**4. Discussion**

#### **4.1 Data from the MIDIA project**

The first nested case-control study in MIDIA on intestinal virus as triggers for Type 1 Diabetes did not support the hypothesis that faecal shedding of enteroviral RNA is a major predictor of advanced islet autoimmunity. Neither was there any association between human parechovirus and islet autoimmunity. Although also the rodent parechovirus, Ljungan virus, has been proposed as a potential environmental trigger for Type 1 Diabetes, the results from the MIDIA study indicate that Ljungan virus is rare in young children since it was not found neither in controls or cases. The two cohort studies performed in MIDIA do, however, show that both maternal weight and self reported lower respiratory tract infections predict risk of islet autoimmunity, and particularly in the youngest age group. The MIDIA study did not find any evidence supporting the notion that genetic risk information about newborns has a negative impact on the mental health of Norwegian mothers. All recruitment to the MIDIA study had, however, to be stopped in December 2007. The following part of the discussion will focus on the reason and the consequences for further research on environmental triggers of T1D.

#### **4.1.1 Stopping of an ongoing T1D study based on the Norwegian Biotechnology Law**

The MIDIA study had the needed approvals for research studies in Norway (from the Regional Ethic Committee and the Data Inspectorate) before recruitment started in the summer of 2001. Since all recruitment was based on special teaching of Norwegian public health care nurses given by the principal investigator and a study coordinator, the recruitment started in small scale. Most of the public health care nurses in Norway started after they had got the needed information and education to voluntary recruit to MIDIA as well as being responsible for most of the blood samples taken. From 2006 the recruitment covered the whole country. In June 2007, one of the mothers of a participating baby was, however, interviewed in the biggest newspaper in Norway. She here complained about not

During the last generation T1D has shown a strong increase in incidence in the Western part of the world. During the same period also the number of children suffering of allergic diseases has increased. In countries in Africa both T1D and allergic diseases are rare. The aim of this study was to examine if this had to do with the decrease in children having enterobius vermicularis (pinworm). Data has shown that intestinal worms are involved in development of intestinal immunity. The prevalence of pinworm has decreased in all European countries. While 40-60% was infected in 1947, only 5-23% has been shown positive in recent reports (Herrström et al., 1997). In MIDIA all who still participated in the project (N=943), was in the period January-June in 2010 invited to send in anal tape samples taken 3 following mornings. Of the 397 who participated, 18% did have pinworm egg on at least one of the tapes. This was a much higher frequency than expected, but more analysis will be performed, including analysis of the particular questionnaires developed for this project.

A MIDIA cohort study was most recently able to study 42 cases and 843 non-cases, which showed that self-reported "pneumonia, bronchitis or RS-virus" gave a hazard ration at 3.5,

The first nested case-control study in MIDIA on intestinal virus as triggers for Type 1 Diabetes did not support the hypothesis that faecal shedding of enteroviral RNA is a major predictor of advanced islet autoimmunity. Neither was there any association between human parechovirus and islet autoimmunity. Although also the rodent parechovirus, Ljungan virus, has been proposed as a potential environmental trigger for Type 1 Diabetes, the results from the MIDIA study indicate that Ljungan virus is rare in young children since it was not found neither in controls or cases. The two cohort studies performed in MIDIA do, however, show that both maternal weight and self reported lower respiratory tract infections predict risk of islet autoimmunity, and particularly in the youngest age group. The MIDIA study did not find any evidence supporting the notion that genetic risk information about newborns has a negative impact on the mental health of Norwegian mothers. All recruitment to the MIDIA study had, however, to be stopped in December 2007. The following part of the discussion will focus on the reason and the consequences for

**4.1.1 Stopping of an ongoing T1D study based on the Norwegian Biotechnology Law**  The MIDIA study had the needed approvals for research studies in Norway (from the Regional Ethic Committee and the Data Inspectorate) before recruitment started in the summer of 2001. Since all recruitment was based on special teaching of Norwegian public health care nurses given by the principal investigator and a study coordinator, the recruitment started in small scale. Most of the public health care nurses in Norway started after they had got the needed information and education to voluntary recruit to MIDIA as well as being responsible for most of the blood samples taken. From 2006 the recruitment covered the whole country. In June 2007, one of the mothers of a participating baby was, however, interviewed in the biggest newspaper in Norway. She here complained about not

**3.4 The frequency of enterobius vermicularis among MIDIA children** 

p=0.001 for developing for islet autoimmunity before 4 years of age.

