The Effect of Chronic Passive Heating on Insulin Sensitivity and Cardiovascular Function in People With Type 2 Diabetes Mellitus: A Pre- and Post-test Trial
Phase: NA
Conditions: Type2 Diabetes
Sponsor: University of Portsmouth

 
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Study Title: The Effect of Chronic Passive Heating on Insulin Sensitivity and Cardiovascular 
function in People with Type 2 Diabetes Mellitus: A pre- and post-test trial. 
Internal Reference No:  
Ethics Ref: 21/LO/0180 
Date and Version No: 10/05/2021 v3        
Chief Investigator: 
Dr Anthony Shepherd 
Investigators:  
See protocol development team below 
Sponsor:  
University of Portsmouth 
Funder (if applicable): 
N/A 
Signatures:  
 
Protocol Development Team:   
Chief Investigator   
- Dr Anthony Shepherd 
   (University of Portsmouth) 
Principal Investigator         - Mr Thomas James                 (University of Portsmouth) 
Co- investigator 1 
 
- Dr Jo Corbett  
 
   (University of Portsmouth) 
Co- investigator 2 
 
- Dr Maria Perissiou                (University of Portsmouth) 
Co- investigator 3 
 
- Dr Clare Eglin                       (University of Portsmouth) 
Co- investigator 4                  - Prof. Mike Tipton                  (University of Portsmouth) 
Co- investigator 5                  - Dr. John Young                      (University of Portsmouth) 
Co- investigator 6                  - Dr Zoe Saynor                        (University of Portsmouth)  
Co- investigator 7                  - Prof. Michael Cummings      (Queen Alexandra Hospital) 
Co- investigator 8                  - Ms Sharon Allard                  (Queen Alexandra Hospital) 
Co- investigator 9                  - Dr Kathryn Carey-Jones      (Oaks Healthcare) 
Co-investigator 10                 - Mr Harvey Belcher                (University of Portsmouth) 
Co-investigator 11                 - Mr Dan Piccolo                      (University of Portsmouth) 
 

 
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TABLE OF CONTENTS 
 
1. 
AMENDMENT HISTORY ................................................................................................ 5 
2. 
SYNOPSIS ......................................................................................................................... 6 
3. 
ABBREVIATIONS .......................................................................................................... 10 
4. 
BACKGROUND AND RATIONALE ............................................................................ 12 
5. 
PRELIMINARY STUDIES AND EXPERIENCE OF INVESTIGATORS .................... 13 
6. 
AIMS AND OBJECTIVES .............................................................................................. 13 
6.1 
Primary Objective ..................................................................................................... 13 
6.2 
Secondary Objectives ................................................................................................ 14 
To establish if chronic passive heating improves: ............................................................... 14 
7. 
STUDY DESIGN ............................................................................................................. 14 
7.2 
Primary and Secondary Endpoints/Outcome Measures ............................................ 16 
8. 
STUDY PARTICIPANTS ................................................................................................ 17 
8.1 
Study Setting ............................................................................................................. 17 
9. 
SAMPLING ...................................................................................................................... 17 
10. 
STUDY PROCEDURES .............................................................................................. 18 
10.1    Recruitment ............................................................................................................... 18 
10.3   Screening and Enrolment ........................................................................................... 19 
10.4 Randomisation .............................................................................................................. 19 
10.5 Study intervention ........................................................................................................ 19 
10.6 Study Assessments ....................................................................................................... 20 
10.7 Discontinuation/Withdrawal of Participants from Study Treatment ......................... 23 
10.8 Definition of End of Study ........................................................................................ 24 

 
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11. 
INTERVENTIONS ....................................................................................................... 24 
11.1 Description of Study Intervention / Treatment ......................................................... 24 
11.2     Adherence to Study Treatment ................................................................................. 24 
11.3     Accountability of the Study Treatment .................................................................... 24 
11.4     Concomitant Medication / Therapies ....................................................................... 24 
12. 
ASSESSMENT OF SAFETY (if applicable) ............................................................... 24 
12.1 Definitions ................................................................................................................. 24 
12.2 Reporting Procedures for Serious Adverse Events ................................................... 25 
12.3 Recording and Reporting Procedures for All Adverse Events .................................. 25 
13. 
Data Handling and Record Keeping ............................................................................. 25 
13.1 Data Collection Forms .............................................................................................. 25 
13.2     Data Management .................................................................................................... 25 
14. 
DATA ANALYSIS ....................................................................................................... 26 
14.1      Description of Analysis Populations ....................................................................... 26 
14.2      Analysis of Endpoints ............................................................................................. 26 
14.3     Procedure for Dealing with Missing, Unused and Spurious Data............................ 26 
14.4     Procedures for Reporting any Deviation(s) from the Original Statistical Analysis Plan
 .............................................................................................................................................. 26 
14.5      Interim analysis and criteria for early study termination ........................................ 26 
15. 
ETHICS......................................................................................................................... 26 
15.1 Participant Confidentiality ........................................................................................ 28 
15.2     Other Ethical Considerations ................................................................................... 28 
15.3     Declaration of Helsinki ............................................................................................ 28 
15.4     ICH Guidelines for Good Clinical Practice.............................................................. 28 
16. 
PATIENT PUBLIC INVOLVEMENT (PPI) ............................................................... 28 

 
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16.1    Study design .............................................................................................................. 28 
16.2    Study implementation ............................................................................................... 29 
16.3    Dissemination ............................................................................................................ 29 
17. 
FINANCING AND INSURANCE ............................................................................... 29 
17.1    Research Costs .......................................................................................................... 29 
17.2    Service Support Costs ............................................................................................... 29 
17.3    Excess Treatment Costs ............................................................................................ 29 
17.4    Study Sponsorship ..................................................................................................... 29 
18. 
TIMETABLE AND ORGANISATIONAL CHART ................................................... 29 
19. 
RESOURCES, EQUIPMENT AND PHYSICAL FACILITIES .................................. 30 
20. 
DISSEMINATION AND OUTCOME ......................................................................... 30 
21. 
REFERENCEs .............................................................................................................. 30 
 
 

 
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1. 
AMENDMENT HISTORY 
Amendment 
No. 
Protocol 
Version 
No. 
Date 
issued 
Author(s) of changes 
Details 
of 
Changes 
made 
1 
2 
18/02/2021 
Mr Thomas James 
• Amendment to 
inclusion and 
exclusion 
criteria 
• Further detail of 
informed 
consent process 
added 
• Further detail 
on safety SOP’s 
added 
2 
3 
10/05/2021 
Mr Thomas James 
• Wording 
change of 
“nurses” to 
“UoP staff” 
• Identification of 
where screening 
blood samples 
will be analysed 
added. 

