PREDICTION AND PREVENTION OF CARDIOVASCULAR COMPLICATIONS

PREDICTION AND PREVENTION OF of this information to current clinical predictors determines only a modest CARDIOVASCULAR COMPLICATIONS improvement in the ability to correctly predict MACEs. Supported By: National Institutes of Health 1-OR Uromodulin Improves Prediction of Coronary Atherosclerosis over 3‑OR 12 Years in Adults with Type 1 Diabetes Levels of Connective Tissue Growth Factor (CTGF) Predict Myocar- PETTER BJORNSTAD, RICHARD J. JOHNSON, RACHEL M. SIPPL, RANDALL dial Infarction in the Veterans Affairs Diabetes Trial (VADT) Study WONG, MARIAN REWERS, JANET K. SNELL-BERGEON, Aurora, CO KELLY J. HUNT, MIRAN A. JAFFA, DEIRDRE K. LUTTRELL, SARA M. GARRETT, Lower serum uromodulin (umod) levels correlate with decreasing kid- KENNETH LIPSON, YIN LIN, MARIA F. LOPES-VIRELLA, LOUS M. LUTTRELL, AYAD ney function, but their relationship with coronary artery disease (CAD) is A. JAFFA, VADT INVESTIGATORS, Charleston, SC, Beirut, Lebanon, San Francisco, unknown. We examined the relationships between serum umod, and the CA development of albuminuria, chronic kidney disease (CKD) and progression Connective tissue growth factor (CTGF) is a potent chemotactic and extra- of coronary artery calcium (CAC) in adults with type 1 diabetes (T1D), over cellular matrix-inducing growth factor that has been implicated in progres- 12-years. Participants with T1D (n=539, mean age of 40±9, HbA1c 7.7±1.2%, sion of inflammatory and fibroproliferative disorders. An emerging role of 53% women) in the Coronary Artery Calcification in Type 1 Diabetes study CTGF is that of a prosclerotic factor implicated in the development of cardiac were assessed for CAC progression (128-slice spiral CT), urinary albumin to disease. Therefore, our objective was to determine the role of CTGF as a creatinine ratio (UACR) and estimated GFR (eGFR) calculated by CKD-EPI cre- predictor of cardiovascular disease events in type 2 diabetes in the VADT atinine. CKD was defined as eGFR <60mL/min/1.73m2, albuminuria as UACR cohort. Levels of CTGF were measured in 952 VADT patients, a median of 1.9 ≥30 mg/g, and CAC progression as a change in the square root transformed years after entry into the study. Participants were followed for an average of CAC volume ≥2.5. Serum umod was measured using immunoassay kits from 3.3 years for vascular outcomes. CTGF categories were defined as below the Meso Scale Discovery. Logistic regression was used to examine the rela- detectable limit (i.e., referent, 54.5%), lower half of detectable values (i.e., tionship between umod and incident albuminuria, CKD, or CAC progression, 22.8%) and upper half of detectable values (22.7%). Hazard ratios (HRs) for controlling for age, sex, diabetes duration, HbA1c, SBP and LDL-C. Integrated CV endpoints in relation to CTGF categories were calculated by Cox propor- discrimination index (IDI) and net-reclassification improvement (NRI) were tional hazard models. During follow-up, 4.8% had an MI and 6.9% had an MI used to assess the added prediction performance of umod to a model with or cardiovascular death. After adjustments by conventional risk factors, indi- age, sex, diabetes duration and ABC risk factors. CAC progression was viduals in the highest category of CTGF were at higher risk of MI [HR=2.40 observed in 49%, incident albuminuria in 6% and incident CKD in 6% of the (95% CI: 1.18, 4.87)] and MI or cardiovascular death [HR=2.73 (95% CI: 1.50, subjects. Serum umod at baseline was associated with CAC progression 4.96)], relative to individuals with CTGF below the detectable limit. Our study (OR: 0.66 95% CI [0.47-0.94] per one SD=138.7 mcg/mg), incident albumin- indicates that high levels of CTGF predict future MI and cardiovascular death uria (0.27 [0.11-0.65]) and incident CKD (0.39 [0.20-0.76]) in adjusted mod- in patients with type 2 diabetes. els. Results were similar for CAC progression when adjusting for baseline eGFR and UACR, and when excluding participants with CKD or albuminuria. The addition of umod to the baseline model improved relative IDI for CAC progression by 6% (p=0.008) and correctly re-classified 22% cases of CAC progression (p=0.02). In conclusion, lower serum umod levels independently predict develop- ment of CAC in adults with T1D. Supported By: National Heart, Lung, and Blood Institute (T32-DK063687, R01HL113029, HL61753, HL79611, HL113029); Diabetes & Endocrinology Research Center (P30DK57516); JDRF (17-2013-313)

2‑OR Prediction of Cardiovascular Events in Type 2 Diabetes by Means of a Genetic Risk Score Derived from the General Population MARIO LUCA MORIERI, HE GAO, HETAL SHAH, CHRISTINE MENDONCA, TIMO- THY HASTINGS, ALISON MOTSINGER, DANIEL ROTROFF, MICHAEL J. WAGNER, JOHN B. BUSE, JOSYF C. MYCHALECKYJ, ALESSANDRO DORIA, Boston, MA, Raleigh, NC, Chapel Hill, NC, Charlottesville, VA Several genetic variants associated with CVD have been identified in the general population. Our goal was to investigate whether these variants pre- dicted the incidence of major adverse cardiovascular events (MACE) among type 2 diabetes (T2D) subjects at high CVD risk from the ACCORD Study. We ORALS analyzed data from 5,360 self-reported white T2D subjects with a median follow-up of 4.7 years. A genetic risk score (GRS) was derived by adding the effect size-weighted number of risk alleles at 40 CVD loci identified in the general population. The association of the GRS with MACE was evalu- ated by logistic regression including age, gender, and study treatments as Supported By: National Heart, Lung, and Blood Institute (R01HL077192) covariates. Clinical CVD risk classes were defined as “very high” (presence of CVD at baseline or AHA-ACC 10-year MACE risk score > 15%) or “mod- erately high” (10 y risk <= 15%). The GRS ranged from 27 to 62, with each 4‑OR unit increase being associated with a 3% additional risk of MACE (OR 1.03; Serum High-Sensitivity C-Reactive Protein Level Predicts Cardio- 95% CI 1.01-1.06, p=0.002). Subjects in the highest GRS tertile had a 55% vascular Events in Chinese Patients with Type 2 Diabetes with No increase in MACE risk as compared to those in the lowest tertile (OR 1.55; Known Cardiovascular Disease 95% CI 1.25-1.93). This effect was attenuated by adjustment for clinical KAREN S.L. LAM, PAUL C.H. LEE, YU CHO WOO, WING SUN CHOW, CAROL H.Y. predictors (OR 1.42; 95% CI 1.13-1.78) and appeared to be stronger among FONG, MICHELE M.A. YUEN, Hong Kong, China subjects at “moderately high” than in those at “very high” clinical risk (OR Background: The association between serum high-sensitivity C-reactive 2.81; 95% CI 1.55-5.11 vs. OR 1.39; 95% CI 1.10-1.77). Addition of the GRS to protein (hsCRP) and cardiovascular disease (CVD) in type 2 diabetes (T2DM) the clinical risk score (including history of CVD) provided a modest increase remains controversial. Previous studies, performed mostly in Western popu- in the relative integrated discrimination index (rIDI +3.3% P = 0.03) and a net lations, demonstrated its prognostic importance only in T2DM subjects with reclassification improvement of 0.137 (P=0.003), with a 9% and 4% increase known CVD but not in those without. Here, we investigated prospectively in the ability to correctly reclassify individuals with MACE events and non- whether serum hsCRP could predict incident cardiovascular outcomes in events, respectively. Chinese subjects with T2DM with no known CVD. In conclusion, a GRS derived from the general population is associated Method: Baseline serum hsCRP levels were measured in 5,746 Chinese with increased MACE risk among patients with T2D. However, the addition subjects with T2DM recruited from the Hong Kong West Diabetes Registry.

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A1 PREDICTION AND PREVENTION OF CARDIOVASCULAR COMPLICATIONS

The role of serum hsCRP in predicting incident CVD was analyzed using Cox patients with neither T2DM nor CKD (16.1%), mortality was significantly regression analysis. higher in patients with T2DM who did not have CKD (30.5%; p<0.001) as Results: Amongst 3,742 subjects with no known CVD, 295 (7.9%) devel- well as in nondiabetic patients with CKD (40.1%; p<0.001) and was highest in oped incident CVD over a median follow-up of 3.8 years. On multivariable patients with both, T2DM and CKD (62.4%; p <0.001), in whom mortality was Cox regression analysis, baseline serum hsCRP levels independently pre- higher than in those with T2DM but no CKD (p<0.001) or those without T2DM dicted incident CVD (Hazard ratio [HR] 1.11; 95% confidence interval [CI] 1.01- but with CKD (p=0.045); mortality was higher in nondiabetic CKD patients 1.22; p = 0.024). Serum hsCRP ≥3mg/L, derived either by hsCRP quartiles than in in diabetic patients who did not have CKD (p=0.013). or from cut-points suggested by the American Heart Association, was an We conclude that CKD in patients with established CVD confers an even independent predictor of incident CVD (HR 1.50, 95% CI 1.06-2.13, p = 0.022 higher mortality risk than T2DM. Mortality is extremely high in CVD patients and HR 1.51, 95% CI 1.13-2.03, p = 0.006, respectively), with significantly with the combination of CKD and diabetes. improved category free net reclassification index (NRI; p=0.036) and inte- grated discrimination improvement (IDI; p=0.012), beyond the prediction 7‑OR by conventional cardiovascular risk factors including gender, age, smoking Effect of Empagliflozin (EMPA) on Anthropometry and Markers of status, diabetes duration, HbA1c, hypertension, dyslipidemia, estimated glo- Visceral and Total Adiposity by Age, Sex, and Degree of Abdominal merular filtration rate and albuminuria status. Obesity in Patients with Type 2 Diabetes (T2D) and Cardiovascular Conclusions: Serum hsCRP, at a cut-off of ≥3mg/L, was an independent Disease (CVD): EMPA-REG OUTCOME predictor of incident CVD and could be usefully employed for risk stratifica- IAN J. NEELAND, DARREN K. MCGUIRE, MICHAELA MATTHEUS, HANS JUER- tion in primary prevention of CVD among Chinese subjects with T2DM. GEN WOERLE, ODD ERIK JOHANSEN, DAVID FITCHETT, Dallas, TX, Ingelheim, Germany, Asker, Norway, Toronto, ON, Canada 5‑OR EMPA significantly reduced CV death, body weight, and visceral adiposity Coronary Microvascular Dysfunction and Albuminuria in Asymp- (VA) vs. placebo (PBO) in the EMPA-REG OUTCOME trial. We explored for tomatic Patients with Diabetes heterogeneity of effects on adiposity by age, sex, and degree of abdominal LOUIS POTIER, FABIEN HYAFIL, KAMEL MOHAMMEDI, SOUAD SISMAIL, RENATA obesity. Patients with T2D and CVD were randomized to receive PBO, EMPA CHEQUER, AGNES HARTEMANN, CHLOÉ AMOUYAL, DOMINIQUE LE GULUDEC, 10 or EMPA 25 mg daily added to standard care. Changes from baseline to RONAN ROUSSEL, Paris, France week 164 for body weight and validated markers of VA (waist circumfer- Albuminuria is of one the strongest predictors of cardiovascular disease ence, index of central obesity, and estimated total body fat), were assessed (CVD) in diabetes. Diabetes is associated with coronary microvascular dys- for PBO and EMPA across subgroups of age, sex, and baseline waist cir- function, a powerful, independent prognostic factor for cardiac mortality. cumference using a mixed model repeated measures analysis in random- The aim of this study was to evaluate the relationship between coronary ized patients who received ≥1 dose of study drug using all measurements microvascular dysfunction and microvascular diabetic complications in obtained until study end. 2333, 2345 and 2342 patients received PBO, EMPA patients without known CVD. Coronary flow reserve (CFR) was measured by 10 mg and EMPA 25 mg. Mean (SE) baseline weight was 86.7 (0.4), 86.0 cardiac 82 Rubidium positron emission tomography in 219 patients with no (0.4), 86.5 (0.4) kg, respectively. There were greater reductions in weight history of CVD in a prospective study. CFR was compared between patients and markers of VA among patients treated with EMPA compared with PBO without and with diabetes. Among the 154 patients with diabetes, CFR was across most age, sex, and abdominal obesity groups (Table). EMPA consis- compared according to retinopathy and albuminuria, stratified by normoal- tently reduced body weight and markers of VA mostly irrespective of age, buminuria (<3 mg/mmol), microalbuminuria (3-30 mg/mmol) and macroalbu- sex, or degree of baseline VA. Further analyses are needed to determine minuria (>30 mg/mmol). Baseline characteristics of patients with or with- the potential contribution of these changes to the observed CV mortality out diabetes were similar except for number of CVD risk factors, higher in benefit with EMPA. patients with diabetes. CFR was significantly lower in patients with diabetes Table. compared with patients without diabetes (2.5±1.1 vs. 3.5±2.1, p<0.001). CFR was 2.8±1.2, 2.1±1.0, 1.8±0.7 in patients with normoalbuminuria, microalbu- minuria and macroalbuminuria, respectively (p<0.0001) and impaired CFR (<2) was observed in 24.5, 52.6 and 70.6% of patients, respectively (p<0.001). A trend toward a lower CFR in patients with retinopathy compared with patients without retinopathy was observed (2.2±1.1 vs. 2.6±1.2 respectively, p=0.054). After multiple adjustments, micro and macroalbuminuria were strongly associated with impaired CFR. Similar results were found when analyses were restricted to patients without coronary stenosis. Impaired CFR was more frequent in patients with diabetes and was strongly associ- ated with the degree of albuminuria. These results suggested that coronary microvascular dysfunction and albuminuria share common mechanism and could participate to the strong association between CVD and nephropathy. ORALS 6‑OR Type 2 Diabetes, Chronic Kidney Disease, and Mortality in Patients with Established Cardiovascular Disease CHRISTOPH H. SAELY, ALEXANDER VONBANK, CHRISTINA LINS, DANIELA ZANOLIN, ANDREAS LEIHERER, ALXANDRA SCHULER, KARL-MARTIN EBNER, PHILIPP REIN, AXEL MUENDLEIN, HEINZ DREXEL, Feldkirch, Austria, Dornbirn, Austria, Triesen, Liechtenstein, Philadelphia, PA Both type 2 diabetes (T2DM) and chronic kidney disease (CKD) are associ- ated with a high risk of cardiovascular disease (CVD) and premature death. We aimed at investigating the single and joint effects of T2DM and of CKD on all-cause mortality in high-risk patients with established CVD. We prospectively investigated 2,108 patients with established CVD (1,789 with angiographically proven coronary artery disease and 319 with sono- graphically proven peripheral artery disease) over 7.0±2.7 years. Deaths occurred more frequently in T2DM patients (n=652) than in non- diabetic subjects (38.2% vs. 19.6%; p <0.001) and in patients with CKD (esti- mated glomerular filtration ratee GFR (eGFR) <60ml/min/1.73m²; n=357) than in those with an eGFR ≥60ml/min/1.73m² (48.8% vs. 19.8%; p <0.001). When both, T2DM and CKD were considered, 1,248 subjects had neither T2DM nor CKD, 503 had T2DM but not CKD, 208 did not have diabetes but had CKD, and 149 had both diabetes and CKD. When compared with mortality among Supported By: Boehringer Ingelheim

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A2 OBESITY AND TYPE 2 DIABETES IN CHILDREN—WHAT’S NEW?

8‑OR 10‑OR Genetic Predictors of Cardiovascular Outcomes during Intensive Impact of Type 2 Diabetes Exposure In Utero on the Development Blood Pressure Control in ACCORD of Childhood-Onset Type 2 Diabetes in First Nations and Non-First HETAL S. SHAH, MARIO L. MORIERI, HE GAO, JAN SKUPIEN, SKYLAR MARVEL, Nations Offspring SANTICA M. MARCOVINA, RONALD J. SIGAL, HERTZEL C. GERSTEIN, MICHAEL BRANDY A. WICKLOW, ELIZABETH A.C. SELLERS, KRISTINE KROEKER, ATUL K. J. WAGNER, ALISON A. MOTSINGER-REIF, JOHN B. BUSE, PETER KRAFT, JOSYF SHARMA, NATHAN NICKEL, WANDA PHILLIPS-BECK, GARRY X. SHEN, Winni- C. MYCHALECKYJ, ALESSANDRO DORIA, Boston, MA, Raleigh, NC, Seattle, WA, peg, MB, Canada Calgary, AB, Canada, Hamilton, ON, Canada, Chapel Hill, NC, Charlottesville, VA Background: Type 2 diabetes is increasingly prevalent in children, as is Most of the high morbidity and mortality associated with type 2 diabetes exposure to type 2 diabetes throughout pregnancy. The effects of type 2 (T2D) is due to cardiovascular (CV) disease. Higher systolic blood pressure (BP) diabetes exposure on the metabolic programming of the fetus are thought to increases CV risk in T2D, but intensively reducing systolic BP to <120mmHg as differ from gestational diabetes exposure. compared to a standard regimen (<140mmHg) did not improve CV outcomes in Aim: To evaluate the impact of type 2 diabetes exposure throughout ges- high risk T2D subjects in the Action to Control Cardiovascular Risk in Diabetes tation on the development of youth onset (<18 years) type 2 diabetes. (ACCORD) BP trial. To identify individuals that could yet benefit from intensive Methods: We created a Manitoba population based historical prospective BP control, we used an unbiased genome-wide approach testing 6.8M com- cohort study utilizing administrative health data linked to a clinical database mon variants to discover polymorphisms (SNPs) predicting the primary com- to investigate the impact of type 2 diabetes exposure and First nations (FN) posite outcome (CV death, non-fatal myocardial infarction and stroke) among status on the development of type 2 diabetes in the offspring. All pregnan- 1,151 white subjects in the intensive BP arm of the ACCORD genetic sub- cies resulting in a live birth between 1984 and 2013 were included in analy- study. A SNP near LOC101929596 at 2p22.1 attained genome-wide signifi- sis. cance (p=3x10-8). SNPs close to LINC00161 at 22q21.3, HDAC9 at 7p21.1, STX8 Results: Of 371,172 deliveries 65,547 were to FN women and 5,050 preg- at 17p13.1, and LINC01630 at 18q21.2 reached p<1x10-7 and 16 other SNPs nancies were complicated by type 2 diabetes exposure. Offspring exposed attained notable significance at p<1x10-6. In a joint analysis of both treatment to FN status and type 2 diabetes had the highest rates of type 2 diabetes arms (n=2,295), the top SNP was a significant modulator of the CV response in childhood (80/1430; 5.6%) while non-FN offspring without gestational to treatment (p=0.0004). Major allele homozygotes at this locus experienced type 2 diabetes exposure had the lowest rates (290/225383; 0.1%). FN off- a significant benefit on the primary outcome from intensive vs. standard BP spring not exposed to type 2 diabetes in utero had similar rates of childhood control [HR 0.66, 95% CI 0.49-0.88, p=0.006], whereas minor allele carriers type 2 diabetes (478/53144; 0.9%) than non-FN offspring who were exposed experienced a 2-fold increase in CV events in response to intensive therapy to type 2 diabetes in utero (16/1693; 0.9%). A higher proportion of offspring [HR 2.22, 95% CI 1.21-4.06, p=0.01]. These findings suggest that a personal- exposed to type 2 diabetes were born preterm (FN 27.0% vs. 7.0%; non-FN ized medicine approach could be potentially used to improve the effective- 24.9% vs. 6.7%) and LGA (FN 41.7% vs. 17.3%; non-FN 32.4% vs. 11.2%). ness of intensive BP control in preventing CV complications of T2D. While Conclusions: Incidence of childhood onset type 2 diabetes is high in chil- several genes near the top loci (such as HDAC9, AUTS2, ESSRG, PTPRM, FHIT, dren exposed throughout pregnancy to type 2 diabetes. This emerging risk SLC8A1, SPHKAP and GRIN2B) have been previously implicated in CV risk fac- factor, exposure to type 2 diabetes throughout pregnancy, represents a sig- tors and/or disease, the genome-wide significant locus (LOC101929596) is a nificant future heath burden, which requires a understanding of its etiology novel CV locus. Mechanistic studies of these genetic effects may expand our and pathogenesis to inform effective public health prevention efforts. understanding of the pathophysiology of atherosclerosis in diabetes. Supported By: Children’s Hospital Research Institute of Manitoba Supported By: National Institutes of Health 11‑OR Are Adverse Effects of Child Overweight on Risk of Type 2 Diabetes OBESITY AND TYPE 2 DIABETES IN CHILDREN— Reversible by Remission to Normal Weight in Young Adulthood? WHAT’S NEW? LISE G. BJERREGAARD, BRITT W. JENSEN, LARS ÄNGQUIST, MERETE OSLER, THORKILD I.A. SØRENSEN, JENNIFER L. BAKER, Frederiksberg, Denmark, Glos- 9‑OR trup, Denmark Relation of Branched-Chain Amino Acids to Insulin Resistance and Background and Aim: Childhood overweight is associated with an Adiposity in Children and Young Adults increased risk of type 2 diabetes. It remains unclear whether children who JUSTIN R. RYDER, JULIA STEINBERGER, DAVID R. JACOBS, JR., ANTTI J. KAN- grow out of their overweight reverse the adverse effects of childhood over- GAS, PASI SOINIEN, MIKA ALA-KORPELA, OLLI RAITAKARI, CHING PING HONG, weight. We studied associations between overweight patterns defined as ALAN R. SINAIKO, Minneapolis, MN, Oulu, Finland, Turku, Finland combinations of weight status in childhood and young adulthood and devel- Plasma branched-chain amino acids (BCAA), including valine (Val), leucine opment of type 2 diabetes later in life. (Leu), and isoleucine (Ile) are related to adiposity, associated with insulin Material and Methods: We included 62,565 men who had weight and resistance, and predict incident type 2 diabetes in adults. These associa- height measured at age 7 years and in young adulthood (17-26 years) avail- tions are not well defined in youth. We examined the cross-sectional and able from the Copenhagen School Health Records Register and the Danish Conscription Database. Overweight was defined by Center for Disease Con- longitudinal relations of BCAA with BMI and insulin sensitivity in children ORALS randomly recruited at mean age 12.9±1.1 (baseline; n=300) and re-examined trol (childhood) and World Health Organization BMI classifications (young at mean age 21.6±1.7 (follow-up; n=160). Body mass index (BMI), insulin adulthood). Type 2 diabetes status (age ≥30 years) was obtained from the sensitivity (measured by the hyperinsulinemic euglycemic insulin clamp; National Patient Register (n=6,710). Hazard ratios (HR) and 95% confidence intervals were estimated by Cox regressions. expressed as Mlbm), and plasma BCAA (measured by NMR spectroscopy) were obtained at each visit. All data are mean±SE. Cross-sectional and Results: Overweight in childhood (5.4%) and in young adulthood (8.2%) longitudinal associations were estimated for individual BCAA or compos- were associated with increased risks of type 2 diabetes (HR7years=1.53 [1.40- 1.68]; HR =2.96 [2.78-3.15]). Only 40% of boys who were overweight as ite BCAA score (Val+Lea+Ile) for dependent variables Mlbm and BMI using adult repeated measures regression models, adjusting for Tanner stage, sex, and children were also overweight in young adulthood. Boys who grew out of their overweight had a similar risk of type 2 diabetes as men who were never race. At baseline, insulin sensitivity was significantly, inversely related to Val (β= -29.7±7.7, p=0.0002), Leu (β = -77.2±19.9, p=0.0001), Ile (β = -89.2± overweight (HR=1.01 [0.87-1.16]). Men who were persistently overweight 23.5, p=0.0002), and composite BCAAs (β = -19.2±4.8, p<0.001), and BCAA or became overweight in young adulthood had a 3-fold increased risk of was also directly related to BMI (p<0.001 all). These associations also were type 2 diabetes as compared with non-overweight men who were over- seen at follow-up. Longitudinal changes in BMI were significantly, positively weight as children (HR=2.88 [2.40, 3.44] and HR=2.95 [2.53, 3.45] respec- associated with concurrent changes in Val (β= 0.23±0.07, p=0.0016), Leu tively). (β = 0.23±0.07, p=0.0003), Ile (β = -0.20±0.05, p=0.0002), and composite Conclusion: Overweight boys who grow out of their overweight do not BCAA (β = -0.27±0.07, p=0.0002), and longitudinal changes in insulin sen- carry an increased risk of type 2 diabetes in adulthood as compared with sitivity were inversely related to concurrent changes in Val (β= -0.44±018, men who were never overweight. These findings suggest that adverse p=0.014) and composite BCAA (β= -0.38±017, p=0.029). However, baseline metabolic health consequences of childhood overweight are reversible and underscore the potential beneficial effects of treatment interventions in BCAA did not predict changes in Mlbm or BMI. These results show that: 1) overweight pediatric populations. BCAA are already significantly related to Mlbm and BMI in childhood; 2) these relations persist and track into young adulthood; and 3) adverse metabolic Supported By: European Research Council (281419); Horizon 2020 (633595) processes effecting insulin sensitivity begins early in biologic development.

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A3 OBESITY AND TYPE 2 DIABETES IN CHILDREN—WHAT’S NEW?