**3.5 Lower respiratory tract infections** 

**4.1 Data from the MIDIA project** 

further research on environmental triggers of T1D.

**4. Discussion** 

haven received good enough information about MIDIA before she and her husband had consented to participate. The Directorate for Health and Social Affairs then immediately decided that recruitment to MIDIA had to be stopped. Some days later it was, however, decided that new evaluation of the project had to take place according to the Norwegian Biotechnology Law, which tells that genotyping of children under the age of 18 years can only take place if there are a clear health benefit for a certain disease to get knowledge about genetics. During the fall of 2007 both the Biotechnology Board, the Ethical Committee for the Norwegian Medical Association, the National Committee for Medical Ethics as well as several experts contacted by the Directorate of Social and Health Affairs evaluated the MIDIA project. All these boards had earlier evaluated the MIDIA study; e.g. during the time of recruitment to the study. In addition the Health Department had clearly told that children who also had developed autoantibodies in MIDIA could get health insurance. The last aspect was based on the Biotechnology Law, which Norway has had since 1994, where it is clearly told that genetic risk for a disease cannot be used by the health insurance companies. The Directorate of Social and Health Affairs found, however, genotyping in MIDIA illegal December 10, 2007. A few days after the Norwegian Data Inspectorate said in newspapers that all data already collected from participants in MIDIA had to be thrown away. All ended luckily up with voting in the Norwegian Parliament in June 2008. As long as the Medical Regional Committee and the Norwegian Data Inspectorate approved the MIDIA study ones more, and all parents of children who already had been identified as high-risk children, gave a new informed consent , research in MIDIA could continue. In this respect Norway is different from Sweden, Finland, Germany and five states in USA were no similar Biotechnology Law Has given problems with genotyping of 350,000 children for the TEDDY study.

#### **4.1.2 Ethics and data protection in human biomarker studies**

The Norwegian Biotechnology Law tells: "Genetic testing of a child under the age of 18 years is not allowed if circumstances cannot be detected that can reduce or prevent health disadvantages for the child." Since the law came in 1994 it had only counted for clinical practice, the MIDIA project had been run for 6 ½ year before it was stopped December 10, 2007. In the work performed before the law got in use, science was never mentioned. Important questions in this context are:


The year after recruitment to MIDIA was stopped funding was given from the Norwegian Research Council to the study "Nutritional Intervention to Prevent Type 1 Diabetes". The project was based on that the incidence of T1D is increasing, particularly in very young children. The hypothesis was that the Decrease of omega-3 fatty acids in the diet has contributed to this increase. One case-control study from Norway reported that children with T1D less often than the control children had a mother who had taken cod liver oil during pregnancy, while a newer study from Norway indicated a protective effect of cod liver oil during infancy (Stene et al., 2000; Stene & Joner, 2003). In the longitudinal, observational study, the Diabetes Autoimmunity Study in the Young (DAISY), conducted in

Genetic Testing of Newborns for Type 1 Diabetes Susceptibility – The MIDIA Study 353

infections predict risk of islet autoimmunity, and particularly in the youngest age group. The MIDIA study did not find any evidence supporting the notion that genetic risk information about newborns has a negative impact on the mental health of Norwegian Mothers. Recruitment to MIDIA was stopped based on the Norwegian Biotechnology Law. It is therefore needed to extend international collaboration to identify the environmental triggers of type 1 diabetes. With the estimated increase of children with 50% having Type 1 Diabetes in 2020, and that the increase will be highest among children younger than 5 years (increase in prevalence with 70%) it is really important to extend collaborative efforts.

The MIDIA study was funded by the Norwegian Research Council (grants 135893/330, 155300/320, 156477/730, 166515/V50), The Norwegian Organisational for Help and Rehabilitation (EkstraStiftelsen), Norwegian Diabetes Association, New Generis (EU Grant Food-CT-2005-016320). The Norwegian Mother and Child Cohort Study Was supported by the Norwegian Ministry of Health, NIH-NIEHS (grant no. N01-ES-85433), NIH-NINDS (grant no. 1 UO1 NS 047537-01), and the Norwegian Research Council/FUGE (grant no. 151918/S10). I am very grateful for all the help I got from Trond Rasmussen in writing this

Abed, Y. & Boivin, G. (2008). New Saffold cardioviruses in 3 children, Canada. *Emerg Infect* 

