The document discusses several myths and misconceptions about type 1 diabetes. It presents evidence that contradicts the ideas that 90% beta cell destruction is needed for diagnosis, that it is solely an autoimmune disease, and that it is a homogeneous disease. It also shows that beta cells can persist long after onset and that obesity is not driving the rise in cases. The document calls for more research using human tissues to better understand the heterogeneity of the disease.

1. Rethinking Dogmas That Define Our Knowledge of Type 1 Diabetes Mark Atkinson The University of Florida

3. *median (range) Myth # 1 Type 1 diabetes occurs when 90% of the beta cells have been destroyed. Gepts, Diabetes 14:619, 1965 Duration of diabetes in young patients (0-31yrs) Number of patients with insulitis Number of beta-cells* / cm 2 Acute (<6 months) 15/22 378 (0-1919) Normal controls 0/26 3104 (950-13060)

4. Insulitis Loss of beta cells ‘ Hydropic” change, hypertrophy Regeneration Fibrosis Age, BMI, etc. Myth # 2 The disease occurs due to the exclusive loss of pancreatic beta cells by white blood cells of the immune system. Atrophy of dorsal pancreas Pancreatic infiltrates Psedoatrophic islets Lobular loss of beta cells

5. Myth # 3 Type 1 diabetes is, well…type 1 diabetes

6. Potential Heterogeneity of Type 1 Diabetes Age (years) b-cell function (%) 10 20 30 40 100 LADA Adult Juvenile Early child- hood T lymphocytes Insulin action etc.

7. Establish a network to procure and characterize, in a collaborative manner, pancreata and related tissues (spleen, lymph node, pancreatic lymph node, peripheral blood) from cadaveric organ donors with type 1 diabetes, those with long-standing (>50yr) disease, as well as non-type 1 diabetic persons whom are islet autoantibody positive Utilizing these tissues, investigators will address key immunological, histological, viral, and metabolic questions related to how type 1 diabetes develops Mission: Program Supported by the Juvenile Diabetes Research Foundation (JDRF)

8. www.jdrfnpod.org

9. Disease Diversity – Long Standing Type 1 Ki67+Insulin Amyloid Insulin+ Medalist (6065) 76 yo FC T1D for 56 yrs Insulin- Medalist (6066) 78 yo MC T1D for 74 yrs Islets are large and ~100% non-beta cells Glucagon

10. Myth # 4 Within a few weeks to months after symptomatic onset, there are no more beta cells in those with type 1 diabetes.

11. 78 yr male Medalist (4 at onset) IA2+ Most islets have no insulin+ but half of sections have scattered insulin+ cells (small clusters, singlets or doublets); no TUNEL+ insulin+ cells seen. insulin TUNEL C peptide undetectable Beta Cells – Long Standing Type 1

12. Myth # 5 Obesity is driving the increase in Type 1 Diabetes

13. Accelerating Incidence Type 1 Diabetes Finland: Lancet 371:1778 Harjutsalo et al May 2008 Environment

14. Finland Type 1 Diabetes Incidence 1965-1996 (32 years) Relative Percent Increase Diabetes Care: 22:1066-1070, 2008

15. Myth # 6 Type 1 Diabetes is caused by a an inciting event, likely a viral infection

16. What is “it”? Omega-3 Fatty Acids Nutrasweet Environment

17. Myth # 7 The immune response against the insulin producing cells ends shortly after the months to few years after onset

18. Insulin- Insulitis+ T1D (6062) 10 yo MAA, T1D for 6 yrs Genotype: DRB1 1/7, DQA1 1/3 Histopath: Ins- islets, CD3+ infiltrates. CD3+Glucagon Insulitis Can Persist Long After Disease Onset (but rare)