12‑OR 13‑OR Long-Term Risk of Type 2 Diabetes in Youth with Increasing Severity Intrauterine Exposure to Maternal Diabetes or Obesity and Off- of Obesity spring Insulin Resistance and β-Cell Function: The EPOCH Study SANIL P. REDDY, STEPHANIE K. TANAMAS, MELISSA CHAMBERS, ELENA KATHERINE A. SAUDER, CHRISTINE W. HOCKETT, BRANDY M. RINGHAM, DEB- CLARK, DIANA DUNNIGAN, ROBERT G. NELSON, ROBERT L. HANSON, WILLIAM ORAH H. GLUECK, DANA DABELEA, Aurora, CO C. KNOWLER, MADHUMITA SINHA, Phoenix, AZ We examined associations of intrauterine exposure to gestational diabetes Background: Few studies assess the long-term risk of developing type 2 and maternal pre-pregnancy obesity with offspring insulin resistance (HOMA2- diabetes (T2DM) in obese youth. The objective of this study was to deter- IR, Mastuda index), β-cell function (HOMA2-B, early insulin response), and mine T2DM risk among obese and severely obese American Indian youth the oral disposition index in a longitudinal observational study of ethnically- from the southwestern U.S. diverse youth. Four hundred thirty-seven youth, including 71 exposed to ges- Methods: Incidence of T2DM was computed in 4,883 nondiabetic youths tational diabetes and 90 exposed to maternal pre-pregnancy obesity, provided ages 10-17 years who were enrolled between 1965 and 2007 and followed fasting blood samples at age 10.5 (SD=1.5) and 16.2 (SD=1.2) years. An oral for up to 20 years or until the onset of T2DM. Age-sex adjusted BMI %iles glucose tolerance test was also performed at the second visit. We used linear were defined using the CDC 2000 growth charts. Obese youth were further mixed models to evaluate the associations of gestational diabetes exposure classified by % of 95th %ile to demonstrate the effect of severity of obesity and pre-pregnancy BMI with offspring outcomes, adjusting for age, sex, race, on incidence. and Tanner stage. In separate exposure models, maternal gestational diabetes Results: Median age of the cohort at baseline was 12.1 years (IQR: 11.7- and a 5 kg/m2 increase in maternal pre-pregnancy BMI were each associated 13.7), 53.4% were female. Over a median follow-up of 11.7 years (IQR: 5.3- with higher HOMA2-IR (β=1.18, p=0.01 and β=1.11, p<0.001, respectively), 20.0), 648 youths developed T2DM (11.1 per 1000 person-years). T2DM inci- lower Matsuda index (β=0.83, p<0.03 and β=0.90, p<0.001, respectively), and dence rates increased with severity of obesity and were generally higher in greater HOMA2-B (β=1.11, p=0.01 and β=1.06, p<0.001, respectively). In a com- girls (Figure A). Compared to those with a BMI between the 50th-75th %ile, bined model with both exposures, estimates were unchanged for pre-preg- obese girls had 3 to 7-fold higher and obese boys had 6 to 20-fold higher nancy BMI but attenuated for gestational diabetes. However, when further diabetes incidence rates (Figure B). adjusted for current offspring BMI, associations for pre-pregnancy BMI were Conclusion: This longitudinal study assesses long-term diabetes risk with attenuated to non-significance, while associations for gestational diabetes incremental increase in BMI among obese youth, it shows that risk contin- remained statistically significant (HOMA2-IRβ =1.11, p=0.04, Matsuda index ues to increase with increasing obesity severity above the 95th %ile; our β=0.84, p<0.02, HOMA2-B β=1.08, p=0.04). Neither gestational diabetes study adds to the understanding of the metabolic risk gradient in obesity nor pre-pregnancy BMI were associated with early insulin response or oral and will help in planning early therapeutic interventions to mitigate this risk. disposition index. Our data support the hypothesis that fetal overnutrition is associated with metabolic abnormalities in adolescence that are precursors Figures. of type 2 diabetes. Supported By: National Institutes of Health

14‑OR Michigan Neuropathy Screening Instrument (MNSI) Profiles in Youth with Type 2 Diabetes (T2D): Results from the TODAY Trial LORRAINE E.L. KATZ, KENNETH C. COPELAND, PHILIP S. ZEITLER, LAURE EL GHORMLI, MARSHA D. MARCUS, CHRISTINE L. CHAN, TERRI LIPMAN, NEIL H. WHITE, Philadelphia, PA, Oklahoma City, OK, Aurora, CO, Rockville, MD, Pittsburgh, PA, St. Louis, MO There are limited data related to diabetic neuropathy (DN) in youth with T2D. The purpose of this report is to describe the frequency of peripheral DN in TODAY Study participants over time. The Michigan Neuropathy Screening Instrument (MNSI) and a 10-gram monofilament exam were performed on each TODAY participant at entry into the study, yearly for the duration of participation (mean follow-up 3.9 yr), at the time of loss of glycemic control (the primary endpoint; persistent HbA1c ≥ 8%), and at the end of the study. The 15-item questionnaire component of the MNSI (MNSI-Q) is considered normal if the score is <4. For the MNSI exam component (MNSI-E), the total score (across both feet) ≤2 is considered normal. For the monofilament, 8 or more correct responses of 10 applications to each foot is considered normal. At entry into the study, subjects were 11-17 yr and had T2D for <2 yr (median 5.0 months). For the MNSI-Q (N=692 at baseline), the frequency of an abnor- ORALS mal score did not increase over time and for all visits combined was 4.4%. The most common symptom/sign was cramps in the feet (28.4%), followed by prickling feelings in the legs and feet (13.8%) and open sores on the feet (13.3%). For the MNSI-E (N=682 at baseline), 3.2% of subjects scored >2 at baseline and this increased to 14.6% by month 72. The most common abnormality was dry skin (15.9%) followed by abnormal ankle reflex (12.8%). Using a Combined Score (MNSI-Q score ≥ 4 and/or MNSI-E score > 2), 6.1% of participants were abnormal at baseline and 15.2% were abnormal by month 72. Only 0.3% of participants had an abnormal monofilament exam at baseline and this increased to 8.7% by month 72. Youth with T2D demon- strate evidence of peripheral DN on MNSI screening early in the course of diabetes and this finding increases over time. Baseline monofilament testing was normal in the majority but also increased over time. These findings raise concern for long-term development of neurologic morbidity requiring further follow-up. Supported By: National Institute of Diabetes and Digestive and Kidney Diseases Supported By: National Institute of Diabetes and Digestive and Kidney Dis- eases/National Institutes of Health (U01DK61212, U01DK61230, U01DK61239, U01DK61242, U01DK61254)

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A4 MECHANISTIC INSIGHTS INTO DIABETES GENE FUNCTION

15‑OR MECHANISTIC INSIGHTS INTO DIABETES GENE Circulating Spexin Is Enhanced by Dramatic Weight Reduction via FUNCTION Roux en-Y Gastric Bypass (RYGB) Surgery in Youth with Severe Obesity 17‑OR SEEMA KUMAR, MD JOBAYER HOSSAIN, BRIAN DUGHI, THOMAS H. INGE, Amino Acid Polymorphisms of the hERG Voltage-Gated Potassium BABU BALAGOPAL, Rochester, NY, Wilmington, DE, Jacksonville, FL, Cincinnati, OH Channel Associate with Altered Plasma Incretin Response and Glu- Background: Spexin is a novel peptide predominantly produced in human cagon Release white adipose tissue and recently implicated in the regulation of obesity, LINE ENGELBRECHTSEN, YUVARAJ MAHENDRAN, ANNA JONSSON, ANETTE energy homeostasis and satiety. It evokes weight loss in rodents with diet P. GJESING, PETER WEEKE, MARIT E. JØRGENSEN, KRISTINE FÆRCH, DANIEL induced obesity. A recent study showed that its concentration solely could R. WITTE, JENS JUUL HOLST, TORBEN JØRGENSEN, ALLAN LINNEBERG, OLUF discriminate between obese and lean children with extreme accuracy, sug- PEDERSEN, HENRIK VESTERGAARD, SIGNE S. TOREKOV, JØRGEN K. KANTERS, gesting its potential as a target for obesity management and potentially TORBEN HANSEN, Copenhagen, Denmark, Gentofte, Denmark, Aarhus, Denmark type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). We Individuals with rare mutations in human Ether-a-go-go related gene hypothesized that dramatic weight reduction would be associated with (hERG) have an increased risk of arrhythmias (alterations in QT interval) and increased endogenous spexin levels in youth with severe obesity. also exhibit alterations in secretion of insulin, glucagon and incretin hor- Methods: Changes in circulating spexin, body mass index (BMI), insulin mones due to a dysfunctional Kv11.1 voltage-gated potassium channel. The resistance (HOMA-IR), total (T)- and high molecular weight (HMW)-adipo- aim of this study was to evaluate the effect of coding polymorphisms in nectin and leptin were measured longitudinally (baseline, 6-m and 12-m) fol- hERG (the minor A-allele of rs36210421 R1047L and the minor G-allele of lowing roux en Y gastric bypass (RYGB) surgery in youth with severe obesity -2 rs1805123 K897T) on electrocardiogram-derived QT interval and circulating (n= 12; Age=16.7±1.5 years; BMI=51.6±2.9 kg.m ). Pearson and Spearman plasma levels of of glucagon-like peptide-1 (GLP-1), glucose-dependent insu- rank correlations were used, as appropriate, to explore associations of linotropic popypeptide (GIP), insulin and glucagon. spexin with other biomarkers of diabetes and CVD at baseline as well as Electrocardiograms from the population-based Inter99 study (n=5895) changes overtime; t-test was used to compare changes at 6-m and 12-m were used for assessment of heart rate corrected QT-interval. Participants following surgery. Data were expressed as mean±SD. from the ADDITION-PRO study of individuals at high risk of diabetes were Results: Spexin increased (p=0.01) at 6-mo following surgery; the mag- included (n=1351) to study the genetic association with glucose homeostasis nitude of change in spexin was correlated with corresponding decreases in and incretins. BMI at 6-mo and stabilized afterwards. Spexin also showed significant cor- The amino acid polymorphisms, rs36210421 and rs1805123, were associ- relations with HOMA-IR (r= -0.796; p=0.002) and T- and HMW-adiponectins ated with shorter QT interval (β =-0.12, p=0.025 and β= -0.11, p= 1.9 x 10-7) (r=0.512 and 0.691 and p=0.08 and 0.01 respectively). and with alterations in plasma incretin response and pancreatic hormone Conclusions: Dramatic weight reduction after RYGB was associated with secretion. Rs36210421 was associated with higher plasma GLP-1 levels (p< enhanced circulating levels of spexin in youth with severe obesity. The find- 0.03), while rs1805123 was associated with lower plasma fasting insulin, ings suggest the relevance of spexin in the regulation of BMI, insulin resis- fasting glucagon, glucagonAUC30min and glucagonAUC120min (p-values ranging tance and adiponectin following RYGB in humans. from 0.003-0.02) levels. The additive effect of both variants was negatively Supported By: American Diabetes Association (1-14-CE-04 to B.B.) associated with fasting insulin, GIP and glucagon as well as GIPAUC30min, glu- cagonAUC30min, GLP-1IAUC30min and GLP-1IAUC120min (p values ranging from 0.005- 16‑OR 0.02). Genetic Predisposition to Adiposity Is Associated with Objectively Amino acid polymorphisms of hERG, rs36210421 and rs180512, affect cir- Assessed Sedentary Time in Young Children culating plasma levels of insulin, GLP-1, GIP and glucagon, suggesting that THERESIA M. SCHNURR, ANNA VIITASALO, AINO MAIJA ELORANTA, the examined hERG channel play an important role in fasting and glucose- CAMILLA T. DAMSGAARD, JUUSO VÄISTÖ, MADS F. HJORTH, LINE B. CHRIS- stimulated release of the specified pancreatic and intestinal hormones. TENSEN, SOREN BRAGE, VIRPI LINDI, MUSTAFA ATALAY, TIMO LAKKA, KIM F. Supported By: Novo Nordisk Foundation MICHAELSEN, TUOMAS O. KILPELÄINEN, TORBEN HANSEN, Copenhagen, Den- mark, Kuopio, Finland, Cambridge, United Kingdom 18‑OR Increased sedentary time has been linked to the growing prevalence of A Partial Loss of Function Variant in the AKT2 Gene Is Associated obesity in children. However, longitudinal studies suggest that increased with Reduced Insulin-Mediated Glucose Uptake in Skeletal Mus- sedentary time and decreased physical activity may be a consequence cle, Liver, Brown Adipose Tissue, and Bone Marrow: A Positron rather than a cause of increased adiposity. To examine whether genetic Emission Tomography Study predisposition to adiposity influences movement behaviour, we tested the AINO HYYPIA, MIIKKA HONKA, ALENA STANCÁKOVÁ,ˇ HEIKKI KOISTINEN, associations of a genetic risk score (GRS) for childhood body mass index LAURA J. SCOTT, TOMI KARJALAINEN, LAURI NUMMENMAA, MICHAEL (BMI) with sedentary time and physical activity in early childhood. BOEHNKE, PIRJO NUUTILA, MARKKU LAAKSO, Turku, Finland, Kuopio, Finland, We studied two child cohorts (SKOT cohort including 279 Danish chil- Helsinki, Finland, Ann Arbor, MI dren aged 3.0±0.1 years; PANIC study including 400 Finnish children aged Rare mutations in the AKT2 gene have been previously associated with ORALS 7.6±0.4 years) with data on BMI, genotypes, and accelerometer-measured monogenic disorders of glucose metabolism. A novel partial loss of func- sedentary time and physical activity. A GRS was derived from 15 indepen- tion coding variant (p.Pro50Thr) in the AKT2 gene was recently identified. dent genetic variants robustly associated with childhood BMI, while five loci This variant is almost entirely specific for Finns (frequency 1.1%), and the included in the GRS (GNPDA2, TMEM18, FTO, MC4R and GPR61) are linked low-frequency allele has been associated with an increase in fasting plasma to hypothalamic function, controlling behaviour reinforcement. All statistical insulin. The effects of this variant on insulin-stimulated glucose uptake (GU) analyses were performed with adjustment for age and gender, and with and in the whole body and in different tissues have not previously been inves- without additional adjustment for BMI. We pooled the effect estimates from tigated. We performed positron emission tomography scanning with [18F]- SKOT and PANIC cohorts using fixed effects meta-analyses. fluorodeoxyglucose during euglycemic hyperinsulinemia on the p.Pro50Thr A higher GRS was associated with higher BMI z-score (P=0.0030) and mutation carriers (N=20) and non-carriers (N=25) identified from the MET- longer sedentary time (P=0.0087) but not with physical activity (P=0.73). SIM Study. We found that the whole body glucose uptake was reduced by Each BMI-increasing allele increased sedentary time by 3.33±1.67 min/day 39.7% (P=0.006), skeletal muscle GU by 36.4% (P=0.012), liver GU by 16.1% in the SKOT cohort and 4.72±2.97 min/day in the PANIC study. The associa- (P=0.030), brown adipose tissue GU by 29.7% (P=0.004), and bone marrow tion between GRS and sedentary time remained statistically significant even GU by 32.9% (P=0.004) in mutation carriers vs. non-carriers, whereas the after adjustment for BMI (P=0.039). rate of endogenous glucose production was increased in mutation carriers Our results suggest that there may be a causal relationship between by 22.6% compared to non-carriers 55.6% higher (p=0.038). No significant genetic predisposition to adiposity and increased sedentary time, but also changes in GU were observed in the cardiac muscle, subcutaneous and vis- that childhood BMI loci may have a direct influence on sedentary time ceral adipose tissue, duodenum, or jejunum. Brain GU was increased in all beyond their association with adiposity. Our results provide novel insights brain regions by 16.8-19.1% (P<0.001). into the genetic regulation of movement behaviour in early childhood. In conclusion, the Pro50Thr substitution of the AKT2 gene has significant Supported By: University of Copenhagen; Danish Diabetes Academy; Novo effects on insulin-mediated GU in the whole body and in several insulin sen- Nordisk Foundation sitive tissues reflecting insulin resistance. Supported By: National Institutes of Health; Academy of Finland

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A5 MECHANISTIC INSIGHTS INTO DIABETES GENE FUNCTION

19‑OR 21‑OR Severe Insulin Resistance with Pseudoacromegaly, a Rare Insulin- CDKN2A/B T2D GWAS Risk-SNPs Impact Locus Gene Expression Resistance Syndrome and Proliferation in Human Islets STEPHEN I. STONE, JENNIFER A. WAMBACH, F.S. COLE, DANIEL J. WEGNER, YAHUI KONG, SOCHEATA LY, ROHIT B. SHARMA, RACHEL E. STAMATERIS, FUMIHIKO URANO, St. Louis, MO LAURA C. ALONSO, Worcester, MA Insulin resistance syndromes are a group of rare, but clinically important, GWAS studies strongly link T2D risk with the CDKN2A/B locus, which conditions typically inherited in a monogenic fashion. These conditions help encodes cell cycle inhibitors p14, p15, p16 and ANRIL, a lncRNA. However, contribute to our knowledge of insulin signaling and resistance. Fibroblast mechanisms by which this locus influences T2D risk remain unclear. The goal growth factor-21 (FGF-21) is a recently discovered peptide that has gained of this study was to determine whether CDKN2A/B T2D risk-SNPs impact attention for its important effects on insulin sensitivity, growth hormone, locus gene expression, or beta cell proliferation, in human islets. We tested and fertility. We report a case of a 12 year old female presenting to pediatric a large cohort (n=92) of human islets from healthy donors for SNP identity diabetes clinic with extremely tall stature, acanthosis nigricans, severe hir- (rs10811661, rs2383208, rs564398, rs10757283) and gene expression (p16, sutism, obesity, and acromegaloid features. The subject and her first-degree p14, p15, ANRIL, PCNA, Ki67, CCND2) using validated Taqman assays. A sub- relatives underwent metabolic phenotyping and whole exome sequencing. set (n=43) was also tested for basal and glucose-stimulated beta cell prolif- The subject’s IGF-1 was normal, however she was noted to have extremely eration. p14, p16 and ANRIL expression were positively correlated with each elevated insulin (1279 uIU/mL) postprandially. She also had biochemical other (p<0.0001) but only nominally with p15. Locus gene expression was hyperandrogenism with elevated free testosterone (16 pg/mL). The subject’s unrelated to donor sex, BMI or ethnicity; p14, p16 and ANRIL, but not p15, bone age was 14 years, giving her a predicted adult height of 1.83m (+3.23 increased with donor age. PCNA and CCND2 expression were highly cor- SDS). Two hour oral glucose tolerance testing indicated an undetectable related (p<0.0001). Intriguingly, p14, p15, p16 and ANRIL showed a paradoxi- growth hormone at 90 minutes, however her insulin was elevated to 799 cal, age-dependent positive correlation with PCNA and CCND2, driven by a uIU/mL at 60 minutes. Whole exome sequencing identified 2 rare, predicted strong positive correlation in the youngest tertile (<33 years old) but little deleterious, variants in 2 genes critical to the FGF-21 signaling pathway, to no correlation in the middle (33-48) or oldest (>48) tertiles. Homozygous- Fibroblast Growth Factor Receptor-1 (FGF-R1) and beta Klotho (KLB). FGF- risk alleles at rs10811661 and rs2383208 were associated with increased R1 and KLB are transmembrane co-factors that bind FGF-21. These vari- expression of ANRIL (p<0.05), but not p14, p15 or p16. SNPs had combinato- ants (p.V102I and p.S9Y) were inherited in trans from each parent. They are rial impact. In samples with homozygous-protective rs564398, risk alleles at extremely rare, and are predicted to be damaging by the majority of in-silico rs10811661 or rs2383208 increased expression of p14 and p16 (p<0.05); in variant prediction programs. The subject’s FGF-21 level was elevated (391.3 samples with homozygous-protective rs10757283, risk alleles at rs2383208 pg/mL) compared to her father (104.3 pg/mL) and mother (225.2 pg/mL). We increased p15 expression (p<0.05). Risk-allele carriers at rs564398 had hypothesize that together, the FGF-R1 and KLB mutations act in a dominant reduced glucose-stimulated beta cell proliferation. and synergistic manner, resulting in this subject’s severe insulin resistance, In conclusion, risk-SNPs at the CDKN2A/B locus may contribute to T2D tall stature, and hirsutism. If true, this would represent a novel category of risk through islet gene expression and beta cell proliferation, but the mecha- insulin resistance syndromes related to FGF-21. nism is complicated, with effects modified by other locus polymorphisms Supported By: National Institutes of Health (P30DK020579) and subject characteristics such as age. Supported By: National Institutes of Health (R01DK095140) 20‑OR Heterozygous Protein-Truncating RFX6 Variants Cause MODY with 22‑OR Reduced Penetrance Progression and Subtypes of Prediabetes with Metabolomics Pro- KASHYAP A. PATEL, MARKKU LAAKSO, ALENA STANCÁKOVÁ,ˇ TOM LAVER, filing in Starr County Mexican Americans KEVIN COLCLOUGH, MATTHEW JOHNSON, JARNO KETTUNEN, TIINAMAIJA GOO JUN, CHARLES EVANS, GRAEME I. BELL, CHARLES F. BURANT, CRAIG L. TUOMI, MIRIAM CNOP, MAGGIE SHEPHERD, SARAH E. FLANAGAN, SIAN HANIS, Houston, TX, Ann Arbor, MI, Chicago, IL ELLARD, ANDREW T. HATTERSLEY, MICHAEL WEEDON, Exeter, United Kingdom, Diagnosis of type 2 diabetes occurs long after underlying metabolic Kuopio, Finland, Helsinki, Finland, Brussels, Belgium changes have occurred. Prediabetes is currently defined by three tests: fast- Background: Maturity Onset Diabetes of the Young (MODY) is a young- ing glucose, 2-hr glucose, and HbA1c. Although all three predict diabetes, onset, autosomal dominant form of monogenic diabetes. Up to 11% of cases they differ somewhat in their biological underpinnings. Furthermore, only do not have a mutation in the 12 known MODY genes. We aimed to identify 12.3% of prediabetics in Starr County meet all three criteria. new causes of MODY in patients with a strong MODY phenotype where We recently performed untargeted metabolomic and lipidomic assays mutations in known genes had been excluded. to obtain a total of 7,661 raw features on 155 samples from 127 unrelated Method: We performed targeted-next generation sequencing of 29 females as a pilot analysis at the University of Michigan. 28 individuals were known monogenic diabetes genes on 36 European individuals with strong profiled at two time points 10 years apart with selection based on their BMI MODY phenotype (diagnosed <25 y, ≥3 generation family history, BMI<30 profiles; 14 showing significant BMI increases vs. 14 showing no changes. kg/m2, negative islet autoantibodies, C-peptide >200 pmol/L). We replicated Results show distinctive amino acid signatures in normal and prediabetic analysis in 131 European and 80 Finnish patients referred for routine MODY individuals. Moreover, we observed differences in amino acid levels between ORALS genetic testing. subtypes of prediabetes. We also performed multi-dimensional variable Results: We identified two probands in the discovery cohort (2/36) with selection to take full advantage of the untargeted metabolomics data with novel Regulatory Factor X 6 (RFX6) heterozygous nonsense variants. This an Elastic Net. The model selected 74 metabolites out of the thousands (k-NN included one large family where the variant co-segregated in 9/10 affected imputed). The resulting PCA plot showed excellent separation of prediabetes family members with one phenocopy of type 2 diabetes. We found an samples from normal individuals based on these 74 metabolites. additional 4 probands (4/131) with novel RFX6 protein-truncating variants We will extend our analyses with full metabolomic and genomic profiles, (PTVs) in the European replication cohort. RFX6 PTVs were enriched in the to enable understanding the biology of the development, progression, and MODY discovery and replication cohorts compared to 33,346 ExAC European subtypes of type 2 diabetes. controls (5.5% vs. 0.045%, P=6.5 X 10-28 and 1.16% vs. 0.045%, P=4 X 10-14 Figures. respectively). RFX6 PTVs are ~10 times more common in the Finnish popu- lation (n=26/7040, 0.37%) compared to Europeans due to a founder effect of a single variant p.His293Leufs. Despite this, p.His293Leufs was enriched in Finnish MODY cases with unknown aetiology (n=6/80, 7.5% vs. 0.37%, P=5.5 x 10-18). These patients were nonobese (median BMI 24), diagnosed at median age of 36 y and had preserved endogenous insulin secretion at median 15 y duration. RFX6 heterozygotes showed reduced penetrance with 27% developing diabetes by 25 y compared to 70% of patients with muta- tions in the commonest MODY gene HNF1A. Conclusion: Heterozygous RFX6 PTVs are a new cause of MODY respon- sible for 1% of European MODY cases and 7% of Finnish cases. Supported By: Wellcome Trust UK; UK Medical Research Council; National Institute for Health Research, UK

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A6 MOLECULAR REGULATORS OF METABOLISM

protein lacking part of the C-terminal histidine phosphatase domain. This study provides new mechanistic insights into the role of UBASH3A in T1D and auto- immunity, and shows that T1D-associated genetic variants affect disease risk by modulating the expression level of full-length UBASH3A in CD4+ T-cells. Supported By: American Diabetes Association (1-16-PDF-041 to Y.G.); National Institutes of Health (DK106718, DK046635, DK085678); JDRF (3-APF-2016-177-A-N)

MOLECULAR REGULATORS OF METABOLISM

25‑OR bZIP Transcription Factor CREBZF Functions as a Novel Metabolic Regulator in the Control of Hepatic Steatosis in Diet-Induced Insu- lin-Resistant Mice 23‑OR FEIFEI ZHANG, ZHIMIN HU, GAOPING LI, YIXUAN SUN, YAMEI HAN, AOYUAN CUI, FENGGUANG MA, ZHENGSHUAI LIU, QI GONG, XUQING CHEN, JING GAO, Increased β-Cell Proliferation before Immune-Cell Invasion Pre- vents Progression of Type 1 Diabetes YAN ZHANG, YU LI, Shanghai, China ERCUMENT DIRICE, ABDELFATTAH EL OUAAMARI, DARIO F. DE JESUS, SEVIM Nutrient overload-caused deregulation of lipid and glucose metabolism is KAHRAMAN, ADRIAN K. TEO, JIANG HU, KIM MIJEONG, CORNELIA SCHUSTER, critical in the development of hepatic steatosis and type 2 diabetes. To iden- STEPHAN KISSLER, THOMAS SERWOLD, ROHIT N. KULKARNI, Boston, MA tify candidate metabolic regulators, we analyzed gene expression profiles of Compensation for β-cell loss is an important therapeutic goal for counter- dietary models of murine obesity, which revealed a cluster of transcription ing type 1 diabetes (T1D). To explore whether enhanced β-cell replication prior factors enriched in the liver of high fat diet (HFD)-fed mice, including CREBZF, to immune cell infiltration, protects against T1D we crossed the Liver-specific a basic region-leucine zipper transcription factor of the CREB/ATF gene fam- Insulin Receptor Knockout (LIRKO) mouse, characterized by robust β-cell pro- ily. To elucidate the function of CREBZF in vivo, we generated a liver-specific liferation, onto the Nonobese Diabetic (NOD) background. Similar to NOD CREBZF knockout (CREBZF LKO) mouse using the Cre-LoxP system. CREBZF mice, female NOD-Lox (control) mice developed diabetes and died; however, LKO mice and their wild type littermates (WT) were divided into groups that surprisingly, >95% of NOD-LIRKO mice were normoglycemic and survived up were placed on a normal chow diet, or a type 2 diabetogenic diet composed to 2 years. NOD-LIRKOs showed increased β-cell proliferation, hyperplastic of high fat, high sucrose (HFHS). Under the condition of chow diet, no obvi- islets and decreased β-cell apoptosis. While NOD-LIRKO mice exhibited virtu- ous phenotypes were observed in mice between two genotypes. However, ally absent lymphocyte infiltration in islets, it was clearly detected in salivary in response to HFHS diet, CREBZF LKO mice were protected against hepatic glands in both groups suggesting islet specific protection. FACS analyses steatosis as evidenced by histological staining such as H&E and Oil Red O, revealed a significant increase in regulatory T-cells (Tregs) (p=0.008) in NOD- as well as lipid quantification using methanol/chloroform extraction. CREBZF LIRKO mice. Adoptive transfer studies showed that total splenocytes (SPLs) LKO mice showed low glucose levels in the fasted condition and during an from normoglycemic NOD-LIRKO mice failed to transfer diabetes into 66.6% intraperitoneal glucose challenge, suggesting improved insulin sensitivity. of immunodeficient NOD.Rag1(-) mice (n=12) and prevented development of Furthermore, hepatic deficiency of CREBZF resulted in a profound reduction of diabetes in 69.2% of prediabetic NOD-Lox animals (n=13). In contrast, 100% the key lipogenic transcription factor SREBP-1 and its target enzyme fatty acid of mice developed diabetes after receiving NOD-Lox SPLs (n=12). Addition- synthase in mice fed with HFHS diet, suggesting that CREBZF is critical for de ally, transfer of SPLs, mixed from NOD-Lox and NOD-LIRKO mice in a ratio novo lipogenesis process in the liver. Given that CREBZF is activated in mouse of 1:1 or 3:1, protected 40% and 65% of recipient NSG mice from diabetes livers fed with HFD diet, hyperactivation of CREBZF may cause accumulation of development respectively. Finally, transfer of diabetogenic SPLs from NOD excessive lipid storage, leading to hepatic steatosis and insulin resistance. Our mouse donors led to diabetes only in NSG but not in NOD-LIRKOs. Immuno- studies indicate that targeting CREBZF may represent an attractive therapeu- flourescent staining of pancreas and proteomics analyses ofβ -cells revealed tic approach for treating fatty liver disease and type 2 diabetes. significantly reduced expression ofβ -cell Beta-2-Microglobulin (B2M) in Supported By: National Natural Science Foundation of China (81270930, NOD-LIRKOs. These data provide novel evidence that enhanced proliferation 31471129, 31671224) early in life alters the identity of β-cells leading to altered self-reactivity of effector cells and a beneficial increase in Tregs to prevent progression of T1D. 26‑OR Supported By: JDRF (2-SRA-2015-17-Q-R) Hepatic Insulin Signaling Regulates Follistatin to Coordinate Hepatic Glucose Production 24‑OR RONGYA TAO, KYLE COPPS, OLIVER STOHR, MORRIS F. WHITE, Boston, MA UBASH3A Mediates Risk for Type 1 Diabetes through Inhibition of Many systemic factors contribute to dysregulated glucose tolerance, which can progress to type 2 diabetes when insulin secretion fails to com- T-Cell Receptor-Induced NF-κB Signaling YAN GE, TAYLOR K. PAISIE, PATRICK CONCANNON, Gainesville, FL pensate for systemic insulin resistance. Excess hepatic glucose production ORALS Although over 40 type 1 diabetes (T1D) risk loci have been mapped in (HGP) is an important cause of fasting hyperglycemia in type 2 diabetes. Pri- humans, the causative genes and variants for T1D are largely unknown. Here, mary hepatic insulin resistance caused by genetic inactivation of the hepatic we investigated a candidate gene in the 21q22.3 risk locus—UBASH3A, which Irs1 (insulin receptor substrate 1) and Irs2 (LDKO-mice) impaired the suppres- is primarily expressed in T-cells. UBASH3A has three functional domains: the sion of HGP by insulin. Deletion of hepatic FoxO1 in LDKO-mice (LTKO-mice) N-terminal UBA (Ubiquitin-associated), SH3 (SRC Homology 3), and the C-ter- completely restored the suppression of HGP by insulin—although without minal histidine phosphatase. UBASH3A is thought to function as a weak phos- restoring hepatic insulin signaling. We also observed that insulin sensitiv- phatase and play a minor role, largely redundant to its paralogue, UBASH3B. ity of white adipose tissue (WAT) was regulated by hepatic FoxO1, which However, genetic variants in UBASH3A have been shown to be associated contributed to the increased HGP in LDKO mice. To establish a molecular with several autoimmune diseases in addition to T1D while no associations link between liver and WAT, we screened for the metabolic effects of hepa- are reported at UBASH3B. In order to identify the unique functions of UBA- tokines that were dysregulated in LDKO-mice, but normalized in LTKO-mice. SH3A underlying the reported disease associations, we used CRISPR/Cas9 as Among these dysregulated hepatokines, excess circulating Follistatin-315 well as overexpression to manipulate UBASH3A levels in the human T-cell line, (FST315) led to WAT insulin resistance and increased HGP, whereas knock- Jurkat. Our study reveals previously unrecognized roles of UBASH3A in human down of FST improves WAT insulin sensitivity and decreased HGP in mice. T-cells: UBASH3A interacts with non-degradative polyubiquitin chains via its Moreover, FST elevated HGP not totally dependent on insulin resistance in UBA domain, and attenuates the NF-κB signal transduction upon T-cell recep- WAT. Mechanistically, excess of FST decreased oxygen consumption and tor (TCR) stimulation by specifically suppressing the activation of the IKK com- carbon dioxide (CO2) production as a result of inhibition of Acetyl-CoA oxida- plex, leading to decreased IL-2 production. Further, we characterized 2 T1D- tion through TCA cycle and oxidative phosphorylation in liver mitochondria, associated, common variants in UBASH3A, rs11203203 and rs1893592: The which facilitated gluconeogenesis. risk allele at rs11203203, which is located in a potential enhancer in T-cells, In summary, the insulin-FoxO1-Follistatin signaling cascade in the liver increases UBASH3A expression in human primary CD4+ T-cells upon TCR stim- plays an important role in the regulation of glucose homeostasis and adipose ulation. The protective, minor allele of rs1893592 leads to a novel transcript tissue insulin sensitivity and hepatic FST can be exploited as drug target to running into intron 9, which is predicted to produce a truncated UBASH3A normalize HGP in diabetes.