 
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2. 
SYNOPSIS 
Study Title 
The Effect of Chronic Passive Heating on Insulin Sensitivity and 
Cardiovascular function in People with Type 2 Diabetes Mellitus: A pre- 
and post-test trial. 
Internal ref. no. 
n/a 
Problem statement 
Type 2 diabetes mellitus (T2DM) is a metabolic condition characterized 
by chronic hyperglycemia and progressive insulin resistance, which 
progressively lead to macro- and microvascular damage and subsequent 
impairments in blood pressure (BP) control. Therapeutic approaches to 
manage T2DM focus on improving glycaemic control and BP and include 
pharmaceutical treatments (e.g. Metformin and insulin), physical activity 
and exercise, and calorie restriction. However, pharmaceutical 
interventions can be expensive and are associated with low adherence. 
Although exercise and diet programs have been shown to be effective, 
like pharmaceutical interventions, they often have poor adherence in 
people with T2DM. With the number of people with T2DM (464 million) 
continuing to rise and expected to reach 700 million by 2045, the costs 
associated with the clinical management of this condition are likely to 
become unsustainable. There is, therefore, a need to explore the potential 
of alternative interventions. In particular, interventions which may be 
cheaper than clinical management and have better adherence than 
exercise, and hypoglycemic agents, to improve glycemic control and 
deleterious cardiovascular manifestations of this condition. 
 

 
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Passive heating may be one such intervention with therapeutic potential. 
Research question / 
hypothesis 
Before passive heating can be considered as a therapeutic option for 
improving metabolic and cardiovascular health in individuals with 
T2DM, we need to explore whether their chronic passive heating (1h x 10 
days) is able to improve: 
1) insulin sensitivity 
2) glycaemic control 
3) metabolic efficiency 
4) vascular health 
 
Study Design 
We plan to run a within-subject, pre-, post-intervention study 
Study Participants 
Adults ≥ 35 years (post-menopausal for females), diagnosed with T2DM 
as defined by the world health organisation (WHO). 
Planned Sample Size 
We aim to recruit 20 individuals with T2DM. 
Follow-up duration 
7 days 
Planned Study 
Period 
18 months 
Primary Objective 
To determine whether chronic passive, warm water therapy increased 
insulin sensitivity in individuals with T2DM? 
Secondary Objectives 
To determine whether chronic passive, warm water therapy improves: 
1) glycaemic control 
2) metabolic efficiency 
3) vascular health 

 
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Primary Endpoint 
Improvement in insulin sensitivity from chronic passive heating. 
Secondary Endpoints 
1) fasting plasma [glucose] 
2) AUC plasma [glucose] 
3) peak plasma [glucose] 
4) HbA1c 
5) plasma [eHSP70] 
6) plasma [IL-6] 
7) plasma [IL-10] 
8)  plasma [butyrate] 
9) plasma [growth hormone] 
10) RMR 
11) fat oxidation 
12) CHO oxidation 
13) macrovascular function  
14) microvascular function 
15) resting heart rate 
16) stroke volume 
17) total peripheral resistance 

 
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18) cardiac output 
19)  heart rate variability 
 
Intervention (s) 
8-12 x1 h water immersion (to the clavicle, @40 °C, rectal temperature 
~38.5 °C and <39 °C) sessions over a period of 14 days. 

 
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3. 
ABBREVIATIONS 
AE 
 
Adverse event 
ANOVA  
Analysis of variance 
AUC   
Area under the curve 
CHO               Carbohydrate 
CPET   
Cardiopulmonary exercise test 
CRF   
Clinical records file 
ECG   
Electrocardiogram  
EDTA  
Ethylenediaminetetraacetic acid 
eHSP   
Extracellular heat shock protein 
GCP  
Good clinical practise 
GH                  Growth hormone (human) 
Hb  
 
Haemoglobin 
HbA1c  
Haemoglobin adult type 1c (Glycated haemoglobin) 
Hct  
 
Haematocrit 
HEC   
Hyperinsulinaemic-euglycaemic clap 
HIIT   
High intensity interval training 
HR  
 
Heart rate 
HRV   
Heart rate variability 
HSP   
Heat shock protein 
IL 
 
Interleukin 
LF  
 
Low frequency 
NHS  
National Health Service 
NIHR   
National institute for health research 
NIRS  
Near infrared spectroscopy 
NRES   
National research ethics service 
OGTT  
Oral glucose tolerance test 
PCPI   
Patient, carer and public involvement 
PPI  
 
Patient public involvement 
QUICKI         Quantitative insulin sensitivity check index 

 
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REC   
Research ethics committee 
RHR                Resting heart rate 
RMR   
Resting metabolic rate 
RMSSD  
Root mean square of the successive differences 
RSA   
Respiratory sinus arrhythmia  
SAE 
 
Serious adverse event 
T2DM  
Type 2 diabetes mellitus 
Trec  
 
Rectal temperature 
UoP   
University of Portsmouth 
V̇ O2                         Oxygen consumption 
WHO   
World health organisation 
 

