1. Removal of Bovine Insulin From Cow’s Milk Formula and Early Initiation of Beta-Cell Autoimmunity in the FINDIA Pilot Study Vaarala O, Ilonen J, Ruohtula T, et al. Removal of bovine insulin from cow’s milk formula and early initiation of beta-cell autoimmunity in the FINDIA pilot study. Arch Pediatr Adolesc Med. Published online March 5, 2012. doi:10.1001/archpediatrics.2011.1559. Copyright restrictions may apply

2. Background –Type 1 diabetes mellitus (T1DM) is an immune-mediated disorder involving T cell–mediated destruction of insulin-producing beta cells in the pancreas. –Dietary wheat and cow’s milk (CM)–derived antigens are candidate triggers of T1DM in epidemiologic studies. –A recent report indicated decreased risk of beta-cell autoimmunity in 10-year-old children exposed exclusively to an extensively hydrolyzed casein-based formula instead of a CM formula; CM formula is known to include bovine insulin. Study Objective –To investigate whether weaning to a bovine insulin–free formula during the first 6 months of life decreases the cumulative incidence of diabetes-associated antibodies by age 3 years. Copyright restrictions may apply Introduction

3. Study Design –Multisite, randomized, controlled, double-blind clinical pilot trial. –Infants randomized to receive CM formula, whey-based formula, or whey-based formula without bovine insulin (FINDIA formula). Study Eligibility –Infants born in 3 Finnish hospitals between 2002 and 2005. –Exclusions: maternal T1DM, gestational DM, preterm birth (<35 weeks). –22% at risk for T1DM based on HLA genotype. Dietary Intervention –Breastfeeding was encouraged, leading to >25% in each group who did not receive formula. Outcomes/Analyses –Blood drawn at ages 3, 6, and 12 months and annually up to 6 years. –Analysis of insulin autoantibodies, glutamic acid decarboxylase, and tyrosine phosphatase–related IA-2 molecule. Copyright restrictions may apply Methods

4. Limitations –Development of T1DM was measured but the study was not powered to detect meaningful differences in the development of T1DM. –It is possible that hydrolyzed whey formulas may differ from nonhydrolyzed formulas in key functional ways. Copyright restrictions may apply

5. Results 908 children provided at least 1 blood sample during the follow-up period. By age 3 months: –Antibody levels binding to bovine insulin were higher in the group receiving CM formula than in all other groups, including exclusive breastfeeding. By age 3 years: –42 children (4.6%) had seroconverted to positivity for at least 1 autoantibody (insulin autoantibodies and/or glutamic acid decarboxylase and/or tyrosine phosphatase–related IA-2 molecule): CM formula (cow’s milk control): 6.3%. Whey-based hydrolyzed formula (whey + bovine insulin): 4.9% (P =.44 vs CM formula). FINDIA formula (no bovine insulin): 2.6% (P =.03 vs CM formula). Copyright restrictions may apply

6. Results Copyright restrictions may apply Kaplan-Meier curves for survival without positive autoantibodies according to the treatment-received analysis. Curves represent survival in infants who received CM formula (CMF) (n = 236), whey- based hydrolyzed formula (WHF) (n = 187), or FINDIA formula (n = 229) and in the group not exposed to any study formula (no exposure) (n = 256). The CMF group was included as a reference group.

7. Results Copyright restrictions may apply Survival Without Positive Autoantibodies During the Follow-up Time 0 to 3 Years and 0 to 6 Years a

8. Comment Weaning to whey-based CM formula essentially free of bovine insulin reduced early induction of beta-cell autoimmunity during the first 3 years of life. The importance of beta-cell autoimmunity in development of T1DM has been established, although T1DM incidence in this young study cohort could not be definitely studied. Caveat: The majority of children exposed to dietary antigens (eg, bovine insulin) develop oral tolerance and not beta-cell autoimmunity. –Therefore, bovine insulin is not universally diabetogenic. Copyright restrictions may apply

9. Comment Need for further study: –Longer-term follow-up in larger cohort to observe for development of T1DM. –More detailed characterization of genotype and phenotype at risk for development of beta-cell autoimmunity on exposure to bovine insulin and similar peptides. –Why some children developed one or another autoantibody and how those are related to tolerance to oral antigen exposure. More broadly highlights the value of persistent breastfeeding well into infancy as a way to limit exposure to sensitizing antigens. Copyright restrictions may apply

10. If you have questions, please contact the corresponding author: –Outi Vaarala, MD, DMSc, Immune Response Unit, Department of Vaccination and Immune Protection, National Institute for Health and Welfare, Biomedicum Helsinki 1, PL 104, FIN-00251 Helsinki, Haartmaninkatu 8 (outi.vaarala@thl.fi). Funding/Support Support was provided by the Academy of Finland, Finnish Diabetes Research Foundation, Valio Ltd, TEKES, Päivikki ja Sakari Sohlberg Foundation, Sigrid Juselius Foundation, and the Finnish Foundation for Pediatric Research. Valio Ltd was involved in the design of the study and writing of the report. Copyright restrictions may apply Contact Information