. 12he Shift-Diabetes study is a mixed methods study with the overall aim to characterise current management of T2D in shift workers as a starting point to understanding where and how support could be given to improve self-management of diabetes in this population. 13The Shift-Diabetes study population was drawn from shift workers with T2D employed in UK hospitals and residential healthcare, as this is one of the largest employment sectors of shift workers in the UK. 14 Previously, shift workers living with T2D were interviewed and the theoretical domains framework (TDF) 15 was applied to understand the barriers and enablers to healthy dietary choices during night work.The results from these semi-structured interviews found that shift workers with T2D wanted to make healthier food choices during night work but faced barriers such as limited access to food and a lack of confidence in their ability to eat healthy during night work. 16ubsequent survey results supported the interview findings and emphasised the importance of the worksite environment on food choices. 17The barriers and enablers generated from these previous behavioural studies were mapped to potential behaviour change techniques using published matrices pairing the TDF with behaviour change intervention frameworks -the Behaviour Change Wheel and Behaviour Change Technique taxonomy. 18,19he aim of this phase of the Shift Diabetes Study was to engage in stakeholder consultation to prioritise amongst the potential intervention packages identified from the behavioural mapping exercise and interview findings.This article reports the results of a stakeholder consultation workshop and makes recommendations for future intervention development and research.

| METHODS
An intervention consultation workshop was held in June 2023 with key stakeholders and had the aim of discussing and evaluating potential interventions to identify those with a potential to take forward for further development and testing.

| Attendees and data collection
Stakeholders identified by the Shift-Diabetes research team were invited to attend the workshop.Three participants from the Shift Diabetes Study (ISRCTN11764942) who agreed to be recontacted were invited, and one was able

Key points
• There is a need to reduce the barriers to healthy eating reported by shift workers living with type 2 diabetes working in the healthcare setting.• The findings from this intervention development consultation workshop with key stakeholders support the need for multi-level interventions.• Priority areas to address were identified as: i) the 24/7 food environment, ii) shift worker inclusive approaches to research and iii) understanding the effectiveness of continuous glucose monitoring in shift workers with type 2 diabetes.
to attend.The reasons for not attending were work scheduling constraints.The final seven attendees included two shift workers living with T2D (one attendee had completed the Shift-Diabetes study and one attendee was a member of the Shift-Diabetes study steering committee), three stakeholders with no prior involvement with the Shift-Diabetes study (staff health and catering dietitian, a provider of structured diabetes education and a primary care/diabetes dietitian), and two members of the Shift-Diabetes Study research team (NO and NG).FL and RG facilitated the workshop.The workshop was conducted using Microsoft Teams (Microsoft Corporation) and lasted two hours seven minutes.Prior to the workshop attendees were provided with a participant information sheet detailing the aim of the workshop.No additional materials were given for review prior to the workshop.The workshop was recorded on the Microsoft Teams platform through meeting video/ audio recording, automated transcript and meeting chat functions.No additional field notes were taken during the workshop.Participants were offered a £50 honorarium for their time to take part in the workshop.

| Ethics and consent
Workshop attendees provided written consent prior to attending the workshop and consented to the recording of the meeting.King's College London Research Ethics Minimal Risk Registration (MRA-22/23-37051).

| Structure of the workshop
The workshop agenda is shown in Table 1.The findings of the Shift-Diabetes Study were summarised by FL and RG, with a focus on the interview and survey findings. 16,17These were presented in the context of the COM-B (Capability, Opportunity, Motivation, Behaviour) model of behaviour change. 19Three interventions, in turn, were presented to attendees by FL (Supplementary material S1), attendees were invited to express their thoughts using the APEASE criteria to guide discussion (Affordability, Practicability, Effectiveness, Acceptability, Side-effects/Safety, Equity), 20 20 Workshop participants were encouraged to contribute to the online discussion and add any comments and thoughts into the text 'chat'.In the final part of the meeting, attendees were invited to put forward any additional ideas that had not already been discussed.Following the meeting, the Microsoft auto-generated transcript was checked against the audio recording and corrections made (RG).Attendee's names were assigned an identification code and any identifiable information (e.g., location of work, colleagues names) was redacted from the meeting transcript and the chat.Thematic analysis was then conducted by one researcher (RG) for each of the three suggested intervention strategies presented at the workshop.A five-step process was followed for each of the three intervention discussions: (1) Data familiarisation through re-reading the transcripts from the verbal discussion and online chat; (2) code book development based on the APEASE criteria, the code book included a description of each criterion; (3) Deductive framework analysis, the transcripts were analysed and sections of text deductively coded (selective coding) according to the APEASE criteria they related to most, when the applicable

| RESULTS
The full set of themes under each APEASE criterion is presented in Table 3 for each of the three interventions.
A narrative description of each is presented in more detail below with supporting quotes.There were limited conflicting views in the workshop, and generally, attendees agreed with their thoughts on the interventions presented.