 
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4. 
BACKGROUND AND RATIONALE 
Current estimates suggest 422 million people worldwide live with a form of diabetes, of which 
~ 90% have type 2 diabetes mellitus (T2DM) [1]. The total direct and indirect cost of care for 
individuals with diabetes in the UK is £23.7 billion, equating to ~ 20% of the annual NHS 
budget [2], this figure is expected to rise to ~£39.8 billion by the year 2035 [2, 3]. 
Approximately 85-90% of cases of T2DM arise from a poor lifestyle and obesity [4-6], with 
the remaining 10-15% resulting from genetic predispositions [7, 8]. Current interventions 
include pharmaceutical treatments, exercise and calorie restrictive diets, which aim to improve 
glycaemic control. However, pharmaceutical interventions carry a high financial cost [9, 10], 
while exercise and diet programmes have a low adherence rate in individuals with T2DM [10-
15]. With the prevalence of T2DM continuing to increase, the costs associated with the clinical 
care of these individuals are likely to become unsustainable. Simple, inexpensive interventions 
to improve the clinical profile of this group are therefore needed.  
One emerging potential therapy to improve glucose homoeostasis is passive heating. 
Preliminary evidence suggests passive heating may have beneficial effects for metabolic health 
in animal models [16-21] and in humans [17, 22-24]. In 1999, the use of hot tubs (38-41°C , 
30 mins / day for 3 weeks) was shown to reduce fasting plasma glucose concentrations by 
~14% (1.3 mmol.L-1) and decrease HbA1c by ~10-11 mmol/mol in 8 individuals with T2DM 
[23]. Given the rate of turnover in haemoglobin this reduction is surprising as the treatment 
period was run over 3 weeks and the total haemoglobin turnover takes ~115 days [25]. While 
more recent work has been conducted into the effects of a single bout of passive heating in 
healthy adults [22] and individuals with T2DM (including ourselves, under review) [22, 24], 
none have been done on chronic heating since Hooper [23]. Hooper [23] postulated that an 
increase in skeletal muscle blood flow may be responsible for this increased glucose clearance, 
citing evidence that this can modulate insulin mediated glucose uptake [26]. Other mechanisms 
have also been purported, but have yet to be elucidated, including; increased insulin sensitivity 
[27, 28], altered inflammatory response [29-31], activation of heat shock proteins (HSP) [32], 
altered gut microbiome and butyrate [33]. Repeated passive heating results in transient 
increases in deep body temperature [24, 34-37] and may improve glucose homeostasis [22, 38-
46] via similar mechanisms to exercise.  
Regular aerobic exercise also improves macro- [47] and microvascular function [47], muscle 
oxygenation [48], autonomic fuction [49], cardiorespiratory fitness [50], lung function [51] and 
delays age related muscle loss [52]. Acute exercise studies show that insulin sensitivity after 
1h of moderate exercise does not change [53, 54], however, insulin sensitivity appears to be 
improved following bouts longer than an hour [54] or performed at greater intensity [55]. 
Increases in insulin sensitivity have a curvilinear relationship with energy expenditure [54] and 
could also be due to greater HSP expression [56]. However, it is unrealistic for people with 
T2DM to perform this level of activity. Passive heating may be one supplemental exercise 

 
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mimetic to augment improvements in insulin sensitivity, cardiorespiratory fitness [60] and 
muscle strength, and function [81].  
We recently provided evidence that acute passive heating in poeple with T2DM (currently 
under review for publication) is well tolerated and increases extracellualr [HSP70], and energy 
expenditure, and reduce diabstolic blood pressure. There is a growing body of evdience that 
suggests passive heating may improve many facets of human physiology, however, the 
mechanisms that underpin these benefits have yet to be established and future research needs 
to explore these further.   
 
 
 
 
 
 
 
 
 
 
 
 
5. 
PRELIMINARY STUDIES AND EXPERIENCE OF INVESTIGATORS 
Dr Anthony Shepherd is the lead applicant and has expertise in trial management and clinical 
exercise physiology and his work has focused on exercise, (oxygen uptake, quality of life, 
functional capacity and glucose homeostasis) in clinical cohorts. Mr Thomas James is a PhD 
candidate currently working with a background in clinical, exercise and environmental 
physiology. He has recently completed a similar study in individuals with T2DM. Dr Jo Corbett 
is experienced in running exercise and thermal physiology trials and is a World leader in the 
area. Dr Maria Perissiou is an early career researcher with extensive experience in assessing 
the acute cardiovascular responses to exercise in clinical population. Dr Perissiou has expertise 
in exercise testing, assessments of cardiovascular function and venous cannulation in clinical 
populations. Dr Clare Elgin is an experienced thermal physiologist and has experience leading 
MoD trials. Prof. Michael Tipton’s World leading expertise in thermal physiology will be used 
to help with data interpretation. Dr John Young’s expertise in biochemistry will be used for 
data analysis and interpretation. Dr Zoe Saynor has expertise in exercise testing and training in 
clinical populations, venepuncture and cannulation and will help with data interpretation. Prof 
Michael Cummings (clinical lead for the local NIHR diabetes research network), will be 
involved in this project and will provide clinical advice, responsible for participant safety and 
helping with participant recruitment. Ms Sharon Allard and Dr Kathryn Carey-Jones will aid 
with participant recruitment through Clinics and primary care. Mr Harvey Belcher and Mr Dan 
Piccolo will help with data collection. Final report and project related publications will be a 
collaborative effort of the team.  
6. 
AIMS AND OBJECTIVES 
This study will provide us with important data that will help ascertain whether passive heating 
has the potential to be used as a future treatment for T2DM and also provide mechanistic insight 
to how passive heating effects individuals with T2DM.  
6.1 
Primary Objective 
To determine whether chronic passive heating can increase insulin sensitivity in individuals 
with T2DM. 

 
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6.2 
Secondary Objectives 
 To establish if chronic passive heating improves:  
 
1) glycaemic control 
2) metabolic efficiency 
3) vascular health 
 
7. 
STUDY DESIGN 
7.1 
Summary of study design 
Plan of investigation: We plan to run a pre-, post-intervention study to assess chronic heating’s 
effect on metabolic health and cardiovascular function in people with T2DM.  We aim to recruit 
20 individuals with T2DM. All visits (11-15) will take place within our physiology laboratories 
(Spinnaker Building, University of Portsmouth). The experimental design will involve an 
initial screening visit (~1 h), two identical experimental visits (pre and post intervention) (~ 3 
h) and 8-12 intervention visits (~1.5 h) (see Figure 1). We will aim for 10 intervention visits 
[57], however for feasibility we have incorporated scope for plus or minus 2 immersions for 
individuals who want to come for extra visits or struggle with time constraints. Both longer 
[58] and shorter protocols [59] have been utilized in the past. The screening visit will consist 
of participant characterisation, safety assessments including resting electrocardiogram (ECG), 
screening bloods (HbA1c, FBC, liver and renal function) and familiarisation with the testing 
procedures. On experimental visits, the participants will arrive at 0800 in a fasted state (12 h), 
and will have refrained from exercise 48 h before, alcohol and caffeine 24 h before, and taking 
any diabetes medication the morning of the visit. Participants will then undergo: baseline 
measurements of bloods, central haemodynamics, RMR, macro- and microvascular function; 
then an oral glucose tolerance test (OGTT) and re-measurements of blood (for analysis of 
plasma [glucose] and [insulin] only here). After the OGTT participants will be provided with 
a snack.  
The intervention visits consist of the participant being immersed into a 40 °C hot tub for 1 h 
with rectal temperature measured throughout to ensure target deep body temperature is attained 
(38.5 - 39°C) and to also monitor deep body temperature for safety (see 10.5). To clamp deep 
body temperature, body positon in the hot tub will be manipulated accordingly to allow heat 
loss to occur. If rectal temperature goes above 39 °C the heating protocol will be terminated 
and cool procedure enacted. Visit measurements and time course are explained in detail in 
section 10.6. 