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A7 MOLECULAR REGULATORS OF METABOLISM

27‑OR Metabolic effects of roflumilast were investigated in C57BL/6J mice Glucagon Regulates Fatty Acid-Mediated Increases in Hepatic (n=15/group) on HFD treated with roflumilast for 11 weeks. Glucose Production via Fatty Acid Oxidation in Human iPS-Derived Roflumilast led to reduced body weight gain (35g [cont.] vs. 32g [rofl.]; Hepatocytes p<0.0001), which became apparent after 2 weeks of treatment. This was WILLIAM C. ROELL, AJIT REGMI, MELISSA K. THOMAS, Indianapolis, IN attributable to an increase of energy expenditure (7.6cal/h/gBW [cont.] vs. Elevated free fatty acid levels in dyslipidemic states have been implicated 8.7cal/h/gBW [rofl.]; p<0.05), mainly driven by enhanced glucose oxidation as potential contributors to dysregulation of hepatic glucose production and (17.5g/min/gBW [cont.] vs. 21.7g/min/gBW [rofl.]; p<0.001), while food intake hyperglycemia in type 2 diabetes (T2D). However, cellular mechanisms that was paradoxically increased by roflumilast treatment (1.5g/day [cont.] vs. integrate fatty acid and glucose metabolism in the liver are incompletely 2.1g/day [rofl.]; p<0.01). Interestingly, roflumilast decreased fasting glucose understood. Using a novel human iPS-derived hepatocyte model in which levels (138mg/dl [cont.] vs. 114mg/dl [rofl.]; p<0.05) and improved glucose tol- glucagon and insulin dose-dependently counter regulate hepatocyte glu- erance by enhancing insulin sensitivity, which was confirmed by increased cose output (HGO), we investigated the regulation and integration of fatty insulin signaling (Akt-phosphorylation in liver and WAT). Roflumilast-treated acid oxidation (FAO) and HGO pathways. Palmitate administration increased mice further exhibited reduced hepatic lipid accumulation (total choles- both FAO and HGO. The contribution of palmitate administration to FAO was terol, triglycerides; p<0.01) associated with a reduction of circulating liver demonstrated by increased oxygen consumption rate (OCR) and 14C-palmi- enzymes (AST, ALT) and hepatic expression of inflammatory (F4/80 and Saa1) and fibrosis (Col1a1 and Col3a1) markers. Mechanistically, roflumilast tate incorporation into CO2. FAO inhibition by the CPT-1 inhibitor etomoxir suppressed palmitate-dependent OCR and 14C-palmitate incorporation. induced hepatic PKA-activity with increased CREB and AMPK activation Notably, glucagon regulated the integration of FAO with HGO. Glucagon leading to PGC-1α induction and increased expression of mitochondrial (mt) dose-dependently enhanced the contribution of palmitate to increase HGO. DNA and mt fission- and fusion markers. Consistently, roflumilast increased Inhibition of FAO with etomoxir abrogated the ability of glucagon to drive cellular respiratory capacity of hepatocytes under in-vitro-conditions in a palmitate-dependent glucose output. Although insulin decreased total HGO, PKA-dependent manner (177pM/min/µg [cont.] vs. 219pM/min/µg [rofl.]; insulin did not reduce palmitate-dependent HGO. Palmitate impaired insulin p<0.05). signaling as demonstrated by reduced Akt phosphorylation (T308, S473), but PDE4-inhibition may provide a novel target for weight loss strategies did not influence glucagon induction of cAMP accumulation. These findings especially in conditions with associated co-morbidities like insulin resis- provide new perspective on glucagon-mediated integration of FAO and HGO. tance and nonalcoholic steatohepatitis. Elucidating regulatory mechanisms of fatty acid utilization by the liver may lead to better understanding of how dyslipidemic and insulin resistant states 30‑OR contribute to dysregulated glucose production in T2D. miR-29 Family Members Target SPARC and Negatively Regulating Glucose Metabolism 28‑OR HAIYAN SONG, LUJIE YANG, YANHE WANG, HUA XIE, Harbin, China Hepatic Insulin Sensitivity Is Improved in High-Fat Diet (HFD)-Fed Recent studies have reported that miR-29 family of microRNAs play PARKIN KO Mice in Association with Increased Hepatic AMPK an important role in biological processes and diseases. Secreted Protein, Activation and Reduced Steatosis Acidic and Rich in Cysteine (SPARC), plays multiple roles in many processes, LIA R. EDMUNDS, BRYDIE R. HUCKESTEIN, YANXIA CHU, YINGZE ZHANG, including obesity and type 2 diabetes. In this study, using TargetScan and MICHAEL J. JURCZAK, Pittsburgh, PA miRanda, we found that SPARC is a potential target of miR-29 family. Bio- PARKIN is a ubiquitin E3 ligase that regulates mitochondrial homeostasis informatic analysis showed that the miR-29 targeting sites on the SPARC via mitophagy. PARKIN KO mice are protected from diet-induced obesity in 3’UTR sequence. Based on luciferase report assays, we found that overex- part due to altered intestinal lipid absorption and have improved hepatic insu- pression of the miR-29 mimics significantly reduced SPARC 3’UTR reported lin sensitivity prior to changes in body weight. To understand the mechanism gene activity, indicating that miR-29a/b/c could directly target the 3’ UTR for improved hepatic insulin sensitivity in HFD fed KO mice we evaluated sequence of SPARC. We cotransfected HEK293T cells with a plasmid encod- changes in hepatic lipids, activation of the ER stress response and altera- ing WT or mutant SPARC 3’UTR or an empty plasmid, together with the miR- tions in inflammatory cytokine levels in low-fat diet (LFD; 10% kcal fat) and 29a, miR-29b and miR-29c mimics. Overexpression of WT but not the mutant HFD (10 days 60% kcal fat) fed WT and KO mice. Liver triglycerides (TG) miR-29 targeting sequence significantly reduced SPARC protein levels, pro- increased 40% in WT mice following HFD (P<0.05) while KO liver TG remained viding further evidence that miR-29 family members could downregulate the unchanged and was 36% less than HFD WT (P<0.05). Diacylglycerol levels, expression of SPARC by directly targeting 3’UTR sequence. To determine which positively associate with insulin resistance, were 60% less in KO mice whether miR-29 family plays a role in the regulation of Glut4 gene expres- (P<0.01) and ceramides were modestly elevated 13% (P<0.05). Transcriptional sion through mediated by SPARC, we transfected 3T3-L1 adipocytes with markers of the IRE1α, eIF2α, and ATF6 arms of the ER stress response were SPARC expression plasmid together with or without miR-29a/b/c mimics. unchanged (Sil1, Atf4, Gadd34) or suppressed (Dnajb9, Edem, Rpn1, Dnajc3, Overexpression of miR-29a/b/c mimics significantly decreased the expres- Erp72, Ero1β; P<0.01) in HFD KO liver. There were no detectable differences sion of Glut4. The downregulation effect of miR-29a/b/c, was significantly in plasma INFγ, IL12p70, IL18, IL2, IL5, IL4 or CXCL1, while TNFα, IL6 and IL10 suppressed by coexpression of SPARC, indicating that SPARC acts down- were significantly increased in HFD KO mice. Plasma leptin was 17.8x less stream of miR-29a/b/c. These findings reveal that miR-29a/b/c regulates ORALS in HFD KO compared with WT (P<0.001) and resistin was modestly reduced Glut4 gene expression by suppressing SPARC in 3T3-L1 adipocytes. Our (1.4x; P<0.08). Hepatic AMP:ATP was increased 1.8x (P<0.05) in HFD KO vs. results showed that all three miR-29 family members can target SPARC. miR- WT mice and was associated with increased phosphorylation of AMPKα 29 is a negative regulator of glucose metabolism, which through reducing (Thr172) (2.2x; P<0.01). Consistent with AMPK activation, malonyl-CoA was glucose uptake and Glut4 expression in 3T3-L1 adipocytes. miR-29 involved reduced 30% (P<0.05) and expression of several genes including Fasn, Hnf1α, in glucose metabolism through inhibiting SPARC expression. Srebp1, Apob, Apoc3, and Pklr were significantly reduced. Supported By: National Natural Science Foundation of China (81370903 to H.S.) Conclusion: PARKIN KO mice are protected from hepatic insulin resistance during HFD due to reduced hepatic energy charge and activation of AMPK. 31‑OR These data demonstrate that negative energy balance produces insulin sen- Activation of Dynamin-Related Protein 1-Dependent Mitochondrial sitizing effects through multiple mechanisms. Fission in the Dorsal Vagal Complex Is Sufficient and Necessary to Supported By: National Institutes of Health (K01DK099402 to M.J.J.) Induce Insulin Resistance MONA A. ABRAHAM, BEATRICE M. FILIPPI, PAMUDITHA SILVA, MOZHGAN 29‑OR RASTI, MARY P. LAPIERRE, PAIGE V. BAUER, JONATHAN V. ROCHELEAU, TONY The PDE4 Inhibitor Roflumilast Reduces Weight Gain by Increasing K.T. LAM, Toronto, ON, Canada, Leeds, United Kingdom, Zürich, Switzerland Energy Expenditure and Leads to Improved Glucose Metabolism Mitochondria undergo fusion, fission, transport, and degradation to JULIA MOELLMANN, FLORIAN KAHLES, CORINNA LEBHERZ, BEN KAPPEL, remain functional and maintain energy homeostasis in eukaryotic cells. Insu- CHRISTER BAECK, FRANK TACKE, CHRISTIAN WERNER, MASSIMO FEDERICI, lin action in parallel regulates cellular and whole-body glucose homeostasis NICKOLAUS MARX, MICHAEL LEHRKE, Aachen, Germany, Saarland, Germany, but whether specific changes of mitochondria dynamics directly alter cellu- Rome, Italy lar insulin signaling and whole-body glucose regulation remain unclear. We The PDE4 inhibitor roflumilast is a approved drug for COPD treatment and here report that high-fat diet feeding in rodents incurred adaptive dynamic was found to reduce body weight and to improve glucose metabolism by a changes of mitochondria through an increase in mitochondrial fission in yet unknown mechanism. parallel to an activation of Dynamin-related Protein 1 (Drp1) in the dorsal

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A8 MECHANISMS OF INSULIN SENSITIVITY AND INSULIN SECRETION vagal complex (DVC) of the brain. Chemical inhibition of Drp1 by MDIVI-1 and improvements in SI to remitters (R) during follow-up. However, at base- negated high-fat feeding-induced mitochondrial fission, ER stress and insulin line, NR had longer diabetes duration, lower insulin secretory capacity, and resistance in the DVC and subsequently restored hepatic glucose production higher proinsulin and proinsulin:insulin ratio levels than did R. They also had regulation in vivo. The effects of MDIVI-1 were complemented with molecu- lower AIRg during follow-up. Similar amounts of DI improvement among R lar inhibition of Drp1 by expressing the dominant negative form of Drp1 in vs. NR were found but were due almost entirely to increases in SI, not AIRg. the DVC. Conversely, molecular activation of DVC Drp1 in healthy rodents In conclusion, NR had worse pre-RYGB beta cell function and lacked beta was sufficient to induce DVC mitochondrial fission and ER stress as well as cell function improvement with RYGB. Islet cell recovery is more important insulin resistance. Taken together, these data illustrate that Drp1-dependent than changes in SI as a determinant of initial and durable DM2 remission mitochondrial fission in the DVC is sufficient and necessary to induce insulin af ter GBP. resistance and dysregulate hepatic glucose production, and suggest that Figure. targeting the Drp1-mitochondrial-dependent pathways in the brain may carry therapeutic potential to reverse insulin resistance. Supported By: Canadian Diabetes Association; Natural Sciences and Engineer- ing Research Council of Canada

32‑OR Impaired Mitochondrial ATP Synthase Supercomplex Formation with Akt1 Led to Loss of Mitochondrial Cristae and Development of Diabetic Cardiomyopathy YUMAY CHEN, YU-HAN CHEN, GRANT MACGREGOR, HSIAO CHEN LEE, MIN LIU, PING H. WANG, Irvine, CA Mitochondria dysfunction plays a critical role during the development of diabetic cardiomyopathy but its underlying mechanisms is not clear. To elucidate the causal relationship between impaired mitochondrial Akt1 signaling and the development of diabetic cardiomyopathy, we have gen- erated a transgenic mouse by knocking in a tamoxifen-inducible mitochon- dria-targeting dominant negative Akt (CAMDAKT mice). Cardiac specificity was achieved with the Cre-Lox system and the cytosolic Akt signaling was not altered. CAMDAKT heart developed loss of mitochondria cristae, fol- lowed by cardiomyocytes apoptosis, cardiac fibrosis, and heart failure. Pro- Supported By: National Institutes of Health teomic analysis indicated two major targets of Akt actions were impaired in mitochondria, pyruvate dehydrogenase complex (PDC) and ATP synthase 34‑OR (OXPHOS Complex V). Akt1 interacted with the E3 subunit of PDC and PDC Subcellular Localization of Diacylglycerol and Ceramide Influences activity was reduced in CAMDAKT mice. Akt1 interaction with ATP synthase Insulin Resistance in Human Skeletal Muscle supercomplex was disrupted. Insulin-stimulated formation of ATP synthase BRYAN C. BERGMAN, SEAN A. NEWSOM, ALLISON STRAUSS, ANNA KEREGE, supercomplex was impaired in the CAMDAKT heart. The C subunit failed DARCY KAHN, KATHLEEN HARRISON, LEIGH PERREAULT, Aurora, CO, Corvallis, to form complex with ATP synthase in the CAMDAKT heart; the gamma OR and delta subunits associated with the complex were also reduced. These Accumulation of diacylglycerol (DAG) and ceramides is thought to promote data suggested structural breakdown of the ATP synthase F0 component, skeletal muscle insulin resistance, and localization plays an important role. which anchors formation of mitochondria cristae, and provided mechanistic Recent data indicate these lipids are located in mixed membrane fractions, explanation of the mitochondria structure phenotype. Mitochondria metabo- however the exact membranes are unknown. We evaluated sub-cellular lomic survey and biochemical assays showed perturbation of TCA cycle to localization of skeletal muscle DAG and ceramides in lean (n=15), endurance compensate for reduced pyruvate available for glycolytic oxidation, and ATP trained athletes (n=16), obese (n=15), and type 2 diabetic (n=12) men and synthase activity was impaired. Mitochondria used alternative substrate for women. Muscle biopsies were fractionated into sarcolemmal, cytosolic, oxidative phosphorylation at the expense of oxidative stress in the CAM- mitochondrial/endoplasmic reticulum, and nuclear compartments. Lipids DAKT heart. These findings suggest that impaired mitochondrial Akt1 sig- were measured using LC/MS/MS, and insulin sensitivity using hyperinsu- naling to PDC and ATP synthase could be novel mechanisms underlying the linemic-euglycemic clamps. Sarcolemmal and mitochondrial/ER membranes development of diabetic cardiomyopathy. contained the majority of DAG and ceramides, and no differences were Supported By: National Heart, Lung, and Blood Institute (R01HL096987); Ko found between groups for 1,3-DAG. Sarcolemmal 1,2-DAG accumulated in Family Foundation obese and T2D compared to lean, but was greatest in athletes (p=0.048). Sarcolemmal ceramide was greatest in T2D compared to the other groups

(p=0.01), with significantly more C16:0, C18:0, and C23:0 species. In the ORALS MECHANISMS OF INSULIN SENSITIVITY AND mitochondrial/ER fraction, 1,2-DAGs were significantly greater in lean and INSULIN SECRETION athletes compared to obese and T2D (p=0.002), and were positively related to insulin sensitivity (r=0.53, p<0.0001). Mitochondrial/ER ceramides were 33‑OR inversely related to insulin sensitivity (r=-0.29, p=0.03), with the strongest Islet Cell Secretory Dysfunction Characterizes Failure to Achieve or relationship observed for C18:0 ceramide (r=-0.44, p=0.001). When admin- Sustain Diabetes Remission after Bariatric Surgery istered to isolated rat mitochondria, C18:0 and C24:0 ceramide, and C18:0 JONATHAN Q. PURNELL, GEOFFREY S. JOHNSON, ABDUS S. WAHED, RONALD dihydroceramide significantly decreased state 3 respiration. Combined, L. PRIGEON, BRET H. GOODPASTER, DAVID E. KELLEY, MYRLENE STATEN, KAREN these data reveal previously unknown differences in sub-cellular localiza- FOSTER-SCHUBERT, DAVID E. CUMMINGS, DAVID FLUM, ANITA P. COURCOU- tion of skeletal muscle DAG and ceramides that relate to whole body insulin LAS, PETER J. HAVEL, BRUCE WOLFE, Portland, OR, Pittsburgh, PA, Baltimore, MD, sensitivity. These differences help explain discrepancies in the literature, Orlando, FL, Rahway, NJ, Bethesda, MD, Seattle, WA, Davis, CA and suggest specific cellular compartments should be considered when Type 2 diabetes (DM2) remission rates are ~60-70% after Roux-en-Y gas- evaluating the impact of DAG and ceramide on insulin sensitivity. tric bypass (RYGB). We sought to better understand the causes of failure to Supported By: National Institutes of Health achieve DM2 remission or of DM2 recurrence after RYGB. Forty DM2 and 20 Control subjects (C) underwent frequently-sampled intravenous glucose tolerance tests to determine insulin sensitivity (SI), islet secretory response (AIRg), and disposition index (DI) before and then 6 and 24 mos after RYGB. SI improved and AIRg increased in DM2. Despite an ~700% increase, the mean DI after 24 months in the DM2 group was still below the normative 5th percentile (Figure). After 24 mos, none of the C but 3 of the DM2 group had diabetes (91% remission rate). At baseline, non-remitters (NR) had simi- lar age and BMI, post-surgical weight loss, changes in adiponectin levels,

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A9 MECHANISMS OF INSULIN SENSITIVITY AND INSULIN SECRETION

35‑OR 37‑OR Significance of Feedback Inhibition of Insulin Secretion by Insulin Transendothelial Insulin Efflux in Skeletal Muscle Capillaries in Healthy Nonobese Men Occurs by Diffusion and Is Restricted in Diet-Induced Obese Mice HIDEYOSHI KAGA, YOSHIFUMI TAMURA, SAORI KAKEHI, YUKI SOMEYA, IAN M. WILLIAMS, ADAM R. MEZO, JAMEY D. YOUNG, K. SAM WELLS, DAVID RURIKO SUZUKI, DAISUKE SUGIMOTO, SATOSHI KADOWAKI, KAGEUMI TAK- H. WASSERMAN, Nashville, TN, Indianapolis, IN ENO, TAKASHI FUNAYAMA, YASUHIKO FURUKAWA, RYUZO KAWAMORI, HIRO- Objective: Before insulin can stimulate muscle glucose uptake, it must first TAKA WATADA, Tokyo, Japan move from the capillary to the interstitial space. The transendothelial efflux Endogenous insulin secretion is suppressed during hyperinsulinemic of insulin is an important regulatory step for insulin action and is potentially euglycemic clamp, which is known as a feedback inhibition of insulin secre- impaired during insulin resistance. The goal of this study was to determine tion (FI-IS) by insulin. Since FI-IS is impaired in obese subjects, inadequate the mechanism by which insulin exits capillaries in vivo and whether insulin FI-IS may partly contribute to enhanced insulin secretion seen in obesity efflux is impaired during insulin resistance. with insulin resistance. However, significance of FI-IS in nonobese healthy Methods: We developed an intravital imaging technique to assess insulin subjects is unknown. To clarify the significance, we studied 49 nonobese efflux. A bolus (4U/kg) of a fluorescent insulin probe (ins-647) was injected healthy Japanese men. We evaluated steady state serum C-peptide (SSSC) into mice. Ins-647 was imaged by confocal microscopy using a novel gas- and muscle insulin sensitivity (MIS) by hyperinsulinemic euglycemic clamp trocnemius preparation. Images were analyzed with a vascular segmenta- with tracer (insulin infusion rate = 20mU/m2 per min). We also measured tion algorithm and transport parameters were estimated by mathematical 1 intrahepatic lipid (IHL) by H-MRS. Based on the median of SSSC, we divided modeling. the subjects into low FI-IS group and high FI-IS group and compared clini- Results and Conclusions: We first examined whether insulin efflux occurs cal parameters. While fasting C-peptide level was comparable between the by a saturable, insulin receptor-mediated process. Male C57Bl/6 mice were groups, the SSSC was suppressed by 50% from baseline in the high FI-IS treated with S961, an antagonist of the insulin receptor. While S961 blocked group (1.14±0.39 to 0.57±0.24 ng/ml, P<0.001), but less suppressed in the the glucose-lowering effect of insulin, S961 had no effect on insulin efflux low FI-IS group (1.34±0.34 to 1.19±0.24 ng/ml, P=0.054). Although most of kinetics. We then tested whether insulin efflux is saturable by treating mice metabolic parameters such as fasting glucose, lipid levels and visceral fat with both ins-647 and unlabeled insulin. Treating mice with either 4U/kg or volume were comparable between the groups, low FI-IS group showed IHL 12U/kg of unlabeled insulin had no effect on the efflux kinetics of ins-647. accumulation (3.0±4.2 vs. 0.6±0.2%, P=0.04) and impaired MIS (0.19±0.04 These experiments suggest that insulin exits capillaries by diffusion. vs. 0.28±0.08 mg/kg FFM·min-1 ·μU-1·ml, P<0.001), compared with high FI-IS We next investigated whether insulin efflux is altered in insulin resistant group. Consistently, we observed elevated AUC of insulin during 75g-OGTT mice. Male and female C57Bl/6 mice were fed a high fat diet for 16 weeks in low FI-IS group (6.6±3.0 vs. 3.9±2.0 μU·min/ml·103, P=0.001), while AUC of to generate diet-induced obese (DIO) mice and subsequently underwent ins- glucose was comparable. 647 imaging. We found that the plasma/interstitial ins-647 gradient decayed In conclusion, even in healthy nonobese men, subjects with inadequate more slowly in both male and female DIO mice following the ins-647 bolus. FI-IS were existed and those were characterized by impaired MIS and hyper- This suggests that transendothelial insulin movement is restricted in DIO insulinemia during OGTT. These data suggested that impaired FI-IS may be mice. These findings raise possibility that delayed insulin efflux may be a early change to maintain metabolic status through enhancing insulin secre- component of muscle insulin resistance. tion in the face of moderate muscle insulin resistance in healthy nonobese Supported By: 1F31DK109594, 5T32DK007563-27, R01DK054; Lilly Research men. Laboratories Supported By: Japan Ministry of Education, Culture, Sports, Science and Tech- nology 38‑OR Effect of GLP-1 Receptor Antagonism Using Exendin-9,39 in the 36‑OR Fasting State on the Subsequent β-Cell Response to an Intravenous Intermuscular Adipose Tissue (IMAT) Inflammation, Extracellular Glucose Challenge in Nondiabetic Humans Matrix Remodeling, and Lipolysis Relate to Insulin Resistance in ANU SHARMA, MARCELLO LAURENTI, RON T. VARGHESE, NANA E. KITTAH, Human Skeletal Muscle CHIARA DALLA MAN, ROBERT A. RIZZA, CLAUDIO COBELLI, ALEKSEY V. MAT- BRYAN C. BERGMAN, LEIGH PERREAULT, JANET K. SNELL-BERGEON, TZU VEYENKO, ADRIAN VELLA, Rochester, MN, Padua, Italy, Padova, Italy PHANG, STEPHAN SACHS, SEAN A. NEWSOM, ALLISON STRAUSS, ANNA Glucagon-Like Peptide-1 (GLP-1) potentiates insulin secretion in response KEREGE, SUSANNA M. HOFMANN, Aurora, CO, Neuherberg, Germany, Corvallis, to an oral challenge. Exendin-9,39 a competitive antagonist of GLP-1, has OR been used to quantify the contribution of endogenous GLP-1 to glucose Intermuscular adipose tissue (IMAT) exists between muscle fibers under tolerance. In the presence of an I.V. glucose challenge with no increase in the muscle fascia and is positively related to insulin resistance. It is not GLP-1 secretion, Exendin-9,39 impairs β-cell function suggesting that fast- known how IMAT may promote insulin resistance as it has never been ing GLP-1 contributes to insulin secretion. We hypothesized that in the fast- directly sampled and studied in humans. We isolated IMAT from vastus ing state GLP-1 secretion primes the β-cell response to subsequent chal- lateralis biopsies, extracted RNA, and performed RNAseq analyses on lean lenges. To test this hypothesis we studied 13 nondiabetic subjects in random (n=10), endurance trained athletes (n=6), obese (n=11), and type 2 diabetic order. Glucose containing [3-3H]-glucose was infused to mimic the systemic ORALS (n=7) men and women. Insulin sensitivity was measured using a hyperin- appearance of glucose after a meal. β-cell function was measured using the sulinemic-euglycemic clamp. Expression of IMAT mRNA’s that significantly oral minimal model. On one occasion, saline (S), was infused for 3 hours prior related to insulin sensitivity and code for secreted proteins revealed sig- (-180 to 0 min) to the I.V. challenge, while on the other Exendin-(9,39) was nificant enrichment of extracellular matrix and inflammation pathways using infused at 750pmol/kg/min (Exe). Contrary to expectations, Exendin-(9,39) gene pathway analysis, which were further compared between groups. infusion prior to the i.v. challenge decreased integrated glucose concentra- mRNA expression of macrophage markers colony stimulating factor 1 (CSF1) tions (361 ± 32 vs. 137 ± 23 mmol per 6 hr, S vs. Exe, p < 0.01). This was due to and macrophage receptor with collagenous structure (MARCO) were signifi- increased peak insulin and C-peptide (2.0 ± 0.2 vs. 3.0 ± 0.4 nmol/l, p < 0.01) -9 -1 cantly greater in T2D vs. lean (CSF1 p=0.003, MARCO p=0.006), and CSF1 concentrations. The basal (ϕb), static (ϕs, 37 ± 12 vs. 49 ± 5 10 min , p = 0.03) was significantly greater in obese compared to lean (p=0.03). The inflamma- components as well as total β-cell responsivity (Φ, 38 ± 11 vs. 59 ± 7 10-9min- tory cytokine plasminogen activator inhibitor-1 (PAI-1) and TNFalpha induced 1, p = 0.02) were increased by prior Exe infusion. Glucagon suppression was protein 3 (TNFAIP3) were significantly greater in T2D compared to lean (PAI-1 unchanged. In separate experiments using perifused isolated human islets p=0.005, TNFAIP3 p=0.02) and athletes (PAI-1 p=0.008, TNFAIP3 p=0.002). from nondiabetic donors, pretreatment for 3 and 12 hours with Exe also Three extracellular matrix genes were significantly related to insulin sen- enhanced integrated insulin secretion in response to hyperglycemia (0.9 ± sitivity, including collagen type XXIV alpha 1 (r=-0.47, p=0.006), collagen 0.5 vs. 3.0 ± 0.5 vs. 4.1 ± 0.5 nmol/l, p<0.01) and hyperglycemia + GLP-1 (1.7 type V alpha 1 (r=-0.40, p=0.022), and fibronectin 1 (r=-0.44, p=0.011). Perili- ± 0.4 vs. 5.2 ± 1.2 vs. 5.6 ± 1.6 nmol/l, p<0.01). Taken together these results pin 5 mRNA expression was significantly lower in obese and T2D compared imply that GLP-1 receptor activation during fasting plays an important role to lean and athletes (p=0.009) suggesting greater IMAT lipolysis in insulin in the β-cell response to subsequent challenges and requires further study. resistance. Combined, these data suggest that IMAT may promote muscle Supported By: Endocrine Fellows Foundation insulin resistance by secreting FFA that drive muscle lipid accumulation, and proteins that alter the extracellular matrix and promote skeletal muscle inflammation. Supported By: National Institutes of Health