| Intervention 1: Educational resources and structured education
The proposed intervention aimed to address reported barriers around (1) challenges adjusting eating patterns and applying healthy eating advice to shift schedules, and (2) the lack of support from healthcare professionals in understanding the challenges of shift work on eating.It also mapped to enablers such as (1) planning meals in advance, (2) taking own food to work and (3) eating at fixed times.Additionally, this intervention could address the low engagement of shift workers with structured diabetes education.
The proposed strategies within this intervention (Supplementary Table S1), included a range of tailored resources (e.g., meal templates, example meal plans for different shifts), facilitating a support network with tips and testimonials from other shift workers with T2D and, incorporation of tailored education into existing structured education provision.

| Affordability
Affordability was not directly discussed in relation to this intervention strategy.However, it was mentioned in the discussion that increasing the number of diabetes education sessions across different times of the day would potentially require additional staffing resources.Additionally, there would be a cost associated with generating digital and physical resources.An addendum from the workshop attendee, suggested that the costs of the intervention need to be balanced with the potential reduction in absences and improved presenteeism 'the potential reduction in absences and improved "presenteeism" that might be expected as a result of effective structured diabetes education is worth considering'.
For context, structured diabetes education in the UK is provided to qualifying NHS patients at no charge.The costs of provision would be to the education provider and commissioning organisation.

| Practicality
It was felt by several workshop participants that the current provision of structured education was a barrier to attendance.For example, those on shift work can find it a challenge to commit to 12 weeks of a structured education course when they have unpredictable work rotas.A potential solution based on previous experience would be to offer a 1-day structured education session -in preference to having to commit to attending for multiple weeks.In terms of attending education sessions, organisational/workplace barriers were felt important to overcome to be able to deliver sessions outside of standard clinical hours or allow employees time off during their working day to attend education sessions (e.g., night time).
…how do we change it to make sure they have the opportunity to attend it [structured education], whether it's something that can be offered, working with their employers to provide it as part of their working day, or how it can be tailored to make it accessible to them.
Offering add-on sessions to established diabetes education was also viewed as an acceptable way to deliver information tailored to shift workers while considering that programmes need to cover broad advice that would be applicable to most attendees.It was also felt from a healthcare professional perspective that having dietary advice for shift work as an add-on element in established education sessions would be practical to deliver.I'd like the idea of sort of add-on module, almost an extra kind of resource that you can give specifically for people who are on shift work.However, a potential barrier was the variability in types of shift work as this may present a potential barrier to developing information resources.Another barrier was the lack of consistency in asking patients in the clinic if they worked shifts and gaps in training and education in healthcare professionals on how to incorporate shift work as part of the assessment and management plan.A further barrier to this was the limited time allocated to consultations.

| Effectiveness
A purely education focus was viewed as unlikely to be effective.Participants felt it was important to go beyond imparting knowledge and skills, towards increasing motivation, addressing psychosocial dimensions, and supporting habit formation.
I agree there's an element of psychology needed to address issues around lifestyle and diet.I've been 'educated' for many years but it's about changing habits.
It was felt that the provision of meal plans may have limited effectiveness for some people, with time constraints cited as a significant barrier.A suggestion would be to supplement this information with lists of more healthy convenience/ ready meals.It was also felt that without changes in the work environment, for example, the provision of healthier food options and the ability to take breaks, this support would not be effective.so even with the education I feel that you know, if you're not making changes to the environment, it's going to be really challenging to people.
people [shift workers] cannot plan breaks as a standard office person does and very often it will be very much on how busy they are… [‥]‥ they generally work with limited staff numbers at night.

