**2. Material and methods**

344 Type 1 Diabetes – Complications, Pathogenesis, and Alternative Treatments

children. There are several viruses that are considered common in childhood that should be studied to test the hygiene hypothesis, and viruses that have been implicated with T1D, or human strains of animal viruses associated with T1D, should be studied. In addition, newly discovered viruses will also be evaluated as candidates for testing. However, these viruses

We are all born with variants in our genes which make us susceptible to diseases. With the developments in biotechnology and increasing knowledge about the relation between genes and diseases, we are faced with both new opportunities and new dilemmas. The use of tests that provide knowledge about risks and possibilities for illness in the future raises many

In the MIDIA study parents were informed about that their child had the high-risk genotype for T1D (babies carrying HLA-DRB1\*03-DQA1\*05-DQB1\*02/ DRB1\*04:01-DQA1\*03- DQB1\*0302) or not. 2.1% of Norwegian newborns carry the high-risk genotype, and this group represents approximately 34% of future cases of T1D. Children with the high-risk genotype have 7% risk for getting T1D before 15 years of age and a lifetime risk at 20% (Rønningen et al., 1991; Undlien et al., 1997; Joner & Søvik, 1982, 1989; Mølbak et al., 1994). Several other studies have used predictive genetic testing of newborns as a strategy to solve research questions about environmental factors contributing to T1D, including BABYDIAB in Germany (Ziegler et al.; 2011, Schatz et al.; 2000), DIPP in Finland (Kimpimaki et al.; 2001), PANDA in Florida (Carmichael et al., 2003, Krischer, 2007), DiPiS in Sweden (Lernmark et al., 2004), DAISY in Colorado (Rewers et al., 1996), and the multinational TEDDY study in the USA and Europe (Kiviniemi et al.; 2007, TEDDY study group; 2008). The main advantage for study participants identified as having increased risk for T1D is the possibility of early detection of the destruction of the insulin producing cells by autoantibodies, resulting in a milder disease onset having parents who are prepared in advance for the possibility of T1D onset, and therefore will handle the new life situation with a child with T1D better than other parents. In addition children with known increased genetic risk for T1D who also have developed autoantibodies will be the first to participate in intervention studies when possible preventive get available. However, there may be disadvantages of living with the knowledge of an increased susceptibility to a disease with no prevention. Thus, even though predictive testing is highly acknowledged as a valuable

research method per se, the predictive testing has given rise to concerned debate.

With the widespread and increasing use of genetic tests, assessing the adverse effects of information about susceptibility genes for disease on the tested subject is important. The MIDIA study aimed to estimate the effect on maternal mental health from receiving genetic risk information about their newborns. Outcome measurements were maternal self-reported scores of anxiety and depression symptoms, satisfactory with life, self-esteem, and serious worry about their child. A number of previous studies (Hood et al., 2005; Johnson et al., 2004; Kerrush et al., 2007) have examined maternal reactions after being informed about their children having elevated genetic risk for T1D. None of these studies have shown a

**1.5.2 Particular aspects for the Norwegian MIDIA and MoBa studies** 

will have a lower priority than the candidates listed above.

fundamental questions of ethical, legal and psychosocial character.

**1.5 Psychosocial effects of risk information** 

**1.5.1 Cohort studies giving risk information** 

#### **2.1 Research design and subjects**

The MIDIA study is a longitudinal cohort study with inclusion of children with the highrisk HLA genotype (DRB1\*04:01-DQA1\*03-DQB1\*03:02/DRB1\*03-DQA1\*05-DQB1\*02), with follow-up from three months of age up to 15 years of age. Recruitment to MIDIA started in small scale in the summer of 2001, covered the whole country of Norway from March 2006 (60,000 births per year) and was stopped in December 2007 since it was suddenly found to be against the Norwegian Biotechnology Law. Both approvals from the Regional Medical Committee and the Norwegian Data Inspectorate had been given before recruitment to MIDIA started. In December 2007 close to 48,000 children were recruited to MIDIA. Of those 1,047 were identified with the high-risk genotype. Approval from the government was given for further follow-up of those already identified with the high-risk genotype. At the end of March 2011, 19 of these children had got Type 1 Diabetes, 33 were confirmed positive for two or three autoantibodies and 24 for one. A total of 4,829 blood samples, 18,275 stool samples and 4,412 questionnaires are presently available for analysis in the cohort.