19. Myth # 8 Beta cells cannot replicate.

20. Beta Cell Replication by Ki67+ Insulin (6052) Ki67+ Insulin

21. The Islet of Hope

22. Myth # 9 NOD mice serve as an effective means for finding a way to prevent and/or cure type 1 diabetes.

23. The List – NOD mice Early 2011 est. - ~400 AAV murine IL-10 AAV rat preproinsulin gene (vLP-1) Adenovirus expressing mIL-4 Aerosolinsulin Allogenic thymic macrophages Alpha Galactosylceramide Alpha-interferon (rIFN-alpha) Alpha/beta T cell receptor thymocytes Aminoguanidine Androgens Anesthesia Antioxidant MDL 29,311 Antisense GAD mRNA Azathioprine Anti-B7-1 Bacille Calmette Gue’rin (BCG) Baclofen Bee venom Biolistic-mediated IL-4 Blocking peptide of MHC class II Bone marrow transplantation Castration Anti-CD3 Anti-CD4 CD4+CD25+regulatory T cells Anti-CD8 Anti-CD28 MAb Cholera toxin B subunit-insulin protein Class I derived self-I-A beta(g7) (54-76) peptide Cold exposure Anti-complement receptor Complete Freund’s adjuvant Anti-CTLA-4 Cyclic nucleotide phosphodiesterases (PDEs) Cyclosporin Cyclosporin A DC deficient in NF-kappaB DC from pancreatic lymph node DC with IL-4 Deflazacort Deoxysperogualin Dexamethasone/progesterone/growth hormone/estradiol Diazoxide 1,25 dihydroxy Vitamin D3, KH1060 1,25 dihydroxycholecalciferol 1,25 dihydroxyl Vitamin D3 Elevated temperature Emotionality Encephalomyocarditis virus (ECMV) Essential fatty acid deficient diets FK506 FTY720 (myriocin) GAD 65 peptides in utero Anti-GAD monoclonal antibody Galactosylceramide Glucose (neonatal) Glutamic acid decarboxylase (intraperitoneal, intrathymic, intravenous, oral) Glutamic acid decarboxylase 65 Th2 cell clone Glutamic acid decarboxylase peptides (intraperitoneal, intrathymic, intravenous, oral) Gonadectomy Guanidinoethyldisulphide Heat shock protein 65 Heat shock protein peptide (p277) Hematopoietic stem cells encoding proinsulin Housing alone Human IGF-1 I-A beta g7(54-76) peptide Anti-I-A monoclonal antibodies Anti-ICAM-1 IgG2a antibodies Immobilization Inomide Anti-integrin alpha 4 Insulin (intraperitoneal, oral, subcutaneous, nasal) Insulin B chain (plasmid) Insulin B chain/B chain amino acids 9-23 (intraperitoneal, oral, subcutaneous, nasal) Insulin-like growth factor I (IGF-I) Anti-intercellular adhesion molecule-1 (ICAM-1) Interferon-alpha (oral) Interferon-gamma Anti-interferon-gamma Interferon-gamma receptor/IgG1 fusion protein Interleukin-1 Interleukin-4 Interleukin-4-Ig fusion protein Interleukin-4-plasmid Interleukin-10 Interleukin-10-plasmid DNA Interleukin-10-viral Interleukin 11-human Interleukin-12 Intrathymic administration of mycobacterial heat shock protein 65 Intrathymic administration of mycobacterial heat shock peptide p277 Islet cells-intrathymic L-Selectin (MEL-14) Lactate dehydogenase virus (LDH) Large multilamellar liposome Lazaroid Anti-leukocyte function associated antigen (LFA-1) Anti-LFA-1 Linomide (quinoline-3-carboxamide) Lipopolysaccharide-activated B cells Lisofylline Lymphocyte choriomeningitis virus (LCMV) Anti-lymphocyte serum Lymphoctyte vaccination Lymphocytic choriomeningitis virus Anti-L-selectin Lymphotoxin LZ8 MC1288 (20-epi-1,25-dihydroxyvitamin D3) MDL 29311 Metabolically inactive insulin analog Anti-MHC class I Anti-MHC class II MHC class II derived cyclic peptide Mixed allogeneic chimerism Mixed bone marrow chimeras Monosodium glutamate Murine hepatitis virus (MHV) Mycobacterium avium Mycobacterium leprae Natural antibodies Natural polyreactive autoantibodies Neuropeptide calcitonin gene-related peptide Nicotinamide Nicotine Ninjin-to (Ren-Shen-Tang), a Kampo (Japanese traditional) formulation NKT cells NY4.2 cells OK432 Overcrowding Pancreatectomy Pentoxifylline Pertussigen Poly [I:C] Pregestimil diet Prenatal stress Preproinsulin DNA Probucol Prolactin Rampamycin Recombinant vaccinia virus expressing GAD Reg protein Reg protein Rolipram Saline (repeated injection) Schistosoma mansoni Semi-purified diet (e.g., AIN-76) Short term chronic stress Silica Sirolimus/tacrolimus Sodium fusidate Soluble interferon-gamma receptor Somatostatin Non-specific pathogen free conditions Streptococcal enterotoxins Streptozotocin Sulfatide (3’sulfogalactosylceramide) Superantigens Superoxide dismutase-desferrioxamine Anti-T cell receptor TGF-beta 1 somatic gene therapy Th1 clone specific for hsp60 peptide Anti-thy-1 Thymectomy (neonatal) Tolbutamide Tolerogenic dendritic cells induced by vitamin D receptor ligands Top of the rack Treatment combined with a 10% w/v sucrose-supplemented drinking water Tumor necrosis factor-alpha TX527 (19-nor-14,20-bisepi-23-yne-1,25(OH)(2)D(3)) Vitamin E Anti-VLA-4 Thymoglobulin Anti-CD3 ALS + Exendin-4 LSF + Exendin-4 EGF + Gastrin Regulatory T Cells Islet Transplantation Microspheres FTY720 sICAM-Ig (Adenovirus Vector) N=193 as of 2004

