A n n u a l R e p o r t

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1 F O R S C H E R G R U P P E D I A B E T E S E. V. Neuherberg near Munich A n n u a l R e p o r t

2 1. Working group Prof. Ziegler...1 I. Members of the working group...1 II. Scientific Reports and Future Perspectives of the working group...1 A. Research Group T1D cohort studies; biobank Dr. Christiane Winkler...2 B. Research Group T1D immune phenotyping Dr. Peter Achenbach...18 C. Research Group Gestational diabetes mellitus Dr. Sandra Hummel...21 D. Research Group T1D Prevention; clinical studies Prof. Anette-G. Ziegler...28 E. Research Group Epidemiology Dr. Andreas Beyerlein. 33 III. Publications IV. Diploma Thesis/ PhD Projects / Honors and Awards V. Third-party funds VI. Guest Speakers VII. Press work and Public Relations Working group Prof. Standl I. Report II. Meetings and Symposia..45 III. Positions..46 IV. Publications Study group Prof. Schnell...47 I. Progress report II. Educational activities, symposia and congresses...52 III. Literature..53

3 4. Working group Prof. Schaaf 57 I. Report II. Literature Working group Prof. Haslbeck 59 I. Members of group 59 II. Report III. References Activities 2012 of Prof. Mehnert

4 1. Working group Prof. Ziegler I. Members of the working group Scientists: Prof. Dr. med. Anette-Gabriele Ziegler, Prof. Dr. phil. Ezio Bonifacio, Dr. hum. biol. Alexandra Achenbach, Dr. med. Peter Achenbach, Dr. oec. troph. Kerstin Adler, Dr. rer. biol. hum. Andreas Beyerlein, Dr. rer. nat. Caroline Daniel, Dr. rer. nat. Orietta D Orlando, PD Dr. med. Martin Füchtenbusch, Dr. med. Minna Harsunen, Dr. rer. nat. Florian Haupt, PD Dr. med. Michael Hummel, Dr. oec.troph. Sandra Hummel, Dr. med. Anna Huppert, Dr. rer. nat. Maren Pflüger, Dr. rer. nat. Ramona Puff, Dr. med. Katharina Warncke, Dr. med. Markus Walter, Dr. hum. biol. Christiane Winkler, Dr. rer. nat. Daniela Much PhD/MD students: Johannes Försch, Katharina Förtsch, Eleni Giannopoulou, Imme Kaiser, Miriam Krasmann, Stephanie Krause, Jörg Maier, Jennifer Raab, Michaela Roßbauer, Michaela Schaller, Carolyn Schendell-Gröling, Fabienne Wehweck Study coordinator, study nurses, technical personnel, and administration: Nadja Antl, Petra Becker, Melanie Bunk, Verena Cermak, Vanessa Dietrich, Bettina Drobnitzky- Kemmerzell, Cordula Falk, Anita Gavrisan, Lydia Henneberger, Melanie Herbst, Susanne Hummel, Susanne Kapfer, Annette Knopff, Oliver Knopff, Gerson Kurz, Dennis Kusian, Lorenz Lachmann, Ramona Liedtke, Claudia Matzke, Claudia Pecher, Claudia Peplow, Claudia Ramminger, Sarah-Maria Riedel, Julia Schenkel, Lisa Schneider, Simone Schneider, Marlon Scholz, Elisabeth Strauss, Joanna Stock, Tuan Tran, Anja Wosch. II. Scientific Reports and Future Perspectives of the working group The working group of Prof. Ziegler consists of five sub-groups, led by senior scientists or senior post-docs on the following areas of research: A. T1D cohort studies; biobank (Dr. hum.biol.christiane Winkler), B. T1D immune phenotyping (Dr. med. Peter Achenbach), C. Gestational diabetes mellitus (Dr. oec.troph.sandra Hummel), D. T1D prevention; clinical studies (Prof. Dr. med. Anette-G. Ziegler, Dr. med. Minna Harsunen and Dr. rer. nat. Florian Haupt) E. Epidemiology (Dr. rer. biol. hum. Andreas Beyerlein). 1

5 A. Research Group T1D cohort studies; biobank Dr. hum. biol. Christiane Winkler Overview The etiology of T1D as well as factors that influence T1D incidence is largely unknown. The overall objective of this research group is to build cohorts and bioresources to study the natural history of T1D and to identify genetic and environmental factors which are associated with disease etiology. For many years, it is known that the clinical manifestation of T1D is preceded by the presence of autoantibodies to islet antigens and that this period of pre-diabetes is of variable duration. However, it was not clear when islet autoimmunity initiated, whether there was a critical age of initiation, and what the primary targets of autoreactivity were. Therefore the group of Prof. Ziegler initiated, already in 1989, the first birth cohort study in diabetes, the BABYDIAB study. The BABYDIAB study with initial funding from German Ministry (BMBF) was the pioneer study of the natural history of T1D in children. Other landmark studies followed in the USA (DAISY), and Finland (DIPP) and eventually in 2002, the NIDDK took the model and started the multicenter TEDDY study which through a projected 19 year recruitment and investigational period will follow over seven thousand genetically susceptible children from birth to autoimmunity and diabetes. Through the BABYDIAB study, this group showed that there is a peak incidence of seroconversion to islet autoimmunity around 1 to 2 years of age (Ziegler AG et al., Immunity 2010), that the initial target of the autoimmunity is insulin in this age group (Ziegler AG et al., Diabetes 1999), that there is relatively quick spreading to other antigens such as GAD and IA-2 (Hummel M et al., Ann of Internal Med 2004), defined the molecular targets of these antigens during the initial response, and determined that the intensity of the immune response to the antigens is a predictor of the rate of progression to diabetes (Achenbach P et al, Diabetes 2004). This group also defined the genetic risks of beta cell autoimmunity in children (Schenker M et al., Diabetologia 1999, Walter M et al., Diabetologia 2003) and was able to identify a target group of newborn children in whom immune intervention to prevent autoimmunity and T1D is possible (Bonifacio E et al., Diabetes Care 2004). The group also took the opportunity provided by BABYDIAB to examine early environmental influences on the development of beta cell autoimmunity, demonstrating associations with diet and with maternal environment (Ziegler AG et al., Jama 2003, Bonifacio E et al., Diabetologia 2008). As a result of these findings, the group executed a dietary intervention study in high risk newborns (BABYDIET, see 2.4), and recently in collaboration with Ezio Bonifacio (Dresden) and George Eisenbarth (USA) has begun an international primary vaccination trial in children with extreme genetic risk for T1D (Pre-POINT, see 2.4). 2

6 Currently, our research group is following children and adults from the BABYDIAB, BABYDIET, TEENDIAB, DiMelli, TEDDY and ImmunDiabRisk cohorts with biomaterial and exposure data. The following objectives are currently addressed through these cohorts: BABYDIAB/BABYDIET Identify phenotypes of islet autoimmunity and T1D and compare characteristics of islet autoimmunity initiating early (within the first two years of life) and late (at and after puberty). This is done within the BABYDIAB and BABYDIET cohorts where children are followed from birth until age 22 years. Our data suggest that early autoimmunity differs substantially from puberty autoimmunity with respect to primary antigen reactivity, genetic susceptibility, spreading, and multiple antibody frequency (Ziegler AG et al., Immunity 2010) Study and characterize children with different rates of disease progression from seroconversion (multiple islet autoantibody-positive subjects who do not develop diabetes compared to fulminant progressors). Model initiation of islet autoimmunity and progression to T1D in a systems biology approach by combining genetic and environmental data, and data on islet autoantibody characteristics (number, affinity, epitope reactivity, isotype reactivity, and change). This is done in collaboration with W. v. Castell (HMGU) by using the BABYDIAB cohort (see preliminary results presented by P. Achenbach, research group 2.2). Study metabolomic pathways and bacterial diversity (microbiome) relative to the initiation of islet autoimmunity. TEENDIAB Assess beta cell function, obesity, and insulin resistance and their contribution to autoimmunity and T1D. These studies include prospective assessment of beta cell function (OGTT and IVGTT), growth, insulin resistance, hormone status, and vitamin D levels in the TEENDIAB study. DiMelli Investigate incidence trends in diabetes in youth and changes in diabetes phenotypes within the Bavarian diabetes register cohort DiMelli. TEDDY Identify infectious agents, dietary factors, or other environmental exposures that modify the risk of autoimmunity and T1D. 3

7 ImmunDiabRisk Analyze differences in the maturation of the immune system between children of mothers with T1D and children of fathers with T1D, and to identify mechanisms which can be used to prevent the development of islet autoimmunity. Cohort descriptions: BABYDIAB cohort: The BABYDIAB study follows 1650 offspring of a mother or father with T1D from birth to age 22 years. Venous blood samples and questionnaires are obtained from the children at study visits scheduled at age 9 months, 2 year, and in three years intervals thereafter. If children have a positive autoantibody result, visit frequencies and islet autoantibody measurements are subsequently performed at 6 to 12 month intervals. Children were recruited between 1989 and 2000; 440 children dropped out of the study: 161 children developed persistent islet autoantibodies, 63 developed T1D during follow-up. BABYDIET cohort: The BABYDIET dietary intervention study includes 150 offspring or siblings of patients with T1D who have one of the following high-risk HLA genotype (DRB1*03-DQA1*0501-DQB1*0201/DRB1*04-DQA1*0301-DQB1*0302; DRB1*04- DQA1*0301-DQB1*0302/DRB1*04-DQA1*0301-DQB1*0302 or DRB1*03- DQA1*0501-DQB1*0201 /DRB1*03-DQA1*0501-DQB1*0201). Children were first exposed to gluten either around age 6 months (control) or age 12 months (intervention). BABYDIET children were followed intensively (3-monthly) until the age of 3 years with blood and stool collection at each visit, and 6-monthly as part of a natural history follow-up protocol thereafter. Islet autoantibodies (IAA, GADA, IA-2A, ZnT8A) were measured on all blood samples. Infections, medication and the introduction of new food groups were recorded daily. TEENDIAB cohort: The TEENDIAB study is a puberty cohort and aims to recruit 1500 children aged 8-12 years who have a first-degree relative with T1D; the children will be followed 6-monthly/yearly until age 18 years for the development of islet autoantibodies and diabetes. The first study visit and the visit at the age of 14 years take place in the study centers Munich (FD-TUM) or Hannover; remaining follow-up visits are performed as remote visits by local pediatricians or family doctors. Beta cell function will be assessed in all 1500 children twice during the study by IVGTT and OGTT and 6-monthly in children developing islet autoantibodies. Biomaterial (serum, PBMCs, stool, RNA) is collected 6-monthly as well as clinical information regarding growth, obesity, diet, demographic information, psychosocial factors, and physical exercise. The recruitment started in 2009 and 397 children have been enrolled (December 2012). 4

8 DiMelli cohort: DiMelli is a Bavarian diabetes register cohort with biomaterial collected. The register was initiated in 2009 and has collected samples from 746 children and adolescents aged <20 years. A questionnaire collecting data on medication, family history, and socioeconomic status is available from all registered patients. Phenotyping includes central measurement of islet-, celiac-, and thyroidautoantibodies, C-peptide, and lipids. TEDDY cohort: The TEDDY consortium comprises six clinical centers located in the USA and Europe: Washington (Seattle), Colorado (Denver), and Georgia (Augusta); Finland (Turku); Sweden (Malmo); and Germany (Munich, FDeV), and a data coordinating center in Tampa, Florida. The primary objective of the multicenter, multinational, epidemiological TEDDY study is the identification of infectious agents, dietary factors, or other environmental exposures that are associated with increased risk of autoimmunity and T1D. The TEDDY study has recruited 8,668 children (7,751 from the general population, and 917 with a first-degree relative with T1D). Newborns were eligible for TEDDY if they were younger than 4.5 months of age and had HLA DR-DQ T1D risk genotypes. Participants are seen every 3 months up to 4 years of age, with subsequent visits every 6 months until the subject is 15 years of age. Blood samples are collected at each visit for detection of islet autoantibodies, candidate infectious agents and nutritional biomarkers; monthly stool samples are collected for infectious agents. Demographic data, information about the child's diet, illnesses, vaccination, allergies and psychosocial factors are obtained by interviews and questionnaires. Recruitment began in 2004 and ended in The German center follows 595 TEDDY children, including 220 with a first-degree relative with T1D. The TEDDY study has a central repository of data and biologic samples for subsequent hypothesis based research. The TEDDY consortium comprises six clinical centers located in the USA and Europe: Washington (Seattle), Colorado (Denver), and Georgia (Augusta); Finland (Turku); Sweden (Malmo); and Germany (Munich, Forschergruppe Diabetes e.v.), and a data coordinating center in Tampa, Florida. The primary objective of this multicenter, multinational, epidemiological study is the identification of infectious agents, dietary factors, or other environmental exposures that are associated with increased risk of autoimmunity and type 1 diabetes. Factors affecting specific phenotypic manifestations such as early age of onset or rate of progression or with protection from the development of type 1 diabetes will also be identified. Identification of such factors will lead to a better understanding of disease pathogenesis and result in new strategies to prevent, delay, or reverse type 1 diabetes. Newborns were eligible if they were younger than 4.5 months and had high-risk human leukocyte antigen alleles (HLA-DR,DQ) in the general population or having a first degree relatives (FDRs) of patients affected with type 1 diabetes. From , TEDDY screened more than 420,000 newborns from both the general population and families already affected by type 1 diabetes and identified 21,577 5

9 children with high-risk HLA-DR,DQ genotypes. Of those, 8,668 (917 first-degree relatives and 7,751 newborns from the general population) are enrolled in the prospective follow-up beginning before the age of 4.5 months. Participants are seen every 3 months up to 4 years of age, with subsequent visits every 6 months until the subject is 15 years of age. Blood samples are collected at each visit for detection of islet autoantibodies, candidate infectious agents and nutritional biomarkers; monthly stool samples are collected for infectious agents. Demographic data, information about child`s diet, illnesses, vaccination, allergies and psychosocial factors are obtained by interviews and questionnaires. The primary outcome is the development of persistent autoantibodies to one or more of the antigens insulin, GAD, IA-2. The secondary outcome is the development of type 1 diabetes according to the criteria drawn up by the American Diabetes Association (ADA) (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997). As of December 31, 2012, 459 children have developed persistent islet autoantibodies (38 from Germany) and 138 children have developed type 1 diabetes (21 from Germany). ImmunDiabRisk: Pregnant women with T1D, pregnant women with a child with T1D, or pregnant women carrying a baby from a father with T1D, are invited to participate in the ImmuneDiabRisk study prior to week 20 of gestation. At week 20 and 28 of gestation, and at the age of two weeks, six months and twelve months postpartum, volume and size of the fetal thymus and pancreas are assessed by fetal ultrasound, and a maternal blood sample taken for DNA, RNA, PBMC, HbA1c, blood count, plasma and serum storage. At birth, and three-monthly thereafter until the age of 24 months, blood samples are collected from the child for immediate T and B cell subset analysis, and for storage (DNA, RNA, PBMCs, blood count, plasma/serum). Demographic data and data on perinatal factors (C section, infections, medication, vaccinations, diet) will be analyzed using questionnaires. Stool samples are collected from the mother during pregnancy (gestation week 20 and 24) and from the child until the age of 24 months. Biobank: The biobank of the IDF contains samples from 4000 patients with T1D, 8000 relatives of patients with T1D, 600 people with positive islet autoantibodies, 600 women with gestational diabetes (GDM), 200 patients with T2D, and 960 healthy control subjects. The numbers of samples are: 89,000 plasma/serum, 8200 DNA, 2300 RNA, 1800 stool, 733 urine, and 12,000 PMBC samples, 600 IVGTTs and/or OGTTs. 6