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A10 THE EXCITED BETA CELL

39‑OR THE EXCITED BETA CELL Reconstruction of Pulsatile Insulin Secretion into the Portal Vein Using Peripheral C-Peptide Concentrations 41‑OR MARCELLO LAURENTI, RON T. VARGHESE, CHIARA DALLAMAN, ANU SHARMA, A Ubiquitin-Dependent Mitophagy Complex Regulates Mitochon- NANA E.N. KITTAH, ROBERT A. RIZZA, GIUSEPPE DE NICOLAO, CLAUDIO COBE- drial Function and Insulin Secretion in Beta Cells LLI, ADRIAN VELLA, Padova, Italy, Rochester, MN, Pavia, Italy GEMMA PEARSON, BIAOXIN CHAI, TRACY VOZHEIKO, XUEYING LIU, MALATHI Diabetes, obesity and aging are associated with alterations in insulin KANDARPA, ROBERT PIPER, SCOTT SOLEIMANPOUR, Ann Arbor, MI, Iowa City, IA pulse amplitude and frequency. The direct contribution of insulin pulsatility Mitophagy is a selective catabolic process critical for the clearance of to type 2 diabetes remains understudied in part because of the difficulties dysfunctional mitochondria and is necessary to maintain cellular bioenerget- associated with its measurement. In humans this requires placement of a ics. While post-translational protein modifications by ubiquitination control hepatic vein catheter. Another limitation is that insulin concentrations in distal mitophagy effectors, including Parkin, the role of ubiquitin signals on the hepatic vein reflect hepatic extraction and insulin secretion. We recon- proximal mitophagy regulators are unknown. Here we report that upstream structed portal insulin secretion from peripheral C-peptide concentrations. control of mitophagy by the E3 ligase Nrdp1 and the deubiquitinase enzyme To do so, we studied 33 nondiabetic subjects (age = 44 ± 2, BMI = 28 ± USP8 is orchestrated by formation of a ubiquitin-dependent complex that 2 1 Kg/M ). After an inpatient, overnight fast, a hepatic vein catheter was includes Clec16a, a recently identified regulator of mitophagy with unclear placed to allow sampling of hepatic vein insulin at 2 minute intervals. Periph- molecular function. We discover that the diabetes gene Clec16a encodes eral venous blood was sampled simultaneously. During the latter phase of an E3 ligase that directly ubiquitinates its partners to promote assembly the experiment glucose was maintained at 150mg/dL using a hyperglycemic of a critical Clec16a-Nrdp1-USP8 mitophagy complex and control activation clamp. Separately, after a euglycemic clamp with somatostatin to inhibit of Parkin. Importantly, we identify that the chemotherapeutic lenalidomide, endogenous insulin secretion, subjects received a C-peptide bolus to cal- a selective ubiquitin ligase inhibitor associated with new onset diabetes, culate individual rates of C-peptide clearance. This enabled calculation of inhibits Clec16a-mediated ubiquitination and impairs β-cell mitophagy, cel- insulin secretion rates (ISR) by deconvolution. Pulse characteristics obtained lular respiration, and insulin release. Patients treated with lenalidomide by deconvolution were compared to hepatic vein insulin concentrations. develop impaired β-cell function, illustrating the importance of Clec16a- We identified an impaired incremental response of basal insulin secretion mediated ubiquitination in the prevention of diabetes in humans. Moreover, to hyperglycemia in people with impaired glucose tolerance (IGT) compared Clec16a-directed ubiquitination of Nrdp1 is vital to regulate β-cell function, to normal glucose tolerance (NGT - 53.5 ± 1.9 vs. 26.1 ± 4.0%, p = 0.05). as a ubiquitination-deficient form of Nrdp1 impairs Clec16a-Nrdp1-USP8 This was also observed with the method using hepatic vein insulin concen- complex assembly and glucose-stimulated insulin release. Furthermore, trations. Insulin pulse amplitude did not differ between NGT and IGT using we determine that formation and function of the Clec16a-Nrdp1-USP8 com- either method. The pulse interval measured from hepatic vein insulin con- plex is disrupted in models of (gluco) lipotoxicity and type 2 diabetes. Thus, centrations also did not differ from that obtained by deconvolution (5.6 ± 0.4 assembly of a ubiquitin dependent Clec16a-Nrdp1-USP8 mitophagy complex vs. 5.5 ± 0.2 min, p = 0.88). These data imply that with appropriate deconvo- is necessary to foster β-cell insulin release, which could be harnessed in the lution of peripheral C-peptide concentrations, peripheral venous sampling of treatment or prevention of diabetes or other mitophagy-related diseases. C-peptide can be used to measure insulin pulsatility. Supported By: National Institutes of Health; JDRF; Central Society for Clinical Supported By: National Institutes of Health and Translational Research

40‑OR 42‑OR Regulation of Mitochondrial Energy Metabolism and Insulin Sensi- C1ql3 Antagonizes GLP-1-Induced Insulin Secretion by Bai3 Adhe- tivity by the Ndufb6 Subunit of the Electron Transport System Com- sion G-Protein Coupled Receptor in Pancreatic Beta Cells plex I in C2C12 Myotubes RAJESH GUPTA, JAMES E. KOLTES, SUSHANT BHATNAGAR, Birmingham, AL, TOMAS JELENIK, SVEN W. GÖRGENS, NINA KRAKO JAKOVLJEVIC, ILKA ROK- Fayetteville, AR ITTA, NEBOJSA M. LALIC, JUERGEN ECKEL, MICHAEL RODEN, Düsseldorf, Ger- We are interested in identifying and characterizing secreted proteins that many, Belgrade, Serbia are regulators of beta cell function. To identify novel secreted proteins, we Impaired mitochondrial function associates with insulin resistance in skel- developed TissueTalk method in R-programming, and in-combination with etal muscle, yet the causal relationships and mechanisms are unclear. We bioinformatic approaches we analyzed microarray gene expression data set have shown that a polymorphism in the Ndufb6 subunit of the mitochondrial for liver, gastrocnemius, adipose, and islets harvested from 10-wk old lean complex I relates to impaired mitochondrial plasticity after exercise and and ob/ob C57B6/J mice. TissueTalk utilizes changes in gene expression, age-related susceptibility to insulin resistance in humans. Here, we hypoth- cross-tissue correlation network, and gene enrichment to predict the tissue esize that reduced Ndufb6 activity reduces oxidative capacity and in turn of origin for a secreted protein and make cellular pathway predictions in insulin signaling in myotubes. Differentiated C2C12 myotubes treated with target tissue(s). We identified C1ql3 as the top candidate and predicted that Ndufb6 siRNA to induce its knockdown (siNdufb6) as well as with nega- it will regulate cellular pathways associated with secretory processes in tive control siRNA (NT) were studied under basal, palmitate-treated, and/or islets. Preliminary data show that the expression of C1ql3 in islets of obese electrical pulse-stimulated (EPS) conditions simulating muscle contraction mice is increased by 32-fold. Adding C1ql3 conditioned media inhibits high ORALS (n=4-6). Mitochondrial oxidative capacity was measured by high-resolution glucose, Excendin-4 (GLP-1 receptor(R) agonist), and cAMP induced insulin respirometry in digitonin-permeabilized cells. Reactive oxygen species (ROS) secretion in mouse and human islets. Strikingly, insulin secretion stimulated were detected by DCF fluorimetry. Insulin signaling was assessed in insu- by low and submaximal glucose, fatty acids, amino acids, mitochondrial lin-treated cells by Western blots. Ndufb6 mRNA and protein levels were metabolites, and membrane depolarization was not affected. Cell adhesion silenced by 70% and by 40%, respectively, after 24 h of siRNA treatment. G-protein coupled Bai3 is a receptor for C1ql3. As yet, Bai3 function is not State u respiration with complex I substrates was 36% lower in siNdufb6 studied in beta cells. We show that the expression of Bai3 is significantly than in NT (p<0.05). While there were no differences in state u respiration increased in islets of obese diabetic vs. nondiabetic mice. Knockdown of with octanoyl-carnitine, EPS-stimulated state u respiration was abolished in Bai3 receptor in beta cells by 50% increases glucose stimulated insulin siNdufb6 myotubes. ROS production was 18% higher in siNdufb6 (p<0.01) secretion by 2-fold and mediates the inhibitory effects of C1ql3 on insulin and not further stimulated by palmitate. In contrast to NT, EPS did not rescue secretion. These findings identify a novel pathway that when activated the palmitate-induced decrease in pAkt(Ser473), which was decreased by inhibits insulin secretion by antagonizing GLP-1/cAMP signaling in islets. 48% in siNdufb6 under these conditions (p<0.001). Thus, reduced Ndufb6 Herein, we propose that activation of Bai3 signaling increases beta-cell fail- activity redirects electrons from oxidative phosphorylation towards electron ure and progression to diabetes. Additionally, designing antagonists of Bai3 leakage. Lower oxidative capacity and higher ROS production could contrib- receptor will increase the efficacy of GLP-1 R agonist drugs currently used ute to the impairment of both insulin sensitivity and lower exercise respon- for the treatment of diabetes. siveness in humans with G/G-single nucleotide polymorphism in Ndufb6. Supported By: German Center for Diabetes Research; German Diabetes Asso- ciation

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A11 THE EXCITED BETA CELL

43‑OR 45‑OR Kv2.1 Clusters and Their Structural Role in Insulin Granule Fusion Does Bariatric Surgery Build Better Beta Cells? Vertical Sleeve in Human Beta Cells Gastrectomy Stimulates Autonomous Improvements to Islet Func- JIANYANG FU, XIAOQING DAI, GREG PLUMMER, KUNIMASA SUZUKI, JOHN tion in Mice GITHAKA, DAFNA GREITZER, METTE JENSEN, JOCELYN E. MANNING FOX, HER- JONATHAN DOUROS, JINGJING NIU, SOPHIA SDAO, TRILLIAN GREGG, MAT- BERT Y. GAISANO, CHRISTOPHER B. NEWGARD, NICOLAS TOURET, PATRICK E. THEW J. MERRINS, JENNY TONG, JONATHAN CAMPBELL, DAVID A. D’ALESSIO, MACDONALD, Edmonton, AB, Canada, Toronto, ON, Canada, Durham, NC Durham, NC, Madison, WI, Charlotte, NC Exocytosis of insulin-containing secretory granules from beta-cells is Bariatric surgery has been used to treat obesity for decades, but recent tightly regulated by ion channels, which control excitability and calcium studies demonstrate these procedures also significantly improve obesity- influx. Kv2.1, which mediates the repolarization of action potentials and related comorbidities like diabetes. There is ongoing debate as to whether interacts with SNARE proteins such as Syntaxin1A, is known to target to resolution of diabetes after surgery is simply a function of negative energy large cell surface clusters on the soma and proximal dendrites of neurons. balance and enhanced insulin sensitivity, or do procedures like vertical We herein sought to test the hypothesis that Kv2.1 may also form clusters in sleeve gastrectomy (VSG) improve β-cell function and glucose disposal inde- human beta-cells, and examined the role for these as facilitators of insulin pendent of weight loss or caloric restriction. We have developed a mouse exocytosis. We found that Kv2.1 clusters, formed by ~8 tetrameric chan- model of VSG, the most widely used bariatric procedure performed today, nels, exist in both insulinoma cells and human beta-cells. These co-localize and used it to test the hypothesis that surgery affects β-cell function inde- with Syntaxin 1A clusters and membrane-resident secretory granules, and pendent of body weight, caloric restriction, or surgical stress. Ten days post- increase in density upon glucose-stimulation. Live-cell TIRF imaging reveals surgery VSG mice and their pair-fed, sham operated controls (PF-sham) have that wild type Kv2.1 increases insulin granule fusion events, while a cluster- similar body weights and insulin sensitivity. However, the VSG group has ing-deficient mutant (Kv2.1-deltaC318) which retains electrical function and reduced glycemia and greater insulin secretion after an IP glucose challenge. syntaxin 1A binding does not. In beta-cells from human donors with type 2 In addition, the VSG animals have increased insulin responses to a mixed diabetes (T2D), Kv2.1 mRNA is reduced by 80% and membrane-associated meal gavage and refeeding after a fast. Islets isolated from VSG animals had Kv2.1 clusters are decreased. The impaired function of T2D beta-cells can significantly increased insulin secretion andβ -cell Ca2+ flux in response to be at least partly rescued by up-regulating the full-length Kv2.1 which glucose stimulation compared to PF-sham animals. Furthermore, transcrip- increases secretory granule recruitment, exocytosis measured by patch- tomic analysis of the islets from VSG operated animals reveals significant clamp capacitance, insulin granule fusion events observed in live-cell TIRF, enrichment of metabolic gene networks linked to insulin secretion and glu- and glucose-stimulated insulin secretion. Finally, the clustering-deficient cose sensitivity. These data indicate that VSG improves glucose tolerance Kv2.1-deltaC318 is unable to rescue the insulin granule fusion deficiency in independent of weight loss, caloric restriction, or surgical stress, and that T2D beta-cells. Our work identified that, Kv2.1 can directly facilitate insulin this effect is due to enhanced insulin secretion. Moreover, our findings sug- exocytosis, and that this likely depends on channel clustering. It suggests an gest that VSG confers intrinsic changes that are autonomous to the islet, important micro-domain structural role for the channel at the exocytotic site, thereby improving β-cell function. which may contribute to impaired insulin secretion when Kv2.1 expression Supported By: American Diabetes Association (1-16-IBS-212 to M.J.M.) is reduced in T2D. Supported By: Canadian Institutes of Health Research; Alberta Diabetes Foun- 46‑OR dation Full Activation of GPR40 by GPR40 Ago-PAMs Impairs Beta-Cell Function and Causes Hyperglycemia in Rats 44‑OR NINA XIAOYAN LI, YUE FENG, SHENG PING WANG, LIMING YANG, MARGA- Characterization of Insulin-Like Growth Factor-2 Receptor (IGF-2R) RET WU, YING QIAN, GE DAI, JUN YAO, JINQI LIU, MICHELE PACHANSKI, DAN in Pancreatic β-Cells KOSINSKI, MARIA E. TRUJILLO, GEORGE EIERMANN, DAVID E. KELLEY, MARK JUN SHIRAKAWA, ERIN R. OKAWA, ROHIT N. KULKARNI, Boston, MA ERION, LIANGSU WANG, ANDY HOWARD, Kenilworth, NJ, Rahway, NJ Growth factors such as insulin, IGF-1, and IGF-2 play crucial roles in pan- G-protein-coupled receptor 40 (GPR40) is a potential target for type 2 dia- creatic β cell function, proliferation, and survival via their cognate receptors. betes (T2D) pharmacotherapy since it is highly expressed in pancreatic islets IGF-2 is involved in GLP-1 mediated insulin secretion and β cell proliferation. and involved in the regulation of insulin secretion. GPR40 small molecule IGF-2R, also known as cation-independent mannose-6-phosphate receptor agonists have been developed with efficacy in augment of beta cell insulin (CI-MPR), functions to transport lysosomal enzymes to the lysosome and to secretion and lowering blood glucose in preclinical and clinical studies; how- clear IGF-2 from the cell surface as a scavenger receptor. However, the role ever, the long-term safety and viability of targeting GPR40 are still unsettled. of IGF-2R in β cell function has been unclear. In this study, we undertook For example, Takeda terminated the clinical trial of TAK-875, because of liver both in vitro knockdown and in vivo knockout approaches to directly assess toxicity. In our current study, we presented unexpected diverging effects the significance of IGF-2R inβ cells. IGF-2R was localized in cytosolic ves- of GPR40 on pancreatic islets activated by GPR40 full (ago-PAM) or partial icles in mouse and human β cells. In a stable IGF-2R knockdown β cell line agonists. We first showed that, unlike partial agonists, GPR40 ago-PAMs (IGF-2RKD), generated by lentiviral transduction, we observed decreased enhanced glucagon secretion in cultured rodent and human islets, and ele- glucose-induced insulin secretion (31% reduction, p<0.05, n=5), and vated plasma glucagon levels by 2-3 folds in eDIO mice, GK rats and lean ORALS enhanced cell proliferation (1.89-fold increase, p<0.01, n=6) as evaluated by NHP animals. Secondly, despite an early acute insulinotropic effect, a single MTT and EdU incorporation assays. Cells with IGF-2RKD also demonstrated dose of intraperitoneal injection of GPR40 ago-PAMs rapidly induced hyper- decreased autophagosomes after starvation, which was accompanied by glycemia in lean rats with remarkable reduction of pancreas insulin content reduction in the expression of p62, LC3B, and ULK1 (>70% reduction respec- and plasma insulin secretion after glucose challenge. In contrast, the rats tively, p<0.05, n=3), compared with control β cells. We also generated a treated with GPR40 partial agonists appeared normal. Lastly, molecular tamoxifen-inducible mouse insulin promoter-driven β cell-specific IGF-2R analyses revealed that GPR40 Ago-PAMs but not partial agonists signifi- knockout (βIGF-2RKO) mouse in which expression of IGF-2R in isolated islets cantly repressed rat and human beta cell insulin gene expression via induc- was reduced by ~80%. Male βIGF-2RKO mice exhibited impaired glucose tion of ER stress PERK-CHOP10 pathway, and pharmacological inhibition of tolerance 16 weeks after tamoxifen injection (p<0.05 at 30 and 60 min, n=7). PERK-CHOP10 activation partially eliminated the damaging effects of Ago- Both male and female βIGF-2RKO mice fed a high-fat diet demonstrated sig- PAMs. Using GPR40 KO rats, we confirmed this outcome of GPR40 ago-PAMs nificant glucose intolerance (p<0.05 at 15 and 30 min, p<0.01 at 60 and 120 was mediated specifically through GPR40. Thus, our data demonstrate that min, n=5) without alterations in insulin sensitivity compared with controls. GPR40 activation in pancreatic islets has a more complicated biology. Full Taken together, IGF-2R plays a potential role in insulin secretion, cell prolif- activation of GPR40 may lead to a detrimental outcome on glucose regula- eration, and autophagy, and participates in the regulation of pancreatic β tion, suggesting that additional attention on beta cell functionality must be cell function. paid during the development of GPR40 agonists for diabetes therapy. Supported By: National Institutes of Health

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A12 TARGETS AND PATHWAYS IN DIABETIC KIDNEY DISEASE

47‑OR TARGETS AND PATHWAYS IN DIABETIC KIDNEY Cystic-Fibrosis-Related Diabetes (CFRD) Results from Pancreatic DISEASE and Islet Inflammation rather than Islet Cell Dysfunction Caused from Defects in the Cystic Fibrosis Transmembrane Conductance 49‑OR Regulator (CFTR) Fibroblast Growth Factor-1 Prevents Diabetic Nephropathy through NATHANIEL J. HART, CODY FAYOLLE, ARIEL HELMS-THAMES, RADHIKA ARA- an Anti-JNK/NF- B Signal Pathway MANDLA, GREG POFFENBERGER, NRIPESH PRASAD, SHAWN E. LEVY, MITCH- κ QIAN LIN, LU CAI, YI TAN, Louisville, KY ELL L. DRUMM, MARCELA BRISSOVA, RITA BOTTINO, ALVIN C. POWERS, Nash- Fibroblast Growth Factor-1 (FGF-1) shows the unexpected metabolic role ville, TN, Huntsville, AL, Cleveland, OH, Pittsburgh, PA in glucose homeostasis, but its strong mitogenic activity hampers its wide CFRD is a common complication in individuals with cystic fibrosis (CF) use in diabetes. We have engineered a FGF-1 partial agonist carrying triple and this has led to the hypothesis that the CFTR plays an intrinsic role in mutations (FGF-1ΔHS). FGF-1ΔHS exhibited a major loss in proliferative poten- regulation of insulin secretion. To investigate this hypothesis, we used pan- tial, while preserving the full metabolic activity of wild type FGF-1 (FGF-1WT). creatic/constitutive (PDXCretuv) and cell specific/inducible (MIPCreERT) β In present study, we further tested the therapeutic effects of FGF-1ΔHS on approaches to delete exon 11 of the CFTR gene and examined human pancre- diabetic nephropathy (DN). Treatment of db/db type 2 diabetes (T2D) with atic tissue and islets from CF donors (n=6; 1 CF/5 CFRD). In both mouse mod- FGF-1s every other day for 2 months, both FGF-1WT and FGF-1ΔHS significantly els, oral glucose tolerance was normal and basal insulin secretion, glucose- reduced blood glucose and prevented glomerular hypertrophy and renal stimulated insulin secretion (GSIS), potentiated GSIS, and insulin content in fibrosis. Similarly, treatment of streptozotocin (STZ)-induced type 1 diabetes isolated islets were similar to controls. In the normal human pancreas, CFTR (TID) with FGF-1s also significantly prevented diabetes-induced renal mor- protein was not detected in islet endocrine cells. In CF pancreata, exocrine phological and functional changes, but without significant effects on blood tissue was almost completely lost and replaced with adipose/fibrotic tis- glucose levels. These results imply that the renal protection of FGF-1s is sue with islets embedded within this tissue. The remodeled CF pancreas independent of blood glucose lowering. Further mechanistic study revealed was inflamed containing a 6-fold greater number of CD45+ cells that were that both FGF-1WT and FGF-1ΔHS treatments significantly reduced the inflam- distributed throughout the fibrotic/adipose tissue and present within and matory cytokines expression and macrophage infiltration in renal tissues in surrounding islets. β cell area in human CF pancreata was decreased by both T1D and T2D, which were accompanied by an inhibition of inflammatory ~75%. Plasma C-peptide of CF patients (n=4) ranged from 0.04-4.54 ng/ml, signal JNK/NF-κB activation. Direct exposure of renal mesangial cell to high with 1/4 donors outside the normal range. In perifusion of CF islets (n=4), glucose or TNF-α induced inflammatory and fibrotic responses observed in 3/4 displayed GSIS and 4/4 showed potentiated GSIS. Glucagon secretion diabetes, which could be prevented by FGF-1s treatment through inhibit- was inhibited by high glucose and induced by low glucose + epinephrine in ing JNK/NF-κB activation. More importantly, administration of FGF-1ΔHS to 3/4 donors. However, insulin secretion was reduced and glucagon secretion 9-month-old db/db mice completely prevented the further development of increased compared to controls. RNA-Seq of CF islets demonstrated greater DN with remarkable amelioration of renal inflammation and fibrosis. These expression of genes related to immune cell function and signaling, but key results demonstrate that FGF-1 prevents DN largely via inhibiting renal islet gene expression was similar between CF and normal islets, including inflammation. FGF-1ΔHS might be a therapeutic approach for DN treatment insulin and glucagon. We propose islet hormone secretion is not directly without promoting undesired tissue proliferation. regulated by CFTR, but rather damage and inflammation in the CF pancreas Supported By: American Diabetes Association (1-13-JF-53 to Y.T.) leads to islet cell death/dysfunction. Supported By: National Institutes of Health; JDRF; U.S. Department of Veterans Affairs 50‑OR Additive Effects of Inhibiting Sodium-Glucose Cotransporter SGLT1 and SGLT2 on Blood Glucose Control in Akita Diabetic Mice 48‑OR PANAI SONG, AKIRA ONISHI, WINNIE HUANG, ROHIT PATEL, HONGYU QIU, Islet Morphology and Cell-Cell Signaling Is Altered after CFTR Inhi- ALEKSANDRA NOVIKOV, HERMANN KOEPSELL, VOLKER VALLON, San Diego, CA, bition Würzburg, Germany FIONA MANDERSON KOIVULA, DAWOOD KHAN, RYAN KELSEY, NEVILLE In euglycemia, SGLT2 and SGLT1 reabsorb 97 and 3% of the filtered glu- MCCLENAGHAN, ALAN HARPER, CATRIONA KELLY, Derry, United Kingdom, Coler- cose in the early and late proximal tubule, respectively. Diabetes and SGLT2 aine, United Kingdom, Stoke-on-Trent, United Kingdom inhibition increase the renal contribution of SGLT1 to renal glucose reabsorp- Introduction: Cystic Fibrosis-Related Diabetes (CFRD) is the largest extra- tion. We compared the effect of genetic Akita type 1 diabetes (AKITA) vs. pulmonary co-morbidity in CF, accelerates lung decline, and leads to earlier nondiabetic control mice (CON) in SGLT1 wild type (WT) and SGLT1 knockout mortality. Differences in islet morphology have been reported in CF. Gap junc- (KO) mice (all DBA2 background) treated with vehicle (VEH) or SGLT2 inhibi- tion (GJ) proteins essential to the maintenance of islet architecture, includ- tor dapagliflozin (DAPA, 7.5 mg/kg of diet, initiated at 4-5 weeks of age) (8 ing connexins (Cx) and the ubiquitous E-Cadherin, interact with CFTR. CFTR groups; n=11-19/group). All mice were fed a glucose-free diet (40% fructose) regulates Cx-mediated cell-cell communication in non-islet cell types. This to prevent glucose malabsorption in KO. At 14-15 weeks of age we measured study aimed to establish if CFTR inhibition affected islet morphology and the glomerular filtration rate (GFR; by plasma kinetics of FITC-sinistrin) and sys- expression of key GJ proteins, and the association with functional deficits. tolic blood pressure (SBP; by automated tail cuff) in conscious mice. In WT- ORALS Methods: Two islet cell lines (BRIN-BD11 and MIN6) and primary islets VEH, AKITA increased fed blood glucose levels (BGL) vs. CON (mean±SEM; (C57B/L6 mice) were used for all experiments. PCR and Western Blot con- 172 554±13 vs. 138±6 mg/dl), associated with higher GFR and urine albumin to firmed CFTR expression. CFTR was inhibited with CFTR-inh , or GlyH101. creatinine ratios (ACR) in AKITA vs. CON (GFR: 853±76 vs. 613±52 µl/min; Expression of Cx36, 43 and E-cadherin was assessed by qPCR. The effect ACR: 673±187 vs. 84±23 µg/mg) whereas SBP was unchanged (125±2 vs. of CFTR inhibition on islet morphology was assessed using an established 126±3 mmHg). The increase in BGL in AKITA vs. CON was slightly reduced pseudoislet model. Insulin secretion in response to glucose (16.7 mM) or in KO-VEH (483±11 vs. 133±4 mg/dl), strongly reduced in WT-DAPA (291±19 GLP-1 (10 nM) was measured by ELISA. vs. 131±3 mg/dl), and further reduced in KO-DAPA (214±8 vs. 125±3 mg/dl). Results: CFTR inhibition significantly reduced (P<0.01-0.001) Cx36, 43 and The increases in GFR and ACR in AKITA vs. CON were reduced in KO-VEH E-cadherin expression in cell lines. Cx43 and E-cadherin expression was also (717±40 vs. 602±33 µl/min; 188±26 vs. 181±48 µg/mg), in WT-DAPA (651±52 reduced (P<0.001) in CFTR-inhibited primary islets. However, Cx36 expres- vs. 605±44 µl/min; 404±83 vs. 229±40 µg/mg), and in KO-DAPA (562±39 vs. sion was unchanged in this instance. CFTR-inhibited pseuodislets displayed 542±34 µl/min; 172±26 vs. 174±18 µg/mg). SBP was modestly increased marked differences in morphology and were smaller (47% in MIN6; 51% in AKITA vs. CON in KO-VEH (133±2 vs. 122±1 mmHg) but not in WT-DAPA in BRIN-BD11) than control pseuodislets. Modest reductions in glucose- (129±2 vs.128±2 mmHg) or KO-DAPA (123±2 vs. 121±1 mmHg). We conclude induced insulin secretion were observed. However, GLP-1 stimulated insulin that in this diabetes mouse model 1) inhibition of SGLT1 and SGLT2 had addi- release was significantly (P<0.01) impaired in cell lines and primary islets tive effects on the rise in BGL; 2) inhibition of SGLT1 or SGLT2 reduced the after CFTR inhibition. increase in GFR and ACR; 3) SGLT1 inhibition can increase SBP; this effect is Conclusion: CFTR inhibition decreases GJ expression in islet cells and prevented by SGLT2 inhibition. alters pseudoislet size and shape. Since islet architecture is critical to the Supported By: National Institutes of Health; AstraZeneca maintenance of biphasic insulin secretion, these disruptions may contribute to impairments in insulin secretion observed here and in patients with CFRD. Supported By: Cystic Fibrosis Trust; Diabetes Research and Wellness Founda- tion; Department for Education, Northern Ireland