| Acceptability
It was suggested that providing people with a choice of joining groups or having individual sessions was an important aspect of acceptability.Also, some people may prefer to engage via a digital platform (either synchronous or asynchronous), while for others an in-person option may be preferable.For in-person or synchronous digital education delivery there may be a need for multiple time options to increase attendance.From a healthcare professional perspective, the approach of providing recipes and meal plans adapted to shift patterns was viewed positively and as an acceptable way to deliver in practice.It was also perceived as acceptable to adapt healthy eating guidelines traditionally geared towards balanced meal planning to apply to the night shift context for example 'snacky foods' and convenience/vending foods.
It was also felt that it was important to offer a range of approaches so employees with T2D can find something that works for them.
something that can work given different dietary approaches [and] different avenues so they can try and find something that works for them.
There was also discussion about positivity and sharing of experiences by shift workers with T2D.A suggested strategy was to set up a forum moderated by a diabetes health professional to facilitate this.It was also felt advice should include wider aspects of life, for example, strategies around food shopping that most people tend to do during the day, which may impact sleep in night workers.It was also suggested that more engagement is needed with shift workers to understand the barriers to attending structured education programmes: Why they hadn't attended?Whether it was they hadn't been offered it [structured education], whether it was the programs on offer weren't a suitable time, or whether it was something beyond that.

| Side-effects and safety
Although the Shift-Diabetes Study focused on employees with T2D not prescribed medications with a high risk of hypoglycaemia, it was felt that many patients seen in clinic or structured education could be on multiple medications.It was felt that there might be some risk in providing change of eating pattern advice without knowing how this might impact medications or, not being able to provide sufficient advice about how to adjust medications on shift 'you're not gonna be able to provide specific suggestions for every individual on every different medication regimen.'However, not advising on any lifestyle changes, may have longer-term implications.Several participants felt that there was a knowledge gap in the guidelines and evidence available to healthcare professionals when it came to being able to advise and support shift workers with T2D they see in the clinic with some elements of '…making it up as you go along, really.'It was viewed that the training of healthcare providers around dietary management of shift workers will be important alongside the provision of educational resources for patients.

| Equity
In discussing the types of resources to use, it was felt that not everyone is comfortable using digital resources.Therefore, to be equitable a range of resources should be made available in physical and digital formats.It was also suggested that dietary advice should be culturally appropriate, for example, considering religious festivals like Ramadan.

| Intervention 2: Increasing availability and accessibility
The second intervention presented was mapped to barriers related to (1) availability and accessibility to food and beverages during night shifts, particularly healthy options, (2) perceived expensiveness of the food and beverages available on-site during night work and, (3) the need for convenience.The strategies outlined as part of this intervention were to increase the availability of food and beverages during night work and including healthier food options in vending machines and at other on-site providers.This could also include subsidies on healthier foods and potential restrictions on less healthy food options.Another strategy was the provision of 'packed lunches' that could be pre-ordered at the start of the shift.

| Affordability
Most attendees felt that affordability for the NHS or healthcare employer to provide subsidised food during night shifts would be a barrier to implementation given the current competing priorities within the healthcare sector.It was also felt that priority was given to maintain revenue from on-site retail spaces rather than invest in new technologies such as healthy vending which has limited availability in NHS sites.
the investment [increasing food provision] in terms of money that has to be put in understanding in the current climate in which budgets are very tight.…you can't use certain spaces because they're that ring fenced for renting out to a business to make profit from it.

| Practicability
A 'top-down' approach with management buy-in was considered important to gain wider stakeholder buy in from facilities, catering managers, and on-site retailers.
I have had several conversations over the years with catering managers [and] with external retailers and so on.It's a hard one.
if you're going to make any kind of changes to the organization then management is key and anything that they then do will cascade down through the workforce.
A suggestion was to consider education sessions for managers around diabetes management in the workplace.There was a discussion around the current standards and guidelines for NHS employers to provide 24/7 healthy food provision to staff, patients and visitors.However, it was felt that despite some examples of good practice these standards are not universally implemented.Raising the question of 'It's more about almost penalties for not implementing it…How do you actually do this?'

| Effectiveness
The effectiveness of any food provision intervention would need to consider the wider workload and working schedule within healthcare.The main concerns raised were around the workload on night shifts limiting the ability to take breaks and the duration of shifts.It was also suggested that to be effective, wider cultural changes would be needed.For example, colleagues and visitors bringing in cakes may limit the effectiveness of on-site food provision interventions.
if you have things changing actually in the working environment, but then people are bringing things in from outside, it's not moving the dial as far as maybe you want.
Several workshop participants talked about the importance of the need for a 'bottom-up' approach and the involvement of people with diabetes in developing and achieving reach of workplace interventions: involving diabetes clinical champions is a really good one because as has been pointed out, there are policies and things that should help with this on a top level that aren't coming down.So, to actually make changes you maybe need to try and find areas that are willing and engaged in and work from the bottom up Another suggestion was to engage with food delivery companies, for example, provide information about making healthy choices when ordering food online to be delivered.