10 Main Results BABYDIAB/BABYDIET cohort: 1) Age-related islet autoantibody incidence in offspring of parents with type 1 diabetes. The development of type 1 diabetes, one of the most common chronic diseases in childhood and adolescence, is preceded by a pre-clinical period of islet autoimmunity. Within the BABYDIAB and BABYDIET cohort we were able to identify periods of high seroconversion incidence, which could be targeted for mechanistic and therapeutic studies. Here we could show that the incidence of islet autoimmunity has a peak between the age of nine months and two years. This is in contrast to thyroid autoimmunity which peaks at around puberty. Children who develop autoantibodies at this early age have a very high risk of developing type 1 diabetes by the age of ten. The other new piece of knowledge we acquired is that autoantibodies at ages 6 months or younger are rare. Seroconversion to insulin autoantibodies occurred earlier than other autoantibodies (against glutamic acid decarboxylase [GAD]-, insulinoma-associated protein 2 [IA-2]- and zinc transporter 8 [ZnT8]-autoantibodies). These results clearly demonstrate the need to develop preventive strategies and immunotherapies for young children in order to help to reduce the incidence of type 1 diabetes. (Ziegler et al. Diabetologia 2012). Figure 1: Autoantibody incidence (cases per 1000/year) in offspring of parents with type 1 diabetes (A. BABYDIAB study; B. BABYDIET study). Incidence is shown at the ages of islet autoantibody testing for the BABYDIAB study children (9 months, 2, 5, 8, 11, and 14 years) and at 6 months, 1, 2, 3, 4, 5, and 6 years for the BABYDIET study children and refer to the age intervals between these time points. The BABYDIET study children were selected for HLA DR/DQ genotypes conferring increased type 1 diabetes risk, hence the higher incidences in these children. 2) A strategy for combining minor genetic susceptibility genes to improve prediction of disease in type 1 diabetes. Genome-wide association studies have identified gene regions associated with type 1 diabetes. With the exception of the HLA and the INS gene regions, the contribution of any single locus to type 1 diabetes susceptibility is relatively small. Aim of this study was to determine how the combined 7

11 allele frequency of 12 type 1 diabetes susceptibility genes (ERBB3, PTPN2, IFIH1, PTPN22, KIAA0350, CD25, CTLA4, SH2B3, IL2, IL18RAP, IL10, COBL) can stratify type 1 diabetes risk in 1290 children of parents with type 1 diabetes. We could show that the non-hla gene combinations were highly effective in discriminating type 1 diabetes and most effective in children with a high risk HLA genotype. We further provide a model for identifying combinations of genes to obtain maximal disease risk stratification. Using this model, we show that the sum of risk alleles derived from combinations of genes provided significant increased discrimination over that which could be achieved by any single gene. The greatest diabetes discrimination was obtained by the sum of risk alleles for 8 genes (IFIH1, CTLA4, PTPN22, IL18RAP, SH2B3, KIAA0350, COBL, ERBB3) in the HLA risk children. Categorizing a risk allele score from these 8 genes in low, moderate and high (scores: <6, 6-9, >9) was able to stratify the risk for developing islet autoantibody and for progression from islet autoantibody positivity to type 1 diabetes (by age 10 years: moderate scores 40%; high scores 80% P=0.03). Overall type 1 diabetes risk by age 14 years ranged from 0% in HLA risk children with low risk allele scores to 26.9% (95% CI, %; P<0.0001) in children with high risk allele scores. Therefore genotyping at multiple susceptibility loci in children from affected families can identify neonates with sufficient genetic risk of type 1 diabetes to be considered for early intervention. (Winkler et al., Genes and Immunity 2012). A B C AUC ROC AUCs for all 4095 possible combinations HLA risk children Number of SNPs used P< P<0.000 P<0.001 P<0.01 Sensitivity alleles <5 alleles >9 alleles AUC: 0.73 P< Specificity Probability of Diabetes % Score > P<0.001 Score Age (years) Score <5 Figure 2: Area under the curve (AUC) calculated from the receiver operator curve analysis (ROC) for all 4095 possible combinations of the 12 SNPs using diabetes as outcome in children with HLA risk genotypes (A), Receiver Operator Curve (sensitivity vs 1-specificity) for type 1 diabetes outcome using risk allele scores of 8 gene SNPs in all genotyped children (B). Cumulative risk for the development of type 1 diabetes and islet autoantibodies by the 8-gene combined risk allele score (C). (Winkler C et al. Genes and Immunity 2012). 3) Obesity, T2D associated genes and T1D risk. It has been suggested that type 1 diabetes and type 2 diabetes may share pathophysiological and genetic aetiology, leading to the concept of double diabetes. In particular, increasing population weight and body mass index (BMI) has been linked to increasing type 1 diabetes trends. Our 8

12 previous studies in children who are offspring of patients with type 1 diabetes found no association of body weight or insulin resistance with islet autoimmunity. We examined the associations of type 2 diabetes susceptibility genotypes on the development of islet autoimmunity and investigated the effect of these genotypes and body weight on progression to type 1 diabetes after islet autoantibody seroconversion in 1350 children from parents with type 1 diabetes participating in the BABYDIAB study. We could show that none of type 2 diabetes risk alleles at the CDKAL1, CDKN2A/2B, FTO, HHEX-IDE, HMGA2, IGF2BP2, KCNJ11, KCNQ1, MTNR1B, PPARG and SLC30A8 loci were associated with the development of islet autoantibodies or type 1 diabetes. Overweight children at seroconversion did not progress to diabetes faster than non-overweight children. Our findings suggest that type 2 diabetes risk factors are not a common feature of type 1 diabetes occurring in first degree relatives of patients with type 1 diabetes and do not support a significant role of these type 2 diabetes associated factors in the pathogenesis of diabetes in families affected with type 1 diabetes. (Winkler C et al., PlosOne 2012). b) Probability of Islet Autoantibody (%) TCF7L2 TT CT/CC P= Age in years Probability of developing diabetes (%) n P> Follow-up after islet autoantibodies (years) Figure 3: Cumulative risk for the development of autoantibodies by the TCF7L2 genotypes. Children are grouped with respect to TCF7L2 SNP rs genotype into those carrying TT genotype (solid line) and the CT or CC genotype (dashed line). Follow-up (x-axis) is from birth. Numbers below the x- axis indicate the number of autoantibody negative children remaining on follow-up with respect to age. (b) Cumulative risk for the progression from islet autoantibody seroconversion to type 1 diabetes. Children are divided into 3 groups: lowest tertile (dashed line), second tertile (dotted line) and highest tertile (solid line). Follow-up (x-axis) is from the age of islet autoantibody seroconverison. 4) Respiratory infections in early life predict the development of islet autoimmunity in children at increased type 1 diabetes risk: Evidence from the BABYDIET study. We examined whether early, short term, or cumulative exposures to episodes of infection or fever during the first three years of life were associated 9

13 with the initiation of persistent islet autoimmunity in children at increased T1D risk. We had data available of 1,245 infectious events recorded for 90,750 person days documented during the first three years of life in high T1D risk children followed up since 2000 in the prospective BABYDIET study. An increased rate of islet autoantibody seroconversion was associated with respiratory infections during the first 6 months of life (HR, 2.18; 95% CI, ) and in the age of months (HR, 1.18; 95% CI, ). During the second year of life, no meaningful effects were detected for any infectious category. A higher number of respiratory infections in the six months prior to islet autoantibody seroconversion was also associated with an increased hazard rate (HR, 1.32; 95% CI, ). These findings were mainly attributed to infections of the upper respiratory tract. Our study identified respiratory infections in early childhood as a potential risk factor for the development of T1D. We found evidence for both early exposure and short term impact effects (Beyerlein A et al. in press) 5) Age of adiposity peak in the first year of life determine risk of islet autoimmunity in susceptible children. We evaluated the associations between growth velocity in infancy and the risk of islet autoimmunity and type 1 diabetes. The adiposity peak was significantly associated with the development of islet autoantibodies. There was a linear correlation between the adiposity peak and the risk for the development of one or more islet autoantibodies (any islet autoantibody: HR 0.6 [95% CI ]; p=0.018 and multiple islet autoantibodies: HR 0.4 [95% CI ] per 2SD increase; p=0.006). Children s adiposity peak were classified in quartiles which showed that children with a adipositiy peak in the first quartile have a significant higher risk for the development of multiple islet autoantibodies compared to children in the 2nd, 3rd and 4th quartile (at age 10 years: 1st quartile 8.1% vs 2nd and 3rd quartile 4.4% vs 4th quartile 2.9%, p=0.017). The adiposity peak was not associated with the progression to type 1 diabetes. These data suggest that an early relative weight gain in the first years of life increase the risk for the development of islet autoimmunity in childhood. The exact mechanisms involved are not yet clear and further examinations are required. 6) Differences between fast and slow progressors. We compared islet autoantibody characteristics, T1D associated genotypes, and environmental factors between children who progressed to T1D within 2 years after seroconversion and children who remained non-diabetic for at least 10 years after seroconverion. We find that the presence of IA-2A at seroconversion is exclusively found in children with fast progression. Furthermore IFIH1, CTLA4, ERBB3 as well as spreading of autoantibody responses to IA-2 were significantly different between fast and slow progressors (Achenbach P et al., submitted). 10

14 T1D within 2 yrs diabetes free > 10 yrs p Chi² Sectio yes no o o o o o o o o o o o o o o o o o o o o o o o o o o o o 0.02 IFIH1 GG highrisk GA AA lowrisk o o o o o o o o o o o o o o o o o o o o o o o o 0.02 CD25 T highrisk TA TT lowrisk o o o o o o o o o o o o o o o o o o o o o o o o 0.02 CTLA4_rs GG highrisk GA AA lowrisk o o o o o o o o o o o o o o o o o o o o o o o o 0.04 IGIH1_proxy_rs GG highrisk GA AA lowrisk o o o o o o o o o o o o o o o o o o o o o o o o 0.02 ERBB3_rs AA highrisk CA CC lowrisk IA2A at seroconversion positive negative Time between first ab and IA2A <1.5yrs >1.5yrs Ab-spreading to multiple abs <1.5yrs >1.5yrs o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o < Figure 4: Risk factors, who differentiate between fast and slow progressors in BABYDIAB offspring who developed multiple islet autoantibodies. TEENDIAB cohort: Evaluating the Diet of Children at Increased Risk for Type 1 Diabetes by Using the Diet History Interview DISHES Junior The development of islet autoimmunity and T1D is potentially influenced by nutrition. Up to now, there are only few studies investigating the diet of children at increased risk of T1D, which was the aim of this analysis. Dietary intake of the last four weeks was assessed using a diet history interview in 268 first degree relatives of people with T1D, aged 8 12 years, who are participating in the TEENDIAB study. The daily nutrient and food intake of these children were compared current German recommendations, the German Dietary Reference Intakes on the nutrient-level as well as the Optimized Mixed Diet developed by the Research Institute of Child Nutrition in Dortmund on the food-level. The macronutrient ratio was within the 11

15 recommended range. The children took up 52.0 % of their energy by carbohydrates (24 % of mono- and disaccharides and 28 % by polysaccharides), 32.6 % from fat (14 % from saturated fatty acids (SFA), 11 % from monounsaturated fatty acids (MUFA), 5 % from polyunsaturated fatty acids (PUFA) and the rest from glycerol and lipoids) and 14 % by protein. In line with the expectations, dietary fiber only made up approximately 1 % of the total energy intake The children had intakes above the reference values for all minerals and vitamins with the exception of iodine with 58.1%, vitamin D with 8.9 % and folate with 30.0% of the recommended intake. The intake for non-desirable food groups (meat, meat products, sweets, snacks, sweetened beverages) was above the recommendations and the consumption for desirable food groups (fruits, vegetables, carbohydrate-rich foods) was below the recommendations. (Weber K et al., manuscript in preparation) DIMELLI cohort: Confirmation of a new Tool to define Insulin Resistance Diabetes incidence in children and youth is increasing worldwide, including autoimmune and non-autoimmune cases. The DiMelli study aims to establish a diabetes incidence cohort registry and to characterize diabetes phenotypes by immunologic, metabolic and genetic markers. The insulin-sensitivity score established within the SEARCH study was reassessed in the DiMelli cohort. From 2009 to 2011, 496 patients (54% male) were registered. 81.7% were positive for multiple islet autoantibodies (Aabs; type 1 diabetes), 10.3% for one Aab (intermediate cases), and 8% were islet Aab-negative (type 2 diabetes). In SEARCH, people with diabetes and a score of less than 8.15 were classified as insulin resistant (score = exp [ x(waist [cm]) x(HbA1c [%]) x(triglyceride [mg/dl])]; Dabelea et al., Diabetes Care 2011). This score was reassessed in DiMelli. It ranged from 1.6 to 20.3 (median 8.6, IQR ). By using the SEARCH cut-off, 38.8% of DiMelli patients with multiple islet AAbs, 52.9% with one AAb, and 75% with no AAbs were insulin resistant. The score was inversely correlated with age (r= -0.6; p=0.01) and body mass index (r = -0.4, p=0.01). Children with islet Aabs had higher scores than children without Aabs (median 8.8, IQR vs. 6.2, IQR ; p=0.02), and children with c-peptide > 2 ng/ml had lower scores than children with c-peptide 2 ng/ml (median 4.0, IQR ; vs 8.9, IQR ; p=0.03). Application of the SEARCH Insulin-sensitivity score in a second cohort confirms its applicability as a surrogate marker of insulin resistance in diabetes patients under the age of 20 years. TEDDY cohort: Performance of the German Clinical Center within the TEDDY consortium General Operations of the German Clinical Site The German (GER) site is led by Dr Ziegler (TEDDY steering committee) together 12

16 with her team that includes Drs. Bonifacio (co-chair immune markers committee), Hummel (diet committee), Winkler (coordinator and diet committee), Koletzko (celiac disease committee), Roth (psychosocial committee), and Pflüger (infectious agents committee), plus a number of staff dedicated to the follow-up of TEDDY children and specimen and data handling. Enrolled subjects at the GER site either have their study visits at the Munich TEDDY clinic (20%) or are followed by the Long Distance Protocol (80%). Long Distance visits are performed by the family pediatrician who performs anthropometric measurements and draws blood which is sent by overnight courier to the processing site. Questionnaires are completed by the family and returned to the clinical center in the appropriate time-window. Final Results: Screening and Cohort Enrollment The German clinical center was expected to screen 30,177 newborns, and screened of 36,105, of which 1679 were eligible for enrollment. The German center was expected to enroll 563 children by July 31, 2010, with a special focus on first degree relatives (FDR) and enrolled 595 children, including 375 general population (GP) and 220 FDR. As of December 2012, 38 children (24 FDR) have developed persistent confirmed islet autoantibodies, and 21 children (15 FDR) T1D. Thus, Germany has contributed 8% of all TEDDY children with islet autoantibodies, 8% with multiple islet autoantibodies, and 16% of children with T1D. Retention of the Study Cohort Since inclusion, 161 (27%) have withdrawn (121 GP; 40 FDR) and 19 (6%) are lost to follow-up. Common reasons for withdrawal from the study are the blood draws, visit frequency, 3-day diet records, families are too busy. Most families participate with the Long Distance Protocol and we have developed strategies and attitudes to enhance participation of the families and local pediatrician to improve retention. Examples include feedback questionnaires to families and pediatricians, newsletters to keep families and pediatricians informed of results, promotional items and modest reimbursement for time and effort, assigning one contact person to a family, taking note of family events and congratulate or respect them. All is facilitated by a log and detailed annotation in the family file. The GER team meets weekly to review current families and families noted as Active Retention Cases or Watch Cases, and plans made for each family on the list. To increase compliance to blood samples we are now offering study visits in our clinical center in Munich and visiting families with the TEDDY mobil for families following the long distance protocol. Additionally we developed the TEDDY mobil also for families on Long Distance Protocol, as a special assistance. Especially families who have problems with the blood draw it is very helpful. TEDDY staff and TEDDY physician visit the family at their home to provide help, explain study procedures and perform the blood draw. To increase the pediatrician involvement and motivation, we have also sent out a Feedback Questionnaire where they indicated how the organization of the follow-up 13