 
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Participants and Recruitment: A power calculation indicates (looking for a difference in 
paired means) that 15 people are required to detect a 1 standard deviation change in insulin 
sensitivity (alpha = 0.05; power = 80%). Given the magnitude of change shown in other chronic 
passive heating studies [60] it is not unreasonable to expect to see this effect size (see 10.1). 
To account for participant drop-out we intend to recruit 20 people aged > 35 years with T2DM 
(as defined by the World Health Organisation (WHO), with an HbA1c > 48 (mmol/mol). 
Participants will be excluded from the study if they have uncontrolled hypertension (systolic 
blood pressure > 180 mmHg); a history of myocardial infarction or cerebrovascular events; leg 
ulcers; unable to give informed consent or any other serious medical condition which would 
interfere with safety or data interpretation.  
Participants will be recruited from a database of known individuals with T2DM who attend 
outpatient clinics at the Queen Alexandra Hospital (Portsmouth) and via posters and word of 
mouth within the University of Portsmouth. We will also recruit from local GP practices via 
mail outs.  
Consent and Screening: Visit 1 will act as a screening, consent and familiarisation (~ 1 h). 
Participants will be given the opportunity to ask any questions they may have after reading the 
participant information sheet.  A standard medical history and clinical examination will be 
undertaken by a member of UoP staff, including for example height, mass, electrocardiogram, 
ankle-brachial pressure index and blood sample collection for lipids and biochemical markers, 
and liver function tests. Seated resting blood pressure measurements will be performed to 
calculate systolic, diastolic blood pressure.  
Will you obtain informed consent from or on behalf of research participants?   
A member of the UoP research team will take consent for all subjects. These individuals are 
familiar with the principles underpinning informed consent and methods to assess capacity to 
give consent, for example asking the participant to summarise what the study involves for them. 
Only participants who have capacity to consent to taking part in research will be recruited into 
the study. If the researchers are in any doubt they will not be consented. The research staff will 
endeavour to keep the participants informed throughout the study and will encourage 
participants to ask questions about any uncertainties throughout their involvement in the study. 
 

 
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 Figure 1. Study overview. OGTT = oral glucose tolerance test. *measurements at baseline will be blood 
(biomaker analysis detailed in 10.6), central haemodynamics and resting metabiolic rate. At the end of OGTT 
only blood will be taken again for the measurment for the analysis of plasma [glucose] and [insulin]. 
7.2 
Primary and Secondary Endpoints/Outcome Measures 
The primary outcome of this study is insulin sensitivity. Secondary outcomes are: 
1) fasting plasma [glucose] 
2) AUC plasma [glucose] 
3) peak plasma [glucose] 
4) HbA1c 
5) plasma [eHSP70] 
6) plasma [IL-6] 
7) plasma [IL-10] 
8)  plasma [butyrate] 
9) plasma [growth hormone] 
10) RMR 
11) fat oxidation 
12) CHO oxidation 
13) macrovascular function  
14) microvascular function 
15) resting heart rate 
16) stroke volume 
17) total peripheral resistance 
18) cardiac output 
19)  heart rate variability 

 
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8. 
STUDY PARTICIPANTS 
8.1 
Study Setting 
Firstly, the Clinical Exercise Physiology Laboratory at the University of Portsmouth has a 
successful history of conducting studies in clinical population. The laboratory contains state of 
the art equipment that is required for conducting this study and a research group involving over 
20 academics and researchers. Dr Anthony Shepherd is the lead applicant and has expertise in 
trial management and clinical exercise physiology and his work has focused on exercise, 
(oxygen uptake, quality of life, functional capacity and glucose homeostasis) in clinical 
cohorts. Mr Thomas James is a PhD candidate currently working with a background in clinical, 
exercise and environmental physiology and will be leading most of the data collection and 
analysis. Mr James has recently completed a similar study in individuals with T2DM. Dr Jo 
Corbett is highly experienced in running exercise and thermal physiology trials and is a World 
leader in the area, running 14 studies over 14 years with 74 publications. Dr Corbett will be 
helping with data interpretation. Dr Maria Perissiou is an early career researcher with extensive 
experience in assessing the acute cardiovascular responses to exercise in clinical population. 
Dr Perissiou has expertise in exercise testing, assessments of cardiovascular function and 
venous cannulation in clinical populations, and will be helping with data collection and 
interpretation. Dr Clare Eglin is an experienced thermal physiologist and has experience 
leading MoD trials. Prof. Michael Tipton’s World leading expertise in thermal physiology will 
be used to help with data interpretation. Dr John S. Young’s expertise in biochemistry will be 
used for data analysis and interpretation. Dr Zoe Saynor has expertise in exercise testing and 
training in clinical populations, venepuncture and cannulation and will help with data 
interpretation. Prof Michael Cummings (clinical lead for the local NIHR diabetes research 
network), will be involved in this project and will provide clinical advice, responsible for 
participant safety and helping with participant recruitment. Ms Sharon Allard and Dr Kathryn 
Carey-Jones will aid with participant recruitment through Clinics and primary care. Final report 
and project related publications will be a collaborative effort of the team. 
8.2 
Overall Description of Study Participants 
Participants will be adults with a clinical diagnosis of T2DM, as defined by the WHO. A 
standard medical history and clinical examination will be undertaken by a member of UoP staff. 
Information taken during the examination will be height, weight, full blood count (analysed 
from a blood sample that will be collected), HbA1c and a resting ECG. ECG will be examined 
for irregularities and a clinical decision will be made on further participation to the study by a 
consultant at QA hospital. 
9. 
SAMPLING 
An a priori sample size calculation was performed based on a passive heating study assessing 
insulin sensitivity in health individuals [60]. The mean difference between pre and post chronic 
passive heating was 16 ± 14.5 a.u. for insulin sensitivity (~1SD). For 80% power and an α-