| Acceptability
Increasing the availability of food during night shifts was generally seen as being acceptable and the provision of preorder packed lunches would be acceptable given the limited food preparation facilities in many healthcare settings: I like this idea.I don't always have the availability to food if I don't bring myself and if I hadn't taken my own the only options on a night shift is sandwiches, biscuits, cake.
We have no facilities to get food on a night shift so being able to pre order would be great.
However, a range of food choices would be important to offer and the night-time food provision should be seen for staff as well as patients.Regarding the price of the food provided, it was felt that was important to consider affordability as a relative term 'What's affordable to me will be different to you.'  Location was also a consideration, and given the limited break times in a large hospital, this may be a barrier to accessibility if the food outlet is not in proximity.…it's very hard for [staff] to come down [from] the wards to actually be able to get to the main entrance of the hospital and that in itself is a barrier.
It was also felt that barriers with catering and retail managers would need to be overcome with an account of previous conversations being difficult.
Several workshop participants expressed the importance of the wider social aspects of food choice this was consistent with participant comments about intervention one.…people kind of bringing in cakes and things for a colleague.So, so I guess any system that's trying to improve the healthfulness of what's available ideally need some buy in from as many members of the team.…I just thought [slow cooker in staff kitchen] was lovely because everybody was then sort of eating similar food.It was all very healthy.It was accessible and available for everyone at any time when they wanted to eat.

| Side-effects and safety
Concerns were raised regarding safety and unintended consequences.Firstly, it was felt that 'demonization' of some foods and blanket restrictions would not to helpful.…And I mean for example, you know something that you can get out of a vending machine could actually really help you with adjusting a hypo.
There was discussion around increasing access to food preparation facilities for staff, with examples where health and safety restrictions would prevent the use of unsupervised cooking machinery due to fire risks, or considerations around food safety of the food being prepared on-site.Additionally, it was acknowledged that there is the potential for a backlash in the restriction of certain foods:

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Some people think it's impinging their rights as people.Whatever it is, to get really extreme reactions.I just think being aware that even if we come up with what seemed like sensible suggestions, it doesn't necessarily mean everyone's going to agree.

| Equity
Provision of food to staff during night work was viewed as key to equity across all staff regardless of the hours worked: '…it seems to me a basic thing that should be provided for a group of healthcare workers who are there at 3 o'clock in the morning and need to be able to eat and drink just as they would do at 3 o'clock in the afternoon'.Although the Shift-Diabetes study focused on shift work employees with T2D working in hospital or residential care settings it was suggested that future consideration should be given to those working in the community setting who may be at particular risk due to isolation and restriction to food outlets.

| Intervention 3: Biofeedback and tailored advice
The third intervention mapped behaviour change strategies to the (1) mixed perceptions around the impact of diet on diabetes management, (2) eating in response to emotional cues, and (3) priority and intention of eating more healthily and improving diabetes management.Proposed strategies were around the use of self-monitoring and biofeedback to provide personalised advice, increase personal relevance and awareness of how different foods consumed might impact blood glucose levels, and enabling self-reflection.For example, diet and symptom recording and continuous glucose monitoring (CGM).

| Affordability
No themes were identified related to affordability from the discussions.

| Practicability
The time burden was considered as a potential barrier to monitoring 'Why are we imposing homework for people with diabetes?' 3.3.3

| Effectiveness
The perceived effectiveness of monitoring and biofeedback was mixed.Several workshop participants considered the potential for effectiveness based on an increasing understanding of how diet impacts blood glucose levels.…in principle it's great and it works really well alongside structured diabetes education because you're encouraging people to experiment with changes and see how they work for them anyway.
in practice, I have seen people, particularly with type 2 diabetes, when they get their glucose monitor and really start to engage with their diabetes and start to manage it a lot better because they can see what's going on.
Several workshop participants raised concerns about how effective monitoring can be and how well CGM monitoring meets the wider aims of diabetes management for example maintaining cardiovascular health.
I think the reflection is contemporaneous, though I don't think anyone goes back and looks at the last week.think it's always important to think back about why?Why do we care about managing type 2? What's the goal?And it's about reducing microvascular disease and cardiovascular disease… I see people eating to the CGM and many times they're eating foods that, for example increase their cholesterol or they might be avoiding foods or dietary choices that lower their blood pressure.
There was more agreement between participants that the use of monitoring and feedback could be effective in shift workers alongside structured education which focuses on the wider health and not focusing on just glucose.I simply cannot see CGM's being effective as a standalone treatment for type 2 diabetes or part of learning unless it's alongside advice about considering those other factors that you aren't measuring because you can't measure them as frequently, right?I agree that this shouldn't be a standalone intervention and just monitoring glucose levels isn't a substitute for, you know, promoting a healthy diet to maintain, you know, heart health and you know reduce the risk from cardiovascular disease.