17 visits can be improved. Furthermore we also sent out a newsletter to the pediatricians containing current study results. Completeness of Key Data Collected GER site compliance to the study components was high and similar to other centers until age 1 year, but has lagged behind some of the centers after that age. This is particularly so for blood draws reaching a minimum at the 3 year visit. We observed lower blood volumes from children visited by family pediatricians as compared to those seen at the Munich Clinical Center. Hence, more attention was placed on communication to the pediatrician with respect to blood draw procedures and the importance of visits and collection. Offers to bring more families to our Munich clinical center and home visits are now implemented to improve compliance and retention. Incentives to increase compliance for dietary recall include rewards for completion and the option to estimate rather than weigh food amounts. These efforts are working as the blood draw compliance has steadily increased since and near now the overall average. These efforts remain high priority. Contributions of the German Clinical Site Investigators to TEDDY Achievements GER site investigators and staff will continue to make substantial contributions to both study-wide and site-specific protocol/manual of operations documents and data analysis, and are actively involved in all TEDDY committees. The GER site has extensive experience in measuring and understanding changes in autoimmunity and factors which modify progression to disease. It uses findings generated in its BABYDIAB and BABYDIET studies to formulate and test hypotheses in TEDDY. This includes novel data on microbiome, metabolomics, and gene expression in the first years of life which are used to plan TEDDY investigations. Key GER site research area contribution will be 1) defining initiation of autoimmunity, 2) identifying factors affecting the rate of progression from islet autoimmunity to diabetes in TEDDY children, 3) developing analytical methods to combine multiple parameters (genetic, immune, environment) 4) developing and validating assays for immune response and status; and 5) exploring novel interactions of infant dietary fiber and innate and adaptive immune responses. GER site investigators have been lead authors on two published TEDDY manuscripts (Ziegler et al. J Autoimmun. 2011; Bonifacio et al. J Clin Endocrinol Metab. 2010), two submitted TEDDY manuscripts, and six in progress manuscripts. The latter include novel work on infectious agent discovery in rapid onset diabetes TEDDY cases, and mathematical models of longitudinal autoantibody changes in relation to progression to diabetes, and confirmatory studies of associations of genes and cesarean section with progression to diabetes Next generation sequencing for viruses in children with rapid onset type 1 diabetes Viruses are candidate causative agents in the pathogenesis of type 1 diabetes. We hypothesized that children with a rapid onset of type 1 diabetes may have been exposed to such agents shortly before the initiation of islet autoimmunity, possibly at 14

18 high dose, and thus could be helpful for the identification of viruses involved in the development of autoimmune diabetes. We used next generation sequencing to search for viruses in plasma samples and examined the history of infection and fever in children enrolled in The Environmental Determinants of Diabetes in the Young (TEDDY) study who progressed to type 1 diabetes within 6 months from the appearance of islet autoimmunity, and in matched islet autoantibody negative controls. Viruses were infrequently detected in the period surrounding seroconversion in cases as well as controls. In addition, infection history was found to be similar between children with rapid onset diabetes and control children, although episodes of fever were less frequent in children with rapid onset diabetes. These findings do not support a major role of virus infection around the time of seroconversion in the pathogenesis of rapid onset type 1 diabetes in young children. (Ziegler AG et al., submitted). Future Perspectives 1) Continuation of follow-up of BABYDIAB, BABYDIET, and TEDDY participants and implementation and development of retention strategies to assure low drop-out rate and high compliance to biomaterial collection and questionnaire data. 2) Continuation of recruitment of children for TEENDIAB, DiMelli and ImmunDiabRisk 3) Examination of infectious agents in fulminant diabetes cases. We reason that the fulminant autoimmune diabetes cases are an ideal source to identify causative infections. We have the opportunity to examine daily infection and medication protocols prior to the initiation of islet autoimmunity in children from the BABYDIET and TEDDY study, and via deep sequencing, search for virus in plasma, stool, and cells available from these children; and bacterial sequencing in stool samples. Deep sequencing will be done in collaboration with T. Briese and WI. Lipkin (Columbia University, USA). 4) Examination of cellular and humoral immune responses in children born via Cesarean section and having the IFIH1 protective and risk genotypes. We aim to test, whether cesarean section and IFIH1 genotype lead to a higher susceptibility towards virus infections (human enterovirus (HEV) and others) and whether children born by cesarean section are less protected through maternal antibody transfer. We also aim to investigate effects from sera pre-, and post-seroconversion on CD4 naive and memory T cells relative to cesarean section and IFIH1, and investigate whether there is an activation humoral 'milieu' prior to seroconversion and after seroconversion that increases progression. 15

19 5) Studies on beta cell function prior to and after seroconversion in relation to puberty, hormones, growth, and T1D and T2D associated genotypes in children participating in the TEENDIAB studies. We aim to examine whether beta cell function may be impaired in children at T1D risk prior to the initiation of islet autoimmunity and whether weight, insulin resistance, and factors influencing beta cell function affect risk of islet autoimmunity or progression to T1D. 6) Development of a bio-resource for ongoing and future collaborative research. We aim to establish an infrastructure for the use of study material from our from birth and puberty cohort bio-resources to facilitate ongoing and future collaborative research into the pathogenesis of T1D. 7) Create one database with results from all sub-projects (microbiome, metabolomics, enteroviruses, immunochip typing, nutritional, metabolic, autoantibody and diabetes status, anthropometric data, see collaborations below) for complex multi-dimensional approach (system biology tools), and provide the diabetes research community access to the data repository. Our ongoing international and national collaborations with our cohorts are: Investigator: Matej Oresic, Helsinki, Finland; Project Metabolomics Matej Oresic published intriguing novel metabolomic data from the Finnish DIPP study using high-end methods and analyses. We had the opportunity to take advantage of this technology by our co-participation in an EU project (DIAPREPP, funding until 4/2011). We specifically addressed the hypothesis that the age of development of islet autoimmunity was associated with different autoimmune and environment phenotype. A total of 133 serum samples from 70 children were sent, tested, and analyzed for 29 metabolites of the amino acid metabolism and 511 lipids. Investigator: Ramnik Xavier, Curtis Huttenhower, Dirk Gevers, Broad Institute; Projekt: Understanding of the gut microbiome in children at increased risk of type 1 diabetes Based on an initiative started by the Juvenile Diabetes Research Foundation (JDRF) in 2011, cooperation has been established between the Helmholtz Zentrum München and the Broad Institute to analyze the microbiome in stool samples of children at increased risk for type 1 diabetes. Samples will be selected from the ongoing prospective TEENDIAB study, the from birth BABYDIET study, and our recently initiated pregnancy-birth cohort ImmunDiab study. As a first step, 71 islet autoantibody-positive children from the TEENDIAB/BABYDIET cohorts have been selected and matched in a case-control approach with two islet autoantibodynegative children per case; matched by gender, age, and duration of sample transport. An aliquot of ~100mg of stool has been aliquoted from each child and shipped to the Broad Institute for DNA extraction, and sequencing. In the next step, 16

20 samples from 150 children from BABYDIET with multiple 3-monthly collected stool samples and from 100 ImmunDiab children will be analyzed. Investigator: Ezio Bonifacio; Project Autoreactive T cell sequencing ; funding from BMBF Ezio Bonifacio in Dresden has developed methodology that provides highly efficient sequencing and cloning of T cell receptor alpha and beta chains from single cells (with 60% efficiency to obtain sequences of both chains from a single cell), followed by expression of the TCR to identify target peptide. Moreover, this is now coupled to single cell cytokine/transcription factor profiling at the single cell level so that his group is able to provide TCR sequence and phenotype of single cells that respond to autoantigen. Validation studies from samples obtained from the BABYDIET study show that the method can distinguish pre-seroconversion from post-seroconversion samples, and sequential sample testing shows that it is possible to identify T cell clones with the same TCR in different samples. We consider this to be a novel approach to the identification of T cell antigen peptide targets in the pre-clinical period and which could eventually provide the possibility to develop molecular assays for tracking autoreactive T cells. Thus, we have initiated the process for collaborative use of the BABYDIET PBMC samples which are frozen at multiple time points from age 3 months. Investigator: John Todd, Cambridge, UK; Project RNA expression signatures The group of John Todd has produced functional data that support genetic and T1D associations with immune response phenotype. With the capacity to perform genotype-phenotype interaction studies, John Todd and David Clayton approached us to obtain samples suitable for RNA analyses from the pre-diabetic period. The project aims to identify peripheral blood RNA expression signatures associated with the development of autoimmunity, infection, and progression to diabetes. To validate sample quality an initial pilot shipment of 16 samples from BABYDIET children were shipped to Cambridge for preparation, QC, and measurement. The data confirmed that the study was feasible and over 700 samples of trizol-stored peripheral blood (approximately 1 million PBMC in each sample) from the BABYDIET study were shipped to Cambridge for RNA expression studies. Currently a database is being prepared in Munich with clinical data, confounding variable data, and islet autoantibody profiles to set up an RNA extraction plan so that a case control subset can be first tested in Cambridge followed by confirmation of the findings in the remaining samples. It will be further considered whether DNA samples will be sent for genotyping with the immune disease SNP chip, Immunochip, in order to correlate gene expression differences with SNP alleles and haplotypes. 17

21 Investigators: Polly Bingley and K. Gillespie; Project characterization of long survivors The mechanisms which dictate why some individuals with ongoing islet autoimmunity do not develop diabetes, or do so only after many years, represent a critical gap in our understanding of the pathogenesis of T1D. The presence of two or more islet autoantibodies in unaffected first-degree relatives of individuals with T1D is associated with more than 25% risk of developing diabetes within 5 years. It is however increasingly clear that in some multiple islet autoantibody-positive individuals disease progression to diabetes is delayed for decades. To explore potential determinants of slow progression, we propose in depth characterization of immune and regulatory pathways in children from the Bart s Oxford (BOX) family study, and the BABYDIAB and BABYDIET cohorts (funded by the JDRF). B. Research Group T1D immune phenotyping Dr. med.peter Achenbach Overview Type 1 diabetes (T1D) is caused by an autoimmune destruction of the islet beta cells. Progression to disease is not uniform between affected individuals and islet autoimmunity can precede the development of clinical T1D by many years. Predicting the risk for progression of islet autoimmunity in pre-clinical T1D is important for identification of individuals that might profit from inclusion in interventional trials aiming to prevent the onset of disease. Autoantibodies to beta cell antigens are a hallmark of T1D. They precede diabetes onset in >95% of children who develop disease and are frequent in insulin requiring diabetes in adults. Although they are not considered effectors of beta cell damage, they are established markers in the clinical classification of diabetes, prediction of the need for insulin treatment, identification of individuals at risk for developing T1D and as end-points in observational studies. Our group has focused research on immunology of T1D, with a special emphasis on characterizing the humoral islet autoimmunity and predicting the disease. Specifically, we ask how autoantibody responses can best be applied to stratify, stage and monitor progression to T1D. The underlying hypothesis is that humoral autoimmune responses can be used to track T1D pathogenesis by identifying distinct immunization profiles at initiation of autoimmunity, demonstrating new autoimmunity on follow-up, and relating immune profiles/phenotypes to T1D development. The prospective cohorts at IDF (e.g. BABYDIAB and Munich family studies) provide unique opportunities to test this hypothesis. Furthermore, we work together with mathematicians at HMGU to modeling our high-dimensional datasets in order to get insight into complex interactions between immunologic, genetic and environmental 18

22 factors in T1D pathogenesis. Our long-term research goals are to contribute to a better understanding of the etiology and pathogenic mechanisms of T1D, and to ultimately find effective therapies that can prevent and cure this disease. Main results 1) IA-2 autoantibody affinity in children at risk for type 1 diabetes. Autoantibodies to insulinoma-associated protein 2 (IA-2A) are associated with increased risk for type 1 diabetes. In this study, we examined IA-2A affinity and epitope specificity to assess heterogeneity in response intensity in relation to pathogenesis and diabetes risk in 50 children who were prospectively followed from birth. At first IA-2A appearance, affinity ranged from 10 7 to L/mol and was high (>1.0 x 10 9 L/mol) in 41 (82%) children. IA-2A affinity was not associated with epitope specificity or HLA class II haplotype. On follow-up, affinity increased or remained high, and IA-2A were commonly against epitopes within the protein tyrosine phosphatase-like IA-2 domain and the homologue protein IA-2β. IA-2A were preceded or accompanied by other islet autoantibodies in 49 (98%) children, of which 34 progressed to diabetes. IA-2A affinity did not stratify diabetes risk. In conclusion, the IA-2A response in children is intense with rapid maturation against immunogenic epitopes and a strong association with diabetes development. Clin Immunol 2012; 145(3): [IF 4.046] 2) Genetic association of zinc transporter 8 (ZnT8) autoantibodies in type 1 diabetes cases. Autoantibodies to zinc transporter 8 (ZnT8A) are associated with risk of type 1 diabetes. Outside of the SLC30A8 gene itself, little is known about the genetic basis of ZnT8A positivity. Here, we hypothesised that other loci in addition to SLC30A8 are associated with ZnT8A. ZnT8A was measured in 2,239 British type 1 diabetes cases diagnosed before age 17 years, with a median duration of diabetes of four years. Cases were tested at over 775,000 loci genome wide (including 53 type 1 diabetes associated regions) for association with ZnT8A positivity. ZnT8A was also measured in 855 type 1 diabetes affected family members. Only FCRL3 on chromosome 1q23.1 and the human leukocyte antigen (HLA) class I region were associated with ZnT8A positivity. rs t>c was the most associated SNP in the FCRL3 region (P = 1.13x10-16 ). The association was confirmed in 855 type 1 diabetes affected family members (P 9.20x10-4 ). rs a>g was the most associated variant in the HLA (P = 2.06 x 10-9 and P = in family cases). ZnT8A positivity was not associated with HLA-DRB1, HLA-DQB1, HLA-A, HLA-B or HLA-C (P > 0.05). Unexpectedly, the two loci associated with ZnT8A positivity did not alter risk of type 1 diabetes and, the 53 type 1 diabetes risk loci did not influence positivity to this disease-specific autoantibody. In conclusion, ZnT8A are not primary pathogenic factors in the disease. Nevertheless, ZnT8A testing in combination with 19