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A13 TARGETS AND PATHWAYS IN DIABETIC KIDNEY DISEASE

51‑OR 53‑OR SGLT2 Inhibition Increases Renal Uric Acid Excretion: Evidence PBI-4050 Protects against Diabetic Nephropathy and Improves Pan- from Mice Lacking SGLT2 and Potentiation in the Absence of SGLT1 creatic Function in High-Fat-Diet db/db Mouse Model ALEKSANDRA NOVIKOV, YILING FU, ROHIT PATEL, CHARLOTTE VAN GINKEL, LYNE GAGNON, MARIE-PIER CLOUTIER, MIKAËL TREMBLAY, LIETTE GERVAIS, AKIRA ONISHI, PANAI SONG, HERMANN KOEPSELL, WINNIE HUANG, VOLKER FRANÇOIS SARRA-BOURNET, ALEXANDRA FELTON, KATHY HINCE, PIERRE LAU- VALLON, San Diego, CA, Würzburg, Germany RIN, BRIGITTE GROUIX, Laval, QC, Canada SGLT2 inhibitors enhance urinary glucose and uric acid (UA) excretion and Introduction: PBI-4050, a novel first-in-class orally active compound which lower serum UA levels, but the mechanisms remain unclear. Glycosuric dia- is currently in a phase II clinical trial, significantly reduced glycated hemo- betic patients also have higher UA excretion and lower serum UA levels indi- globin (HbA1c) after 12 and 24 weeks of treatment in patients with type 2 cating that increased luminal glucose may facilitate urinary UA excretion. To diabetes and metabolic syndrome with elevated HbA1c despite anti-hyper- test this further we studied UA handling in nondiabetic mice in response to glycemic treatment. In the present study, we examined whether PBI-4050 i) genetic deletion of SGLT2 (SGLT2-/-) or SGLT1 (SGLT1-/-) and ii) the SGLT2 affected high fat diet (HFD)-induced triglycerides, insulin and adiponectin inhibitor, canagliflozin, in wild type (WT) and SGLT1-/-. i) Blood and spot urine levels and the development of diabetic nephropathy induced by HFD in db/ was collected from SGLT1-/-, SGLT2-/- and littermate WT to determine UA db mice. (Amplex red uric acid assay) and creatinine (HPLC) to calculate fractional Methods: db/db mice were fed with a HFD and received vehicle (water) or renal UA excretion (FEUA)(n=6-10/group). SGLT2-/- strongly increased urine PBI-4050 (200 mg/kg/day) by daily gastric gavage from 6 to 21 weeks of age. glucose to creatinine ratio (Gl:Cr; μmole/mg) vs. WT (4194±550 vs. 3±1) asso- Results: High fat diet induced an increase in triglycerides and a decrease ciated with a doubling of FEUA (5.3±0.8 vs. 2.7±0.3%; P<0.05). Glycosuria in adiponectin levels in serum which were significantly improved by PBI- was relatively minor in SGLT1-/- vs. WT (92±6 vs. 4±1) and FEUA unchanged 4050 treatment. PBI-4050 increased serum insulin which correlated with the (3.4±0.2 vs. 4.1±0.3%). ii) Urine was collected pre-treatment and at 1.5 hours improvement of β-cell function observed by immunohistochemistry analy- after i.p. application of the SGLT2 inhibitor canagliflozin (2 mg/kg i.p.) or vehi- sis. Kidney function was also improved by PBI-4050 treatment, as shown cle (1% ethanol, 2µl/g bw)(n=9-10/group). In WT, canagliflozin increased uri- by a decrease in hyperfiltration measured by inulin clearance. Furthermore, nary UA:Cr vs. vehicle (148±66 vs. -62±61 nmol/mg, P<0.05) associated with expression of IL-6, collagen I, CTGF, MCP-1, and iNOS in kidney were down- an increase in urinary Gl:Cr (1891±247 vs. 1±1 µmol/mg). In SGLT1-/-, these regulated by PBI-4050 treatment. uricosuric and glycosuric effects of canagliflozin vs. vehicle were enhanced Conclusion: These studies suggest that PBI-4050 improves insulin produc- (306±63 vs. -53±59 nmol/mg [P<0.001] and 3795±326 vs. 23±22 µmol/mg). tion and β-cell function and survival, and prevents diabetic nephropathy in Thus, genetic deletion of SGLT2 increased FEUA. This argues against the association with regulation of profibrotic biomarkers in HFD obese db/db need for a direct effect of the SGLT2 inhibitor on UA transporters, consis- mice. tent with a proposed role of increased luminal glucose delivery. The latter is supported by the observation that absence of SGLT1, which by itself has 54‑OR no effect on renal UA excretion, enhances both the glycosuric and uricosuric The Binding Kinetics of Linagliptin Uniquely Mediate Its Kidney- effect of canagliflozin. Specific DPP-4 Inhibition Supported By: National Institutes of Health; Janssen Research and Develop- GERD LUIPPOLD, THOMAS KLEIN, MICHAEL MARK, KERSTIN AMANN, CHRIS- ment TOPH DANIEL, Biberach, Germany, Erlangen, Germany Dipeptidyl peptidase (DPP)-4 inhibitors delay chronic kidney disease pro- 52‑OR gression in experimental models but the underlying molecular pathways are Mechanisms of Insulin Resistance by FFA in Renal Podocytes and not well defined. There are also differences between agents. We investi- Diabetic Nephropathy gated the kidney-specific DPP-4-inhibition of linagliptin (LINA) and sitagliptin PEDRO M. GERALDES, Sherbrooke, QC, Canada (SITA) in an ex vivo model. Normal Wistar rats received a single oral dose Diabetic nephropathy (DN) is the leading cause of chronic renal failure of 3 mg/kg LINA, 30 mg/kg SITA, or vehicle. Kidney and plasma specimens in diabetic patients and is characterized by the dysfunction of podocytes. were taken 6, 10, 24, 48, and 72 h after dosing. Koff and KD values were Our laboratory has shown that hyperglycemia caused insulin unresponsive- detected by surface plasmon resonance spectroscopy. In situ DPP-4 activity ness and apoptosis in podocytes via the upregulation of PKC-δ and SHP-1, was assessed with Gly-Pro-4-methoxy-β-naphtylamide on kidney cryosec- a tyrosine phosphatase. In contrast, free fatty acids (FFA)-induced insulin tions of 5 µm thickness and specific DPP-4 activity was assessed with Gly- resistance in podocytes is not associated with SHP-1 expression. Thus other Pro-pNA in kidney protein homogenates. LINA and SITA had KD values of -4 signaling pathways could be implicated and involved the activation of the 5.3 nM and 0.0066 nM and Koff values of 630 and 0.51 (10 /s), respectively. Mammalian target of rapamycin (mTOR) complexes pathway. The aim of this DPP-4 in situ activity was strongly seen in proximal tubulus segments and study is to investigate the insulin resistance mechanisms caused by FFA glomeruli of vehicle-treated rats. LINA produced a more sustained inhibition in podocytes leading to diabetic nephropathy in type 2 diabetes. In vitro, of in situ DPP-4 activity than SITA. Specific DPP-4 inhibition after 6 and 24 h cultured podocytes were exposed to normal (5.6 mM; NG) or high glucose was 36.7% + 2.4 and 5.6% + 7.9, respectively, for SITA and 92.7% + 1.7 and (25 mM; HG) levels for 96 h and to palmitate (25 µM) the last 24 h with 86.2% + 0.7, respectively, for LINA (mean + standard deviation). or without insulin stimulation (10 nM). As previously showed, podocytes ORALS Figure. In Situ DPP-4 Activity in Rat Cortex and Medulla. exposed to HG decreased Akt activation upon insulin stimulation. Palmi- tate treatment alone reduced insulin-induced Akt phosphorylation by 49% while a combination of palmitate and HG blunted Akt activation by 90%. The inhibition of Akt by palmitate was associated with the increase of PKC-α activation leading to mTOR phosphorylation and its substrate S6. Moreover, the mTORC1 complex activation enhanced the serine 307 phosphorylation of IRS1 known to deactivate IRS1. In vivo, the implication of mTORC1 complex in DN development was evaluated using 25 weeks old type 2 diabetes mice (db/db). Mice developed increased albuminuria, mesangial cell expansion and glomerular hypertrophy compared to nondiabetic mice, which correlated with the phosphorylation of mTOR and S6. In conclusion, elevated FFA levels cause activation of PKC-α/mTORC1 pathway leading to insulin resistance in podocytes and DN progression. Supported By: Kidney Foundation of Canada

Supported By: Boehringer Ingelheim

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A14 PHYSIOLOGICAL EFFECTS OF EXERCISE IN HUMANS WITH DIABETES OR OBESITY

PHYSIOLOGICAL EFFECTS OF EXERCISE IN HUMANS 57‑OR WITH DIABETES OR OBESITY Exercise Training Improves Depot Specific Adipose Tissue Metabo- lism Regardless of Baseline Glucose Tolerance and Sex 55‑OR PIRYANKA MOTIANI, SANNA M. HONKALA, KUMAIL K. MOTIANI, JOONAS J. Effect of Exercise and Diet on Glucose Effectiveness ESKELINEN, KIRSI A. VIRTANEN, ELIISA LÖYTTYNIEMI, PIRJO NUUTILA, KARI K. KALLIOKOSKI, JARNA C. HANNUKAINEN, Turku, Finland ADITHYA HARI, CIARAN E. FEALY, THOMAS SOLOMON, JACOB M. HAUS, Effects of exercise training on muscle metabolism are well characterized KAREN KELLY, HOPE BARKOUKIS, JOHN P. KIRWAN, Cleveland, OH, Birmingham, whereas the adipose tissue (AT) responses on training are poorly under- United Kingdom, Chicago, IL, San Diego, CA Glucose effectiveness (Sg) refers to the ability of glucose itself to stimu- stood. We studied the effects of high-intensity interval (HIIT) and moderate late glucose uptake and to suppress endogenous glucose production through intensity continuous training (MICT) on AT substrate metabolism and tested insulin-independent mechanisms. It has been reported that diminished Sg is whether the AT responses are similar regardless of baseline glucose toler- a predictor of progression to type 2 diabetes. Exercise training improves Sg, ance and sex. however, it is unknown whether the glycemic index of diets impact exercise We randomized totally 54 sedentary subjects of whom 26 had defective induced improvements in Sg in an at risk population. We enrolled 34 obese, glucose tolerance (DGT) (8 IGT/IFG and 18 T2D; BMI 30.1 (2.5); age 49 (4)) and prediabetic adults (18 males, 65.7+4.3 yrs, 34.9+4.2 kg/m2) into a 12-week 28 were healthy (BMI 26.1 (2.4); age 48 (5)) into HIIT and MICT for two weeks. exercise training program (1 hr/d, 5 d/wk at ~85% of maximum heart rate) AT masses were quantified by MRI, glucose uptake (GU) during euglycemic while being randomized to concurrently receive either a low (LoGIX: 40+0.3 hyperinsulinemia and fasting free fatty acid uptake in visceral (VAT), abdomi- au) or high (HiGIX: 80+0.6 au) glycemic index diet. A 75-g oral-glucose- nal (ASAT) and femoral (FSAT) subcutaneous AT with PET. tolerance test (OGTT) was performed before and after the intervention. Sg At baseline, compared to healthy men, DGT men were insulin resistant, was calculated from the OGTT using the Nagasaka equation: [PPG-without had higher body adiposity and lower insulin-stimulated GU in all AT depots and FFAU in VAT and ASAT. Considering the sex, DGT women had 59% lower insulin and Sg]-[PPG-without insulin/with Sg] x [(2hPG)/2hPGE, where [PPG- without insulin and Sg] was calculated as: [fasting plasma glucose (mg/dl) + VAT and 50% higher ASAT mass, higher GU in VAT and FFAU in VAT and FSAT [0.75 × 75,000]/[0.19 × BW(kg) × 10]. Secondly, “PPG-without insulin/with Sg” than DGT men. Training increased whole body insulin sensitivity and GU in VAT and FSAT and decreased FFAU in VAT and ASAT (p<0.05, all) irrespective was obtained from inverse correlation between log10DI(O) and 2-h post- glucose plasma glucose during OGTT (2hPG) across the spectrum of glucose of baseline glucose tolerance and sex. HIIT was superior in increasing aero- tolerance, with DI(O) being oral disposition index. Lastly, the expected 2hPG bic capacity (VO2max) and GU in VAT in DGT group whereas MICT reduced (2hPG ) was obtained from the regression, and the ratio of 2hPG/2hPG FFAU in VAT more than HIIT in both healthy and DGT groups. E E Although females have higher body adiposity they have less VAT mass constituted the required adjustment factor. The increase in VO2max was comparable for both groups (~6+3.5 ml.kg-1.min-1; P<0.001). Baseline Sg was and higher AT substrate uptake rate compared to males. Short-term training similar for LoGIX and HiGIX groups (1.49+0.38 vs. 1.68+0.46 mg.dL-1.min-1, improves AT metabolism similarly in healthy and DGT men and independently respectively; P>0.05). When compared to baseline, Sg increased by ~35% of the sex. HIIT is more effective in improving aerobic capacity and VAT insu- post-intervention in the LoGIX arm (95% CI: 0.07-0.57, P<0.05), but did not lin sensitivity in DGT whereas MICT is preferable for VAT lipid metabolism. change in the HiGIX group. Our data suggest that a high glycemic index diet may suppress the exercise-induced increase in Sg. Future studies are under 58‑OR way to determine the molecular mechanisms. Muscle Oxygen Delivery Is Impaired by Lipid/Heparin Infusion in Supported By: National Institutes of Health (R01AG12834); National Center for Young Healthy Adults Research Resources (1UL1RR024989) MASON MCCLATCHEY, JANE E.B. REUSCH, JUDITH G. REGENSTEINER, IRENE E. SCHAUER, Aurora, CO 56‑OR Background: People with type 2 diabetes (T2D) or insulin resistance (IR) have defects in functional exercise capacity (lower peak O consumption Cardiorespiratory Fitness and All-Cause Mortality in Veterans with 2 (peak VO ) and slowed VO kinetics). Lipid/heparin (LIPID) infusion induces IR Stage II-IV Chronic Kidney Disease 2 2 in healthy adults. We had observed that it also partially recapitulates these PUNEET NARAYAN, CHARLES FASELIS, JONATHAN MYERS, ERIC NYLEN, exercise defects, slowing VO kinetics. We hypothesized that LIPID infusion ANUBHAV KUMAR, PETER F. KOKKINOS, Washington, DC, Palo Alto, CA 2 Introduction: Patients with chronic kidney disease (CKD), have signifi- impairs microvascular function and decreases muscle oxygen supply. cantly higher cardiovascular (CV) and all-cause mortality. Cardiorespiratory Methods: Twenty lean adults (55% female, age 30 ± 6 years) with normal fitness (CRF) has been shown to favorably modify co-morbid conditions of fasting glucose, HbA1c, glucose tolerance, and family history were studied. CKD including hypertension (HTN), diabetes mellitus (DM) and dyslipidemia Exercise capacity was measured by cycle ergometry with gas exchange mea- but independent effect of CRF on all-cause mortality in veterans with Stage surements and vastus lateralis oxy/deoxyhemoglobin (Hb) were assessed by II-IV CKD is not known. near-infrared spectroscopy after 6 hours of LIPID or saline infusion. Methods: We identified 1268 patients with Stage II-IV CKD, aged Results: As expected LIPID infusion induced IR (glucose infusion rate: 8.5 64.7+10.6 years, 75.2% with HTN, 40.1% DM, and a BMI of 29.1+5.3 kg/ ± 2.7 vs. 6.6 ± 2.2, p = 0.0002). Total hemoglobin (tHb) at rest and microvas- 2 cular recruitment from rest to submaximal exercise (∆tHb) were reduced by m . All underwent routine exercise tolerance testing (ETT) at Washington ORALS DC and Palo Alto Veterans Affairs Medical Centers at baseline. Peak work- LIPID infusion (45.6 ± 6.4 vs. 37.2 ± 6.1 µM, p=0.03; 2.1 ± 1.2 vs. 0.7 ± 0.9 µM, load was estimated in metabolic equivalents (METs). Based on age-stratified p=0.04). The lower tHb at rest was largely due to decreased oxygenated Hb quartiles of peak METs achieved, we established three fitness categories: (OHb: 26.9 ± 5.5 vs. 20.0 ± 5.0, p=0.02). In addition, the OHb decline from rest to exercise was greater after LIPID infusion (-0.97 ± 0.76 vs. -1.84 ± 0.64). VO Low-fit (4.3±0.8 METs; n= 436); Moderate-Fit (6.1±0.9 METs; n=557) and 2 High-Fit (8.3±1.1 METs; n=275). Cox proportional hazards model with Low-fit kinetics were slowed (tau2: 34.7 ± 12 vs. 29.9 ± 9 sec, p = 0.023) by LIPID infu- category as the reference group, was constructed to assess mortality risk sio n consistent with impaired oxygen delivery at submaximal exercise. Peak VO was not altered (31.4 ± 5.5 vs. 31.3 ± 5.5, p = 0.9) suggesting that these associated with exercise capacity. The model was adjusted for age, BMI, 2 young adults were able to adapt at higher exercise intensity. At baseline race, tobacco/alcohol/drug use, HTN, DM, CV/antihypertensive medica- 2 both tHb and insulin sensitivity correlate with peak VO2 (R =0.59, p<0.001; tions. P-values <0.05 using two sided tests were considered statistically 2 significant for all test. R =0.45, p=0.01, respectively). Results: During a follow-up of 9.6+6.8 years after the baseline ETT, 514 Conclusions: LIPID infusion in nondiabetic individuals induces IR and reca- pitulates the slowing of VO kinetics seen in T2D. NIRS data suggest LIPID or 40% of these patients died accounting for 42.1 events per 1000 person 2 years of observation. The CRF-mortality risk association was inverse and infusion-induced microvascular dysfunction contributes. Targeting NEFA lev- graded. For each one MET increase in CRF mortality risk decreased by 11%. els in T2D may improve exercise performance. When CRF categories were considered, mortality risk declined progressively Supported By: U.S. Department of Veterans Affairs by 20% in the Moderate-fit (HR: 0.80; CI: 0.66-0.96;p=0.019) and 44% (HR: 0.56; CI: 0.42-0.73; p<0.001) in the High-Fit group. Conclusions: High levels of CRF were protective against all-cause mortal- ity in veterans with Stage II-IV CKD and other risk factors.

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A15 WHERE IS GLUCOSE MONITORING TAKING US?

59‑OR WHERE IS GLUCOSE MONITORING TAKING US? Exercise Training Enhances Mitochondrial Fusion in Human Skel- etal Muscle 61‑OR CHRISTOPHER L. AXELROD, ANNY MULYA, CIARAN E. FEALY, CHARLES L. HOP- A Randomised Controlled Trial of Self-Monitoring of Blood Glucose PEL, JOHN P. KIRWAN, Cleveland, OH in Noninsulin-Treated Type 2 Diabetes: The SMBG Study Mitochondria exist as a morphologically plastic network driven by the SHARON N. PARSONS, STEPHEN D. LUZIO, DAVID R. OWENS, SMBG STUDY bioenergetic demand of the cell. Induction of the cellular fusion and fission GROUP, Swansea, United Kingdom, Cardiff, United Kingdom machinery allows the organelle to regulate quality control and substrate Background: The benefit of Self-Monitoring of Blood Glucose (SMBG) in flux. Physiologic stressors promote fragmentation of the mitochondrial people with noninsulin treated type 2 diabetes (T2DM) has been debated for network, resulting in a loss of membrane potential. Mitochondrial fragmen- many years with inconsistent evidence from randomised controlled trials. tation has been implicated in a number of metabolic diseases, including Aim: To determine if proactive, structured SMBG with or without telecare type 2 diabetes and obesity. It is well known that exercise training improves can enable poorly controlled, noninsulin treated people with T2DM to better the volume, number, and density of skeletal muscle mitochondria. However, manage their diabetes. the effect of chronic exercise training on muscle mitochondrial dynam- Study Design and Methods: A 12 month, multi-centre, randomised con- ics remains unknown. 12 sedentary, older (65.8 ± 4.6 years) obese (34.3 ± trolled trial was performed in people with established (>1 year) T2DM not on 2.4 kg/m2) adults underwent 12 weeks of supervised aerobic exercise train- insulin therapy with poor glycaemic control (HbA1c≥7.5% ≤ 13%). A total of ing at 85% of HRMAX for one hour daily, five times per week. Body composi- 666 participants were recruited from 16 primary and secondary care sites. tion analysis, cardio-metabolic testing, hyperinsulinemic-euglycemic clamps, 447 were randomised into one of three groups; G1: control group receiv- and skeletal muscle biopsies were performed after an overnight fast, prior to ing usual diabetes care; G2: structured SMBG with clinical review every 3 and after the intervention. Protein expression of MFN1, MFN2, OPA1, OMA1, months; G3: structured SMBG with additional monthly telecare support. In FIS1, and Parkin was assessed via Western blot. The intervention resulted in G2 and G3 participants and healthcare professionals were blinded to HbA1c improvements in clamp insulin sensitivity, aerobic capacity, and fat oxidation and glycaemic management was based only on glucose results. The primary (all P<0.01), as well as reductions in body weight, BMI, fat mass and fasting outcome measure was HbA1c at 12 months. plasma glucose (all P<0.001). Exercise training also increased skeletal muscle Results: Of the 447 participants randomised, 259 were male (58%) with MFN2, OPA1, and OMA1 (P<0.05), while decreasing FIS1 and Parkin (P<0.05) mean (range) age 61.7 (27-80) years. 267 participants (60%) had diabetes for protein expression. Changes in OPA positively correlated with improvements 5 years or more with 85 (19%) having complications associated with the con- 2 in insulin sensitivity (r =0.53, P<0.05). Thus, exercise training appears to dition. Mean HbA1c for all participants at randomisation was 8.6% (8.6%, remodel the mitochondrial architecture towards a more fused, tubular net- 8.5%, 8.6% for G 1, 2 and 3, respectively, p=ns). 323 participants attended work. These changes may contribute to the increase in insulin sensitivity and the final visit at 12 months when the mean (sd) HbA1c was 8.3(1.31)% (n=116, improvement in substrate utilization that is seen after exercise training. p<0.01), 7.4(1.22)% (n=99, p<0.001), 7.3(0.89)% (n=108, p<0.001) for Groups Supported By: National Institutes of Health 1, 2 and 3, which were all significantly lower than at randomisation. Conclusion: This randomised controlled trial shows that the use of struc- 60‑OR tured SMBG in this population provides clinically and statistically signifi- Fear of Hypoglycemia and Exercise in Youth with Type 1 Diabetes cant benefits in terms of glycaemic control with a mean reduction of 0.9% ALISSA J. ROBERTS, JOYCE P. YI-FRAZIER, MICHAEL F. PASCUAL, CRAIG E. TAP- (95% CI -1.18 to -0.62, p=<0.001) between the combined SMBG groups com- LIN, Seattle, WA pared to the control group. Fear of hypoglycemia (FoH) in type 1 diabetes (T1D) is inversely associated Supported By: European Foundation for the Study of Diabetes with glycemic control and quality of life and is a major barrier to physical activity. However, little is known regarding the impact of FoH on behav- 62‑OR iors around exercise, especially related to insulin adjustments. It has been Achieving Glycemic Control in the Cardiac Surgery Intensive Care recently reported that youth are not making insulin adjustments around Unit Utilizing an Electronic Glucose Management System exercise (Roberts et al, 2016). The goal of this pilot study was, therefore, to LINDA A. CURRIE, Richmond, VA examine the association between FoH and key behaviors around exercise in Purpose: To achieve safe glycemic control in a quaternary urban academic youth with T1D. We studied 30 youth with T1D, 43% female, mean age 15.0 medical center cardiac surgery intensive care unit (CSICU), utilizing an elec- ±2.4, on insulin pump therapy. Parent and child hypoglycemia fear surveys tronic glucose management system (EGMS). (HFS) were collected, with 3 subscales: behavior, worry, and total hypo- Background: Post-operative cardiopulmonary bypass induced hyperglyce- glycemia fear scores, along with the “Type 1 Diabetes Report of Exercise mia is associated with delayed wound healing and increased morbidity and Practices Survey (T1D-REPS),” and 3-day physical activity (PA) recall. Ninety- mortality. The Society of Thoracic Surgeons (STS) and Surgical Care Improve- three percent of participants met daily PA recommendations (≥60 min PA ment Project (SCIP) recommend a glycemic control <180 mg/dL to achieve daily). From T1D-REPS responses, an exercise hypoglycemia avoidance score optimal patient outcomes. Protocolized insulin titration failed to prevent was generated based on key behaviors before, during, and after exercise. hyperglycemia or hypoglycemia, resulting in the CSICU trialing an EGMS. Higher exercise hypoglycemia avoidance scores were associated with child ORALS Methods: An EGMS was implemented on September 10, 2013. Staff educa- HFS behavior scores (r= 0.38, p=0.04). Those who reported a target glucose tion included: online training module, bulletin board education and bedside 1:1 of over 180 mg/dL prior to exercise had higher child HFS worry and total assistance. Daily reports for goal range success, timeliness of blood glucose scores compared to those with a target glucose of 120-180 mg/dL (t=-1.71, (BG) checks and hypoglycemia were monitored and presented to end users. p<.10). Higher child HFS behavior scores were associated with higher physi- Results: EGMS data analysis from 10/10/2013 to 12/16/2016 yields 2,169 cal activity levels (r= 0.40, p=0.04), and higher child HFS worry and total patient visits and 72,451 evaluable glucose results. Insulin infusion duration scores were associated with higher A1c (r’s=.48, .46, p’s<.05 respectively). is a minimum of 48 hours per STS guidelines. The CSICU goal target range is Parent HFS scores were not associated with exercise behaviors or glycemic 100-150 mg/dL, with 99.6% attainment. Starting from a glucose value >180 control. mg/dL, overall 99.77% of patients achieve control. The average time to a In summary, this pilot study demonstrates an association between FoH in control of <180 mg/dL is 1.45 hours. The overall BG average is 135 mg/dL, youth and exercise behaviors to avoid hypoglycemia, which may also explain and 127 mg/dL after the goal target of 150 mg/dL is reached. Based on the some of the detrimental impact of FoH on glycemic control. percentage of evaluable blood glucose readings, hypoglycemia rates are as follows: <40 mg/dL 0.00%, <50 mg/dL 0.02%, <60 mg/dL 0.08% and <70 mg/dL 0.31% and hyperglycemia (>200 mg/dL) is 4.47%. Percent of patient visits that achieved control each of the three years is 99.86%, 100.00% and 99.34% respectively. Discussion: The EGMS incorporates patient specific data parameters, providing a safe platform for insulin administration and maintenance. Target BG rates are achieved consistently, while maintaining hypoglycemia rates <70 mg/dL.

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A16 WHERE IS GLUCOSE MONITORING TAKING US?