 
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level set at P = 0.05 (two tailed), to detect a 1 SD difference 15 individuals are required. In 
order to account for dropout, we anticipated that 20 individuals would need to begin the study. 
10. 
STUDY PROCEDURES 
10.1    Recruitment 
Our typical recruitment rates via GP practices is approximately one in ten people with T2DM. 
Recruitment via the local DESMOND course (T2DM education clinic) is approximately one 
in five people with T2DM. We will need to approach between 90 and 113 people with T2DM 
to ensure we recruit enough (n = 15) people to account for drop outs.  
Recruitment will be carried out by members of the UoP research team (or clinical team if 
participant clinical records are needed) acting with appropriate contracts with the responsible 
care organisation. The clinical staff will be briefed in detail regarding the current project and 
they will be provided with the inclusion and exclusion criteria of the study in order to perform 
any database searches. In the case of the computerised search of GP databases, this will be 
conducted by the direct healthcare team. Following receipt of the reply slips to the UoP research 
team, consent and screening will take place and results forwarded (for those willing) to our 
consultants who will review the results against the inclusion / exclusion criteria. Posters and 
word of mouth will also be utilised.  Screening blood will be analysed at QA pathology or at a 
commercial pathology laboratory. 
Inclusion criteria: 
● 
Male or female (post-menopausal) aged 35 years or above. 
● 
Diagnosed with T2DM as defined by the WHO (≥48 mmol/mol).   
● 
Participant is willing and able to give informed consent for participation in the study. 
● 
Participant is able to understand and fully cooperate with the study protocol. 
Exclusion criteria: 
• 
Severe peripheral neuropathy (to the point to which they cannot sense temperature) 
• 
Uncontrolled hypertension (≥180 systolic / 100 diastolic mmHg) 
• 
Taking any medication which may interfere with data interpretation or safety  
• 
Who have had a myocardial infarction or cerebro−vascular event 
• 
Any cardiac abnormalities which restrict hard exercise  

 
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• 
Current smokers or who have stopped within 3 months 
• 
Participant is unable to understand and/or fully cooperate with the study protocol 
• 
Any other serious medical condition which would interfere with data interpretation or 
safety will be excluded from participation. 
• 
Skin ulcerations 
• 
Eczema 
• 
Pre-existing postural hypertension 
• 
Existing cardiac diseases (identified during screening) 
 
10.2 Participants approach strategy  
The clinical team will provide interested parties with an invitation letter and the PIS when they 
attend the clinic. Additionally, the clinical team may send out an invitation letter including a 
return slip to potential participants on their clinic list or GP database, who could then opt in to 
finding out about the study. A member of the UoP research team will attend the DESMOND 
meeting 3 times a month to advertise, discuss and disperse information about the study. 
10.3   Screening and Enrolment 
Consent and Screening: Visit 1 will act as a screening, consent and baseline assessment (~1 
h). Participants will be given the opportunity to ask any questions they may have after reading 
the PIS.  A standard medical history and clinical examination will be undertaken by a member 
of UoP staff, including height, mass, electrocardiogram, full blood count and HbA1c. Seated 
resting blood pressure measurements will be performed to calculate systolic, diastolic blood 
pressure.  
10.4 Randomisation 
Due to study design, randomisation will not be necessary. 
10.5 Study intervention 
Daily passive heating: Participants will attend the laboratory on 8-12 occasions within a period 
of 14 days (~ 90 min per visit) with the aim of completing 10, at any point in the day. Anyone 
completing less than 8 will be excluded from analysis. During each visit participants will self-
insert a rectal thermistor and will then be immersed into a hot tub (~ 40 oC) for 60 min. Body 
position will be manipulated as required to achieve and maintain a target Trec at 38.5 oC using 
40 oC water. Aural temperature will also be measured every 15 min for determination of 

 
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validity and time lag compared to Trec, for possible use in future studies. BP will also be 
measured at 15 min intervals after passive heating in the first intervention visit to firstly, 
establish safety data on the protocol (i.e. to avoid syncope) and secondly, be used as a 
benchmark for recovery time in subsequent intervention visits. Participants will be required to 
wear a bathing suit and a t-shirt for all heating visits. 
10.6 Study Assessments 
Study assessments of the outcome measures will take place before (< 72 h) and after (< 72 h) 
the intervention. The pre- and post- experimental visits should take ~ 3 hours. Briefly, in, line 
with OGTT guidelines, participants will arrive at ~0800 following an overnight fast. The 
research coordinator will confirm with the participants that they have completed a 48 h food 
and physical activity log, that no exercise has been performed and that no alcohol or caffeine 
has been consumed on the day before. To ensure that participants arrive in a euhydrated state, 
they will be asked to consume ≥17 mL·kg-1 of water before each visit.  Participants will rest 
for 15 min in a semi-recumbent position, in comfortable ambient conditions (23 °C, 50% 
relative humidity), then have baseline bloods (collected via venipuncture), ECG, central 
haemodynamics, RMR collected / measured and brachial artery FMD measurements will start 
followed by iontophoresis. At ~0830 a 2 h OGTT will start with the ingestion of a glucose 
drink (Rapilose, 75 g glucose). At the end of the OGTT after bloods have been taken again, 
participants will be provided with a snack. A detailed description of the outcome measures are 
given below.  
 
Primary Outcome:  
Insulin sensitivity: Venous blood will be drawn in a fasted state after a resting period of 15 min 
for analysis of plasma [glucose] (Fluoride/Oxalate tubes, BD, USA) and [insulin] (EDTA 
tubes, BD, USA). An OGTT (75 g glucose solution) (Rapilose OGTT solution, Penlan 
healthcare, Japan) will then start and after 120 min of rest, venous blood will be drawn again. 
Insulin sensitivity will then be calculated via the Gutt method [61]. 
 
Secondary Outcomes: 
Biomarkers 
Blood samples will be taken at screening in EDTA tubes for assessment of full blood count 
and HbA1c. Fasting and area under the curve (AUC) plasma [glucose] will be assessed as a 
marker of glucose control. Change in circulating plasma [Growth Hormone (GH)] (EDTA, K2, 
BD, NJ, USA) will be assessed due to its diabetogenic effects via gluconeogenesis and 
glycogenolysis from the liver and kidneys and suppression of glucose uptake in adipose tissue 
[59, 60]. Change in circulating plasma [Butyrate] (EDTA K2, BD, NJ, USA) caused from 
alterations in gut microbiome [64] will be assessed due to its effect on insulin secretion [65], 