23 other autoantibodies facilitates disease prediction, despite the biomarker not being under the same genetic control as the disease. Diabetologia 2012; 55(7): [IF 6.814] 3) Characteristics of rapid versus slow progression to type 1 diabetes in multiple islet autoantibody-positive children. Islet autoantibody-positive children progress to type 1 diabetes at variable rates. In this study, we asked whether characteristic autoantibody and/or gene profiles can be defined for extreme progression phenotypes. Autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA), insulinoma-associated antigen-2 (IA-2A) and zinc transporter 8 (ZnT8A) were measured in follow-up sera and genotyping for type 1 diabetes susceptibility genes (HLA-DR/DQ, INS VNTR, and single nucleotide polymorphisms at PTPN22, PTPN2, ERBB3, IL2, SH2B3, CTLA4, IFIH1, KIAA0350, CD25, IL18RAP, IL10, COBL) was performed in DNA samples of children born to a parent with type 1 diabetes and prospectively followed from birth for up to 22 years. Of 1650 children followed, 23 developed multiple autoantibodies and progressed to diabetes within 3 years (Rapid Progressors), while 24 children developed multiple autoantibodies and remained non-diabetic for more than 10 years from seroconversion (Slow Progressors). Rapid and Slow Progressors were similar with respect to HLA-DR/DQ genotypes, the development of IAA, GADA, and ZnT8A, and the progression to multiple autoantibodies. In contrast, IA-2A development was considerably delayed in Slow Progressors. Furthermore, both groups were effectively distinguished by the combined presence or absence of type 1 diabetes susceptibility alleles of non-hla genes, most notably IL2, CD25, IL10, and IFIH1, and discrimination was improved among children carrying high-risk HLA-DR/DQ genotypes. In conclusion, our data suggest that genotypes of non-hla type 1 diabetes susceptibility genes influence the likelihood or rate of diabetes progression amongst children with multiple islet autoantibodies. 4) Immune Platform at IDF and Central Laboratory for the measurement of islet autoantibodies for the CNDM. We provide an Immune Platform at the IDF for highend phenotyping of humoral autoimmune responses in T1D. The platform is open for collaborations with investigators at HMGU and from outside. In 2012, we have provided core measurements of islet autoantibodies for the Network (e.g. DPV study, DiMelli study, TEENDIAB study, CNDM pediatric diabetes biomaterials bank [pedbmb] project). The centralized high-quality measurement of all major T1D-associated autoantibodies (IAA, GADA, IA-2A, ZnT8A) improves diabetes classification and allows determination of autoantibody phenotypes at diabetes onset. Furthermore, it allows direct comparison of autoantibody results between different Network studies and, in case of GADA and IA-2A, large NIH-funded international studies (e.g. TEDDY) because of the use of harmonized autoantibody detection methods. This expert diagnostic service is unique in the field of diabetes in Germany. 20

24 It is expected that there will be further collaborations with CNDM studies within the next years. C. Research Group Gestational diabetes mellitus Overview Dr. oec. troph. Sandra Hummel Gestational diabetes (GDM), defined as glucose intolerance that begins or is first detected during pregnancy, has a prevalence of 2-6% with an increasing trend across most racial/ethnic groups studied and is the most frequent metabolic problem during gestation. GDM is associated with an increase in perinatal morbidity and mortality as well as a greater frequency of long-term complications in the mother and her offspring. It is expected that the increase in the prevalence of GDM heralds a future increase in both atherosclerotic disease and type 2 diabetes (T2D). Women with GDM are a high-risk population for the development of diabetes mellitus. Risk estimates for T2D after GDM range from 17% to 63% within 5 to 16 years after pregnancy, depending upon the ethnic background of the study population and the detection method for GDM and glucose intolerance. GDM is not only associated with complications for the mothers. Several studies indicated that in utero exposure to GDM is a strong risk factor for overweight and T2D in the offspring during childhood and adolescence. As the prevalence of pregnancies complicated by GDM is increasing, the number of children at high risk for overweight combined with a high risk to develop GDM themselves will also further increase. The main aims of our research group are to 1.) stratify risk for the development of postpartum diabetes in mothers with GDM, 2.) to investigate mechanisms underlying postpartum development of diabetes in mothers with GDM, 3.) to conduct a prevention trial in women with recent insulin-treated GDM using life style intervention and vildagliptin after pregnancy, and 4) to identify risk factors and mechanisms underlying the increased overweight risk in offspring of mothers with GDM. To address these aims, more than 800 mothers with GDM together with their offspring are currently followed in two cohort studies: the Prospective German Gestational-diabetes-study and the Postpartum outcomes in women with Gestational Diabetes and their offspring POGO-study. In both studies women with GDM and their offspring are followed for the development of impaired glucose tolerance (IGT) and T2D in the mother postpartum, and insulin resistance and obesity in the offspring. At follow-up, an OGTT is performed and blood samples (Plasma, Serum, DNA, RNA, PBMC) as well as stool samples are collected and stored to enable further genetic, 21

25 metabolomic and gut-microbiome studies. Furthermore we are conducting a study aiming to prevent postpartum onset of diabetes in women with GDM. In this placebocontrolled phase II study (PINGUIN) mothers are treated with life style intervention and the DPP4-inhibitor Vildagliptin to prevent postpartum development of T2D. Main Results The prospective German GDM study enrolled a total of 302 mothers with GDM and their offspring at birth between 1989 and Both, mothers and their offspring were followed at 9 months, 2, 5, 8, 11, 14, 17 and 20 years after birth, and blood samples and DNA were collected. In the mothers an OGTT was performed at each visit for the detection of postpartum diabetes. Demographic data that included the age at delivery, the numbers of preceding pregnancies, the duration of gestation, diabetes treatment during pregnancy, and family history of T1D or T2D were obtained shortly after delivery. In offspring, data on height and weight were collected at each follow-up visit. Insulin resistance (HOMA-IR) was determined at age 8 and 11 years. Furthermore, data on maternal BMI during early pregnancy, birth weight, and maternal smoking behavior during pregnancy were collected by questionnaire shortly after birth as well as breastfeeding habits were recorded at age 9 months and 2 years. 1) Predictors of postpartum diabetes in women with GDM. To investigate whether breastfeeding influences short and long term postpartum diabetes outcomes, women (n=304) with GDM participating in the prospective German GDM study were followed from delivery for up to 19 years postpartum for diabetes development. Postpartum diabetes developed in 147 women and was dependant on the treatment received during pregnancy (insulin versus diet), body mass index, and presence/absence of islet autoantibodies (Figure 5). Among islet autoantibodynegative women, breastfeeding was associated with median time to diabetes of 12.3 years as compared to 2.3 years in women who did not breastfeed. The lowest postpartum diabetes risk was observed in women who breastfed for >3 months (Figure 6). Based on these results, we recommend that breastfeeding should be encouraged among these women, as it offers a safe and feasible low-cost intervention to reduce the risk of subsequent diabetes in this high-risk population. 22

26 100 ) (% s te 80 e b ia d m 60 rtu a tp s 40 o p e tiv 20 la u m u C Follow up af ter delivery (years) Islet Aab-positive Islet Aab-negative, insulintreated, BMI >30 kg/m Islet Aab-negative, insulintreated, BMI =30 kg/m Islet Aab-negative, diet-treated, BMI >30 kg/m Islet Aab-negative, diet-treated, BMI =30 kg/m 2 Figure 5: Combining risk factors for classification of postpartum diabetes risk. Life table analysis of patients with GDM categorized as islet autoantibody-positive; islet autoantibody-negative, insulin- or diet-treated during pregnancy and having a BMI >30 or 30 kg/m² in early pregnancy (Ziegler et al., Diabetes 2012). 23

27 100 ) (% s te 80 e b ia d m 60 rtu a tp s o 40 p e tiv la u 20 m u C 0 No breastfeeding breastfeeding =3 months breastfeeding >3 months Follow up af ter delivery (years) No breastf eeding breastfeeding =3 months breastfeeding >3 months Figure 6: Cumulative life-table risk of postpartum diabetes in islet autoantibody negative women with gestational diabetes who breastfed for >3 months compared with those who breastfed for 3 months (p=0.029) or did not breastfeed (p=0.002). 2) Predictors of overweight and insulin resistance during childhood in offspring of mothers with GDM. In a current analysis we were studying the influence of Type 2 Diabetes (T2D) susceptibility alleles at the HHEX-IDE and CDKAL1 loci on weight development in offspring of mothers with GDM by analyzing a total of 549 records on weight, height and BMI were from 185 offspring aged 1 to 17 years participating in the prospective German GDM offspring study. This analysis revealed that the T2D risk allele at the HHEX-IDE locus is associated with reduced BMI-SDS over the entire observation period (-0.28 SDS per risk allele, p=8.1e-03). After stratification by age tertiles the HHEX-IDE risk allele was strongly associated with reduced BMI-SDS (-0.38 SDS, p=3.6e-03) in the first age tertile ( years) whereas this association was less pronounced later in childhood ( years). After stratification by maternal obesity, the HHEX-IDE risk allele was associated with reduced BMI-SDS in offspring of non-obese mothers only (-0.40 SDS, p=0.001). In contrast, the T2D risk allele at the CDKAL1 locus was not associated with childhood growth. Based on these results we conclude that the T2D susceptibility allele at the HHEX-IDE locus is associated with reduced BMI in offspring of mothers with GDM, especially in children up to 2.3 years of age and in offspring of mothers with BMI<30kg/m². The finding that the genetic influences did 24

28 not persist during puberty may indicate that the relationship between reduced BMI and the T2D associated allele of the HHEX-IDE gene in early childhood changes towards increased BMI during adulthood, a relationship that appears to be more consistent with the association of the genotype with T2D later in life. However a longer follow-up of this cohort will be required to ascertain this. Figure 7: Effect of HHEX-IDE risk alleles on BMI-SDS. Effect per allele (95% CI) on BMI-SDS stratified by A) age tertile (n=183 records each, 1. tertile: years, 2. tertile: years, 3. tertile: years) and B) maternal BMI 30kg/m² in early pregnancy. 3) Postpartum outcomes in women with Gestational Diabetes and their Offspring (POGO). Results from our previous studies have shown that mothers with GDM are at increased risk for T2D postpartum, and that their offspring are at increased risk for childhood obesity and insulin resistance. We found that maternal obesity and insulin treatment increases the risk for postpartum development of T2D in GDM mothers, while breastfeeding seemed to have protective effects; however the mechanisms behind these associations are still unclear. To identify mechanisms related to the development of T2D postpartum in mothers with GDM and overweight/obesity in offspring of mothers with GDM, we have designed a cohort study in mothers who were referred for screening of GDM to the outpatient clinic of Prof. Dr. Ziegler, PD Dr. Hummel and PD Dr. Füchtenbusch in Munich (Klinikum Schwabing), and their offspring. More than 1800 mothers with and without GDM and their children aged 1 to 11 years will be invited to participate in this follow-up study called Postpartum outcomes in women with Gestational Diabetes and their Offspring (POGO). At the study visit, demographic, nutritional and anthropometric data are recorded. Additionally, data about physical activity, metabolism and genetic susceptibility are collected using accelerometers, breath gas analyses, 75g oral glucose tolerance 25

29 tests (OGTT) and bio-samples, such as blood and stool. The expected outcome of the project is to provide fundamentally new insight to the underlying mechanisms of the development of overweight and insulin resistance in high-risk children and in the next step, open a new research field on developing intervention/prevention strategies. A further aim is to establish an infrastructure for the use of the bioresource in collaborative studies including gut microbiome, metabolomics, and genomics. Therefore, biomaterial including serum, plasma, DNA, RNA, PBMC and stool samples will be stored in a biobank. The POGO study started in January As yet, 96 women (median follow-up time postpartum: 5.1 years) have been enrolled together with 105 index children (i. e. children who were carried out in the pregnancies screened for GDM). GDM had been diagnosed through OGTT in 82 women (mothers of93 children respectively). At the postpartum study visit, 36 mothers had abnormal glucose tolerance, comprising 16 cases of impaired glucose tolerance, 13 of impaired fasting glucose, six with T2D and one with T1D. The prevalence of obesity in the offspring of GDM mothers was 6.5 %. Of 41 children tested by OGTT, three were diagnosed as having impaired glucose tolerance, and two as having impaired fasting glucose. None of the children had T1D or T2D. 4) Postpartum Intervention in Women with Gestational Diabetes using Insulin (PINGUIN). Current treatment approaches to managing pre-diabetes are diet and exercise. Both are shown to be efficacious in controlled clinical trials. However, many people do not respond to lifestyle advice and adherence to diet and exercise recommendations is generally poor. Under these circumstances pharmacological intervention may be necessary to provide glucose control and to prevent further decline in beta cell function and progression to T2D. Several pharmacological interventions have been studied in patients with pre-diabetes. One study has been performed in women with a history of GDM and has indicated that progression to T2D can be decreased from 12.1% to 5.4% over 30 months using pharmacological intervention with triglitazone. Thus, women with previous GDM can be targeted for prevention of T2D. Results from the Prospective German GDM study have shown that women with a history of gestational diabetes (GDM), in particular women requiring insulin therapy to control hyperglycemia during GDM, are at increased risk to develop T2D postpartum. There are no approved therapies that prevent development of T2D in women with recent GDM. Vildagliptin is a highly selective and reversible inhibitor of dipeptidyl peptidase IV, the enzyme responsible for the degradation and inactivation of the incretin hormones GLP-1 and GIP. Based on these findings, the PINGUIN study, a T2D Prevention Study was initiated in PINGUIN is a randomized double-blind placebo controlled and investigator-initiated trial (randomization 1:1) study. The study will investigate the durable effects of vildagliptin 50 mg b.i.d. in pre-diabetic women who have a recent history of GDM (<9 months) that required insulin therapy. The primary objective is to determine the efficacy of 24 month DPPIV inhibitor 26

30 (Vildagliptin) treatment to reduce progression to T2D in islet autoantibody-negative women with recent insulin treated GDM. The secondary objectives are to determine the mechanism of action of Vildagliptin treatment by testing the hypothesis that Vildagliptin 50 mg b.i.d. improves beta cell function and insulin sensitivity; and to determine the durability of clinical benefit of 24 month Vildagliptin 50 mg b.i.d. treatment. The exploratory objective is to test whether 24 month Vildagliptin 50 mg b.i.d. treatment reduces the risk for GDM in subsequent pregnancies. As concomitant treatment, all subjects will receive standard lifestyle recommendations. The primary outcome is diabetes diagnosed on the basis of a sixmonthly oral glucose tolerance test according to 1997 ADA criteria. So far, 79 of 140 women have been included. Future Perspectives 1) Maternal hyperglycemia programs metabolic responsiveness of the neonate. Maternal diabetes alters fetal metabolism and modifies future risk of diabetes in the offspring. Of interest, the risk for overweight and type 2 diabetes is increased in the offspring of diabetic mothers. We have demonstrated that the increased risk for overweight is influenced by maternal weight and fetal growth (Boerschmann, Diabetes Care 2010). We hypothesize that maternal hyperglycemia programs metabolic responsiveness of the neonate. We expect that genes that confer susceptibility to diabetes will further interact with this programming to exacerbate metabolic phenotypes as suggested by our previous findings (Winkler, JCEM 2009; Winkler, Diabetes 2010). Therefore we aim to identify metabolic signatures that correlate with intrauterine exposure and genetic risk status in children born to mothers with gestational diabetes or a non-diabetic mother. Distinctive metabolic profiles will be modeled to define biochemical pathways involved and these will be proposed as metabolic pathways that biologic therapies should correct in order to reduce diabetes risk in the offspring. Specifically, we will determine metabolic signatures in early childhood that portray the intrauterine environment (hyperglycemia, obesity, autoimmunity) and genetic susceptibility in children of mothers with gestational diabetes, type 1 diabetes, or normoglycemia. 2) The long-lasting effect of breastfeeding on maternal metabolomics in mothers with GDM. Breastfeeding was shown to improve early postpartum glucose tolerance (O Reilly, 2011) and reduce the subsequent risk of type 2 diabetes in mothers with preceding GDM (Ziegler, 2012). We hypothesize that breastfeeding in mothers with GDM might have a long-lasting programming effect on maternal metabolomics profile, and thereby exerts protective effects on type 2 diabetes development. To proof this, a targeted and non-targeted metabolomics approach will be applied in using high throughput platforms in samples of mothers participating in the POGO-study. 27