63‑OR 65‑OR Sugar.IQ Insights: An Innovative Personalized Machine-Learning Effect of Continuous Glucose Monitoring on Glycemic Control in Model For Diabetes Management Adults Using Multiple Daily Insulin Injections PRATIK AGRAWAL, ALEX ZHONG, ANUPAM PHUKAN, BOYI JIANG, TONI COR- DAVID A. PRICE, TONYA RIDDLESWORTH, ROY W. BECK, HOWARD A. WOLPERT, DERO, HUZEFA NEEMUCHWALA, FRANCINE KAUFMAN, Northridge, CA RICHARD M. BERGENSTAL, ANDREW J. AHMANN, San Diego, CA, Tampa, FL, The Sugar.IQ app, developed by Medtronic and IBM Watson, uses cogni- Boston, MA, Minneapolis, MN, Portland, OR tive computing to reduce the burden of diabetes management. The cogni- Clinical trials showing benefit of continuous glucose monitoring (CGM) have tive computing component helps uncover behavior patterns associated with largely been conducted in insulin pump users. The DIaMonD study examined specific glycemic outcomes using CGM, insulin delivery, and contextual data. effectiveness of CGM in adults with T1D (n=158) or T2D (n=158) with elevated The Sugar.IQ phone application shows the user informative insights in a per- A1c using multiple daily injections (MDI). Subjects at 29 sites were randomized sonalized and timely manner. to CGM or SMBG for 24 wks. Subjects were diverse but similar between the Blood glucose, CGM, food logs, and insulin data from 2611 users who CGM (n=184) and SMBG (n=132) groups with respect to age (mean ±SD, 52±14 uploaded their MiniMed® 530G insulin pumps to CareLink® Therapy Man- vs. 57±11 yr), baseline A1c (8.6+0.6 vs. 8.6+0.6%), DM duration (median [IQR], 17 agement software 10/15/2013 to 10/12/2016 (344,646 patient-days) were [10-26] vs. 19 [12-25] years), ≥1 severe hypo event in previous 12 months (5 vs. retrospectively analyzed. Sugar.IQ algorithms evaluated 155 input features 8%), education < bachelor’s degree (52 vs. 57%), and race (non-Hispanic whites, derived from bolus insulin doses, CGM trends, carbohydrate entries, use of 73 vs. 76%). Despite only 1 study related contact after wk 4 and none after wk threshold suspend, sensor glucose ranges, and frequency of glycemic excur- 12, the trial was completed by 97% of participants and CGM use was high, with sions. From these evaluations, specific insights were characterized. 93% using CGM ≥6 days/wk at wk 24. A1c change from baseline to 24 wks was Unique insights (n=609) were identified and categorized into: (1) Glyce- greater in the CGM than the SMBG group (-0.9±0.7 vs. -0.5±0.8, mean adjusted mic Insights (GI), (2) Motivational Insights (MI), and (3) Adherence Insights difference -0.5%, P<0.001). Secondary A1c analyses were confirmatory and (AI). Common examples of GI included finding the correlation between one treatment effect appeared largest at higher baseline A1c (Table). A1c reductions or more specific days and repeated high frequency of hypoglycemia or were similar across ages, baseline SMBG frequencies, education, and diabetes hyperglycemia, finding the correlation between high fasting glucose values type. CGM users increased time in range, decreased time <70 and 60 mg/dL, and hyperglycemia the rest of the day, and finding the correlation between and decreased time >180 and 300 mg/dL more than SMBG users. CGM benefits bolus at high rate of glucose change and hypoglycemia. Examples of MI a wide range of adults with T1D and T2D using MDI in suboptimal control. included uncovering a pattern of more time-in-range on days with smaller, Table. A1c Outcomes at 24 Weeks. more frequent bolus insulin doses, and hypoglycemia after manual boluses. Examples of AI included reminders for infusion set changes and calibrations CGM Group SMBG Between- 95% CI P (N=179) Group Groups at night to avoid waking up. On average, data from the uploads would have (N=128) Difference generated 0.75 GI, 2 MI, and 0.5 AI insights per day. Algorithms in Sugar.IQ can uncover personalized insights from user data. All Subjects -0.9±0.7 -0.5±0.8 -0.5 -0.6 to -0.3 <0.001 (Primary Outcome) These insights may advance users’ understanding of glucose trends and ΔA1C from BL A1C ≥8.0% -1.0±0.7 -0.6±0.8 <0.001 enhance the value of glucose monitoring. Baseline (BL) BL A1C ≥8.5% -1.2±0.7 -0.6±0.8 <0.001 64‑OR BL A1C ≥9.0% -1.4±0.8 -0.7±0.8 <0.001 Diabetes Devices and Profiles of the Clinicians Who Prescribe Them Odds Ratio 95% CI P MOLLY L. TANENBAUM, REBECCA N. ADAMS, REGAN C. BARLEY, SARAH A1C <7.5% 66 (37%) 27 (21%) 2.6 1.5 to 4.7 0.001 J. HANES, ESTI ITURRALDE, DIANA NARANJO, KELLEE M. MILLER, RICHARD Secondary A1C Outcomes at 24 A1C Reduction ≥1% 86 (48%) 33 (26%) 2.7 1.6 to 4.6 <0.001 WOOD, KOREY K. HOOD, Palo Alto, CA, Tampa, FL, San Francisco, CA, Stanford, CA Weeks Diabetes devices (insulin pump; continuous glucose monitoring-CGM) or A1C <7.0% are linked to improved glycemic outcomes and quality of life in people with T1D. Diabetes care clinicians often take on the roles of introducing devices, addressing barriers to use, troubleshooting device problems, and prevent- 66‑OR Obstructive Sleep Apnea Syndrome and Glucose Variability in Type 1 ing discontinuation with their patients. This study aimed to develop clinician Diabetes profiles of technology attitudes and perceived barriers to device use, with LAURENT MEYER, CLÉMENCE CANEL, ANNE-ELISABETH PERRIN, PARISA HAS- the goal of creating tools to increase device uptake based on these profiles. SEMI, ROMAIN KESSLER, ELISABETH WURTZ, ALEXANDRE LECLERCQ, BENJA- Participants were 209 clinicians who treat people with T1D in the U.S. MIN RENAUD-PICARD, LAURENCE KESSLER, Strasbourg, France, Saverne, France Clinicians were nurses (47%), dietitians (22%), and endocrinologists (15%). Introduction: Prevalence of obstructive sleep apnea (OSA) in type 1 dia- Most clinicians were also CDEs (60%), female (92%), over 45 years old (59%), betic patients is high, reaching up to 40% in previous studies. However, and had been in practice 14±9 years. K-means cluster analyses generated the link between OSA and type 1 diabetes is still poorly studied, especially clinician profiles; ANOVA and chi-square analyses described differences regarding glucose variability. between profiles by clinician characteristics and patient device uptake. Material and Methods: OSA, defined by an index of apnea-hypopnea ORALS Analyses yielded 3 profiles. Clinicians whose patients had the highest (AHI)>10/h was investigated in 89 type 1 diabetic patients using ventilatory device uptake reported the most positive technology attitudes, most time polygraphy (n=78) or polysomnography (n = 11). A continuous glucose moni- to review CGM data with their patients, and fewest barriers. Clinicians toring (CGM, Dexcom, Animas) was performed over a 24 hour time period, whose patients had moderate device uptake reported positive technology which included the investigated sleeping period. The CGM data were com- attitudes but lacked time to review CGM data, reported the most patient pared in patients with and without OSA. barriers to using devices and were least trusting of diabetes companies. Results: For the total population, mean age was 45.4 ± 13.6 years, body Clinicians whose patients had the lowest uptake had the most negative mass index: 26.1 ±4.4 kg/m², diabetes duration: 23.4 ± 14 years and HbA1c: technology attitudes, hardest time keeping up with new developments, and 7.8 ± 1.3%. OSA was diagnosed in 31.4% (n = 28) of the patients (14.2% least amount of time to review device data with their patients. Years in prac- with severe OSA). Patients with OSA were mostly men: 67.9% (p <0.05), tice did not differ among profiles. Providers in all 3 profiles cited company older: 51.9 ± 14.4 years (p <0.05), with longer duration of diabetes: 31.4 ± representative visits as the most common way they learned about devices. 14.4 years (p <0.05) and with a higher BMI: 28.4 ± 4.5 kg/m² (p <0.05). The These profiles provide useful guidance on how to educate and support CGM data were similar between the 2 groups (mean interstitial glucose, clinicians as they introduce devices and address patient barriers. Increasing standard deviation, coefficient of variation, time spent below 0.60 g /l time the time clinicians have to work with patients on devices and review device spent above 1.80 g/l). However, in patients with hypoglycemia during sleep data may also aid in increasing device uptake. (<0.6 g/l, n=25), time spent below 0.6g/l was significantly longer in the OSA Supported By: The Leona M. and Harry B. Helmsley Charitable Trust group (n=7) than in the non-OSA group (n = 18): 95 ± 60.6 vs. 21.4 ± 22.1 mn (p <0.05). In these patients a positive correlation was found between AHI and time spent below 0.6g/l (r=0.43, p=0.02). Conversely, in patients with hyperglycemia (>1.8g/l), time spent above 1.8g/l during sleep was longer in the group without OSA (AHI<10/h, n = 43): 224.7 ± 149.1 minutes vs. only 143.5 ± 122.8 minutes for OSA patients (AHI>10/H, n = 20), p <0.05.

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A17 GLP-1S AND SGLT2S—TO DO OR NOT TO DO IN TYPE 1 DIABETES MELLITUS?

Conclusion: In type 1 diabetes, OSA is associated with an increase in the GLP-1S AND SGLT2S—TO DO OR NOT TO DO IN time spent below 0.6 g/l during sleep. TYPE 1 DIABETES MELLITUS?

67‑OR 69‑OR High Wear Time and Improved Accuracy with Implantable Continu- Twenty-Four-Week Efficacy and Safety of Sotagliflozin, a Dual ous Glucose Monitoring: The PRECISE Trials SGLT1 and SGLT2 Inhibitor, as Adjunct Therapy to Insulin in Type 1 J. HANS DEVRIES, MARK P. CHRISTIANSEN, LYNNE KELLEY, Amsterdam, Nether- Diabetes (inTandem1) lands, Walnut Creek, CA, Germantown, MD JOHN B. BUSE, SATISH K. GARG, JULIO ROSENSTOCK, PHILLIP BANKS, SAN- Continuous glucose monitoring has been demonstrated to improve glu- GEETA SAWHNEY, PAUL STRUMPH, THE SOTAGLIFLOZIN INTANDEM1 WRITING cose management both in real time with alerts and trend data as well as with GROUP, Chapel Hill, NC, Aurora, CO, Dallas, TX, The Woodlands, TX retrospective analysis over time that can influence behavior and treatment. Sotagliflozin (SOTA) is a dual SGLT1 and SGLT2 inhibitor in Phase 3 devel- However, a significant number of individuals who start using CGM stop for a opment for type 2 diabetes (T2D) and as adjunct to insulin in type 1 diabe- variety of reasons including skin reactions, alarm fatigue, discomfort, size of tes (T1D). Inhibition of SGLT1 delays and reduces glucose absorption in the devices and technology issues. New CGM systems with improved accuracy proximal intestine, improving postprandial glycemic control. SGLT2 inhibi- and ease of use may promote sustained use. tion reduces renal glucose reabsorption. In a double-blind Phase 3 trial, 793 ® The Eversense CGM System (Senseonics Inc, MD) is an implantable long- adults with T1D, treated with multiple daily injection or pump therapy, with term (90 day) fluorescence-based glucose sensor with a removable transmit- A1C 7.0-11.0% at Screening were randomized 1:1:1 to placebo or SOTA 200 or ter that wirelessly communicates with a smartphone-based medical app to 400 mg after a 6-week insulin optimization period. Baseline characteristics display glucose results providing alerts, alarms and trend data. Two prospec- were comparable among groups. Total mean (SD); age: 46.1 (13.1) yrs, T1D tive single-arm trials enrolled 161 adults with T1DM and T2DM at 15 clinical duration: 24.4 (12.8) yrs, BMI: 29.7 (5.4) kg/m2, Total daily insulin dose: 0.73 sites in Western Europe (PRECISE) and the U.S. (PRECISE II). Subjects used (0.36) U/kg, Baseline A1C: 7.58 (0.73)%. After 24 weeks, adjunctive SOTA the CGM system at home and in-clinic. The European subjects had access to 200 and 400 mg resulted in greater A1C reduction than placebo with more their data while the U.S. study was blinded. During in-clinic visits (8 h-24 h) patients achieving the prespecified “net benefit” composite endpoint of A1C venous reference glucose measurements were taken (YSI2300 Stat plus) to <7.0% and no severe hypoglycemia (SH) and no DKA (Table). Incidences of compare with data from the Eversense CGM system. treatment-emergent adverse events were similar across groups. There was PRECISE and PRECISE II trials both demonstrated sustained accuracy more SH in the placebo arm and more genital mycotic infections, diarrhea, throughout the 90 day wear without attenuation. Improvements in the glu- and DKA in the SOTA arms. cose calculation algorithm resulted in a higher degree of accuracy in the In conclusion, in this study, SOTA adjunct therapy to insulin in T1D, PRECISE II study with the MARD of 8.8% vs. 11.6% in the PRECISE study. improved glycemic control with a safety profile supporting further clinical Average insertion and removal times were 2.6 minutes and 4.6 minutes development. respectively. Average wear time was over 23 hours in both studies for over 30,000 in-vivo days suggesting ease of use and comfort. Safety data Table. showed 3 limited reactions in the PRECISE trial and no infections or adhesive reactions in PRECISE II. The implantable Eversense® CGM system provides sustained accuracy and ease of use although it requires replacement every three months.

68‑OR Use of Remote Digital Monitoring by Glucose Management Teams in Hospitalized High-Risk Patients to Reduce Hypo- and Hypergly- cemia MARIA ISABEL GARCIA, LAURA TALAVERA, ADDIE L. FORTMANN, NOEMI ALONSO, REMY BABANTO, TERESA VELA, TAYLOR CLARK, BRITTANY CASTEL- LANOS, DAVID WINKLER, DANIEL EINHORN, GEORGE E. DAILEY, III, JEFFREY SANDLER, ATHENA PHILIS-TSIMIKAS, San Diego, CA, Del Mar, CA, La Jolla, CA Hypo- and hyperglycemia in hospitalized patients contributes to the development of complications with increased lengths of stay (LOS) and costs. New CGM technology can wirelessly transmit values to specially trained teams to prevent adverse events. A pilot randomized controlled trial conducted at a large hospital in San Diego evaluated the acceptability and performance of an integrated digital 70‑OR

ORALS approach to glucose management for 45 high-risk patients with T2D. Par- ticipants had an expected LOS > 48 hours, A1c > 8% or point-of-care blood A 12-Week Dose-Ranging Study of Sotagliflozin, a Dual SGLT1 and glucose > 180 at admission, and required insulin during the hospitalization. SGLT2 Inhibitor, as Adjunct Therapy to Insulin in Type 1 Diabetes DexCom G4 CGMs were placed on all participants; bedside values were (inTandem4) blinded. Intervention group CGM values were wirelessly transmitted to a CLAIRE BAKER, SUMAN WASON, PHILLIP BANKS, SANGEETA SAWHNEY, PAUL management team while the control group had usual care. Protocols were STRUMPH, THE SOTAGLIFLOZIN INTANDEM4 WRITING GROUP, Omaha, NE, The designed for early intervention to prevent hypo- and hyperglycemia. Woodlands, TX Age ranged from 43 to 82 yrs (M=61.4, SD=9.8); the majority were male (56%), Sotagliflozin (SOTA) is a dual SGLT1 and SGLT2 inhibitor in Phase 3 Hispanic (73%), and Spanish was a preferred language (60%); A1c (M=10.2%, development for type 2 diabetes (T2D) and as adjunct to insulin in type 1 SD=2.3) and BMI (M=32.9, SD=8.0). CGM data was obtained for an average diabetes (T1D). Inhibition of SGLT1 delays and reduces glucose absorption of 4.27 days/patient (SD=2.49; range 2-10). Number of CGM readings ranged in the proximal intestine, improving postprandial glycemic control. SGLT2 from 102 to 2334/patient (M=859.4, SD = 627.8). There were no statistically inhibition reduces renal glucose reabsorption. In a double-blind Phase 2 significant differences between groups on the amount of CGM data obtained dose-ranging trial, 141 adults with T1D treated with MDI or pump and A1C (p >.05). Trends of small-to-moderate effect size were observed for intervention 7.0-10.0% at screening were randomly assigned 1:1:1:1 to once-daily SOTA vs. control group differences in the percentage of values per patient < 70 mg/dL (75, 200, 400 mg) or placebo, and stable insulin dosing for 12 weeks. Baseline (0.7% vs. 1.4%; d = 0.26), > 250 mg/dL (9.8% vs. 13.2%; d = 0.23), and >300 mg/ characteristics (expressed as range of means for the arms) were comparable dL (2.6% vs. 5.1%; d = 0.30). Patient survey revealed that the CGM group felt among groups; age: 42-48 yrs, duration of T1D: 22-27 yrs, BMI: 27-32 kg/m2, this “Helps prevent problems rather than fixing them after they’ve happened” total daily insulin: 0.65 -0.77 U/kg, A1C at randomization: 7.95-8.07%. After (p=.04). No difference in comfort, sleep or interruptions (p>.05). 12 weeks, adjunctive SOTA 200 and 400 mg were more effective than This pilot demonstrates remote monitoring by glucose management placebo in reducing A1C. All dosages of SOTA reduced body weight and teams in hospitalized high-risk patients is feasible, safe, and acceptable increased UGE vs. placebo. SOTA 400 mg was more effective than placebo with trends for reduced hypo- and hyperglycemia. in decreasing 2-hour PPG, and decreasing SBP in those with SBP ≥130 mm Supported By: Confidence Foundation Hg at baseline. The overall incidence of TEAEs was lower in the SOTA arms.

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A18 GLP-1S AND SGLT2S—TO DO OR NOT TO DO IN TYPE 1 DIABETES MELLITUS?

Incidences of DKA, SH, nausea, diarrhea and genital mycotic infections, 72‑OR were low. These results support the use of SOTA 200 mg and 400 mg as Changes in Insulin Dosing Induced by Adding Liraglutide to Insulin Phase 3 doses in the T1D development program. Pump Treatment in Type 1 Diabetes Table. SIGNE SCHMIDT, THOMAS F. DEJGAARD, CHRISTIAN S. FRANDSEN, DORTE VISTISEN, STEN MADSBAD, HENRIK U. ANDERSEN, KIRSTEN NOERGAARD, Hvi- dovre, Denmark, Gentofte, Denmark In a 26-week randomized placebo-controlled trial, 44 overweight C-pep- tide negative adults with insulin pump treated type 1 diabetes in suboptimal glycemic control (HbA1c >7.5%) received either 1.8 mg liraglutide (Victoza) or placebo. Liraglutide induced significant reductions in HbA1c and body weight compared with placebo (-0.6% vs. 0.2% (p<0.001) and -6.4 kg vs. -0.6 kg (p<0.001)). We used insulin pump downloads to investigate insu- lin dosing patterns in the 2 treatment groups. Table 1 depicts daily insulin dosing patterns. Basal/bolus-distributions were similar between groups (53.2%/46.8%) at baseline and remained unchanged. Daily carbohydrate (CHO) intake as registered in the pumps was constant in both groups over 26 weeks of follow-up; however, insulin:CHO-ratios increased significantly in the midday (11am-4pm) and evening hours (4pm-12am) in the liraglutide group (0.5 and 0.5 grams/unit) compared with the placebo group (-0.2 and -0.1 grams/unit) (both p<0.05). Morning insulin:CHO-ratios and correction factors were unchanged. 71‑OR In conclusion, adding liraglutide to insulin pump treatment had no effect Efficacy and Safety of Liraglutide in Insulin-Pump-Treated People on total basal and bolus insulin doses, although daytime basal insulin was with Type 1 Diabetes: The Lira Pump Trial reduced and insulin:CHO-ratios were increased 11am-midnight. Observed THOMAS F. DEJGAARD, CHRISTIAN S. FRANDSEN, SIGNE SCHMIDT, DORTE improvements in HbA1c during liraglutide treatment may not be explained VISTISEN, STEN MADSBAD, HENRIK U. ANDERSEN, KIRSTEN NØRGAARD, Gen- by changes in insulin dosing. tofte, Denmark, Hvidovre, Denmark Glucagon-like peptide-1 receptor agonists reduce body weight and risk of Table 1. Baseline Values (Mean (SD)) and Changes (Estimated Mean hypoglycemia with moderate effect on HbA1c in people with type 1 diabetes (95% CI)) Over 26 Weeks of Treatment. (T1D) using basal-bolus insulin therapy. The evidence in people with insu- Liraglutide - Liraglutide - Placebo - Placebo - Between-group lin pump treated T1D is sparse. This randomized, double-blinded, placebo- Baseline Change Baseline Change difference in controlled, 26-week trial evaluated the efficacy and safety of liraglutide change (Victoza) 1.8 mg added to insulin pump therapy in overweight people with Total daily insulin dose 47.7 (15.2) 0.5 53.9 (19.0) 2.5 -2.0 T1D and insufficient glycemic control. Forty-four persons with insulin pump (units) (-2.1;3.1) (0.1;5.0) (-5.6;1.6) treated T1D, HbA1c >7.5% and BMI >25 kg/m2, were randomized to liraglu- p=0.714 p=0.044 p=0.270 tide or placebo added to insulin pump therapy. Baseline characteristics were Total daily insulin dose 0.56 (0.19) 0.06 0.60 (0.15) 0.04 0.02 per kilo body weight (0.03;0.09) (0.01;0.06) (-0.02;0.06) similar between groups (mean (SD) or median (interquartile range)) HbA1c 8.2 (0.5) %, diabetes duration 20 (15;35) years, daily insulin dose 51 (17) IU/day (units/kilo) p<0.001 p=0.013 p=0.327 and body weight 87 (12) kg. After 26 weeks of treatment liraglutide reduced Total basal insulin 24.9 (8.5) -1.2 27.7 (7.1) 0.1 -1.3 HbA1c and body weight compared with placebo (Table). No differences were (units) (-2.2;-0.2) (-0.9;1.0) (-2.6;0.1) found in changes in daily insulin dose, time spent in hypoglycemia (<3.9 p=0.017 p=0.909 p=0.067 mmol/l), heart rate or blood pressure between groups. One event of severe Daily basal insulin 18.9 (5.8) -0.9 21.1 (5.5) 0.7 -1.6 hypoglycemia was reported during the trial. 6am-midnight (units) (-1.9;0.1) (-0.3;1.6) (-3.0;-0.2) In conclusion, liraglutide added to insulin pump treatment in overweight p=0.080 p=0.156 p=0.025 people with T1D and poor glycemic control reduces HbA1c and body weight with no effect on daily insulin dose or time spent in hypoglycemia compared Nightly basal insulin 6.1 (2.2) -0.1 6.8 (2.0) -0.1 0.0 with placebo after 26 weeks of treatment. midnight-6am (units) (-0.4;0.2) (-0.4;0.2) (-0.5;0.4) p=0.487 p=0.594 p=0.887 Table. Bolus insulin (units) 22.8 (8.6) 1.4 26.2 (13.8) 2.4 -1.0 (-4.3;2.3) (-1.0;3.8) (0.2;4.7) p=0.545 p=0.240 p=0.032 ORALS 73‑OR Effects of Liraglutide on Body Composition and Food Preferences in Type 1 Diabetes CHRISTIAN S. FRANDSEN, SIGNE SCHMIDT, THOMAS F. DEJGAARD, THORH- ALLUR I. HALLDORSSON, SJUDUR F. OLSEN, JENS-ERIK B. JENSEN, DORTE VISTISEN, STEN MADSBAD, HENRIK U. ANDERSEN, KIRSTEN NOERGAARD, Hvidovre, Denmark, Copenhagen, Denmark, Gentofte, Denmark Glucagon-like peptide-1 receptor agonists reduce appetite, energy intake Supported By: Novo Nordisk A/S and body weight. However, the effect on body composition and food pref- erences has not been fully envisioned. This randomized, double-blinded, placebo-controlled, 26-week trial evaluated the effect of liraglutide 1.8 mg (Victoza) on body weight, body composition and food preferences when added to insulin pump therapy in 44 overweight (BMI >25 kg/m2) persons with type 1 diabetes (T1D) and insufficient glycemic control (HbA1c >7.5%). At baseline and week 26 body composition was measured with dual-energy X-ray absorptiometry (DXA) while food preferences were assessed at base- line, week 13 and week 26 using a validated food frequencies questionnaire. Baseline characteristics were similar between groups (mean (SD)) HbA1c 8.2 (0.5)% and body weight 87 (12) kg. After 26 weeks of treatment body weight, fat mass, android fat, and lean mass were significantly reduced with liraglu- tide vs. placebo (p<0.001) (Table). The proportion of energy intake from added

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A19 RACE AND SOCIETAL INFLUENCES ON DIABETES

sugar was reduced with liraglutide vs. placebo (3.3 vs. 5.8%E, p=0.001); no insulin dose the night before each experimental day; no insulin was given dur- other treatment-related differences in food preferences were found. ing the meal tests. Blood was sampled for measurements of plasma/serum In conclusion, liraglutide added to insulin pump therapy significantly concentrations of glucose, glucagon, C-peptide and acetaminophen. Lixisena- reduced body weight, fat mass, android fat, and lean mass compared with tide significantly reduced postprandial plasma glucose excursions in totally placebo in overweight patients with T1D. Liraglutide had only modest effect pancreatectomized patients (AUC: 2,715±179 vs. 3,473±177 mM×min, P=0.006) on food preferences. and controls (AUC: 814±14 vs. 1,152±57 mM×min, P<0.0001). In controls, lix- Table. Key Results: Liraglutide 1.8 mg vs. Placebo Added to Insulin Pump isenatide reduced postprandial plasma C-peptide responses and decelerated Treatment after 26 Weeks of Treatment. gastric emptying significantly whereas postprandial glucagon responses were unaffected (AUC: 426±47 vs. 512±74 pM×min, P=0.089). In totally pancreatec- Liraglutide, Placebo, Difference P value n=22 n=22 [95% CI] tomized patients, C-peptide was undetectable and lixisenatide significantly [95% CI] [95% CI] reduced gastric emptying as well as postprandial glucagon responses (AUC: 462±66 vs. 694±119 pM×min, P=0.045). The GLP-1 receptor agonist lixisena- Change in body weight (g) -6400 -700 -5700 <0.001 [-7900; -4900] [-2100; 800] [-7900;-3600] tide reduces postprandial plasma glucose excursions in totally pancreatecto- mized patients. The mode of action seems to involve deceleration of gastric Change in fat mass (g) -4538 -214 -4752 <0.001 emptying and reduced postprandial responses of gut-derived glucagon. [-5956;-3122] [-1121;692] [-5960;-2688] Supported By: Sanofi-Aventis Change in android fat (g) -551 15 566 <0.001 [-792;-310] [-107;137] [-827;-305] 76‑OR Change in lean mass (g) -2468 -64 2404 <0.001 Liraglutide Improves Glycemic Control in T1D Patients after Iso- [-3436;-1500] [-690;562] [-3525;-1283] lated Pancreatic Islet Cell Transplantation Supported By: Novo Nordisk A/S SHEETAL MALHOTRA, JENNY BLAU, KRISTINA I. ROTHER, Bethesda, MD Isolated pancreatic islet transplantation temporarily diminishes or elimi- 74‑OR nates the need for exogenous insulin, but patients eventually require reintro- Effect of GLP-1 Receptor Agonists on Pancreatic Islet Function in duction of exogenous insulin treatment. Patients with C-Peptide-Positive Type 1 Diabetes Mellitus Objective: We tested the hypothesis that adjunct glucagon like-1 (GLP-1) SABINE ZENZ, WERNER REGITTNIG, MICHAEL WOLF, MARTINA BRUNNER, agonist therapy improves glycemia in patients after islet transplantation. EVA EKARDT, REINGARD RAML, STEFAN RUPP, CHRISTOPH MAGNES, THOMAS Case Results: Two patients with T1D received solitary allogenic islet AUGUSTIN, THOMAS R. PIEBER, Graz, Austria transplantation in 2001, followed by steroid-sparing immunosuppression Preservation of overall pancreatic islet function remains an eminent tar- (Edmonton protocol). Patient A, a 42 y/o female with a 12-year history of get in early type 1 diabetes mellitus (T1D). Preclinical studies suggest that T1D, received two islet infusions; patient B, a 53 y/o female with a 40-year GLP-1 receptor agonists suppress glucagon secretion and may preserve T1D history, after only one islet infusion. Pre-transplant, both patients had endogenous insulin secretion. Objective of the study was to examine the undetectable C-peptide concentrations, hemoglobin A1c (HbA1c) 7.8% and effect of liraglutide treatment on overall pancreatic islet function in C-pep- 8.8% and insulin requirements of 0.47 and 0.33 units/kg/day, respectively. tide positive T1D patients with short diabetes duration. In a double-blind, Post-transplant, C-peptide levels remained detectable as long as immuno- two-period cross-over trial patients with fasting C-peptide ≥0.3 ng/ml were suppression was continued, but decreased over time. Insulin was re-started allocated to 3 months therapy adjunct to insulin with daily injections of 2 years post-transplant in both patients. Patient A’s glycemia and insulin either 1.2 mg liraglutide (lira) or placebo in random sequence, separated by a requirements trended towards pre-transplant levels, and immunosuppres- wash out of at least 4 weeks. At the end of each period, all patients under- sion was discontinued after 13 years, resulting in a sudden cessation of went a hyperinsulinemic (1.5 mU/kg/min), stepwise hypoglycemic clamp C-peptide secretion. Patient B continues on immunosuppression, requiring with blood glucose (BG) plateaus of 100, 63, 45 and recovery at 70 mg/dl. about half the insulin requirement compared to pre-transplant. Patient A During the overnight fast before the clamp BG was normalized by iv. infusion was started on Liraglutide in June 2015 and patient B in May 2016. Within of regular insulin. Glucagon was measured with a specific, double-sandwich 6 months, HbA1c decreased from 7.5% to 7% in patient A with a modest ELISA (Mercodia). Baseline characteristics of the 14 included T1D patients weight loss of 2 kg. HbA1c improved from 7.7% to 6.5% in patient B with a (7 females) were [mean±SD]: age 34±12 years, fasting C-peptide 0.7± weight loss of 5 kg after starting Liraglutide. 0.4 ng/ml, diabetes duration 3.4±2.4 years, HbA1c 6.8±0.6%. C-peptide lev- Discussion: The trend toward worsening glycemia after allogenic pancre- els after overnight normoglycemia were significantly higher after lira treat- atic islet transplantation may be reversed with adjunct GLP-1 analog therapy. ment compared to placebo (0.38±0.1 vs. 0.17±0.1 ng/ml; p= 0.033) and were Conclusion: GLP-1 agonist should be considered as adjunct therapy to equally suppressed during hypoglycemia. Glucagon levels were significantly insulin in patients with worsening glycemia after islet cell transplantation. lower with lira at ambient glucose and at normoglycemia compared to pla- cebo (1.8±0.7 vs. 3.4±0.7 pmol/L; p= 0.002). The glucagon response during hypoglycemia (BG from 100 to 45 mg/dl) was comparable in both groups RACE AND SOCIETAL INFLUENCES ON DIABETES (15.6±3.8 vs. 11.4±3.8 pmol/L; p= 0.067). ORALS In conclusion, our data demonstrate that lira adjunct to insulin preserves 77‑OR overall pancreatic islet cell function (β-cell and α-cell function) in C-peptide The Burden of Diabetes, Hypertension, and Noncommunicable Dis- positive T1D patients and could play an important role in combination ther- ease Risk Factors among Adults Aged 30 Years and Above in Rural apy in early T1D. Bangladesh—A Cross-Sectional Epidemiological Survey Supported By: Novo Nordisk A/S EDWARD FOTTRELL, HANNAH JENNINGS, ABDUL KUDDUS, NAVEED A. AHMED, JOANNA MORRISON, KOHENOUR AKTER, SANJIT K. SAHA, BADRUN NAHAR, 75‑OR TASMIN NAHAR, HASSAN HAGHPARAST-BIDGOLI, ABUL K.A. KHAN, ANTHONY The GLP-1 Receptor Agonist Lixisenatide Reduces Postprandial M. COSTELLO, KISHWAR AZAD, London, United Kingdom, Dhaka, Bangladesh, Glucose Excursions in Totally Pancreatectomized Patients Geneva, Switzerland CAROLINE T.B. JUEL, ASGER LUND, CARSTEN P. HANSEN, JAN H. STORKHOLM, Background: Noncommunicable chronic conditions such as diabetes and NICOLAI J. WEWER ALBRECHTSEN, JENS JUUL HOLST, TINA VILSBØLL, FILIP K. hypertension pose a substantial health burden as well as an economic one. KNOP, Hellerup, Denmark, Copenhagen, Denmark T2DM in particular is reaching epidemic proportions specially in developing The extrapancreatic effects of glucagon-like peptide-1 (GLP-1) have been countries like Bangladesh. Prevalence estimates of intermediate hypergly- difficult to disentangle and treatment of diabetes secondary to total pan- caemia and T2DM in Bangladesh range between 12%-30%, with apparent createctomy remains a challenge. We investigated the effects of the GLP-1 regional differences. This study aims to accurately describe the prevalence receptor agonist, lixisenatide, on postprandial glucose metabolism in totally and pattern of diabetes, IFG, IGT, hypertension and common non-communi- pancreatectomized patients. In a double-blinded, randomized, cross-over cable disease risk factors among adults in a rural community. study, totally pancreatectomized patients (n=12, age: 65.0±2.7 [mean±SEM] Method: A survey among a random sample of adults aged 30 years and years; BMI: 22.9±1.1 kg/m2) and controls (n=12, age 64.4±2.4 years; BMI: 24.0± above was conducted in 96 villages in rural Faridpur, Bangladesh. Glycaemic 0.8 kg/m2) underwent two 3-hour liquid mixed meal tests (with 1.5 g acet- status was measured by the OGTT and was determined according to WHO aminophen for evaluation of gastric emptying) after single-dose injection of 20 criteria. BP, height, weight, waist and hip girth were measured by standard µg of lixisenatide or placebo, respectively. Patients received their regular basal