Andreoletti, L. et al. (1997). Detection of coxsackie B virus RNA sequences in whole blood

Bach, J. F. (2002). The effect of infections on susceptibility to autoimmune and allergic

Bachlin A, Degremont A. (1997). Pinworm infection in kindergartens of Basel. *Schweiz* 

Barrett JC, Clayton DG, Concannon P, Akolkar B, Cooper JD et al. (2009). Genome-wide

Benson VS, Vanleeuwen Ja, Taylor J, McKinney PA, Van Til l. (2008). Food consumption and

Bingley PJ, Bonifacio E, Ziegler AG, Schatz DA, Atkinson MA, Eisenbarth GS. (2001). Proposed guidelines on screening for risk of type 1 diabetes. *Diabetes Care,* 24, 398. Blaser MJ. (1998). Helicobacters are indigenous to the human stomac; duodenal ulceration is due to changes in gastric microecology in modern era. *Gut,* 43, 721-727. Blinkova, O. et al. (2009). Cardioviruses are genetically diverse and cause common enteric

Brantsæter AL, Haugen M, Rasmussen S, Alexander J, Samuelsen SO, Meltzer HM. (2007a).

Urinary flavonoids and plasma carotenoids in the validation of fruit, vegetable and

study in Prince Edward Island, Canada. *J Am Coll Nutr*, 27, 414-20.

infections in South Asian children. *J Virol*, 83, 4631-41

samples from adult patients at the onset of type I diabetes mellitus. *J Med Virol,* 52,

associationstudy and meta-analysis find over 40 loci affect risk of type 1 diabetes.

the risk of type 1 diabetes in children and youth: a population-based, case-control

**6. Acknowledgement** 

book chapter.

**7. References** 

*Dis,* 14, 834-6.

diseases. *N Engl J Med,* 347, 911-20.

*Rundsch med Prax,*11, 1183-1185.

*Nat Genet,* 41, 703-707.

121-7.

Denver, Colorado, between January 1994 and November 2006, 1770 children at increased genetic risk were followed. Islet autoimmunity was assessed in association with reported daily intake of polyunsaturated fatty acids. The data strongly indicated that dietary intake of omega-3 fatty acids is associated with reduced risk for autoimmunity in children at increased risk for T1D (Norris et al., 2007). We therefore proposed to conduct a prospective double blinded dietary intervention trial using high dosage of the omega-3 fatty acid DHA or "placebo" (containing the same amount of DHA found in the recommended daily dosage of cod liver oil). The reason for choosing 1,8 g DHA daily was to be able to be included in a multi-centre study since a pilot study in USA already have been performed as a feasibility study using exactly this dosage. But in USA they use plant oil as placebo (Chase et al, 2009). In Norway this cannot be given since mother of babies in Norway get recommended from their public health care nurse to give cod liver oil. But they are told to start with one tea spoon and to increase the daily intake to 5 ml within the child is 6 months. But at this stage babies start spotting. Indeed very few parents continue to give their infant cod liver oil. The Directorate for Health decided, however, that "Nutritional Intervention to Prevent Type 1 Diabetes" was illegal, and could therefore never be started based on the Norwegian Biotechnology Law.

#### **4.1.3 Need for trans-national studies**

Most recently two big NIH funded studies are going on. In the Type 1 Diabetes Genomics Consortium forces worldwide have been working together. All genotyping has been based on linkage studies (two siblings with Type 1 diabetes and parents without the disease is needed). Getting all who earlier was competing in identifying new T1D susceptibility genes to collaborate gave access to all available multiplex families. All genes that earlier was indicated to be of importance for T1D were confirmed, and 40 genes conferring susceptibility to T1D has now been identified (Barrett et al, 2009). In addition genome wide association studies have been performed by the same group (Welcome Trust Case Control Consortium, 2010).

In TEDDY (The Environmental Determinants for Type 1 Diabetes in the Young), another NIH funded study, centres in Denver, Colorado, Seattle, Washington, parts of Georgia and Florida, parts of Finland, Sweden and Germany have recruited and genotyped 350,000 newborns and inform the parents about the high genetic risk. The protocol is the same everywhere, and all collected samples are sent to the coordinating centre in Florida. The follow-up is more intense than in MIDIA. Here all who participate, both scientists and parents know that it is an observational study where any intervention never can be given. The children Will be followed-up for 15 years.