| Acceptability
The idea of blood glucose monitoring along with diet recording was viewed as positive to provide an understanding of how diet can impact blood glucose changes.
I have always thought if I could see how certain types of food impacts glucose levels etc. this is a brilliant idea.
The diary can be incorporated into the glucose monitor to keep all data in one place.
However, workshop participants talked about the importance of positive rather than negative feedback through any digital app.
…is that going to be constructive feedback that they're going to learn from it, or is it going to be negative feedback or, is it going to be positive feedback?…it's not about sort of saying, you know, naughty, naughty -you shouldn't?have had that chocolate bar last week.It's more, ohh, that's what happened when you did have that chocolate bar.So actually, that's something that you can consider for the future.

| Side-effects and safety
There was concern about the risks associated with CGM use in relation to the sole focus on glucose levels rather than people considering the wider diet quality or the impact of diet on other health outcomes.
People becoming scared of certain foods if they see a small increase in blood glucose don't think that's pathological.it's not just the high sugar that you need to just focus on.Also, the possible complications, which is a heart problem and peripheral vascular disease.
Considering these side effects and safety concerns there was also a comment about appropriateness for some people living with T2D and potentially over-reliance on blood glucose readings potentially leading to anxiety.…and some people will become really, really obsessed with it and scan a million times a day.I think that's probably one of the issues that that I've seen in the past when introducing a new glucose monitoring.
Would someone need some kind of psychological assessment before being given [CGM]……to understand if it's appropriate to them?From an anxiety stress point of view.
…making sure that when it's offered [continuous glucose monitoring] there's the right education around it and being clear about, you know, what's expected and not.Not to scan a million times a day because you're not gonna gain any benefit from that because that can just cause additional anxiety.

| Equity
The main comment around equity was the provision of a range of options as some people will not engage or wish to use technology.
I think the suggestion about making it available to people who want to use it as a good one, and I think it just fits into having a menu of options for having different ways to access the education, having different dietary approaches, having different tools.

| Additional considerations
Additional suggestions from workshop participants related to the need to consider the impact of other health behaviours such as physical activity and sleep.…I think including in any education resources and the importance of sleep and any resources on sleep as well, because I do know lots of people who come from night shift who won't go to sleep.
Stress management was also talked about as being an important consideration in taking a holistic approach.
I think what would be great is incorporating some information on stress management as well, because there we see that can really affect the way people eat and the way they sort of conduct their lives.
The social context should also be considered especially family and wider support network when we think about the ability to support behaviour change.
I think it individuals are often guided by… what's going on at home, for maybe, family support as well for that individual.I don't know if there's any ability to run sort of family programs perhaps.
From a clinical view point, it was felt that there were gaps about how to manage shift workers with T2D and that this was a key area that needed to be addressed.I don't have any evidence base for the most effective medication.I don't have an evidence base for the most effective regimen and timing for that medication…[‥]…I have never seen any healthcare professional education about how we empower and enable people to work different shift patterns safely and effectively while living with diabetes

| Summary and closing remarks
The meeting facilitator summarised the main discussion points and brought the workshop to a close.Overall, it was felt that elements of all three interventions were important to take forward to the next stage of development.The next stage of development is to take these findings forward to a co-design and feasibility study.However, it was felt that there were gaps in healthcare providers knowledge linked to the limited guidelines and evidence available that needed to be addressed to enable support to be provided.