31 3) Prevention of T2D after GDM. One major aim is to complete recruitment of diabetes prevention trial PINGUIN: We aim to complete recruitment by the end of 2013 to complete treatment by the end of 2015 and follow-up by the end of The analysis of the trial outcome will be in This study is funded by the Competence Network Diabetes Mellitus (CNDM). D. Research Group T1D Prevention; clinical studies Prof.Dr. med. Anette-G. Ziegler; Dr. med. Minna Harsunen, Dr. rer. nat. Florian Haupt, Dr. med. Katharina Warncke Overview In 2012 IDF1 was highly active in clinical intervention to prevent and reverse type 1 diabetes. The objective was to identify, develop and test predictive strategies and therapies that will: 1) Prevent islet autoimmunity, 2) Prevent progression to T1D in islet autoantibody positive subjects, 3) Preserve beta cell function after onset of T1D. Prof. Ziegler led these activities which were supported by Dr. Harsunen, Dr. Haupt, Dr. Huppert, Dr. Walter, Dr. Warncke and doctoral candidates Giannopoulou and Krasmann at the clinical level together with several medical and laboratory staff. The activities included investigator initiated trials conducted by IDF1 or as a major investigator, and participation as investigators in sponsored trials. Main Results 1) Prevent islet autoimmunity. The IDF1 participates in the primary intervention trail Pre-POINT ( Achenbach P et al., Curr Diab Rep 2008). This trial is based upon BABYDIAB study data showing that (pro)insulin is a very early target of autoimmunity (Ziegler AG et al., Diabetes 1999; Achenbach P et al., J Clin Invest 2004) and that children with T1D risk of around 50% can be identified for the study (Bonifacio E et al., Diabetes Care 2004), as well as numerous reports that mucosally administered antigen (including insulin) can induce antigen specific tolerance and regulatory T cells. Pre-POINT is the first primary vaccination trial in autoimmune diseases. Insulin is the chosen antigen. While proinsulin may be the primary target in pre-t1d, we expect that if administration of insulin led to a protective insulin-directed immune response, 28

32 this would also impact regulation of eventual proinsulin responses. Pre-POINT is a randomized double blind multi-centre dose-finding trial led by Ezio Bonifacio (Dresden) and Anette Ziegler (IDF1) with additional participation from the UK (Bingley), Austria (Schober), and US (Denver; Klingensmith). The objective of the trial is to identify a dose of orally administered insulin that induces an immune response to insulin with a regulatory phenotype. Four doses are given in the study (2.5 mg per day up to 67.5 mg per day). Children with an expected 50% risk for developing T1D based on family history and HLA genotype, and who are islet autoantibody-negative are eligible. Thus far, 75% of subjects have been recruited; the vast majority (70%) by the Munich clinical site. None of the four doses showed adverse safety issues. Beside the role of the Adaptive Immune Response to the development/maintenance of T1D, IDF1 started to investigate also the contribution of the Innate Immune System for the disease. Recently Dr Harsunen demonstrated the existence of a perturbation of leukocyte homeostasis at and prior to onset of type 1 diabetes suggesting a general involvement of the innate immune system in the pathogenesis of type 1 diabetes (Harsunen M et al., Horm Metab Res 2013). Complete and differential blood counts were analyzed from 107 adult patients with newly diagnosed type 1 diabetes, 21 children with persistent islet autoantibodies and a family history of type 1 diabetes, and age and gender matched control subjects, all individuals without any signs of acute infection. Adult patients with newly diagnosed type 1 diabetes had significantly lower total WBC (p<1 10-6), neutrophil (p<1 10-6), basophil (p<1 10-6), monocyte (p=4 10-6) and lymphocyte (p<1 10-6) counts compared to control subjects. Erythrocyte, eosinophil and platelet counts did not differ between groups. Similarly, children with persistent islet autoantibodies had decreased WBC (p=0.001), neutrophils (p=0.003), and lymphocytes (p=0.006) in comparison to control children. These findings suggest that these cells are directly or indirectly involved in the pathogenesis of T1D and that alterations are unlikely to be a consequence of hyperglycemia and diabetes complications. 2) Prevent progression to T1D in islet autoantibody positive subjects. IDF1 is a member of the NIDDK sponsored TrialNet consortium that executes clinical trials to prevent T1D and to preserve beta cells after onset of T1D. As part of the activities, IDF1 is screening for the oral insulin study. Since January 2012 a total of 173 subjects were screened for islet autoantibodies within phase 1. Of those, 157 were below age 20 years, and 160 were first degree relatives of patients with T1D. Four were tested to be islet autoantibody positive (1 single, 3 multiple islet Abs). The IDF1 is also part of the Diabetes Vaccine Development Center sponsored INIT II (intranasal insulin trial) study as a partner institute to the Royal Melbourne Hospital (PI, Len Harrison). The trial recruits islet autoantibody-positive (at least two autoantibodies) relatives of patients with T1D for randomization to treatment with 29

33 intranasal insulin (440 IU) or placebo for a period of 12 months. This trial uses a much higher amount of insulin with a different timing of administration as compared to the unsuccessful DIPP intranasal insulin trial. Primary aim of INIT II is to determine whether intranasal insulin can delay or prevent the development of T1D in relatives of people with T1D. Secondary aim is to determine whether intranasal insulin can prevent loss of beta cell function, improve insulin sensitivity, and induce a regulatory immune response to insulin. INIT II started recruiting in Germany in December 2011 and the first subject was staged on the 2 nd of January Munich site is expected to contribute 30 subjects to the trial which will have a total of 102 participants. Since then, a total of 27 children and young adults have been staged. 9 of these subjects fulfilled entry requirements and were enrolled into the study. Three month follow-up has been completed for 7 participants and six months follow-up for 3 participants so far. The recruitment is unfortunately delayed due to a higher rate of staging failures as expected. The staging failures are due to an insufficient first phase insulin response (FPIR) for 4 participants. 5 participants were not eligible because of pathological OGTT and 5 because of insufficient autoantibody profile. One participant withdrew his consent during the staging phase, some staging results are still pending The screening for the oral insulin study as well as the prevention activities in the INIT II study complement our Pre-POINT study with respect to tolerance via mucosal antigen delivery ( ; Skyler JS & Ricordi C, Diabetes 2011), Fourlanos S et al., Diabetes 2011). 3) Preserve beta cell function after onset of T1D. Since the last years, IDF1 has also been a major partner or participant in other investigator-initiated trials (CORDY, AIDA Mansdrup- Poulsen T et al., Nat Rev Endocrinol 2010) and a participant in pharmaceutical company driven trials (DIA-AID 2) aimed at preserving beta cell function after diabetes onset. The IDF1 included 13 patients Into the AIDA (Anti-Interleukin-1 in Diabetes Action) study which was terminated in January The entire study was presented at the ADA meeting and IDS meeting in No significant benefit was reported for patients receiving Anakinra compared to patients receiving placebo. The baseline corrected mean differences in C-peptide AUC at nine months were -118 (95% CI: - 221, -25) compared to -155 ( -246, -63) pm in Anakinra and placebo groups, respectively (p = 0.58). The study also failed to meet secondary outcome measures. 30

34 DIA-AID 2 is a pharmaceutical driven confirmatory Phase III trial, testing whether the HSP60-derived peptide DiaPep277 may be effective in preserving ß-cell function, improving HbA1c and reducing insulin requirement by inducing tolerance and remission. In this double-blinded randomized placebo-controlled global Study 457 recent-onset (< 3months) T1D patients, 13 of them enrolled in the Munich study side, receive nine injections of 1 mg DiaPep277 over a time period of 2 years. First results showed a slower reduction in ß-cell function (assessed by change in area under the curve of C-peptide from baseline) at 2 years of follow-up (3 months after the end of treatment). Furthermore the percentage of subjects who maintained treat-to-target HbA1c <7% was significantly higher in the patients treated with DiaPep277 without presenting relevant adverse events. Immunotherapy for type 1 diabetes: getting beyond a negative first impression (Pozzili P & Strollo R, Immunotherapy 2012). CORDY is an intervention pilot study for young children suffering from new onset T1D. The aim is the retention of beta cell function and the improvement of glycemic control through a single autologous cord blood infusion. Possible changes in immune function leading to islet destruction or regeneration will also be investigated. The trial was initiated by IDF1 as a collaborative project with the Gainesville group headed by Schatz and Atkinson. The Munich trial is independent of the US trial (Haller MJ, Diabetes Care 2011) and in contrast to the US trial a control group of young children is included. So far, 19 of the planned 30 patients have been enrolled; 7 underwent a single autologous cord blood infusion and 12 take part as control subjects. No infusion-associated adverse events have been observed so far. To date, 8 children have completed the CORDY 2-year trial. Data from this trial include efficacy (fasting and stimulated C-peptide, HbA1c and daily insulin requirements) and mechanistic (autoimmunity, including regulatory T cells, FOXP3+ memory T cells and recently activated T cells measured locally and by Bonifacio; RNA expression analysis).regarding beta cell residual function no significant differences have been observed so far between the two groups. In terms of immune function, FACS analyses have been performed on peripheral blood mononuclear cells (PBMC) to determine changes in regulatory T cells (Tregs), FOXP3+ memory T cells and recently activated T cells (figure 1). An increase of recently activated T cells has been observed 6 months after cord blood infusion (screening: ± % of CD4+ T cells vs. 6 months: ± 0,413 % of CD4+ T cells) whereas the percentage of recently activated T cells in control children remained relatively constant (screening: ± % of CD4+ T cells vs. 6 months: 0,417 ± 0,285 % of CD4+ T cells). So far no significant differences have been observed in the course of Tregs and FOXP3+ memory T cells between the control and transfused group but there is a tendency to higher changes in both T cell populations in transfused children. It is expected that the study will provide a precedent for cell infusion in young patients with T1D allowing further studies to be contemplated, which can combine cell infusion with immune modulators or antigen. These notions are being 31

35 developed collaboratively with the Bonifacio and Atkinson groups. Furthermore we expect to gain information about the process of the beta cell destruction and regeneration in individuals with T1D. Figure 7: FACS T cell monitoring of enrolled patients. Shown are the percentages of real FOXP3+ Tregs (Fig. 1A: Controls; Fig. 1B: Cases), FOXP3+ memory Tregs (Fig. 1C: Controls; Fig. 1D: Cases) and recently activated T cells (Fig. 1E: Controls; Fig. 1F: Cases) before transfusion (screening), and during Follow-up to 24 months. Future Perspectives 1) T1D is a complex autoimmune disease that is caused by the destruction of insulin-producing pancreatic β-cells by autoreactive T cells. Much attention has focused on the analysis of diabetogenic T and Treg cells. However there is increasing evidence that also cells belonging to the innate immune system play a role in the development of T1D. Thus IDF1 will focus its attention also on basic research uncovering details about the role of Innate Immune cells, i.e. neutrophils 32

36 and NK, in the pathogenesis of T1D. An improved knowledge of the features and role of the various components of the Innate Immune System in T1D development can be of peculiar interest in the clinic for disease prevention or therapy. 2) IDF1 will continue its clinical trial efforts in prevention of T1D and preservation of beta cell mass. Pre-POINT trial will be completed 2013: recruitment will be finished by March and therefore the trail is expected to be completed by June. Resulting data will be analyzed with Ezio Bonifacio and the Data Coordinating Center. It is hoped that evidence of a favorable immune effect will be seen with one or more doses currently tested, allowing a Phase II efficacy study to be developed. 3) Secondary prevention in autoantibody-positive subjects will focus on participation and completion of INIT II. We will enroll 30 subjects over the next 12 months and follow these 3-monthly for the first year and 6-monthly thereafter. We have identified several new candidates for the INIT II study from our database and they are currently contacted by us and offered participation and staging for intervention. We will also continue screening for islet autoantibodies to identify further eligible subjects. In this context an antibody screening request for 1 st degree relatives of patients with T1D will be published in the Diabetes Journal in early spring ) An important objective in secondary prevention for 2013 will be the activation of IDF1 as study site for the oral insulin study of TrailNet: Oral Insulin for Prevention of Diabetes in Relatives at Risk for Type1 Diabetes Mellitus. This study is a 2- arm, multicenter, randomized, double-masked, placebo-controlled clinical trial. Subjects will receive oral insulin 7.5 mg of recombinant human insulin crystals or placebo in capsules. The primary objective is to determine whether intervention with repeated oral administration of recombinant human insulin will prevent or delay the development of clinical T1D in subjects at risk for T1D. The primary outcome is the elapsed time from random treatment assignment to the development of diabetes among those enrolled in the primary analysis cohort consisting of subjects with insulin autoimmunity and absence of metabolic abnormalities. The study recruits relatives of T1D with miaa and at least one other islet autoantibody present and a normal OGTT performed within 7 weeks prior to randomization. The IDF1 will enroll 5 participants in the oral insulin trail until the end of ) With respect to clinical trials at T1D onset, IDF1 will continue recruitment and complete the cord blood trial. We will also continue to recruit relatives into the Natural History Study with a rate of approximately 150 new subjects per year, and follow autoantibody positive relatives according to the SOP for the study. 6) Important for all these activities is infrastructure to recruit and execute the trials. Hence, the involvement of HMGU and TUM in providing infrastructure is fundamental for IDF1 to continue its strong position in this area. 33

37 E. Research Group Epidemiology Dr. rer. biol. hum. Andreas Beyerlein Overview The research group Epidemiology has been established in February Its main focus lies on the identification of determinants and consequences of T1D, T2D, GDM and overweight on a population level. This includes complex statistical analyses of the data collected at the IDF1 as well as statistical counseling with respect to study design and other issues. Main results 1) Infections and islet autoimmunity. Infections have been discussed as important environmental determinants in the pathogenesis of T1D. We hypothesized three scenarios to explain how infectious diseases might be involved in this context. First, early exposure, e.g. in the first months of life, may be instrumental in inducing a state of susceptibility for future islet autoimmunity. Alternatively, infections may have a short-term impact, causing islet autoimmunity in the following few months. Third, infections might have a cumulative impact such that the frequency of infectious events would increase the likelihood of islet autoimmunity irrespectively of when they occur. Using data from the BABYDIET study, in which children with high risk for T1D had been followed from three months of age with daily documentation of illnesses during the first three years of life, we identified respiratory infections in early childhood, especially in the first year of life, as a risk factor for islet autoimmunity. We also found some evidence for short term effects of infectious events on development of autoimmunity, while cumulative exposure alone seemed not to be causative (Beyerlein, JAMA Pediatrics 2013). 2) Interactions of genetic and environmental risk factors with respect to body fat mass in children. Genetic factors are likely to determine the risk of overweight in children, and recent studies suggest that interaction with environmental risk factors may be important. We assessed interactions between a so-called obesity-risk-allele score, summarizing a number of established genetic risk factors for overweight, and a number of priming, life-style and nutritional factors with respect to body fat mass in children at primary school age, using data from the prospective Avon Longitudinal Study of Parents and Children (ALSPAC). Our analyses suggest potential interactions between a diet with a low content of unsaturated fatty acids and genetic risk factors for overweight on fat mass. Apart from maternal overweight, which might also reflect unknown genetic factors, we found no evidence for interactions of genetic disposition with other environmental or nutritional factors (Riedel, Obesity 2013). 34