24. The List – Humans 2011 Estimate - 0

25. BUT – 2011 a Year of Promise A Sampling of Large clinical trials seeking to reverse T1D whose results are due for reporting in 2011 Drug Compound Type of Trial Abatacept CTLA4-Ig Phase II (NIH TrialNet) Diamyd GAD-alum Phase III (Diaprevent) Phase III (European) Phase II (NIH TrialNet) DiaPep277 HSP peptide Phase III Prochymal Mesenchymal stem Phase II Teplizumab Anti-CD3 Phase II/III (Protégé) Phase II (Protégé encoure) Phase II (NIH, AbATE) Otelixizumab Anti-CD3 Phase III (Defend-1)

26. Myth # 10 Most of what we can learn about type 1 diabetes can be determined in mouse models…and most of the important questions about human disease have been answered.

27. Diabetes 14:619-633, 1965 Courtesy Peter In’t Veld

28. In’t Veld and Atkinson, Diabetes (Submitted) Pipeleers and Ling, Diabetes/Metabolism Reviews 8:209, 1992. Gepts et al, 1965, 1978; ,Doniach et al, 1973; Kl öppel et al, 1984; Bottazzo et al, 1985; Foulis et al, 1986; H änninen et al, 1992; Somoza et al, 1994; Lernmark et al, 1995; Shimada et al, 1999; Dotta et al, 2007; Uno et al, 2007; Butler et al, 2007, Gianani and Atkinson, 2010. Insulitis – T1D Patients Stratified to Age at Onset and Duration of Disease Duration of disease ≤ 1 week >1 week - ≤1 year >1 year total Onset childhood (0-14 yrs) 22/ 23 37/42 3/32 62/97 Onset young adult (15-39 yrs) 8/ 14 17/26 1/23 26/63

29. One Bottom Line Message….. At our current level of diagnosis and classification, type 1 Diabetes is a VERY heterogeneous disease AND one that needs much more in the way of research, to bring a cure. The JDRF is vital to this cause

30. THANK YOU Anastasia Albanese-O'Neil, Martha Campbell Thompson, Desmond Schatz Roberto Gianani & George Eisenbarth Teo Stavea, Marie Nierras, Dick Insel & the JDRF for their support nPOD leadership (Executive Committee members, Chairs, Committee members) Scientists Our Cores and their staff Our partners (Kronus, OPO) George King, Susan Bonner-Weir, Al Powers NDRI and IIAM Organ donors & their families