| DISCUSSION
In the UK the prevalence of T2D is predicted to be 5.5 million by 2030 21 and with the drive to increase the duration of being economically active, a significant proportion of the workforce is likely to be living with T2D, many of whom will be employed in night shift work.Currently, there is no tailored programme of support available to either shift workers living with T2D or employers.The aim of the consultation workshop was to discuss and evaluate potential interventions to identify those with a potential to take forward for further development and testing.Based on theory-based formative qualitative and survey research, the Shift Diabetes Study mapped potential interventions to the barriers and enablers reported by shift workers living with T2D. 16In a stakeholder consultation workshop the likely acceptability, feasibility, and impact of three intervention options that sought to address the reported barriers and enablers were discussed with shift workers with T2D, healthcare providers.The APEASE framework guided discussions and supported thematic analysis.The framework is designed to aid systematic decisions about the development of behaviour change interventions at the initial development stage in line with the Medical Research Council framework for developing complex interventions. 22he workshop highlighted the importance of multilevel interventions to support dietary behaviour change, targeting the food environment and as well as shift workers.This agrees with a systematic review that investigated the effectiveness of worksite health interventions on dietary outcomes. 23The work environment (e.g., the ability to take breaks) was highlighted as a barrier to the 'Education' and 'Availability' interventions' effectiveness.Therefore, although there is evidence to support the efficacy of self-management education in adults with T2D 24 providing education without structural changes in workload and breaks will likely be of limited value.However, addressing workload and staffing shortage in the UK healthcare sector is a higher-level strategic challenge requiring macropolitical intervention.
Addressing the limited availability of healthy food during the night was viewed as essential to the effectiveness of 'Education'-based interventions.The existence of the national standards for food and drink in the NHS that includes the commitment to provide healthy food to staff, patients and visitors 25 should be an enabler to achieving this goal.However, based on previous findings, these guidelines are not universally implemented. 16,17herefore, further research needs to understand the barriers to implementing the guidelines.
A fundamental barrier to providing support to shift workers with T2D is the limited guidance and evidence available to clinicians.Chrono-nutrition is a relatively new field of dietary research which considers eating patterns (e.g., time and frequency) and their impact on health.Current evidencebased dietary guidelines support several dietary patterns in people living with T2D 26 however, there is limited guidance regarding eating patterns.To date observational studies have suggested that eating later in the chronological day is with increased cardiometabolic risk in the general population 27,28 and limited intervention studies show higher glucose response to equivalent meals consumed at night compared to during the day. 29However, there are currently no evidence-based nutritional guidelines for the shift work population, and very little primary data to draw on. 30dditionally, there is limited evidence for medical clinicians to support chrono pharmacological decision-making in the management of T2D.It is therefore important to ensure that research trials include a large enough subgroup of people working night shifts to assess the relative effectiveness of pharmaceuticals on diabetes management of this population, or studies which specifically recruit people who work night shifts.

| Limitations of the workshop
The workshop was restricted to stakeholders involved in nutritional and clinical care as well as experts through experience.Scheduling constraints of the workshop limited the attendance of shift workers living with T2D and other clinicians.Increasing the diversity of end users in any subsequent co-design work will be important to ensure any intervention meets the needs of users.The workshop highlighted the need for wider stakeholder engagement particularly at the workforce, facilities, and business management level.There is an element of subjectivity in applying the APEASE criteria and not all criteria were discussed.The Shift-Diabetes Study was conducted on hospital and residential healthcare workers in the UK, as it aimed to understand behaviour in a specific workplace context, therefore the results may not be generalizable to shift worker with T2D employed in other sectors.

| RECOMMENDATIONS
Several research priorities were identified from the workshop, Table 4.The findings from the workshop point to important considerations when designing interventions for shift workers with T2D -potentially beyond just dietary behaviour, but also practical considerations for other T2D behaviour change interventions.These priorities could be of more generalisable interest to other researchers, policymakers or organisations looking to implement such initiatives in practice.As several of the challenges reported from this consultation workshop support previous behavioural investigations into shiftwork and healthy eating, some of the priorities will also be of benefit to the wider UK healthcare shift work population.

| CONCLUSION
The workshop highlighted the importance of multilevel interventions to support dietary behaviour change in shift workers living with T2D.The limited guidance and evidence available to clinicians and allied health professionals to provide support to shift workers with T2D was identified as a key barrier.Priority action points include (i) understanding barriers to 24/7 food availability in healthcare settings, (ii) including shift workers in clinical studies, and (iii) research to understand the effectiveness of continuous glucose monitoring in shift workers with T2D.

T A B L E 1
Shift Diabetes intervention development consultation workshop structure.

T A B L E 2 APEASE criteria outline presented to workshop attendees for intervention discussion. Affordability What resources would be needed? Could it be delivered within a reasonable budget?
Summary of APEASE criteria across each intervention.
T A B L E 3 you're really busy and you're, you know, you're not able to step away from whatever work it is that you're doing at that critical time.knowing that you're gonna get a break and a chance to sit down.It all flows in and it just spirals if you don't know when or if you're gonna have the chance to stop and do any of these things [healthy eating]. …if