 
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insulin action [65] and inflammatory status [66]. Change in circulating plasma [eHSP70] 
(EDTA K2, BD, NJ, USA) will be assessed due to eHSP’s role in reducing inflammatory status. 
Change in circulating plasma [IL-6] (EDTA K2, BD, NJ, USA) and [IL-10] (LH, BD, NJ, 
USA) will be assessed to determine inflammatory status. Blood samples for assessment of 
fasting plasma [glucose], HbA1c, [GH], [Butyrate], [eHSP70], [IL-6] and [IL-10] will be from 
the venous collection at a fasted state and at the end of the 120 min OGTT for AUC plasma 
[glucose] and insulin sensitivity only. With exception to screening samples which will be taken 
for analysis immediately after visit, all samples will be immediately placed in a chilled (4°C) 
centrifuge and spun at 4000g for 10 min. Once spun, the plasma will be pipetted into 
Eppendorf’s and placed into a -80°C freezer for storage. Additional biomarkers may be looked 
at in future if extra funds become available. 
Metabolic measures 
Fuel utilisation: Breath-by-breath changes in pulmonary gas exchange and ventilation will be 
non-invasively measured at rest to enable the estimation of resting metabolic rate (RMR). The 
assessment of pulmonary gas exchange (e.g. Vo2 and Vco2) will give us the respiratory 
exchange ratio (RER). RER is a reliable and valid measure of fuel utilisation. To assess RMR, 
participants will be asked to lie down and rest for 15 mins, following this, pulmonary gas 
exchange will be measured via a gas analysis system for 5 min. Participants will be required to 
use a mask covering their nose and mouth (no restriction to breathing). In order to assess 
inspired and expired gas (volume and concentration), gases will be sampled through a capillary 
line attached to the turbine inside the face mask. A sub analysis of this breath by breath data 
will give us the respiratory exchange ratio (a value of 0.7 indicates only fatty acid metabolism 
and values of > 1 indicates only glucose metabolism, any value in the middle equates to a 
combination of both). This is an accurate assessment of rate of energy expenditure and fuel 
utilisation, and will be indicative of what proportion of carbohydrate and fat is being 
metabolised [67]. In order to calculate the RMR and rate of carbohydrate, and fat metabolism 
the ISO 8996 equations will be used [68]. Pulmonary gas analysis will be performed on all 
testing visits. Calibration will follow the guidelines given in the user manual produced by 
COSMED Omnia. Briefly, this involves calibrating the gas analyser by passing through a 
sample of gas with a known concentration and calibrating the volume on the gas flowmeter by 
using a 3 L syringe to pass a known volume of air through the flowmeter. 
 
Cardiovascular measures 
Macrovascular function: Brachial artery FMD will be used as a measure of endothelial function 
[69]. Endothelial-dependent function is assessed by measuring FMD in response to a 5 minute 
ischaemic stimulus, induced by forearm cuff inflation [69]. Measurements will be performed 
in the supine position on the right arm with the cuff placed distal to the olecranon process. 
High-resolution duplex ultrasound (SonoSite Edge II, Bothell, Washington, USA) with a 12-
MHz multifrequency linear array probe will be used to image the brachial artery at the distal 

 
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third of the upper arm and simultaneously record the longitudinal B-mode image and Doppler 
blood velocity trace. The angle of Doppler insonation will be 60°. Images will be optimized, 
and settings (depth, focus position, and gain) will be maintained between FMD assessments 
within each individual visit, and the location of the transducer will be recorded and marked on 
the skin using an indelible marker. Following a 60-s baseline recording period, the cuff will be 
rapidly inflated to 220 mmHg and maintained for 5 min (moorVMS-PRES, Axminster, UK). 
Ultrasound recordings will resume 30 s before rapid cuff deflation (<2 s) and be continued for 
3 min thereafter in accordance with recommendations [66, 67]. All ultrasound scans will be 
performed by a member of the UoP research team (same researcher within participant). 
Analysis of brachial artery diameter will be performed using custom designed edge-detection 
and wall-tracking software, which is largely independent of investigator bias. Recent papers 
describe the analysis approach in detail [66, 67]. Briefly, from recordings of the synchronised 
artery diameter and blood velocity data, blood flow (the product of lumen cross- sectional area 
and Doppler velocity) will be calculated at 30 Hz. Shear rate (an estimate of shear stress 
independent of viscosity) will be calculated as four times the mean blood velocity/vessel 
diameter via commercially available software. 
 
Microvascular function:  
Individuals will be acclimated for a minimum of 30 minutes in an ambient temperature of 23 
ºC prior to acetylcholine (ACh) and insulin being delivered transdermally via iontophoresis to 
volar aspect of the left forearm as previously described [71].  
Briefly, following cleaning of the skin surface with water for injection, two perspex rings will 
be attached to the skin with one acting as an anode, and the other as the cathode. These 
electrodes will be connected to the iontophoresis controller (MIC 2, Moor Instruments, UK). 
Both chambers have an 8 mm inner diameter. The anode chamber will be filled with ~ 0.5 mL 
of ACh (Braun, Melsungen, Germany), with a 1% concentration dissolved in water for 
injection. The cathode chamber will be filled with ~ 0.5 mL of insulin (Sigma-aldirch, 
Missouri, USA) with a 0.01% concentration dissolved in water for injection. The protocol for 
electrical pulses included: four at 25 μA, followed by a single pulse of 50 μA, 100 μA, 150 µA 
and 200 µA. These pulses will last for 20 s with 120 s intervals between each pulse where no 
current will be applied. An interval of five minutes will be given between testing each site 
(forearm, finger and foot).  
Laser doppler probes (VP1T / 7, Moor Instruments, UK), connected to a perfusion monitor 
(moor VMS-LDF, Moor Instruments, UK) will be used to assess skin blood flow. Data will be 
recorded using an acquisition system (Powerlab, AD Instruments, Australia) and software 
(LabChart 7, AD Instruments, Australia). The laser doppler probes will be secured in the 
Perspex rings prior to the iontophoresis protocol on the forearm and on the corresponding site 
on the contra-lateral limb (to differentiate between local and systemic responses). Skin blood 

 
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flow responses will be expressed as CVC (CVC = skin flux/MAP; flux.mmHg-1). The average 
skin blood flow for both ACh and insulin will be calculated over the final 20 s of the intervals 
between each successful pulse (i.e. 100-120 s post each pulse) [71]. Maximal skin blood flow, 
taken at the highest point which will not always be following the final pulse and area under the 
curve (AUC) will be calculated for each participant. Skin temperature (Tsk) will be recorded 
with skin thermistors (Grants Instruments, Cambridge) placed next to the Perspex chambers. 
BP will be measured on the contra-lateral arm to the site of iontophoresis using an automated 
BP monitor (Omron M5, Omron, Milton Keynes, UK) before and after each iontophoresis 
protocol to calculate mean arterial pressure (MAP).    
 