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A20 RACE AND SOCIETAL INFLUENCES ON DIABETES methods. Demographic and socio-economic characteristics and behavioural (15.4%, 17.0%, 46.1% in Group 1, 2, and 3, respectively, p<0.001). This asso- risk factors were collected using a structured survey. ciation was significant (p<0.001) after adjustment for baseline demographics, Results: 12,280 individuals were surveyed. Prevalence of normoglycae- socioeconomic status, and clinical factors (body mass index z-score, insulin mia, intermediate hyperglycaemia, diabetes, hypertension and noncommu- regimen, dose, glucose self-monitoring frequency). Depressive symptoms nicable disease risk factors by age, sex and wealth group were assessed. measured by the Center for Epidemiologic Studies Depression scale attenu- Prevalence of diabetes in this population was 10.3%, IFG 4.9%, IGT 15.6% ated this association [OR of minority r/e in Group 3 vs. Group 1: 2.92 (95% CI and normoglycaemia 69.3%. Prevalence increased with age in both sexes, 1.65, 5.16) vs. adjusted OR 2.20 (95% CI 1.09-4.43]. Minority youth with T1D ranging from 19.9% to 36% and 31% to 45% in men and women, respec- are more likely than their white counterparts to have persistently poor glucose tively. Prevalence of hypertension was 19.4%. Prevalence of intermediate control. Depressive symptoms may mediate this association. hyperglycaemia, diabetes and hypertension correlated with wealth quintile, Figure. with those in higher wealth groups having greater burdens of disease. Conclusion: To our knowledge, this is the largest epidemiological study of diabetes, hypertension and noncommunicable disease risk factors in rural Bangladesh. Findings identify a huge burden of disease and risk factors across the population, even among younger adults and those of lower wealth. Supported By: Medical Research Council, UK

78‑OR Effect of Medicaid Expansion on the Uptake of Diabetes Screening in 2013-2014 MIN WOONG SOHN, JENNIFER M. LOBO, HYOJUNG KANG, ELBERT S. HUANG, Charlottesville, VA, Chicago, IL Objective: Medicaid expansion has been linked to an overall increase in preventive care use and a surge in diagnosed diabetes. We aim to examine the relationship between Medicaid expansion and the uptake of diabetes screening. Methods: BRFSS data for 2013 and 2014 was used to compare the uptake of diabetes screening among adults aged 45-64 years who were not diag- nosed with diabetes at the time of survey between states that expanded Supported By: National Institutes of Health/National Institute of Diabetes and Medicaid under the Affordable Care Act and those that did not. Twenty-five Digestive and Kidney Diseases; Centers for Disease Control and Prevention states that started expanded Medicaid coverage on January 1, 2014 were defined as expansion states and others as non-expansion states. Michigan 80‑OR started coverage on April 1, 2014 and was excluded. A “Yes” response to The Productivity Burden of Diabetes “Have you had a test for high blood sugar or diabetes within the past three DIANNA J. MAGLIANO, VALENCIA MARTIN, ALICE OWEN, DANNY LIEW, Mel- years?” was used to identify receipt of diabetes screening. We used the bourne, Australia inverse probability of treatment weighting to account for potential bias due Recent reports suggest that the prevalence of diabetes is increasing in to violation of difference-in-difference assumptions and self-selection. All working populations. Given this, it is important to quantify the productivity analyses were weighted and were conducted using Survey suite of com- impact of diabetes. This study aimed to quantify the future burden of dis- mands in Stata SE 14. ease in Australia attributable to diabetes from a productivity perspective. Results: The expansion states showed a “surge” in the uptake of diabetes Using a published productivity index attributable to type 2 diabetes (akin to screening between 2013 and 2014 (39% to 58%), while its uptake in non- the quality of life index) and life table modelling, we estimated years of life expansion states decreased slightly from 47% to 43% (both p < 0.001). Par- and “Productivity-Adjusted Life Years” (PALYs) lost to diabetes. Life-tables allel trends were observed among low income persons (annual household were constructed for age-cohorts of 1000 Australians aged 15 to 75 years income < $35,000). After adjusting for respondent demographic, socioeco- with diabetes, using age-and-sex specific mortality rates to model their nomic, health and access-to-care factors, expansion states had 7% lower progress until age 80 years or death. The same age-cohorts were modelled uptake in 2013 but 15% higher uptake in 2014, resulting in an average treat- again, but assumed not to have diabetes, and the differences in total years ment effect of 21.3% (95% CI, 19.8%-22.8%; p < 0.001) in diabetes screening and PALYS lived between the 2 cohorts reflected the impact of diabetes. due to Medicaid expansion. Overall, there was a 11.8% difference in years of life lived, and the greatest Conclusion: Our results show that Medicaid expansion had a significant loss was most notable in those aged 45-54 years for both men and women. effect on the uptake of diabetes screening. This may explain the observed The proportional reductions in PALYs were 26.8% and 19.4% for men and “surge” in diagnosed diabetes in 2014 among Medicaid expansion states. women, respectively. For both sexes, the impact of diabetes on productivity National health policy should take this beneficial effect of Medicaid expan-

was greatest at 45-54 years (30.3% and 21.4%). The findings highlight the ORALS sion into account. potential economic impact of diabetes (outside the healthcare system), and Supported By: Agency for Healthcare Research and Quality the value of preventing it. The concept of PALYs (akin to QALYs) is novel and provides a useful way to measure productivity loss due to diabetes. 79‑OR Table. Productivity-Adjusted Life Years Lived Simulated from Life Table Race/Ethnicity as a Predictor of Hemoglobin A1c Trajectory in Youth Modelling. with Type 1 Diabetes ANNA R. KAHKOSKA, CHRISTINA M. SHAY, JAMIE CRANDELL, DANA DABE- Men Women LEA, GIUSEPPINA IMPERATORE, JEAN M. LAWRENCE, ANGELA D. LIESE, CATI Age group PALYs lived: PALYs lived: % PALYs lived: PALYs lived: % PIHOKER, BETH A. REBOUSSIN, JANET A. TOOZE, LYNNE E. WAGENKNECHT, cohort with cohort without reduction cohort with cohort without reduction VICTOR W. ZHONG, ELIZABETH MAYER-DAVIS, Chapel Hill, NC, Dallas, TX, Aurora, diabetes diabetes of PALYs diabetes diabetes of PALYs CO, Atlanta, GA, Pasadena, CA, Columbia, SC, Seattle, WA, Winston-Salem, NC, 25-34 383,576 495,917 29.3 447,502 534,643 20.2 Chicago, IL 35-44 760,469 991,841 30.4 935,312 138,557 21.7 Glycemic control varies by race/ethnicity (r/e) in youth with type 1 diabetes 45-54 1,387,258 1,807,547 30.3 1,484,121 1,801,208 21.4 (T1D) and hemoglobin A1c (HbA1c) often worsens over puberty. It is unknown how disparities in glycemic control persist over time. Data were analyzed from 55-64 1,750,352 2,239,212 27.9 1,521,472 1,832,479 20.4 1,313 T1D youth in the SEARCH for Diabetes in Youth study (diagnosed 2002- 65-74 1,158,714 1,415,177 22.1 958,860 1,118,730 16.7 2005, mean T1D duration at baseline = 9.2 months + 6.3; mean age = 9.7 years Total 6,183,117 7,843,149 19.4 6,159,397 7,342,345 19.2 ± 4.3) who had ≥3 HbA1c measures. The sample was 77.2% non-Hispanic white, 10.7% Hispanic, 9.7% non-Hispanic black, and 2.5% other. Group-based trajectory modeling identified three HbA1c trajectories ranging from minor to major deterioration in HbA1c over 109 months of diabetes duration (Figure). The prevalence of minority youth was higher in higher HbA1c trajectories

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A21 RACE AND SOCIETAL INFLUENCES ON DIABETES

81‑OR 83‑OR A Longitudinal Study of Plasma Acylcarnitine Profiles and the Risk Diabetes and Risk of Tuberculosis of Gestational Diabetes in a Multiracial Pregnancy Cohort CECILE PIZOT, PETER BOYLE, Lyon, France YUAN LIN, JING WU, YEYI ZHU, LIMING LIANG, STEFANIE HINKLE, SHRISTI Observational studies have suggested that diabetes increases the risk of RAWAL, NATALIE WEIR, MICHAEL TSAI, CUILIN ZHANG, Bethesda, MD, Rockville, developing tuberculosis. The global burden of diabetes is rising worldwide, MD, Oakland, CA, Boston, MA, Minneapolis, MN especially in tuberculosis endemic areas which could participate in the rise Emerging data suggested that elevated levels of acylcarnitines may be of tuberculosis cases and become a public health problem. A systematic lit- indicative of impaired beta-oxidation and mitochondrial dysfunction, and erature search and quantitative analysis was conducted following PRISMA have been implicated in disrupted glucose homeostasis. However, prospec- guidelines in order to assess the risk of tuberculosis in diabetic patients tive and longitudinal data on the roles of acylcarnitines in the development compared to nondiabetics. Studies were selected if they were in English, of gestational diabetes (GDM) are lacking. We prospectively investigated with a prospective design and if they reported a quantitative estimate of individual and subclasses of acylcarnitines in relation to subsequent GDM the association between diabetes and tuberculosis. Summary relative risks risk in a case-control study within the NICHD Fetal Growth Studies-Single- (SRR) were computed using a random-effects model and standard meth- ton cohort. A total of 107 GDM cases confirmed by OGTT results and medical ods were used to assess heterogeneity and publication bias. Based on 13 record review and 214 non-GDM controls matched on age, race/ethnicity, cohorts which included 27,732 cases of tuberculosis, the SRR of tuberculo- and gestational week (GW) at blood draw were included. We measured lev- sis in diabetic patients compared to nondiabetics was 2.01 (95% CI (1.59; els of 28 acylcarnitines using plasma samples collected through pregnancy 2.54)). There was a large heterogeneity between studies (I²=93%, p<0.01) at GW 10-14, 15-26, 23-31, and 33-39. We further derived scores of short-, and no strong evidence of publication bias. The result was heavily driven by medium- and long-chain acylcarnitines for each participant by chain length one study which had a weight of 56%. When this study was removed, the (i.e., carbon chains ≤7, 8-14, and ≥16, respectively). Adjusted odds ratios SRR was slightly increased to 2.10 (95% CI (1.65, 2.68)) and there was still (aOR) and 95% confidence intervals (CI) for GDM risk were estimated using large amount of heterogeneity between studies (I²=86%, p<0.01). When conditional logistic regression adjusted for pre-pregnancy body mass index the two studies conducted in renal transplant patients were removed, the (BMI) and other major risk factors. Long-chain acylcarnitines levels during SRR was slightly decreased to 1.94 (95% CI (1.50, 2.52)) with still large both first and second trimester were significantly and positively associated amount of heterogeneity (I²=94%, p<0.01). Few studies investigated the with subsequent GDM risk. At GW 10-14, the aOR of GDM comparing the association by gender and reported a higher increased risk in men than in highest vs. lowest quartile was 2.52 (95% CI: 1.15-5.51) (Ptrend=0.004). Cor- women (SRR = 2.77, 95% CI (1.59, 4.82) vs. SRR = 2.34, 95% CI (1.07, 5.13)). responding aOR at GW 15-26 was 3.31 (95% CI: 1.33-8.21) (Ptrend=0.003). No This analysis gives strong evidence of a significant two-fold increased risk significant associations were observed for short- or medium- chain acylcar- of tuberculosis in patients with diabetes compared with nondiabetics. nitines after adjusting for other risk factors. However, further studies are needed to investigate effect modification by In conclusion, we demonstrated that a metabolomics signature of sex, age, duration and type of diabetes and diabetic treatments to better increased level of long-chain acylcarnitines in early and mid-pregnancy was understand the association between diabetes and tuberculosis to improve associated with subsequent GDM risk, and further highlighted the poten- prospects for prevention. tially differential roles of acylcarnitines of various chain lengths in GDM development. 84‑OR Exposure to Perchlorate, Nitrate, and Thiocyanate and Prevalence 82‑OR of Diabetes Mellitus Spousal Diabetes as a Risk Factor for Baseline and Incident GANG LIU, GENG ZONG, KLODIAN DHANA, QI SUN, Boston, MA Depression and Anxiety: Analysis from the Panel Study of Income Background: Perchlorate, nitrate, and thiocyanate are known as sodium- Dynamics iodide symporter inhibitors. In addition, some animal studies suggested that JANNIE NIELSEN, SHIVANI A. PATEL, SOLVEIG A. CUNNINGHAM, Copenhagen, these compounds might also interfere with insulin secretion. However, the Denmark, Atlanta, GA association between their exposure and diabetes risk is largely unknown. Family members of people with diabetes often report negative psycho- Methods: Among 11,443 participants (mean age 42.3 years) from the social effects of the disease. However, there is little longitudinal evidence National Health and Nutritional Examination Survey 2001-2014, urinary on the effect of spousal diabetes on the development of depression/anxiety. perchlorate, nitrate, and thiocyanate were measured by using ion chroma- Therefore, we aimed to investigate the association between spousal diabe- tography coupled with electrospray tandem mass spectrometry. Diabetes tes and current and incident depression/anxiety. We analyzed data from the mellitus was defined as self-reported doctor diagnosis, use of oral hypogly- Panel Study of Income Dynamics (PSID) a longitudinal U.S. national study. cemic medication or insulin, fasting plasma glucose ≥126 mg/dL, or glycated Individuals with spousal diabetes information in 1999 were analyzed at haemoglobin A1c (HbA1c) ≥6.5%. baseline (3916 males and 3905 females) with baseline depression and anxi- Results: The median levels of urinary perchlorate, nitrate, and thiocyanate ety (combined) reported in 1999 or to be diagnosed before 1999. Incidence of were 3.32 μg/L, 46.4 mg/L, and 1.23 mg/L, respectively. The prevalence of depression or anxiety (combined) as an outcome of newly diagnosed spousal diabetes mellitus was 11.6%. Urinary perchlorate was positively associated diabetes (diagnosed between 2001-2003) was based on self-reports in 2001, with fasting glucose, HbA1c, insulin, and homeostatic model assessment ORALS 2003, 2005, 2007, 2009, 2011 and 2013 (in 2820 males and 2731 females). of insulin resistance (all P<0.01). After multivariate adjustment including Logistic regression was used to calculated baseline odd ratios and Cox urinary creatinine and body mass index (BMI), urinary perchlorate, but not proportional hazards model was applied to obtain hazard ratios (HRs), with nitrate and thiocyanate, was significantly associated with the prevalence spouses’ diabetes status as exposure and depression/anxiety of the index of diabetes mellitus. Comparing extreme quintiles, the odds ratio (95% con- individual as outcome. Models were adjusted for the index individual’s age, fidence interval) of diabetes mellitus was 1.53 (1.21, 1.93; P trend <0.001) for sex, employment status, health insurance, and diabetes status at baseline. perchlorate, 1.01 (0.77, 1.32; P trend =0.44) for nitrate, and 0.98 (0.73, 1.31; At baseline, 5.2% had a spouse with diabetes. The fully adjusted odds ratio P trend =0.64) for thiocyanate. When perchlorate, nitrate, and thiocyanate of having depression/anxiety at baseline in individuals with a spousal history were further mutually adjusted, the results did not materially change. Similar of diabetes was 1.48 [95% CI:1.08;2.03]. The overall incidence of depression/ results were observed when analyses were stratified by age, sex, smoking anxiety was 3.5 cases/1000 person years. Individuals with a spouse newly status, kidney function, and BMI. diagnosed with diabetes had similar risk of developing depression/anxiety Conclusion: Higher urinary perchlorate levels are associated with as those without spousal diabetes. Adjustment for the index’s own age, sex, increased prevalence of diabetes mellitus, independent of traditional risk employment status or health insurance coverage did not change the HR [1.47 factors. Future prospective studies are needed to confirm these findings. 95% CI:0.80;2.71]. Thus, our results suggest that the association between Supported By: National Heart, Lung, and Blood Institute spousal diabetes and depression/anxiety may be affected by the duration of spousal diabetes.

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A22 CLINICAL TRANSPLANTATION

CLINICAL TRANSPLANTATION ng/mL with corresponding glucose of 107 and 175 mg/dL. At one year, fast- ing C-peptide declined to 0.43 ng/mL and 90min C-peptide to 1.22 ng/mL. Fasting glucose was 120 mg/dL and 90min glucose 266 mg/dL with HbA1c 85‑OR 6.0%. At 15 months, insulin degludec (4 units daily) was introduced result- Glucose Variability in Subjects with T1D Early after Pancreas ing in stabilization of glucose control. Patient maintains excellent glycemic Transplantation control at 16 months with 7-day mean capillary blood glucose 100±14 mg/dL VIKASH DADLANI, BYRON H. SMITH, KEISHA P. BONNER, WALTER K. KREMERS, (n=28) on 4 units of basal insulin and without hypoglycemia. MIKEL PRIETO, PATRICK G. DEAN, MARK D. STEGALL, YOGISH C. KUDVA, Roch- An islet-containing biologic scaffold transplanted within an omental fold ester, MN appears to be a safe alternative to intra-hepatic ITx with persistent graft Type 1 diabetes (T1D) is characterized by significant glucose variability function observed over 15 months. Long-term follow-up is required to deter- (GV) with current insulin based therapeutic options. Pancreas transplanta- mine sustainability of graft function with this novel strategy and implanta- tion (PT) is performed in certain individuals with T1D with or without End tion site. Stage Renal Disease (ESRD). However, GV has not been studied in detail Supported By: JDRF; The Leona M. and Harry B. Helmsley Charitable Trust; after PT. The goal of this study was to compare GV in patients with T1D Diabetes Research Institute Foundation; National Center for Advancing Trans- managed with insulin pumps to patients with T1D early after PT. GV was lational Sciences; National Institute on Minority Health and Health Disparities assessed using continuous glucose monitoring (CGM, Dexcom G4) 3-6 (1UL1TR000460) weeks after PT in patients with T1D and in T1D subjects with normal kid- ney function managed with insulin pumps. Measurements were both mean glucose concentrations and standard CGM metrics including: 1) % time 87‑OR spent in various glucose ranges; 2) indices of hypo and hyperglycemia [Low Insulin Secreting Cell-Derived Microparticles as Biomarkers of blood glucose index (LBGI), high blood glucose index (HBGI)] and 3) average Early Pancreatic Islet Graft Dysfunction daily risk range (ADRR). Table 1 describes demographics and GV metrics for LAMIA AMOURA, BLANDINE YVER, FATIHA EL-GHAZOUANI, NICOLAS MEYER, 15 T1D PT recipients and 31 T1D subjects without PT. Mean glucose was SALAH EDDINE SAHRAOUI, LAURENCE KESSLER, FLORENCE TOTI, Strasbourg, lower in PT recipients compared to those on insulin pumps. (127±23.1 vs. France, Algiers, Algeria 155.8±23.4, p=0.0002). 91% of time was spent in 70-180mg/dL range in Microparticles (MPs) shed from the plasma membrane of stimulated or PT recipients compared to 64% in T1D subjects (p=<0.0001). PT recipients damaged cells are vesicles that circulate as biomarkers of cell stress. In islet showed superior ADRR 12.7±6.1, HBGI 2.1±2.5 and LBGI 0.5±0.7 compared to transplanted-patients (ITXP), a peak of MPs precedes the C-peptide drop, T1D subjects without PT. PT led decreases in GV compared to insulin therapy. suggesting a prognosis value in early graft dysfunction. Plasma variations CGM appears to provide robust methods to compare efficacy of PT to other of MPs shed from insulin secreting cells (IC-MPs) that bear PSA-NCAM, a therapies. characteristic feature of IC, were measured in ITXP. Blood from 19 ITXP was harvested before each islet infusion and 3, 6, 9, 12, 24, 36 months post last Table 1. islet infusion. IC-MPs were insolubilized onto anti PSA-NCAM antibody and CGM readings T1D with PT T1D without PT P value measured by ultra-sensitive prothrombinase assay. Based on the β-score (n=15) (n=31) value that reflects graft efficacy, ITXP were allocated to Full (FTXS, 6≤ β ≤8) Age (Years) 46.5±8.4 43.7±12.3 0.17 or Partial (PTXS) Transplantation Success (3 < β <6), or Failure (TXF, β ≤3, Gender (F/M) 6/9 19/12 0.174 n=3) subsets. IC-MPs were also assessed in DT1 (n=4), DT2 (n=7) patients Creatinine (mg/dl) 1.4±0.5 mg/dl 0.9±0.2 0.0005 and in healthy subjects (HV, n=3). In FTXS, IC-MP concentrations were simi- lar to those in HV (0.26 ± 0.05 nM vs. 0.3 ± 0.0 nM, n=8) indicating minimal 2 BMI (kg/m ) 25.4±4.1 29.3±5.6 0.44 cell damage. Longitudinal assessment identified an IC-MP peak with a 2-3 Total Number of readings 1100.5 ± 544.7 2644 ± 1130.3 <0.0001 fold-range elevation previous to each β-score drop and the concomitant rise Mean readings per day 206.8 ± 37.2 246.9 ± 11.3 0.0005 in insulin needs, suggesting an early IC damage or dysfunction. The mean value of MPs was significantly lower in FTXS vs. TXF or PTXS (0.26 ± 0.05 Mean BG 127 ± 23.1 155.8 ± 23.4 0.0002 nM, vs. 0.51± 0.42 or 0.44 ± 0.26 nM, p < 0.0001). PTXS MPs were as high % ≤70mg/dL 0.9 ± 1.9 5.4 ± 3.6 <0.0001 as in T2D (0.62 ± 0.17 nM), indicating high MP shedding from residual IC. In % ≥180mg/dL 8 ± 11.8 31.1 ± 14.4 <0.0001 TXF, MPs values assessed at distance from the initial IC-MP peak did not % 70-180mg/dL 91.1 ± 11.6 63.5 ± 13.3 <0.0001 statistically differ from those in DT1 patients (0.40 ± 0.08 vs. 0.28 ± 0.04 nM, p= 0,297), in agreement with a massive -cell loss. PSA-NCAM+-MPs-appear Mean HBGI 2.1 ± 2.5 7.1 ± 3.5 <0.0001 β a valuable and non-invasive tool for the early detection of islet graft dys- Mean LBGI 0.5 ± 0.7 1.3 ± 0.8 0.0007 function. Identification of other circulating MPs shed from leukocytes, liver or Mean ADRR 12.7 ± 6.1 45 ± 8.8 <0.0001 endothelium could further extend our understanding of the underlying cellular mechanisms and help to the development of new monitoring procedures. 86‑OR

88‑OR ORALS Persistent Graft Function following Clinical Islet Transplantation in The BETA-2 Score Correlates with Islet Yield and Insulin Indepen- the Omentum Using a Biologic Scaffold dence in Islet Autotransplantation after Pancreatectomy DAVID A. BAIDAL, CAMILLO RICORDI, DORA M. BERMAN, ANTONELLO PILEGGI, VEENA R. AGRAWAL, TATSUYA KIN, ANNA LAM, ANDREW J. MALCOLM, ANA M. ALVAREZ, NATHALIA PADILLA, GAETANO CIANCIO, ELINA LINETSKY, JAMES SHAPIRO, PETER A. SENIOR, Edmonton, AB, Canada RODOLFO ALEJANDRO, Miami, FL Background: Loss of both insulin and glucagon after total pancreatectomy The liver is the preferred site for clinical islet transplantation (ITx) but is leads to brittle, insulin-dependent diabetes, with high risk of hypoglycemia. not ideal due to several limitations affecting engraftment. Islet autotransplantation (IAT) can prevent or ameliorate diabetes, but poor We evaluated the safety and efficacy of ITx in the omentum within a islet yields from diseased pancreata contribute to variable outcomes. The resorbable biologic scaffold in a 43-year-old woman with 25-year history BETA-2 score has been validated in allogeneic islet transplantations to pre- of type 1 diabetes complicated by hypoglycemia unawareness and severe dict insulin independence, but has not been studied in the IAT population. hypoglycemia. Pre-transplant insulin requirements were 31 units/day, HbA1c Methods: We performed a retrospective chart review of all patients who 6.8%, weight 53.4 Kg, and BMI 21.5 Kg/m2. underwent pancreatectomy with IAT at our institution between 2002 and 602,395 islet equivalents from single donor were combined with autolo- January 2016. BETA-2 scores were compared with islet yield and insulin use. gous plasma and layered laparoscopically on the omentum. Recombinant Results: Forty patients received an IAT during the study period. Mean age thrombin (Recothrom®) was added followed by an additional autologous was 41 (range 3-84) years. Thirty-six underwent total or completion pan- plasma layer to generate a scaffold adherent to the omental surface. The createctomies. Indications for pancreatectomy were chronic or recurrent omentum was folded over the scaffold and additional thrombin used to pancreatitis (60%), benign or malignant tumours (37.5%), and trauma (5%). seal the edges. Induction immunosuppression consisted of anti-thymocyte Mean total islet equivalents (IE) transplanted was 286,768 (range 20,468 globulin (Thymoglobulin®) and etanercept (Enbrel®). Tacrolimus and myco- to 710,224) IE, with a yield of 4057 (range 301 to 10,276) IE/kg. 9 patients phenolate sodium were used for maintenance. There were no surgical com- died during follow-up. All subjects had detectable c-peptide (>0.01 nmol/L). plications. 52% of subjects were insulin-independent at follow-up ranging from 1.5 Insulin independence was attained on day 17 post-ITx. At day 75, fasting months to 14 years. BETA-2 score was significantly associated with islet and 90min C-peptide post mixed meal tolerance test were 0.80 and 2.79

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A23 CLINICAL TRANSPLANTATION

yield (r=0.69, p<0.004). BETA-2 scores in insulin-independent subjects were significantly higher than in insulin dependent subjects (mean score 18 ± 6 vs. 5 ± 4, p<0.0001). 70% of insulin-independent patients had BETA-2 scores > 15, which has been associated with insulin independence in islet allotrans- plant patients; all insulin-dependent patients had scores < 15. Conclusion: The BETA-2 score corresponds with islet yield and insulin independence in patients receiving IAT, similar to patients receiving islet allotransplants. The BETA-2 score may therefore be a useful tool to monitor islet function following pancreatectomy with IAT.

89‑OR An Increase in Islet-Associated Oxygen Consumption Rates between Islet Isolation and Transplantation Is Associated with Superior Graft Function at One-Month Posttransplant in Clinical Islet Transplantation SHAREEN FORBES, DOUG O’GORMAN, ANNA LAM, ANDREW MALCOLM, A. JAMES SHAPIRO, TATSUYA KIN, PETER A. SENIOR, Edinburgh, United Kingdom, Edmonton, AB, Canada Human islet oxygen consumption rates standardised to DNA measure- ments (OCR/DNA; nmol/min-mg DNA) predicts diabetes reversal in animal 91‑OR models, but are highly correlated with islet number, while studies in man Improved Insulin Sensitivity following Islet-Cell Transplant for are lacking. Type 1 Diabetes Aim: To determine the relationship between the islet-OCR/DNA to the KIRSTIE K. DANIELSON, BRETT RYDZON, JESSICA MADRIGAL, REBECCA MON- BETA-2 score at one month post-first islet transplantation. SON, Chicago, IL Methods: Islet preparations (n=28; donor age (mean±SD)(51±13 years), Diminished insulin sensitivity (IS) is a feature of type 1 diabetes (T1D). IS cold and total ischaemia: (10.5±3.5 hours vs. 60±17.5 hours), Islet Equiva- normalizes after curing T1D via islet cell transplant, yet little is known regard- lents (IEQs: 502,594±177,531), purity (57±16%), viability (87±5%)), were ing clinical management and/or biomarkers associated with enhanced IS. studied at isolation and pre-transplant, after 24-48 hour culture. Islets (1000 This study aimed to determine such factors to inform patient care, with the IEQs; measurements in triplicate) were taken from each preparation, OCR goal of improving IS to support islet function after transplant. IS was deter- measured directly using fibre-optic sensors, DNA determined and OCR/ mined in 22 patients receiving 1-3 islet transplants in clinical trials at Univer- DNA calculated. Type 1 diabetic recipients of these preparations (10 males: sity of Illinois at Chicago. Average (range) follow-up after first transplant was 18 females), age: (48±10 years), body weight: (74±14 kg) had fasting C-pep- 4.2 (0-8.2) years. IS was estimated by the Simple Index of Insulin Sensitiv- tide, glucose, HbA1c (%) and insulin doses measured at 1 month and the ity, using glucose and insulin levels from oral glucose tolerance testing done BETA-2 score derived. Univariate and multivariate regression analyses of pre-transplant and 1-2 times annually post-transplant. Potential predictors OCR/DNA (adjusted for total islet number, purity, viability, ischemic time included demographics, BMI, medications, and transplant characteristics. (cold and total) recipient body weight and donor age) were performed with The biomarkers adiponectin and leptin were measured pre-, and 1 and 20 the BETA-2 score at 1-month posttransplant as the outcome variable. weeks post-transplant. Multivariable regression modeling of repeated mea- Results: The BETA-2 score at 1 month was 14±6. An increase in OCR/ sures determined longitudinal associations. Mean (SD) age, T1D duration, and DNA between isolation and transplant was positively associated with the BMI at first transplant were 45.3 (11.9) and 27.9 (11.8) years, and 23.3 (1.9), BETA-2 score on multivariate analyses (p=0.02); univariate and multivariate respectively; 82% female. IS significantly increased during the first year post- analyses of OCR/DNA at isolation and transplant were not associated with transplant (p=0.02), then stabilized (p=0.39). Adjusting for age, sex and BMI, the BETA-2 score (p>0.05). IS was positively associated with number of transplanted islets (p=0.001) and Conclusions: An increase in OCR/DNA between islet isolation and trans- exenatide dose (p=0.01), and negatively associated with leptin (p=0.03) and plantation was associated with clinical islet transplant success at 1-month tacrolimus dose (p=0.04). Further, IS was negatively associated with HbA1c posttransplant. Further studies are required to determine if such indices are (p=0.06) and fasting C-peptide (p=0.02) following transplant. associated with long-term outcomes. In summary, IS after transplant improved with higher number of trans- Supported By: Alberta Health; Government of Alberta; JDRF; Alberta Innovates planted islets and use of exenatide; interventions lowering leptin prior to Health Solutions; Canadian Institutes of Health Research; Diabetes Research transplant (exercise and diet), and targeting low tacrolimus levels, may Institute Foundation of Canada improve IS. These results may be clinically significant as enhanced IS was associated with better glycemic control and lower fasting C-peptide reflect- 90‑OR ing lower metabolic demand on the islets.