38 3) Reduced blood leukocyte and neutrophil numbers in the pathogenesis of T1D. Very little is known about the role of the innate immune system in the course of human T1D. Here we investigated neutrophil numbers along with other leukocyte populations in patients at diagnosis of T1D and during prediabetes, using data from 107 adult patients with newly diagnosed T1D, 21 children with persistent islet autoantibodies and a family history of T1D, and 1238 age and gender matched control subjects, all individuals without any signs of acute infection. Adult patients with newly diagnosed type 1 diabetes had significantly lower total WBC (p<0.001), neutrophil (p<0.001), basophil (p<0.001), monocyte (p<0.001) and lymphocyte (p<0.001) counts compared to control subjects. Erythrocyte, eosinophil and platelet counts did not differ between groups. Similarly, children with persistent islet autoantibodies had decreased WBC (p=0.001), neutrophils (p=0.003), and lymphocytes (p=0.006) in comparison to control children. Our findings thus demonstrate a perturbation of leukocyte homeostasis at and prior to onset of T1D suggesting a general involvement of the innate immune system in the pathogenesis of T1D (Harsunen, Horm Metab Res 2013). Further, we found a non-significant trend towards lower soluble dietary fiber intake in children with islet autoimmunity compared with respective controls (data not published). Future perspectives Amongst others, the following projects will be approached in 2013: 1) Examination of further potential risk factors of T1D, such as vaccinations, with respect to their timing of islet autoimmunity; 2) Identification of subgroups with high risk of overweight in childhood, for which targeted prevention measurements might be appropriate; 3) Investigation of soluble fiber intake with development of islet autoimmunity using the TEDDY data; 4) Longitudinal analyses of beta cell secretion products insulin and c- peptide, and its precursor proinsulin, during the first two years of life as a measure of beta cell function to gain further insight into the pathogenesis process of T1D; 5) Immune response to tetanus vaccination in children born by cesarean section or vaginal birth. 35

39 III. Publications Adler K, Krause S, Fuchs YF, Foertsch K, Ziegler AG, Bonifacio E. The effect of gestation and fetal mismatching on the development of autoimmune diabetes in non-obese diabetic mice. Clin Exp Immunol 2012; 168(3): Baxter J, Vehik K, Johnson SB, Lernmark B, Roth R, Simell T, TEDDY Study Group. Differences in recruitment and early retention among ethnic minority participants in a large pediatric cohort: the TEDDY Study. Contemp Clin Trials 2012; 33(4): Chatenoud L, Warncke K, Ziegler AG. Clinical immunologic interventions for the treatment of type 1 diabetes. Cold Spring Harb Perspect Med 2012; 2(8). pii:a D'Orlando O, Zhao F, Kasper B, Orinska Z, Müller J, Hermans-Borgmeyer I, Griffiths GM, Zur Stadt U, Bulfone-Paus S. Syntaxin 11 is required for NK and CD8(+) T-cell cytotoxicity and neutrophil degranulation. Eur J Immunol 2012; doi: /eji Fuchs YF, Adler K, Bonifacio E. Beta-cell autoimmunity. Methods Mol Biol 2012; 933: Gerlach K, Daniel C, Lehr HA, Nikolaev A, Gerlach T, Atreya R, Rose-John S, Neurath MF, Weigmann B. Transcription factor NFATc2 controls the emergence of colon cancer associated with IL-6 dependent colitis. Cancer Res 2012; 72(17): Halbritter S, Fedrigo M, Höllriegl V, Szymczak W, Maier JM, Ziegler AG, Hummel M. Human Breath Gas Analysis in the Screening of Gestational Diabetes Mellitus. Diabetes Technol Ther 2012; 14(10): Harsunen MH, Puff R, D Orlando O, Giannopoulou E, 2, Lachmann L, Beyerlein A, von Meyer A, Ziegler AG. Reduced Blood Leukocyte and Neutrophil Numbers in the Pathogenesis of Type 1 Diabetes. Horm Metab Res 2012; 44: Howson JM, Krause S, Stevens H, Smyth DJ, Wenzlau JM, Bonifacio E, Hutton J, Ziegler AG, Todd JA, Achenbach P. Genetic association of zinc transporter 8 (ZnT8) autoantibodies in type 1 diabetes cases. Diabetologia 2012; 55(7): Johnson K, Wong R, Barriga KJ, Klingensmith G, Ziegler AG, Rewers MJ, Steck AK. rs is associated with type 1 diabetes risk in population pre-screened for high-risk HLA-DR,DQ genotypes. Pediatr Diabetes 2012; 13(8):

40 11. Krause S, Achenbach P. Neue Immunplattform zur Messung von Autoantikörpern bei Diabetes mellitus. Diabetes, Stoffwechsel und Herz 2012; 3: Krause S, Chmiel R, Bonifacio E, Scholz M, Powell M, Furmaniak J, Rees Smith B, Ziegler AG, Achenbach P. IA-2 autoantibody affinity in children at risk for type 1 diabetes. Clin Immunol 2012; 145, Lernmark B, Lynch K, Ballard L, Baxter J, Roth R, Simell T, Bennett Johnson S. Reasons for Staying as a Participant in the Environmental Determinants of Diabetes in the Young (TEDDY) Longitudinal Study. J Clin Trials 2012; 2:2 ( ) 14. Salami F, Ländin M, Hyöty H, Vaziri-Sani F, Aronsson CA, Vehik K, Delli A, Hagopian WA, Rewers M, Ziegler AG, Simell O, Akolkar B, Krischer J, She J, Lernmark A and the TEDDY study group. Detection of lactobacilli in monthly mail-in stool samples from 3-18 months ols infants at gentic risk for type 1 diabetes. International Journal of Probiotics and Prebiotics Vol. 7, No. 3/ Weigmann B, Daniel C. Treg vaccination with a strong agonistic insulin mimetope. Curr Diab Rep 2012; 12(5): Winkler C, Krumsiek J, Lempainen J, Achenbach P, Grallert H, Giannopoulou E, Bunk M, Theis FJ, Bonifacio E, Ziegler AG. A strategy for combining minor genetic susceptibility genes to improve prediction of disease in type 1 diabetes. Genes Immun 2012; 13(7): Winkler C, Raab J, Grallert H, Ziegler AG. Lack of association of type 2 diabetes susceptibility genotypes and body weight on the development of islet autoimmunity and type 1 diabetes. PLoS One 2012; 7(4):e Ziegler AG, Bonifacio E, the BABYDIAB-BABYDIET Study Group. Age-related islet autoantibody incidence in offspring of patients with type 1 diabetes. Diabetologia 2012; 55(7): Ziegler AG, Meier-Stiegen F, Winkler C, Bonifacio E, TEENDIAB Study Group. Prospective evaluation of risk factors for the development of islet autoimmunity and type 1 diabetes during puberty--teendiab: study design. Pediatr Diabetes 2012; 13 (5): Ziegler AG, Wallner M, Kaiser I, Rossbauer M, Harsunen M, Lachmann L, Maier J, Winkler C, Hummel S.Long term protective effect of lactation on the development of type 2 diabetes mellitus in women with recent gestational diabetes mellitus. Diabetes Care 2012; 61(12):

41 Abstracts 1. Achenbach P, Hagen M, Bhardwaj M, Harsunen M, zu Castell W, Ziegler AG. Modelling type 1 diabetes pathogenesis. Program & Abstracts (IDS 2012, poster) 2. Chmiel R, Krause S, Knopff A, Matzke C, Höfelmann D, Schenkel J, Ziegler AG, Achenbach P. Immunization profiles and progression of islet autoimmunity in children at type 1 diabetes risk. Diabetologie und Stoffwechsel 2012; 7[Suppl 1]:S13. (DDG 2012, talk) 3. Krause S, Chmiel R, Bonifacio E, Powell M, Furmaniak J, Ziegler AG, Achenbach P. IA-2 autoantibody affinity and epitope specificity in children at risk for Type 1 diabetes. Program & Abstracts (IDS 2012, poster) 4. Winkler C, Krumsiek J, Lempainen J, Achenbach P, Grallert H, Giannopoulou E, Bunk M, Theis FJ, Bonifacio E, Ziegler AG. A strategy for combining minor genetic susceptibility genes to improve prediction of disease in type 1 diabetes. Diabetologia 2012; 55[Suppl 1]:S76. (EASD 2012, talk) 5. Winkler C, Lempainen J, Achenbach P, Grallert H, Giannopoulou E, Bunk M, Bonifacio E, Ziegler AG. Ein Typ 1 Diabetes Risikoallelescore verbessert die Stratifizierung des Typ 1 Diabetes Risikos. Diabetologie und Stoffwechsel 2012; 7[Suppl 1]:S2. (DDG 2012, talk) Chapters 1. Achenbach P. Autoantibody markers. 2012; Diapedia rev. no. 17. Available from: 2. Achenbach P. Metabolic markers. 2012; Diapedia rev. no. 10. Available from: 3. Achenbach P. Autoantibodies. 2012; Diapedia rev. no. 18. Available from: 4. Achenbach P. Natural history of pre-type 1 diabetes. 2012; Diapedia rev. no. 16. Available from: diabetes-mellitus/ /natural-history-of-pre-type-1-diabetes 5. Achenbach P, Scherbaum WA. Autoimmunity in diabetes mellitus. In Autoimmune Diagnostics. Renz E, Ed., Walter de Gruyter Verlag Berlin New York, 2012, pp

42 IV. Diploma Thesis/ PhD Projects / Honors and Awards 2012 Dr. Ruth Chmiel: Recipient of the DZD Award for Young Scientists of the German Center for Diabetes Research (DZD) (BMBF) Dr. cand. Eleni Giannopoulou: Recipient of a stipendium of the IKY-State Scholarships Foundation Dr. Maren Pflüger: Recipient of the Silvia-King-Award of the German Diabetes Association (DDG) Dr. Christiane Winkler: Recipient of the Ernst-Friedrich-Pfeiffer-Award of the German Diabetes Association (DDG) V. Third-party funds 2012 (to be verified by Klaus Schober) NIH (National Institute of Health, USA) Consortium: The Environmental Determinants of Diabetes in the Young (TEDDY) Study October 2002 April 2008 and May April 2013 Per year: USD 536,023 Principal Investigator University of South Florida/Teddy DCC Consortium: The Environmental Determinants of Diabetes in the Young (TEDDY) Funding in 2011: USD 450,000 University of South Florida/Teddy DCC Consortium: The Environmental Determinants of Diabetes in the Young (TEDDY) Study - Nutrition October 2002 April 2008 and May April 2013 Per year: USD 41,027 Principal Investigator JDRF (Juvenile Diabetes Research Foundation, USA) Type 1 Diabetes TrialNet Januar 2009 Dezember 2011 Funding in 2011: USD 71,500 Principal Investigator JDRF (Juvenile Diabetes Research Foundation, USA) und 313 Primary intervention with mucosal insulin for prevention of type 1 diabetes in infants at high risk to develop diabetes: Diabetes Pre-POINT trial

43 Funding in 2011: USD 45,000 Co-Investigator JDRF (Juvenile Diabetes Research Foundation, USA) The Anti-Interleukin 1 in Diabetes Action trial (AIDA) Period: and 06/ /2012 Total for Nov Okt 2013 : USD 110,360 Co-Investigator NIH (National Institute of Health, USA) Type 1 Diabetes TrialNet Natural history ( ) Per year: USD 30,000 Adromeda Biotech Ltd. DiaPep277TM and 11/ /2013 Funding in 2011: EUR 24,000 + EUR 22,500 Co-Investigator University of Florida Dr. Schatz Cord Blood Therapies 11/ /2012 Total: USD 35,000 Different studies (Faustmann, General Hospital Boston, MSD Sharp, University of Glasgow, Novartis) Funding in 2011: EUR 20,000 Deutsche Forschungsgemeinschaft (DFG) Gene-environment interactions of risk factors for obesity in childhood 02/ /2012 Funding: EUR 31,650 Principal Investigator: Dr. Andreas Beyerlein VI. Guest Speakers 2012 Oktoberfest-Symposium: Mechanistic Immune ResponsS studies in Type 1 Diabetes (October 2 nd, 2012) Clive Wasserfall, Diabetes Center of Excellence, University of Florida, USA IL-2 and IL-18 Denise Kühn, Center for Regenerative Therapies, TU Dresden, Germany T cell reactivity in type 1 diabetes 40

44 Yannick Fuchs, Center for Regenerative Therapies, TU Dresden, Germany CD8 T cells Mara Catani, Center for Regenerative Therapies, TU Dresden, Germany TCR expression Christian Stumpp, Center for Regenerative Therapies, TU Dresden, Germany Proinsulin / C-peptide Fortbildungsveranstaltung Diabetes und Infektion / Entzündung Pathogenese, Klinik und Therapie (November 11 th, 2012) Matthias Blüher, Klinik und Poliklinik für Endokrinologie und Nephrologie, Universitätsklinik Leipzig Fettgewebe wie determiniert es den gesunden und den kranken Adipösen? Ulrike Protzer, Institut für Virologie, TU München Darm, Enteroviren und T1D Hannelore Daniel, Wissenschaftszentrum Weihenstephan, Technische Universität München Ernährungsfaktoren beim T2D jenseits der Kalorien Stefan Gambihler, Becker, Olgemöller & Kollegen, Laboratoriumsmedizin München Antibiotikaresistenz im Raum München Update Ulrich Seybold, Klinische Infektiologie der Medizinischen Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München Infektionen: Was ist beim Diabetiker anders? Klinik und Therapie Jochen Schmidt, Ärztezentrum Prien Diabetes und Parodontitis Roland M. Schmid, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, TU München NASH Diagnostik, Therapie 41

45 Uwe Heemann, Transplantationszentrum, Klinikum rechts der Isar, TU München Nieren- und Harnwegs-Infektionen bei Diabetes: Klinik und Therapie VII. Press work and Public Relations 2012 Since the end of the year 2004 press and public relations work exists. This expansion of operations aims among other things the support of recruiting members for the ongoing studies and faster publishing of the results of the studies. Single operations of the press work All-the-year announcements o in magazins for parents like Baby und Familie, Eltern family, KIDSgo o in diabetes and pharmacy magazins for laymen like Diabetes Journal, Insuliner, Befund Diabetes, Diabetes Ratgeber, Subkutan, Diabetes aktuell, Diabetes Eltern Journal, Insuliner, Apothekenkurier o in magazins for professionals like Hebammeninfo, bvkj Kinder- und Jugendarzt, Diabetes, Stoffwechsel und Herz, Kompendium Diabetes, Deutsche Apothekerzeitung, Deutsches Ärzteblatt, Medical Tribune, Ärztezeitung, Münchner Ärztliche Anzeigen, DZKF, Medizinische Welt o several websites in the internet like bild.de, welt.de, bunte.de, rtl.de, spiegel.de, NetDoktor.de, diabetes-eltern-journal.de, diabetes-kids.de, diabetes-journal.de, diabetesnews.info, aktion-praevention.de, diabsite.de, diabetes-risiko.de, Diabetes-ratgeber.net, diabetesforumonline.de, news.de, diabetes-informationszentrum.de, springermedizin.de, kirchheim-verlag.de, nachrichten.de o in the daily press like Frankfurter Allgemeine Zeitung, Süddeutsche Zeitung, Hamburger Abendblatt, Münchner Merkur, tz, Stuttgarter Zeitung, Dresdner Neueste Nachrichten, Recklinghäuser Zeitung, Mainpost, Berliner Morgenpost, Der Standard (Österreich) o in newsletters like curado, Diabetes-Deutschland, MRI, Helmholtz Zentrum München, Diabetesinformationsdienst München, rssnachrichten.de, twitter.de, DDG Informationen, AOK Magazin o in other magazins like Focus (Sonderausgabe Gesundheit), Bella, das Goldene Blatt, Neue Welt der Frau, Reformhauskurier, frau und gesund, aktive Senioren, TV gesund & leben, Blickpunkt Gesundheit Announcements in the television: Rundschau (BR), Quarks & Co. (WDR) 42