 
ECG: HR will be automatically calculated from the ECG (Dynascope, Fukuda Denshi, Japan). 
Heart rate variability (HRV) will be calculated as a low frequency (LF) variable and root mean 
square of successive differences (RMSSD). LF has been chosen as it indicates a physiological 
origin of both sympathetic and vagal activity. RMSSD is then being calculated additionally as 
it gives a stronger representation of vagal tone (due to it being affected much less by respiratory 
sinus arrhythmia (RSA)) than LF thus improving validity of the vagal tone measure [72]. Both 
measures will be calculated from an ECG trace (Kubios HRV software, Kubios, Finland). 
 
  
 
 
 
Other measures 
 
Central haemodynamics: Using thoracic bio-reactance technology (Physioflow), which will 
derive heart rate, stroke volume, cardiac output and total peripheral resistance, at rest. Four 
electrodes are placed on the participant’s chest between which a small, painless current is 
passed. 
 
 
10.7 
Discontinuation/Withdrawal of Participants from Study Treatment 
Participants may be withdrawn from the study if they ask to withdraw; if participant safety is 
in question; or if the study is stopped early.   

 
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10.8 
Definition of End of Study  
The end of study will be the date of the last visit of the last participant.  
11. 
INTERVENTIONS 
11.1 
Description of Study Intervention / Treatment 
Daily passive heating: Participants will attend the laboratory on 8-12 occasions within a period 
of 14 days (~ 90 min per visit) with the aim of completing 10, at any point in the day. Anyone 
completing less than 8 will be excluded from analysis. During each visit participants will self-
insert a rectal thermistor and will then be immersed into a hot tub (~ 40 oC) for 60 min. Body 
position will be manipulated as required to achieve and maintain a target Trec at 38.5 oC using 
40 oC water. Participants will be required to wear a bathing suit and a t-shirt for all heating 
visits. 
 
11.2     Adherence to Study Treatment 
The research coordinator will confirm that the participants have completed at least 8, 1 h 
passive heating sessions between experimental visits. 
11.3     Accountability of the Study Treatment 
Due to the nature of the study, blinding of the participants will be impossible. 
11.4     Concomitant Medication / Therapies 
Medication will be recorded on enrolment and updated throughout their time on the trial. For 
each experimental visit, hypoglycaemic aids will be stopped for the morning (see pre 
experimental instructions for details).   
12. 
ASSESSMENT OF SAFETY (IF APPLICABLE) 
12.1 
Definitions  
A serious adverse event is any untoward medical occurrence that: 
• Results in death, 
• Is life-threatening, 
NOTE: The term "life-threatening" in the definition of "serious" refers to an event in which the 
participant was at risk of death at the time of the event; it does not refer to an event which 
hypothetically might have caused death if it were more severe. 
• Requires inpatient hospitalisation or prolongation of existing hospitalisation, 
• Results in persistent or significant disability/incapacity, or 

 
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• Is a congenital anomaly/birth defect. 
• Other important medical events* 
  *Other events that may not result in death, are not life threatening, or do not require 
hospitalisation, may be considered a serious adverse event when, based upon appropriate medical 
judgement, the event may jeopardise the participant and may require medical or surgical 
intervention to prevent one of the outcomes listed above. 
12.2 
Reporting Procedures for Serious Adverse Events 
A serious adverse event (SAE) occurring to participant should be reported to the REC that gave 
a favourable opinion of the study where in the opinion of the Chief Investigator the event was: 
‘related’ – that is, it resulted from administration of any of the research procedures; and 
‘unexpected’ – that is, the type of event is not listed in the protocol as an expected occurrence. 
Reports of related and unexpected SAEs should be submitted within 15 days of the Chief 
Investigator becoming aware of the event, using the NRES report of serious adverse event form 
(see NRES website).  
12.3 
Recording and Reporting Procedures for All Adverse Events 
All adverse events will be recorded in participant file notes. Distinction between SAE and AE 
will be made by an independent medical officer. All SAE will be reported to the sponsor and 
the REC regardless of if it is related or not.   
13. 
DATA HANDLING AND RECORD KEEPING 
13.1 
Data Collection Forms 
Visit 1 will act as a screening, consent and baseline assessment (~1 h). All measures for this 
visit will be stored in the clinical records folder (CRF). Separate forms will be prepared for; 
anthropometrics, medical history, screening (i.e. blood pressures etc) and blood markers. All 
paper copies will be stored in the CRF’s.  
13.2     Data Management 
 All data will be double data entered into excel. Macro’s will be used to check for anomalies and 
corrected. The participants will be identified by a study specific participants number and/or code 
in any database. The name and any other identifying detail will NOT be included in any study 
data electronic file. The chief investigator (Dr Anthony Shepherd) is responsible for database 
maintenance and management.  
 
13.3 Record keeping 
Participant consent forms will be kept for 30 years and then destroyed in accordance with 
University of Portsmouth guidelines. Data and documentation will be kept for 10 years and then 
reviewed. Data storage allows us to undertake any necessary or retrospective data analysis. It 

 
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also allows us to keep records for people who have indicated that they will be willing to 
participate in studies in the future. We will destroy any details if requested. The data will be 
stored in the School for Sport and Exercise Science at the University of Portsmouth. The unit is 
secured with key codes and locks and is alarmed out of hours. All computer files are password 
protected and only study investigators will have access to these data. 
14. 
DATA ANALYSIS 
14.1      Description of Analysis Populations  
Participants who complete both experimental visits and at least 8 intervention visits will be 
entered into the analysis. 
14.2      Analysis of Endpoints  
All data will be tested for normality. Where data are not normally distributed, a nonparametric 
test will be performed. Data will be presented as means ± SD. Statistical analyses will be 
performed on SPSS software version 24.0 (Chicago, IL). Statistical difference will be accepted 
when P < 0.05. Statistical differences will be assessed by paired samples t-test or Wilcoxon 
signed –rank test (for non-parametric data). 
14.3     Procedure for Dealing with Missing, Unused and Spurious Data  
Outliers will remain within the data. Within the data analysis software missing data will be 
coded 9999 and the data point missed during analysis.   
14.4     Procedures for Reporting any Deviation(s) from the Original Statistical Analysis Plan 
For this study a statistical analysis plan is not required (excluding the above). 
14.5      Interim analysis and criteria for early study termination  
Given the small samples size and timeframe, no interim analysis will be performed. Early 
termination will only occur if the safety of participants is in question.  
15. 
ETHICS 
NHS Local Research Ethics Committee (REC) approval will be obtained prior to 
commencement of the study. The REC, local NHS, research and development department and 
all site specific forms and participant identification centre forms will be forwarded to the R&D 
department at Queen Alexandra Hospital Portsmouth, prior to recruitment of participants. 
Written informed consent will be obtained from all participants. Insurance indemnity will be 
provided by the University of Portsmouth for this study.  
Every effort has been made to keep the risks and discomforts to a minimum, with first aid cover 
and extensive screening procedures in place but there are some risks associated to taking part. 