A questionnaire summarizing weekly diaries was filled out at 3, 6, 9 and 12 months of age. Blood samples were taken at the same intervals. After this period, a questionnaire and a blood sample are asked for annually (Stene et al., 2007). For more information on MIDIA, see www.fhi.no/midia. In The Norwegian Mother and Child Cohort Study (MoBa), questionnaires have been asked for at 17th, 22nd and 30th week of pregnancy, and when the child is 6 and 18 months old as well as then the child get 3, 5, 7 years of age (Magnus et al., 2006) . Blood samples were asked for at 17th week of pregnancy and at the time of delivery from the mother and cord blood was taken from the baby (Rønningen et al., 2006). For more information on MoBa, see www.fhi.no/morogbarn.

#### **2.2 Outcome measurements**

The incoming blood samples in the MIDIA study are immediately tested at the Hormone Laboratory, Aker Hospital, for diabetes associated autoantibodies as marker of -cell autoimmunity, autoantibodies against insulin, anti-glutamic acid decarboxylase (GAD), and against the protein tyrosine kinase related protein IA-2 (Petersen et al., 1994; Bingley et al., 2001). High titres of one autoantibody or titres above the cut-off for two or three

Genetic Testing of Newborns for Type 1 Diabetes Susceptibility – The MIDIA Study 347

Parents of children participating in MIDIA have been asked to collect tape samples touching the anal region on three following mornings. They have then sent the samples in specially designed containers for tape sampling to the central laboratory in Oslo. Here all the tape samples have been examined by two scientists at different times. A child has been regarded

**3.1.1 Effects of genetic risk information on mental health variables among MIDIA** 

In the study of mothers who had participated in both MIDIA and MoBa (N=166 for those having a child with high genetic risk for T1D and N=7,224 for those who had been told that their child did not have the high-risk genotype) there were no sosiodemographic characteristics differences between those who had got the risk-information and those who had let their child be genotyped in MIDIA, but had been told that their child did not carry the high-risk genotype. Information on genetic risk in newborns was found to have no significant impact on maternal symptoms of anxiety and depression, self-esteem, satisfaction with life, or serious worry about their child. Mental health before birth was strongly associated with mental health after birth, see Table 1. Maternal symptoms of anxiety and depression were assed using a short version of SCL-25, including 4 question for anxiety and 4 for depression (Aas et al., 2010). The five-item Satisfaction With Life (SWLS) was developed to measure the cognitive component of subjective well-being. The short-form of the Rosenberg Self-Esteem Scale (RSES) used in the MoBa study includes four items. Maternal worry about their child was one of the items in an 11-item checklist of life events experienced during the last year, given in the 6 month questionnaire. The question was phased "Have you been serious worried that there is something wrong with your child?" Responses were coded as "yes" or "no". A dichotous variable was constructed to indicate the presence of maternal T1D. The variable was based on health questions from both The Medical Birth Registry of Norway (MBRN) and the MoBa questionnaires. The results from the linear regression analyses of the association between genetic risk information and change in maternal mental health are shown as unstandardized (B) and standard (β) coefficients in Table 1. The upper part of the table shows the results from the regression analysis with symptoms of anxiety and depression (SCL) as the dependent variable. The estimated regression coefficient (B=-0.001, p=0.95) for child's genetic risk indicate no effect of genetic information on changes in maternal mental health from baseline to postdisclosure. The maternal T1D status had neither any effect (B=0.040, p=0.409). However, as expected, the baseline anxiety/depression score was strongly associated with post-

**3.1.2 How often do parents think on that they have a child with high genetic risk for** 

sometimes think about having a high-risk child for T1D, see Figure 1 and 2.

Although 5% of mothers and 2% of fathers did think of their child's high genetic risk for T1D when they filled out the 3 month questionnaire, usually just 2 week after they had got the information, very few parents continued to think often about their child's high genetic risk for T1D. To answer the questionnaire with the same questions each time needs that you

**2.5 Identification of eggs from enterobius vermicularis** 

**3.1 Psychosocial effects of risk information** 

disclosure scores (B=0.536, p<0.001).

**T1D** 

**3. Results** 

**mothers** 

as positive if down to one egg have been identified on one of the tapes.

autoantibodies on at least two consecutive time periods (3-6 months apart) is defined as islet autoimmunity for the purpose of data analysis, and will be used as the first outcome (optimal cut-off values for the autoantibodies has been defined after participation by the Hormone laboratory in international autoantibody standardisation workshops; DASPs). Clinical diagnosis of T1D will also be used as outcome, and analysis will be performed when a sufficient number of children have developed either autoimmunity or T1D.