46 Announcements on the radio: Gesundheit (BR 5), Deutschlandradio Single operations of the Public Relations In spring and autumn 2012 we held a nationwide diabetes telephone campaign. Both campaigns were quite successful. We provided information materials for different events like midwives workshops, events of self-help groups, diabetic information days and the conference of the DDG. In December 2012 we sent out a special Christmas mailing to a selection of important journalists who supported us with remarkable articles all over the last year. We organized two symposia for Physicians and Nutritionists: the Oktoberfestsymposium Mechanistic Immune Response Studies in Type 1 Diabetes and the Symposium Diabetes und Infektion / Entzündung Pathogenese, Klinik und Therapie. 43

47 2. Working Group Prof. Standl I. Report 2012 The exploitation of the Schwabing registry data bases continued together with the working team of Prof. Schnell (see detailed reports there). Besides presentations at scientific meetings, 2012 a paper on All-cause hospital mortality and comorbidity in diabetic and non-diabetic patients with stroke was published in Diabetes Research and Clinical Practice. Beyond that, risk predictors of cardiovascular events in a contemporary population with impaired glucose tolerance were analysed in a huge cohort of close to patients of the NAVIGATOR Trial and published in the British Medical Journal bmj.open. Among 9306 participants, 639 experienced a cardiovascular event, and 244 cardiovascular death, over 6.4 years. While predictors of both outcomes included established risk factors such as existing cardiovascular disease, male gender, older age, current smoking and higher LDL-cholesterol, other variables such as reduced estimated glomerular filtration rate, previous thrombo-embolic disease, atrial fibrillation, higher urinary albumin/creatinine ratio and chronic obstructive pulmonary disease were also important predictors. Disappointingly, glycaemic measures were not predictive. C- statistics for predicting cardiovascular events and cardiovascular death were 0.74 and 0.82, respectively. Use of cardiovascular risk reducing agents was highest in those with established cardiovascular disease. However, in the primary prevention subgroup, lipid lowering agents were prescribed infrequently in those at high calculated risk. In addition, a whole series of scientific review papers, e.g. What should be the antihypertensive drug of choice in diabetic patients and should we avoid antihypertensive drugs that increase glucose levels? Pro and Cons, Dysglycemia and abdominal obesity, Alpha-glucosidase inhibitors 2012 cardiovascular considerations and trial evaluation, Statins and beyond: Concurrent strategies for prevention of cardiovascular disease in patients with type 2 diabetes, and Glycemic Control: A Combination of Lifestyle Management and the Use of Drugs have been published in international journals of good profile. The cooperation in several of the large randomized long term multi-centre intervention trials looking into varying concepts of blood glucose lowering and cardiovascular outcomes was further expanded. Partners are the Oxford Trial Unit, United Kingdom, and the Duke University, United States of America. 1) Steering-Committee TECOS Trial (Trial Evaluating Cardiovascular Outcomes with Sitagliptin in Patients with Type 2 Diabetes). TECOS aims to enrol some patients with type 2 diabetes and to follow those subjects under usual care conditions for a minimum of four years and for a minimum number of predefined hard cardiovascular endpoints. The incretin enhancer sitagliptin will be evaluated in specific strata on top of treatment with metformin, or a sulfonylurea, or pioglitazone, or insulin, respectively. By the end of July 2012 some patients had been 44

48 enrolled worldwide including China and the targeted goal of participants been reached. 2) Data Safety Monitoring Board, ACE Trial (Acarbose Cardiovascular Evaluation). ACE looks at 7500 patients with impaired glucose tolerance and a previous myocardial infarction (more than 3 month prior) in China. Patients are equally randomized to the alpha-glucosidase inhibitor acarbose or placebo and followed for a predefined number of hard cardiovascular endpoints. At the end of 2012 some 75 % of the patients have been enrolled. 3) Data Safety Monitoring Board, NAVIGATOR (Nateglinide And Valsartan in Impaired Glucose Tolerance Outcomes Research). NAVIGATOR has evaluated some cardiovascular high risk patients with an impaired glucose in a 2x2 factorial design. The two drugs investigated in a randomized, double blind, placebo controlled study were the angiotensin receptor blocker valsartan and the short acting sulfonylurea analogue nateglinide. The main results of the six year follow-up study have been published A further paper on the basic risk predictors of cardiovascular events and deaths has been published in bmj.open 2012, as mentioned. Currently are several epidemiological evaluations of this large and unique data base under review, e.g. on Stroke, on heart failure, on atrial fibrillation, cancer, multifactorial risk management etc. II. Meetings and Symposia In the context of the publication of the new landmark study ORIGIN at the American Diabetes Congress 2012, a web-cast was performed together with Prof. Hanefeld, Dresden, and Prof. Schnell, Munich, discussing and commenting on the key findings and how they convert into recommendations for daily practice ( A joint symposium (Managing blood glucose lowering in the context of CAD: An independent view) was organized together with the EASD Study Group on Diabetes mellitus and Cardiovascular Disease at the Annual Meeting of the European Society of Cardiology (ESC Congress 2012) in Munich. The lectures of the international panel of scientists of this highly successful meeting are again available as web-cast on the website of our Diabetes Research Group/Institute ( Finally, E. Standl attended the CODHy Congress in Shanghai, China, with several lectures and developed the contact and cooperation with the Chinese Diabetes Society ( President: Prof. Linong Ji) and the Chinese Endocrine Society (President: Prof. Ning) further. Joint educational modules of the Chinese Diabetes Society and the EASD Study Group have been recorded and are available at the website of the Study Group. Similarly, Prof. Standl was invited to the Latin American CODHy Congress in Rio de Janeiro with several scientific presentations as well as to the Thai Endocrine Meeting in Bangkok, the Turkish Endocrine Meeting in Antalya, the Romanian Diabetes Meeting in Sibiu, and the Lebanese Diabetes Meeting in Beirut. 45

49 III. Postitions E. Standl has been re-elected as the Vice-Chair of the EASD Study Group on Diabetes and Cardiovascular Disease and continues to work as a Fellow of the European Society of Cardiology (FESC). He currently is also engaged as a Scientific Advisory Board Member of the Journals Diabetes & Vascular Disease Research and Cardiovascular Diabetology. IV. Publications (1) Braun KF, Otter W, Heinrich SM, Standl E, Schnell O. All-cause hospital mortality and comorbidity in diabetic and non-diabetic patients with stroke. Diabetes Research and Clinical Practice (2012) 98: (2) Preiss D, Thomas L, Sun J, Haffner SM, Holman R, Standl E, Leiter L, Mazzone T, Rutten GEHM, Tognoni, Martinez, Califf R, McMurray J. Predictors of cardiovascular events in a contemporary population with impaired glucose tolerance; an observational analysis of the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial. bmj.open (2012) (3) E. Standl, M. Erbach, O. Schnell. What should be the antihypertensive drug of choice in diabetic patients and should we avoid antihypertensive drugs that increase glucose levels? Pro and Cons. Diabetes Metabolism Research and Reviews (2012); 28 (Suppl2):1-7 (4) E. Standl. Dysglycemia and abdominal obesity. Current Vascular Pharmacology (2012) 10: (5) E. Standl, O. Schnell. Alpha-glucosidase inhibitors 2012 cardiovascular considerations and trial evaluation. Diabetes & Vascular Disease Research (2012) DOI: / (6) E. Standl. Statins and beyond: Concurrent strategies for prevention of cardiovascular disease in patients with type 2 diabetes. Diabetes & Vascular Disease Research (2012) DOI: / (7) Standl E, Erbach M, Schnell O. Glycemic Control: A Combination of Lifestyle Management and the Use of Drugs. Cardiology and Therapy (2012) DOI /s

50 3. Study Group Prof. Schnell I. Progress Report Diabetes and vascular disease In the Silent Diabetes Study copeptin levels were also analyzed (1,2,5). Patients with no CAD had significantly lower copeptin levels compared to patients with minor CAD (p= 0.023), 1-VD (p= 0.03), 2-VD (p= 0.012) or 3-VD (p<0.0001). Interestingly, both pts with DM (p<0.0001) and IGT (p= ) had higher copeptin levels compared to pts with NGT; there was no significant difference (p= 0.08) between patients with DM and IGT. Similarly, patients with NGT had lower ADM levels compared to patients with IGT (p< ) or patients with DM (p= 0.005). Copeptin was elevated in patients with CAD compared to those with no CAD, but there was no grading based on severity of CAD. The fact that copeptin was elevated in IGT may indicate their early involvement in the pathophysiology of the metabolic-vascular syndrome. The follow-up of the Silent Diabetes Study is currently being conducted and the results are awaited for A study of the Munich Stroke Registry aimed at comparing diabetic and non-diabetic patients with stroke with regard to their all-cause in-hospital mortality and possible differences regarding their comorbidities (3). All patients in the Munich Stroke Registry ( , n = 537) were assessed. Hospital mortality in diabetic (n = 160, 29.8 %) and non-diabetic (n = 377, 70.2 %) patients was compared. Pre-existing comorbidities such as hypertension, coronary heart disease (CHD), peripheral arterial disease (PAD), albuminuria and impaired kidney function (IKF) were noted. No significant differences were found regarding all-cause in-hospital mortality between diabetic and non-diabetic patients. Overall 71 patients (13.2 %) died of whom 27 (16.9 %) where diabetic and 44 (11.7 %) non-diabetic patients (n.s.). Hypertension, CHD, PAD, albuminuria and IKF were more frequent in diabetics. Despite multiple comorbidities and risk factors no significant difference in all-cause in-hospital mortality was seen in diabetic patients as compared to non-diabetic patients. Improved treatment strategies and early intervention may compensate for their poorer prognosis. New mechanistic and clinical studies on aspirin increase the need to revisit its role on the prevention of cardiovascular disease (CVD) in diabetes. Recent results were 47

51 summarized in a review article (6). Enhanced platelet turnover may partly contribute to the fact the primary prevention studies have created unequivocal results. The need for a potential modification of dosages is currently being assessed. Primary prevention of CVD in diabetes with aspirin is currently based on the individual risk for CVD, as suggested in the guidelines. In secondary CVD prevention, the use of aspirin in diabetic patients is supported by key evidence. Novel aspects of aspirin, e.g. its potential role for the prevention of cancer were also summarized (6). A review article on antihyptertensive drugs of choice in diabetic patients was created (7). It was noted that new onset diabetes is significantly increased in association with the use of thiazides or beta blockers, respectively, compared to placebo, whereas treatment with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers is associated with a lower than expected frequency, as also assessed in several meta-analyses. Hence, and in view of the fact that comparable blood pressure lowering with any of the five major classes of antihypertensive drugs, including calcium channel blockers, give comparable benefits in reducing cardiovascular complications, unless there are specific indications or contraindications for an individual drug, caution should be exercised, therefore, to use beta blockers or thiazides as first-line drugs for blood pressure lowering indications in subjects at high risk to develop diabetes, especially in patients with so called metabolic syndrome. It was concluded that awareness of these facts and highly individualized therapy seem to be the way forward (7). The increasing incidence of type 1 diabetes in children and adolescents emphasizes the need to also focus on potential diabetic complications. A review article focussed on microvascular complications in children and adolescents with type 1 diabetes (8). In type 1 diabetes, the absence of microvascular complications such as nephropathy, retinopathy, and neuropathy is associated with a life expectancy comparable with that of the general population. Therefore, successful screening and prevention of microvascular complications play a key role in the management of diabetic patients at younger age. The frequency of screening for nephropathy, retinopathy, and neuropathy also depends on age, diabetes duration, and individual risk factors such as family predisposition, puberty, or elevated blood pressure. To efficiently reduce 48

52 the risk and progression of all microvascular complications, an optimized glycemic control is the key pillar. In 2012 also the German S3-guideline on diagnosis and therapy of carotid stenosis was completed (9). Oliver Schnell was the representative and author of the German Diabetes Association for the creation of the Guideline. Another review article gave some guidance for cardiologists to integrate care for coexisting diabetes in their patients and, hence, to summarize key aspects in achieving appropriate glycemic control in these patients (10). Cardiovascular results of treatment with alpha-glucosidase inhibitors, i.e. acarbose, voglibose and miglitol, were summarized in a review article (11). Today, in some Asian countries with large diabetic populations, such as China, this class of drugs (especially acarbose) has become the most commonly prescribed glucose-lowering medication. Given the penetrant uptake of the alpha-glucosidase inhibitors and the availability of generic formulations in some cases, the issue of their CV affects is of practical importance. Diabetes and colorectal cancer Diabetes mellitus has been reported to be associated with an increased risk for colorectal cancer. A review article analyzed current epidemiological data on the association of diabetes and the risk for colorectal cancer (12). Hyperinsulinemia, hyperglycemia, and inflammation were suggested to play a key-role in the pathophysiology of cancer in diabetes. Data regarding potential treatment-related risks, particularly in conjunction with the use of insulin and insulin analogues, were also presented. Furthermore, the impact of glycemic control and cardiorespiratory fitness on cancer prognosis was considered. Finally, the preventive potential of aspirin, other nonsteroidal anti-inflammatory drugs, and the recommendations concerning colonoscopy-screening were presented. 49

53 Diabetic neuropathy Neuropad is an indicator test for the assessment of sweating and, hence, cholinergic innervation in the diabetic foot. A review summarized current knowledge on this diagnostic test (13). The diagnostic ability of Neuropad is based on a colour change from blue to pink. It has a high sensitivity and negative predictive value with moderate specificity and positive predictive value for the diagnosis of diabetic peripheral neuropathy. It remains to be established whether Neuropad can predict foot ulceration and amputation, thereby contributing to the identification of high-risk patients. Self-monitoring of blood glucose in diabetes We evaluated the impact of an automated decision support tool (DST) on clinicians ability to identify glycemic abnormalities in structured SMBG data and then make appropriate therapeutic changes based on the glycemic patterns observed (4). In this prospective, randomized, controlled, multi-center study, 288 clinicians (39.6% family practice physicians, 37.9% internal medicine physicians and 22.6% nurse practitioners) were randomized to structured SMBG alone (STG, n=72); structured SMBG with DST (DST, n=72); structured SMBG with an educational DVD (DVD, n=72); and structured SMBG with DST and the educational DVD (DST+DVD, n=72). Clinicians analyzed 30 patient cases (type 2 diabetes), identified the primary abnormality, and selected the most appropriate therapy. 222 clinicians completed all 30 patient cases with no major protocol deviations. Significantly more DST, DVD and DST+DVD clinicians correctly identified the glycemic abnormality and selected the most appropriate therapeutic option compared with STG clinicians: 49%, 51% and 55% vs. 33%, respectively (all p<0.0001), with no significant differences between DST, DVD and DST+DVD clinicians. Use of structured SMBG, combined with the DST, the educational DVD, or both, enhances clinicians ability to correctly identify significant glycemic patterns and make appropriate therapeutic decisions to address those patterns. Structured testing interventions using either the educational DVD or the DST are equally effective in improving data interpretation and utilization. The DST provides a viable alternative when comprehensive education is not feasible, and it may be integrated into medical practices with minimal training. 50