 
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Not all volunteers will experience any or all of the risks stated below, but participants will be 
made aware of them. 
The main burden to participants is a 12 h fasting period before their experimental visits. 
Participants will be asked to cease all hypoglycaemic agents on the morning of testing and will 
be instructed to bring them with them on the day. This is in line with a normal fasted OGTT 
typically used in clinics. Prior to leaving the laboratory, participants will be provided with 
lunch, they can take their tablets and blood sugars checked prior to leaving.  
We will also be asking people with T2DM to be immersed in 40 °C water for all intervention 
visits. This may cause some discomfort which will be assessed with a thermal sensation and 
comfort scale. We will be measuring the core temperature via rectal thermistor and monitoring 
it closely at all times. Participants will be reminded that they are free to withdraw at any time 
point and will also be withdrawn and cooled if Trec raises above 39°C (as stated in the school 
SAP’s).  
 
Participants will be asked to insert a rectal thermistor on 8-12 occasions (water immersions). 
This can be uncomfortable upon insertion; however, this is necessary for safety purposes.  
Participants will be provided with lubrication and instructions.  
Other less burdensome tests will be performed such as:  
Blood pressure; participants will feel a cuff squeeze their arm and this can be uncomfortable 
for a few moments. Blood samples taken via intravenous access can cause discomfort 
associated with insertion of the needle.  
 
Indelible ink: Participant will be asked to keep remarking their arm with indelible ink where 
the ultrasound probe was used, for just over 2 weeks. This could cause slight annoyance over 
the 2 week duration. 
 
Other risks that have been accounted for are hypotension and loss of consciousness in the water. 
If at any point the participants BP is measured at ≥ 180/100 mmHg the trial will be terminated 
and the participant withdrawn from the study. If there is loss of consciousness in the water the 
participant will immediately be removed securely via (SAP’s). This can be done quickly as 
they will already be lying on a sling. Once they are out of the water and placed on a bed, their 
breathing will be checked and first aid administered. They will also be cooled via cold water 
spray and a fan. Additionally, their head will never go underwater as their head will be elevated 
above waterline throughout all immersions.   
 

 
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At consent participants will be asked “I agree to having my photo taken for the purposes of 
publication and also presentation at conferences (all identifying features will be blacked out 
i.e. your face)”. Participants have the option to agree or decline. This is to mainly aid in the 
presentation of the methodology in papers and conferences if necessary. 
In the event of any adverse event, researchers follow IMO approved SOP’s. The process in 
brief, involves researchers administering first aid and while another then goes and dials “3333” 
on the laboratory phone. This number directly links to the ambulance service who will 
automatically know where to come (~10 min arrival time). The other researcher will then go 
and seek help from another first aid member of staff in the building. The participant will have 
first aid administered until paramedics arrive. 
 
15.1 
Participant Confidentiality 
The study staff will ensure that the participants’ anonymity is maintained.  The participants will 
be identified only by initials and a participants ID number on the CRF and any electronic 
database. All documents will be stored securely and only accessible by study staff and authorised 
personnel. The study will comply with the Data Protection Act which requires data to be 
anonymised as soon as it is practical to do so.   
15.2     Other Ethical Considerations 
N/A 
15.3     Declaration of Helsinki 
Refer to declaration and that the study protocol will be carried out in accordance with it. 
15.4     ICH Guidelines for Good Clinical Practice 
All staff will be GCP trained and will be monitored by the sponsor to ensure adherence to GCP. 
16. 
PATIENT PUBLIC INVOLVEMENT (PPI) 
16.1    Study design 
Evidence of patient, carer and public involvement (PCPI):  
Our team has a strong track record of patient, carer and public involvement (PCPI) work. Dr 
Shepherd has been involved in a PCPI award winning project presented at the UK Stroke 
Forum (2016). At least 15 individuals with T2DM have been consulted (during a local 
conference for World Diabetes Day and DESMOND) and have stated that they liked the idea 
of that going in a hot tub could improve their health. Some concerns over travel funds were 

 
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raised and over the number of visits in the week (for those that work). In response we have 
made weekend testing available, we will offer travel reimbursement to be as inclusive as 
possible. The results of this project will be disseminated through publication in peer reviewed 
scientific and clinical journals and via presentations at local, national and international 
meetings. A summary of the results will be sent to all the participants.  
16.2    Study implementation 
Issues will be managed by the senior members of the UoP research team. 
16.3    Dissemination 
We endeavour to disseminate findings through local groups, local/national media, research 
papers and international conferences.  
 
17. 
FINANCING AND INSURANCE 
17.1    Research Costs 
The majority of consumables and personnel required for testing have been funded by the 
University of Portsmouth. All hardware and software is already available. 
17.2    Service Support Costs 
No service support costs are being sought. 
17.3    Excess Treatment Costs 
No excess treatment cost are being sought. 
17.4    Study Sponsorship 
This study is being sponsored by the University of Portsmouth. 
18. 
TIMETABLE AND ORGANISATIONAL CHART 
November 2020: Funding for consumables has been secured 
November 2020: Application for ethical approval 
February 2021 - October 2021: Participant recruitment 
March 2021 – February 2022: Data collection 
February 2021 – April 2022: Data analysis 
April 2021: Study completion date 
Post-April 2022: Dissemination of results through conference proceedings, journal submissions 
and practitioner outlet 

 
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19. 
RESOURCES, EQUIPMENT AND PHYSICAL FACILITIES 
In addition to the school support, and in order to facilitate the completion of the work, the UoP 
research team will have full access to all of the necessary world-leading extreme environment 
facilities that are housed within the school estate given that they are pivotal to the success of 
the project. Specifically, this will enable temperature control within the facilities to ensure 
reproducibility. Finally, the school will ensure that full technical assistance is provided to 
enable the set-up of the laboratories and testing rooms. 
20. 
DISSEMINATION AND OUTCOME 
The research is to be disseminated in internationally recognised, peer reviewed journals and at 
relevant scientific conferences, as well as contributing to Mr. Thomas James’ PhD thesis. 
Furthermore, all screening data will be utilised as part of the participants’s annual report, and 
distributed to clinicians and participants upon request. 
21. 
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