54 A European Perspective and Expert Recommendation addressed the role of Self- Monitoring of blood Glucose (SMBG) in GLP-1 based treatment approaches (14). Although SMBG has been performed in numerous studies on GLP-1 analogues and DPP-4 inhibitors, the potential role for SMBG in GLP-1 based treatment strategies has not been elaborated. The expert recommendation suggests individualized SMBG strategies in GLP-1-based treatment approaches and suggests simple and clinically applicable SMBG schemes. Potential benefits of SMBG in GLP-1-based treatment approaches are: Early assessment of treatment success or failure, timely modification of treatment, detection of hypoglycemic episodes, assessment of glucose excursions and support of diabetes management and diabetes education. Its length and frequency should depend on the clinical setting and the quality of metabolic control (14). The European Commission is currently in a reflection process to identify options for better response to the challenges of prevention and management of chronic diseases. The intention of a publication was to provide ideas on personalised chronic disease management which are based on experience with one major chronic disease, namely personalised diabetes management (15). Self-monitoring of blood glucose in diabetes was taken as a case study for personalized management of a chronic disease. A letter to the editor focussed on critical aspects of the Cochrane analysis on selfmonitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin (16). The authors aimed at emphasizing that only two, which also had methodological limitations, did not warrant the conclusions of the 12 months followup given in the Cochrane analysis. Also recent prospective and randomized studies on SMBG in non-insulin treated type 2 diabetes mellitus, e.g. STeP-study, St. Carlos study and ROSES, demonstrated a benefit of self-monitoring of blood glucose in noninsulin treated type 2 diabetic patients and their results were not appropriately considered in the analysis. 51

55 II.Educational activities, symposia and congresses Two highly-scientific symposia were organized as educational activities. The meetings were supported by the Verein zur Förderung der internationalen wissenschaftlichen Kommunikation im Bereich der Diabetologie e.v. and they were held under the auspices of the Diabetes Research Group e.v. at the Helmholtz Center Munich. 1.ESC Congress, Munich 26 August 2012, 18:30 23:00 Speakers Dinner, Palm House, Nymphenburg Castle Chair: Lars Rydèn (Stockholm, Sweden) The ORIGIN Trial The never Ending Story of Blood Glucose Lowering in Type-2-Diabetes Markolf Hanefeld, (Dresden, Germany) 27 August 2012, 13:00 13:45 A symposium of Forschergruppe Diabetes e. V. am Helmholtz Zentrum München and the Diabetes & Cardiovascular Disease EASD Study Group Managing blood glucose lowering in the context of CAD: An independent view Chair: Antonio Ceriello (Barcelona, Spain) & Francesco Cosentino (Rome, Italy) Blood Glucose lowering drugs: old problems, new promises Lars Rydèn (Stockolm, Sweden) Compensating for the effect of glycemic worsening drugs, e.g. statins Eberhard Standl (Munich, Germany) Self-monitoring of blood-glucose to be or not to be in non-insulin treated patients Oliver Schnell (Munich, Germany) 2.WCPD, Madrid 13 November 2012, 11:30 13:00 Cardiovascular risk in Diabetes. EASD DM-CVD Study Group Session Chairs: Javier Muñiz (Coruña, Spain) & Oliver Schnell (Munich, Germany) Diabetes and CVD: How to diagnose and treat. Oliver Schnell (Munich, Germany) Perspective of the diabetologist: Prevention of cardiovascular events in diabetes. Bruno Vergès (Dijon, France) Perspective of the cardiologist: Interventional strategies in diabetic cardiovascular disease. Marco Roffi (Genève, Switzerland) 52

56 III. Literature Abstracts 1. Kusche S, Doerr R, Hartmann O, Morgenthaler N, Schnell O, Lohmann T. Copeptin and adrenomedullin in a large cohort of patients with coronary heart disease and newly diagnosed glucose intolerance ( Silent diabetes study ). Diabetologie & Stoffwechsel 2012; 7: S26 2. Doerr R, Stumpf J, Spitzer SG, Krosse B, Kusche S, Lohmann T, Hartmann O, Morgenthaler N, Tschoepe D, Schnell O. Copeptin and adrenomedullin in a large cohort of catheterisation laboratory Patients with newly detected diabetes or impaired glucose tolerance: the Silent Diabetes Study. European Heart Journal 2012: 33: Original articles 3. Braun KF, Otter W, Sandor SM, Standl E, Schnell O. All-cause in-hospital mortality and comorbidity in diabetic and non-diabetic patients with stroke. Diabetes Res Clin Pract. 2012; May 14: Epub ahead of print 4. Rodbard HW, Schnell O, Unger J, Rees C, Amstutz L, Parkin CG, Jelsovsky Z, Wegmann N, Axel-Schweitzer M, Wagner RS. Use of an Automated Decision Support Tool Optimizes Clinicians Ability to Interpret and Appropriately Respond to Structured Self-Monitoring of Blood Glucose Data. Diabetes Care 2012; 16:

57 Review articles 5. Doerr R, Stumpf J, Spitzer SG, Krosse B, Tschoepe D, Lohmann T, Schnell O. Prevalence of undetected diabetes mellitus in invasive and interventional cardiology. Silent diabetes in the catheterization laboratory. Herz 2012; 37: Schnell O, Erbach M, Hummel M. Primary and secondary prevention of cardiovascular disease in diabetes with aspirin. Diabetes & Vascular Disease Research 2012; 9 (4): Standl E, Erbach M, Schnell O. What should bet he antihypertensive drug of choice in diabetic patients and should we avoid drugs that increase glucose levels? Pro and Cons. Diabetes / Metabolism Research and Reviews 2012; 28 (Suppl 2): Barkai L, Gurieva I, Stirban A, Tesfaye S, Czupryniak L, Mankovsky BN, Spallone V, Veresiu IA, Schnell O, Kempler P. Microvascular Complications in Children and Adolescents with Type 1 Diabetes. Diabetes, Stoffwechsel und Herz 2012; 21: Eckstein H-H, Kühnl A, Berkefeld J, Diel R, Dörfler A, Kopp I, Langhoff R, Lawall H, Ringleb P, Sander D, Storck M, Antoniadis G, Arning C, Brückmann H, Diehm C, Flessenkämper I, Fraedrich G, Fründ A, George S, Görtler MW, Görtz H, Gross-Fengels W, Hennerici M, Hoffmann U, Hörstgen A, Huppert P, Jansen O, Litz R, Mudra H, Nabavi DG, Neugebauer E, Niedermeier H, Plones CH, Stingele R, Rantner B, Tacke J, Schnell O, Schulte KL, Schwerdtfeger K, Vorwerk D, Walluschke KP, Walterbusch G. S3-Leitlinie zur Diagnostik, Therapie und nachsorge der extracraniellen Carotisstenose. AWMF-Register 2012; 004/028:

58 10. Standl E, Erbach M, Schnell O. Glycemic control: A combination of Lifestyle management and the use of drugs. Cardiology & Therapy 2012; published online (27 November 2012) 11. Standl E, Schnell O Alpha-glucosidase inhibitors 2012 cardiovascular considerations and trial evaluation. Diab Vasc Dis Res. 2012; April 16 (epub ahead of print) 12. Erbach M, Mehnert H, Schnell O. Diabetes and the risk for colorectal cancer. J Diabetes Complications 2012; 26(1):50-55 (epub ahead of print) 13. Papanas N, Boulton AJ, Malik RA, Manes C, Schnell O, Spallone V, Tentolouris N, Tesfaye S, Valensi P, Ziegler D, Kempler P. Neuropad : A simple new non-invasive sweat indicator test for the diagnosis of diabetic neuropathy. Diabetes Med. 2012; (epub ahead of print) 14. Schnell O, Alawi H, Battelino T, Ceriello A, Diem P, Felton A, Grzeszczak W, Harno K, Kempler P, Satman I, Vergès B. The role of self-monitoring blood glucose in glucagon-like peptide-1-based treatment approches: a European expert recommendation. J Diabetes Sci Technol. 2012; 6 (3): Ceriello A, Barkai L, Christiansen JS, Czupryniak L, Gomis R, Harno K, Kulzer B, Ludvigsson J, Némethyová Z, Owens D, Schnell O, Tankova T, Taskinen MR, Vergès B, Weitgasser R, Wens J. Diabetes as a case study of chronic disease management with personalized approach: The role of a structured feedback loop. Diabetes Research and Clinical Practise 2012; 98(1):

59 Letter to the editor 16. Schnell O, Alawi H, Battelino T, Ceriello A, Diem P, Felton A, Grzeszczak W, Harno K, Hummel M, Kempler P, Satman I, Vergès B. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin: letter to the editor. Cochrane Database Syst Rev. 2012; Issue 1. Art. No.: CD DOI: / CD pub3. 56

60 4. Working Group Prof. Schaaf I. Report 2012 Cognition and mood as a function of food preference/eating habits in prediabetic/diabetic subjects and metabolic comorbidities in patients with psychiatric diseases Funding: Max-Planck-Society, cooperation project research group Neuropsychology and Clinical Neuroendocrinology of the Max-Planck-Institut of Psychiatry and the Clinic for Endocrinology and Diabetology, Clinic Munich Schwabing Eating is a highly overlearned behavior which is mainly controlled for by environmental factors and thus only to a lesser extent self-regulated. The amount of food eaten is strongly influenced by factors such as portion size, food visibility and salience, and the ease of obtaining food. Studies on the eating of multiple meals in amnesic patients suggest that the memory of recent food intake plays a role in controlling everyday eating because information about a recent eating episode may be factored into decisions about how much to consume at the next meal. In this context different groups (controls, depressed patients, pre-diabetic, diabetic patients) will be evaluated to answer the question in how far cognition and mood are a function of food preference/eating habits with particular consideration of gender, age (younger group years, older group years), educational level, personality and physical, social, intellectual activities by monitoring biological variables, such as BMI, blood pressure, blood sugar, serum-insulin concentration, sleep quality and resting state. The antidepressant mirtazapine often causes a considerable weight gain in psychiatric, especially depressive patients. The exact mechanism leading to this considerable weight gain is not yet clarified in detail. A recently completed study with healthy volunteers showed that mirtazapine induced important metabolic effects, such as a shift to a more atherogenic lipoprotein profile. Moreover, even a short time intake of mirtazapine showed an increase of appetite, especially craving for sweet and carbohydrate-rich food. An additional part of the study is the influence of mirtazapine on the resting state. A considerable part of the data on changes in the metabolome (urine, plasma and spinal fluid) is conducted in cooperation with the Max-Planck-Institute of Plant Physiology in Berlin. 57

61 II. Literature: (1) Hennings JM, Schaaf L, Fulda, S Glucose metabolism and antidepressant treatment Current Pharmaceutical Design (Current Pharmaceutical Design; 2012, 18, ) (2) Lechner K, Heel S, Hennings J, Dose T, Fulda S, Schaaf L, Holsboer F, Lucae S, Kloiber S Short Term Effects of Mirtazapine on Fasting Plasma Lipoprotein Profiles in Healthy Young Men Biological Psychiatry (in revision) (2012) (3) Fulda S, Kloiber S, Dose T, Lucae S, Holsboer F, Schaaf L, Hennings J Mirtazapine provokes periodic leg movements during sleep in young healthy men Sleep (accepted) (2012) (4) Heel, S Veränderungen der Glukosetoleranz und des Grundumsatzes unter dem Antidepressivum Mirtazapin bei gesunden Probanden Inaugural-Dissertation an der Med. Fakultät der Ludwig-Maximilians- Universität München (2012) 58

62 5. Working group Prof. Haslbeck I. Members of the working group Prof. Dr. M. Haslbeck, A. Ruf (Dokumentations- und Funktionsassistentin) II. Report 2012 Diabetic Neuropathy Several papers concerning Diabetic Neuropathy have been published recently in a guideline within the German Disease Management Program. After approval and consent of national medical authorities in August 2011 (1,2,3, this Report 2011) detailled tabulated informations appeared in Deutsches Ärzteblatt in January 2012 (3). M. Haslbeck has been appointed by the German Diabetes Assoziation (DDG) and the German Society of Internal Medicine (DGIM) for an interdisciplinary expert group to elaborate the guideline. After nearly 20 Meetings in Berlin and before the official publication short overviews have been published (2,3). Besides basic data on epidemiology, classification, screening, diagnosis and treatment as well as specific aspects like psychological implications, patient education and comorbidities in sensorimotor and autonomic diabetic neuropathy are discussed extensively. In long and short versions of the guideline all results and statements were attached to grades of recommendations (1,3). Diabetic Foot An overview of the diagnostic value of pedobarography (a widely used diagnostic method for measurement of high pressure exposure and pressure distribution in the diabetic Foot Syndrome) was published in a monography (4, see Report 2011). The paper has been iudged to be so important by the editorial board (4), that it was elected to be reprinted in an interdisciplinary journal of Angiology (5). In this comprehensive summary theoretic backrounds and actual clinical applications are discribed and discussed. Additional Topics Medical opinions and estimations include wide spread problems in all parts of medicine (6). Therefor qualitative guidelines are necessary especially in frequent diseases like diabetes mellitus of all types. M. Haslbeck has been invited by Springer-Verlag and the editorial board of the manual Medizinische Gutachten to contribute in a chapter concerning diabetes mellitus as one of the most important systemic diseases. For example knowledge of actual licencing rules with licensing requirements, risk of diabetes and driving, medical evaluation, patient education and licensing restrictions are absolutely necessary for diabetic people with a licence to drive as well as their treating medical personal. 59

63 After the successful first edition in 2008 a new revision of the book is now in preparation which will be published in 2013 (6) III. References 1. Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften (AWMF). Nationale Versorgungsleitlinie Neuropathie bei Diabetes im Erwachsenenalter Langfassung, Version 1.10, http// Internet: Khan C., Abholz H.H., Ellger B., Gries F.A., Haller N, Haslbeck M, Hübner P., Keller J., Landgraf R. et al.: National Disease Management Guideline for Diabetic Neuropathy in Adults, Short Version, Version 1.0, April 2012, AWMF-Register no: nvi ode Diabetologie 2012 (Thieme Verlag, Stuttgart), 2012, 7 : Mitteilungen. Bundesärztekammer, Kassenärztliche Bundesvereinigung: Neuropathie bei Diabetes im Erwachsenenalter veröffentlicht. Internet: Autoren der NVL: Abholz H., Ellger B., Gries F.A., Haller N., Haslbeck M., Hübner P., Keller J., Landgraf R., Layer P., Maier C., Marx N., Neundörfer B., Pannek J., Prange H., Rietsch H., Spranger J., Wilms S., Ziegler D., Richter B. Deutsches Ärzteblatt 1012, 109(4), C Haslbeck M., Kalpen A., Haslbeck K.M.: Pedographie beim Diabetischen Fußsyndrom. In: Nicht invasive Diagnostik angiologischer Krankheitsbilder. Hrsg.: Kröger K., Gröchenig E., Santosa F., 2. aktualisierte und erweiterte Auflage ABW Wissenschaftsverlag GmbH, Berlin, 2012, S Haslbeck M, Kalpen A, Haslbeck K.-M.: Gefäßmedizin.net (interdisziplinäre Zeitschrift für Gefäßkrankheiten). AWW Wissenschaftsverlag Berlin, 2012, 8 (2), S Dörfler H., Haslbeck M.: Diabetes mellitus In: Medizinische Gutachten. Dörfler H., Eisenmenger W., Lippert H.D., Wandl U. (Hrsg.): Springer-Medizinverlag Heidelberg 2008; S (1. Aufl.) 2.Aufl., 2012/13 in press. 60

64 6. Activities 2012 of Prof. Mehnert Publications Prof. Dr. Hellmut Mehnert 2012 (1) 20 Editorials for Ärzte Zeitung (2) Four Mehnerts Diabetes Tipps in Der Allgemeinarzt (3) Unpopuläre Begleitkrankheiten in Der Allgemeinarzt (4) Seven Papers in Diabetes, Stoffwechsel und Herz