ORALS Stabilization of Kidney Function after Islet-Cell Transplant JESSICA M. MADRIGAL, DANMEI HUANG, REBECCA S. MONSON, JOSE OBER- 92‑OR HOLZER, KIRSTIE K. DANIELSON, Chicago, IL Early Hyperglycemia after Initiation of Glucocorticoid Therapy Islet transplant potentially cures type 1 diabetes (T1D). However, kidney Predicts Adverse Outcome in Patients with Acute Graft-vs.-Host impairment due to immunosuppression may occur. We examined kidney Disease function in 28 patients with T1D before and after (mean 1.7 ± 1.3 years) final FELIX ABERER, JULIA K. MADER, MELANIE STAUBER, PETER NEUMEISTER, islet transplant in phase 1/2 (n=10) and 3 (n=18) clinical trials. Mean age ABDERRAHIM OULHAJ, ARMIN ZEBISCH, THOMAS R. PIEBER, HILDEGARD was 46.6 years, 22 were female, and all received 1-3 transplants. Serum GREINIX, HEINZ SILL, ALBERT WOELFLER, HARALD SOURIJ, Graz, Austria, Dubai, creatinine was measured at each study visit, and urine albumin to creatinine United Arab Emirates ratio (ACR) was measured 3-4 times annually. Mean (SD) baseline estimated Graft-vs.-host-disease (GvHD) is a common and life-threatening immu- glomerular filtration rate (eGFR) and ACR were 84.5 (18.3) ml/min/1.73m2 and notoxic complication in patients undergoing stem cell transplantation for 15.4 (20.5) mg/g, respectively. Changes in eGFR and ACR following trans- hematological malignancy. Due to first-line treatment with high-dose gluco- plant were investigated using multivariable regression of repeated mea- corticoids (GC), steroid-induced hyperglycemia occurs frequently. sures. Adjusting for recipient age, sex, T1D duration, baseline eGFR/ACR, In a retrospective analysis of 104 patients (56% male) who received sys- and number of transplants, eGFR decreased (-1.1 per year; p=0.26) and ACR temic GC for acute GvHD we investigated the consequences of impaired increased (1.2 per year; p=0.25) but not significantly. Blood pressure also did glucose metabolism. In particular, we focused on glucose parameters early not change. After adjusting for confounders, eGFR was positively associated after initiation of GC. with number of transplants (p=0.02) and female sex (p=0.002), and nega- Early hyperglycemia, as defined by mean blood glucose levels >125mg/ tively associated with use of antihypertensive medication (p=0.02). ACR was dL during the first 3 days of GC therapy, was found to be highly associated positively associated with systolic blood pressure (p=0.02). with adverse outcome (hazard ratio (HR) of 2.5 for death and HR of 3.3 for In summary, islet transplant recipients may experience stabilization of death due to non-relapse mortality in a competing risk analysis). A score eGFR and albuminuria after transplant, which was unrelated to immunosup- based on early hyperglycemia and non-response to GC within 7 days allowed pression dose and levels, but better blood pressure management. the identification of 3 risk groups: patients with both risk factors (n=25) had

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A24 GLUCAGON AND GLP-1 PHYSIOLOGY AND PHARMACOLOGY an inferior OS at 5 years of 4.1% as compared to 75.4% in patients with the largest GIP-response in the obese control subjects (iAUCGIP in RYGB: G: none (n=32). Patients with 1 risk factor (n=47) had a 5 year OS rate of 32.0% 4600±1365, F: 2645±446, P: 2029±272; in CON: G: 3241±635, F: 6085±1778, (p=0.0002 for trend). P: 2843±427). The largest CCK response occurred after protein in the RYGB We identified early hyperglycemia after GC therapy as an independent group, while fat induced the most robust response in obese controls. risk factor for adverse outcome in patients with GvHD. A score based solely In conclusion, after RYGB glucose is the most potent stimulus of L-cell on early hyperglycemia and lack of response to GC was highly predictive for products and GIP, opposing the secretory pattern seen in obese controls survival in these patients. where fat produces the largest response. Accordingly, secretion of the entero-endocrine hormones strongly depends on the ingested macronutri- ents and differs between RYGB operated and obese control subjects. GLUCAGON AND GLP-1 PHYSIOLOGY AND Supported By: Danish Council for Independent Research PHARMACOLOGY 95‑OR 93‑OR Dapagliflozin Improves Incretin Sensitivity of Pancreaticβ -Cells Novel Approach to Estimate Glucagon Turnover in Humans: Use CHANG HO AHN, TAE JUNG OH, SE HEE MIN, YE SEUL YANG, SUN JOON MOON, of 13C Glucagon SOO HEON KWAK, KYONG SOO PARK, YOUNG MIN CHO, Seoul, Republic of Korea ANANDA BASU, LING HINSHAW, DANIEL MCCORMICK, KENNETH JOHNSON, The insulinotropic effect of glucagon-like peptide-1 (GLP-1) and glucose- LEON FARHI, MICHAEL SLAMA, RICKEY CARTER, RITA BASU, Rochester, MN, dependent insulinotropic polypeptide (GIP) is reduced in patients with Charlottesville, VA type 2 diabetes mellitus (T2DM). The impairment of pancreatic β-cell func- Unlike the C-peptide model for measuring insulin secretion, there are cur- tion is considered as the primary mechanism of the reduced incretin effect. rently no available methods to measure glucagon secretion in humans. To do We hypothesized that dapagliflozin improvesβ -cell sensitivity to incretins so, we applied the isotope dilution approach to probe glucagon secretion, by by alleviating glucotoxicity in patients with inadequately controlled T2DM. synthesizing a non-radioactive, 13C labeled glucagon isotope (FF-glucagon; Subjects with T2DM (n = 19) and NGT (n = 10) were enrolled in this study. 13 15 13 15 NGT subjects underwent a single baseline hyperglycemic clamp study with Phe 6 C9, N; Phe 22 C9, N) that was reproducibly detectable in plasma (LOD: 5 pg/ml) by nanoLCMS/MS. To estimate post-absorptive glucagon incretin hormone infusion. T2DM subjects underwent the same hypergly- turnover, we conducted a pilot study in 5 nondiabetic (ND) and 2 type 1 dia- cemic clamp study before and after 8-week treatment with dapagliflozin betes (T1D) subjects with normal liver and kidney functions. Subjects were 10 mg daily added to the background treatment. During the 180 min of hyper- admitted at 6 PM to the Clinical Research Trials Unit, consumed a standard glycemic clamp study, plasma glucose levels were clamped at 15.5 mmol/l. meal at 7 PM and remained NPO except water for the rest of the study. Synthetic GLP-1 (60-180 min) and GIP (120-180 min) were sequentially Insulin was infused in T1D subjects to maintain euglycemia. FF-glucagon infused during the clamp study. Incremental area under the curve (iAUC) of was infused intravenously at 0.18 pmoles/kg/min for 6 hours starting at plasma C-peptide levels were calculated to estimate the pancreatic β-cell 7 AM. The heated hand vein method was used to collect blood periodically to responses to the induced hyperglycemia with or without GLP-1 and GLP-1/ measure glucose, insulin, glucagon and FF-glucagon concentrations. Gluca- GIP infusion. The GLP-1 response (iAUC of C-peptide60-120 min) significantly gon (native + FF-glucagon) was measured by a radioimmunoassay (Millipore) increased after dapagliflozin treatment (83.6 ± 42.1 nmol/l*min to 106.6 ± and by nanoLCMS/MS. The assay results correlated (r2=0.99) with each 45.7 nmol/l*min, P = 0.011). The GIP response (iAUC of C-peptide120-180 min) other. Plasma glucose, insulin and glucagon concentrations did not change increased with marginal significance (82.5 ± 58.4 to 101.9 ± 50.3 nmol/l*min, during and after cessation of FF-glucagon infusion. A stable tracer-tracee P = 0.087). The total and first phase C-peptide response to hyperglycemia ratio (TTR) enabled measurement of Glucagon kinetics with the steady-state significantly increased after dapagliflozin treatment. However, these values were far lower than those of the NGT subjects. Intriguingly, the improve- equation: Raglucagon = ([FFF-glucagon/TTR] - FFF-glucagon), where Raglucagon = rate of ment of the β-cell response to hyperglycemia was closely correlated with systemic post-hepatic glucagon appearance; FFF-glucagon = rate of infusion the improvement of the β-cell response to incretin. of FF-glucagon. Raglucagon was 0.14±.06pM/kg/min in ND and 0.18±.08pM/ kg/min in T1D; glucagon clearance was 11.5±3.3 ml/kg in ND and 11.1±4.5 In conclusion, 8 week treatment with dapagliflozin significantly improved ml/kg in T1D. We believe this represents the first report of a novel method the incretin sensitivity of the pancreatic β-cell in conjunction with the to measure in vivo glucagon kinetics in humans. A better understanding of improvement in pancreatic β-cell function in T2DM patients. glucagon kinetics could lead to valuable insights into future research and Supported By: AstraZeneca (ISSDAPA0003) development of dual-hormone (insulin + glucagon) algorithms for closed loop control in T1D. 96‑OR Supported By: National Institutes of Health Regulation of Endogenous Rodent GLP-1 and Human Islet Insulin Secretion by Antagonism of Somatostatin Receptor 5 94‑OR THOMAS B. FARB, MARTA ADEVA, THOMAS J. BEAUCHAMP, OVER CABRERA, Differential Effects of Individual Macronutrients on Enteroendo- DAVID A. COATES, TAMIKA DESHEA MEREDITH, BRIAN A. DROZ, ALEXANDER crine Hormone Responses in Obesity and after Roux-en-Y Gastric EFANOV, JAMES V. FICORILLI, SUSAN L. GACKENHEIMER, MARIA A. MARTINEZ-

Bypass GRAU, VICTORIANO MOLERO, GEMA RUANO, MICHAEL A. STATNICK, TODD M. ORALS MARIA S. SVANE, CHRISTIAN Z. JENSEN, KIRSTINE N. BOJSEN-MØLLER, NICO- SUTER, SAMREEN K. SYED, MIGUEL A. TOLEDO, FRANCIS S. WILLARD, XIN LAI J. WEWER ALBRECHTSEN, LINE M. HOLST, JENS F. REHFELD, KJELD HER- ZHOU, KRISTER B. BOKVIST, DAVID G. BARRETT, Indianapolis, IN, Alcobendas, MANSEN, JENS JUUL HOLST, STEN MADSBAD, Hvidovre, Denmark, Copenhagen, Spain Denmark, Aarhus, Denmark In patients with T2D, blunted incretin and insulin responses to nutrient The secretion of gut-hormones is altered after Roux-en-Y gastric bypass, loads result in decreased glycemic control. Whereas agents including sul- but the regulation of secretion and stimulation by the individual macronutri- fonylureas and DPP-4 inhibitors (DPP-4i) partially reverse these effects and ents remain poorly understood. We investigated the secretion of glucagon- provide therapeutic benefit, their modes of action limit efficacy. Because like peptide-1 (GLP-1), glicentin, glucose-dependent insulinotropic peptide SST has been shown to suppress insulin and GLP-1 secretion through the (GIP) and cholecystokinin (CCK) in response to glucose (G), fat (F) and protein Gi-coupled SSTR5 isoform in vitro, antagonism of SSTR5 may improve gly- (P) in RYGB-operated subjects and in non-operated obese control subjects cemic control via intervention in both pathways. Here we show that SSTR5 (CON). 10 RYGB operated subjects (3.7±0.4 years post-RYGB, 46±2 yrs, BMI antagonism reverses the blunting effects of SST on insulin secretion from 33.6±1.5 kg/m2) and 8 CON (matched for age, sex and BMI) underwent 3 human islets and demonstrate for the first time that SSTR5 antagonism experimental days with 4-h isocaloric, isovolemic liquid meal tests contain- affords increased levels of systemic active GLP-1 (a-GLP-1) in vivo. Treat- ing >90E% of either P (53g whey proteins), F (26g butter) or G (52g) dispersed ment of fasted C57BL/6 mice with a potent and selective SSTR5 antago- in water. After RYGB, glucose was the most potent stimulus of both GLP-1 nist, S5A1 (human, mouse, rat Ki= 0.54, 4.87, 3.77 nM), afforded a sustained and glicentin with >2-fold responses compared with fat and protein (both three-fold elevation in systemic a-GLP-1 levels (ED50 = 0.30 mg/kg). Knocking p<0.01) and >10 fold increases when compared with glucose ingestion in out SSTR5 in mice afforded a similar increase in systemic a-GLP-1 levels, obese controls (p<0.01). In the obese control group the highest response which were not increased further by treatment with S5A1. Following an oral of both GLP-1 and glicentin was seen after fat (~2-fold) compared with glucose challenge in mice, S5A1 dose-dependently increased a-GLP-1 levels (ED = 0.38 mg/kg) and improved glycemic control. The effects of SSTR5 glucose and protein (p<0.01) (iAUCglic in RYGB: G: 16252±3038 pmol/l*min, 50 F: 5057±1346, P: 3408±1058; in CON: G: 609±881, F: 1870±496, P: 540±365). antagonism on levels of a-GLP-1 and on glycemic control were also seen in Also GIP was highest after glucose in the RYGB group, whereas fat produced DIO mice, and did not diminish following two weeks of dosing. Treatment of

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A25 GLUCAGON AND GLP-1 PHYSIOLOGY AND PHARMACOLOGY

mice and male ZDF rats with S5A1 in combination with a DPP-4i afforded 2 99‑OR to 3.5-fold increases in systemic a-GLP-1 over DPP-4i treatment, resulting in Beta-Cell Sensitivity to Incretin Infusions in Healthy Adults greater glycemic control than either agent alone. In isolated human islets, MARK D. MILLER, DAVID A. D’ALESSIO, CRIS A. SLENTZ, Durham, NC S5A1 completely reversed the inhibitory effect of exogenous SST-14 on The incretins glucagon-like peptide-1 (GLP-1) and glucose-dependent insulin secretion. The data presented here suggest that SSTR5 antagonism insulinotropic polypeptide (GIP) stimulate insulin secretion in response to should stimulate both GLP-1 and insulin secretion (directly and via GLP-1), enteral glucose. Animal studies have shown that deletion of the receptor and afford robust glycemic control in patients with T2D. for one incretin leads to a compensatory increase in b-cell sensitivity to the other. Based on these findings we hypothesized an interaction between 97‑OR the incretins such that one or the other would be dominant and the com- The Core Clock Gene Bmal1 Positively Regulates Circadian Secre- bination of GLP-1 and GIP sensitivity would be relatively constant. To test tion of Glucagon-Like Peptide-1 from the Intestinal L Cell this hypothesis, we performed a paired hyperglycemic clamps that started ALEXANDRE MARTCHENKO, PATRICK GURGES, SARAH E. WHEELER, ROBIN OH, with a 90-minute glucose ramp to target glycemia, followed by a step-wise BRIAN J. COX, PATRICIA L. BRUBAKER, Toronto, ON, Canada graded infusion of GIP or GLP-1 over 120 minutes. The slope of plasma insulin Glucagon-like peptide-1 (GLP-1) is an intestinal incretin hormone released to blood glucose determined b-cell sensitivity to glucose; the slope of insu- by the L cell in response to nutrient intake. We have recently identified a cir- lin secretion across the GIP/GLP-1 infusions determined incretin sensitivity. cadian pattern of GLP-1 secretion that parallels rhythmic expression of the b-cell glucose sensitivity ranged from 3.8 to 19.8 in this cohort of healthy core clock gene Bmal1 in the mGLUTag L cell line. We thus hypothesized that subjects, while b-cell sensitivity to GIP ranged from 3.4 to 30, and to GLP-1 Bmal1 is a positive regulator of circadian secretion of GLP-1. The peak and 22 to 59. There was no relationship between the b-cell sensitivity to glucose trough of Bmal1 mRNA and protein expression in mGLUTag cells occurred and the sensitivity to either incretin. However, there was a positive relation- at 8 and 20 hr after synchronization, respectively, and glucose-dependent ship between GLP-1 sensitivity and GIP sensitivity (r = 0.51). These findings insulinotropic peptide (GIP)-stimulated GLP-1 secretion was increased at indicate that b-cell sensitivity to glucose, GIP and GLP-1 varies widely across 8 hr as compared to 20 hr (p<0.01). Pre-treatment with the saturated fatty a group of healthy young adults, but that subjects who respond strongly to acid palmitate dampened Bmal1 expression (p<0.01) at 8 hr after synchroniza- one incretin are also sensitive to the other. These results suggest that the tion, in association with suppressed levels of ATP (p<0.05), NAD+ (p<0.01), and actions of the incretins to promote insulin secretion are additive rather than GIP-induced GLP-1 secretion (p<0.001). In contrast, palmitate had no effect on compensatory. either Bmal1 expression or GLP-1 secretion at 20 hr, suggesting that Bmal1 positively regulates circadian secretion of GLP-1. To elucidate the downstream 100‑OR pathways involved in GLP-1 secretion that may be regulated by Bmal1, mass Is Glucagon Regulated Mainly by Glycemia or Direct α-Cell Effects spectrometry analysis was conducted at 8 and 20 hr after synchronization. during SGLT2 Inhibition? At the peak of Bmal1 protein expression, there was a significant enrichment PER LUNDKVIST, MARIA J. PEREIRA, PETROS KATSOGIANNOS, RUSSEL ESTER- for proteins involved in ATP-dependent cellular processes, secretory granules, LINE, ANNA MARIA LANGKILDE, EVA JOHNSSON, JAN W. ERIKSSON, Uppsala, and protein transport (p<0.001). In vivo studies using Bmal1 KO vs. WT mice Sweden, Mölndal, Sweden showed that KO animals have impaired rhythms in fasting blood glucose, insu- SGLT2 inhibitors (i) can increase glucagon (glg) secretion, but it is not lin, and GLP-1. Furthermore, in response to oral glucose tolerance tests at 6 known to what extent a direct islet effect or plasma glucose (PG) lowering time points through the 24 hr-day, KO animals showed dysregulation in their contributes. In a 3-way open-label crossover study, 15 metformin-treated rhythms for glycemic tolerance, insulin, and GLP-1 secretion. Finally, primary T2D patients (age 67±2y, BMI 25.1±1.9 kg/m2, HbA1c 7.3±0.2%; mean±SEM) cultures of ileal crypt cells from KO mice also showed impaired forskolin- were investigated after overnight fast. A single oral dose of dapagliflozin stimulated GLP-1 secretion vs. WT controls (n=2). In combination, these data (Dapa) 10mg (± oral saxagliptin 5mg) was directly followed by a 5 h infusion suggest that Bmal1 is a positive regulator of circadian GLP-1 secretion. of glucose (isoglycemic clamp) or saline and then a 2 h OGTT. Glg, insulin (ins) and energy substrates were measured repeatedly. Here we report results 98‑OR from saline vs. glucose infusion after Dapa alone (n=13 completers). Follow- A Decrease in Insulin Action, but Not In β-Cell Function, Impairs ing Dapa, PG was unchanged with isoglycemic clamp (delta-AUC 0 ± 1%), but Glucagon Suppression in Nondiabetic Humans fell by 17 ± 1% during 5 h saline infusion. Glg was significantly lower with RON T. VARGHESE, ANU SHARMA, NANA E.N. KITTAH, MARCELLO LAURENTI, isoglycemia vs. saline infusion but fell from baseline in both cases. Insulin CHIARA DALLAMAN, ROBERT A. RIZZA, CLAUDIO COBELLI, ADRIAN VELLA, and C-peptide were lowered with saline but not isoglycemic clamp. Glg/ Rochester, MN, Padova, Italy ins ratio markedly rose with saline and fell with isoglycemia. β-OH-ketones A decline in insulin secretion and action characterize development of increased with saline and levels were higher than with isoglycemia. Our type 2 diabetes. Along with impaired β-cell function, abnormal fasting and data in T2D patients given a single dose Dapa indicate that the glg level postprandial glucagon concentrations in type 2 diabetes contribute to hyper- and glg/ins ratio are largely regulated by glycemic changes, and that direct glycemia. The mechanism of α-cell dysfunction in humans is unclear. In a α-cell effects by SGLT2i may be of minor importance. No short-term rise in series of experiments examining the pathogenesis of prediabetes, we mea- glg was seen after Dapa administration. (NCT02765204).

ORALS sured glucagon concentrations during a frequently sampled OGTT. In nondia- Table. Percent Change from Baseline with Dapa 10 mg; 5 h Glucose vs. betic subjects (n = 190, age = 66 ± 1, BMI = 27.5 ± 0.3 Kg/M2), β-cell responsiv- Saline Infusion. ity ( ) and insulin action (S ) were measured using oral minimal model. Fasting Φ i Infusion Glucagon Insulin Glucagon/Insulin β-OH-ketones and integrated postprandial glucagon concentrations correlated positively Saline -8±3 -32±3 39±6 71±18 with fasting C-peptide concentrations and with ϕbasal (after correcting for age, sex and BMI; R2=0.25, p < 0.01). An inverse correlation was seen with Glucose -22±4 22±17 -22±9 9±11 2 Si (R = 0.24, p < 0.01). No association with Φ and Disposition Index (DI) was Difference -13±3** 54±16** -62±10** -61±26* seen. Similar findings were observed in another cohort (n = 120, age 41 ± 1, BMI Mean±SEM, %delta-AUC plama conc; *p<0.05 **p<0.01. = 27.4 ± 0.4 Kg/M2). The latter cohort was studied on two additional occasions in random order; on one, free fatty acid (FFA) elevation to cause insulin resis- tance, achieved by infusion of intralipid + heparin. On the other day subjects received the same amount of glycerol (GLY) present in the intralipid infusion. FFA elevation decreased insulin action (19 ± 1 vs. 13 ± 1 10-4 dl/kg/min per μU/ml, p <0.01) and a rise in fasting glucagon concentrations (71 ± 2 vs. 78 ± 2 ng/l, p <0.01) but no change in postprandial glucagon concentrations (23.9 ± 0.6 vs. 23.6 ± 0.6 μg per 6 hr, p = 0.36). On both FFA (R 2 =0.26, p < 0.01) and GLY days (R 2 =0.19, p < 0.01) fasting glucagon was inversely correlated with Si. Again, no association of glucagon with Φ and with DI was seen. In summary, cross-sectional data and an interventional study where Si was decreased, suggest that glucagon secretion is altered by changes in insulin resistance. β-cell function across a wide spectrum of glucose toler- ance does not alter glucagon suppression in nondiabetic humans. Supported By: National Institutes of Health

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A26 PUTTING OUR BEST FOOT FORWARD—THE LATEST IN DIABETIC FOOT RESEARCH

PUTTING OUR BEST FOOT FORWARD—THE LATEST 103‑OR IN DIABETIC FOOT RESEARCH Excess Risk of Lower Extremities Amputation in Persons with Type 1 Diabetes 101‑OR ARNDIS F. OLAFSDOTTIR, ANN-MARIE SVENSSON, SOFFIA GUDBJORNSDOT- Circulating Microparticles in Acute Diabetic Charcot Foot Exhibit a TIR, ANNIKA ROSENGREN, ALDINA PIVODIC, HANS WEDEL, MARCUS LIND, High Content of Inflammatory Cytokines and Support Monocyte-to- Uddevalla, Sweden, Gothenburg, Sweden Osteoclast Cell Induction How the excess risk of lower extremity amputations (LEA) in persons with type 1 diabetes (T1D) differ to the general population for various levels of gly- JENNIFER PASQUIER, BINITHA THOMAS, JESSICA HOARAU-VÉCHOT, TALA caemic control and renal complications is not fully understood. We analysed ODEH, OMAR CHIDIAC, SOHA DARGHAM, REBAL TURJOMAN, ROBERT MEN- data from persons with T1D in the Swedish national diabetes register with no ZIES, AMIN JAYYOUSI, MAHMOUD ZIRIE, JASSIM AL SUWAIDI, ARAH RAFII, prior LEA between Jan. 1998 and Dec. 2011. For each patient (n=33616), 5 con- RAYAZ A. MALIK, TALAL TALAL, CHARBEL ABI KHALIL, Doha, Qatar Objectives: Circulating Microparticles (MPs) are major mediators in T2D; trols matched by sex, age and county (n=167721) were randomly selected from however, their contribution to Charcot foot (CF) disease is not known. the nondiabetes population. All were followed until first LEA, death or end of Methods: We purified and assessed the origin, content and concentra- follow-up. Patients mean age was 35.6 years, 45.3% were women, mean A1c tion of circulating MPs from 33 individuals: 11 with T2D and acute CF, 11 8.2%, mean diabetes duration 20.2 years and 3.7% had prior foot ulcers. Inci- T2D patients with equivalent neuropathy and 11 nondiabetic controls. All dence of all LEA/1000 patient years was 3.11 (95% CI 2.9-3.33) for T1D and 0.12 participants were matched for age, gender and BMI, and HbA1c for diabetic (95% CI 0.1-0.13) for controls, adjusted hazard ratio 21.1 (95% CI 17.7-25.2). For patients. patients with HbA1c <7.8%, no renal complications and =<20 years diabetes Results: Using CD31, CD62E, CD42b, CD142 and CD16, we demonstrated duration there were no LEA events. When including all patients, irrespective that there were no differences in the distribution of MPs of endothelial, of diabetes duration, the excess risk was 5 times higher with good glycaemic platelet and leukocyte origin among the 3 groups. Moreover, we didn’t find control and no renal complication. The excess risk increased with diabetes any difference in their content using angiogenesis-related proteins. How- duration, worse glycemic control and severity of renal complications (Table). ever, 5 cytokines (G-CSF, GM-CSF, IL-1-ra, IL-2 and IL-16) were significantly In conclusion, persons with T1D with good glycemic control, no renal compli- increased in MPs from acute CF patients. Applying ingenuity pathways cations and <20 years of diabetes no excess risk existed while the risk increased analysis, we found that those cytokines interacted well and induced the with higher A1c, increased renal complications and longer diabetes duration. activation of pathways that are involved in osteoclast formation such as Table. Adjusted Hazard Ratios for LEA for A1c, Albuminuria, eGFR Catego- IL-17, IL-1, P38 MAPK, Jnk or ERK1/2. Further, treatment of THP-1 monocytes ries, and Diabetes Duration vs. the Reference Group. with MPs from acute CF patients increased their differentiation into osteo- clast precursor cells. Conclusion: In summary, circulating MPs in diabetic acute CF have a high content of inflammatory cytokines and could contribute to the increased number of osteoclasts, known to be the hallmark of CF disease. Supported By: Weill Cornell Medicine-Qatar

102‑OR DNND (Diabetic Neuropathy Nerve Decompression) Study: A Con- trolled, Randomized, Double-Blinded, Prospective Study on the Role of Surgical Decompression of Lower Extremity Nerves for the Treatment of Patients with Symptomatic Diabetic Neuropathy with Chronic Nerve Compression SHAI ROZEN, GIL WOLFE, PHILIP RASKIN, STEVEN VERNINO, GEETHA PANDIAN, Supported By: Novo Nordisk Foundation KATHLEEN WYNE, JOAN REISCH, LINDA HYNAN, RITA FULMER, ANNAMARIA SALVADORE, Dallas, TX, Buffalo, NY, Columbus, OH 104‑OR Approximately one third of patients suffering from Painful Diabetic Neu- Influence of Offloading Induced Limb Length Discrepancies upon ropathy (PDN) are prone to nerve compression. Current evidence on nerve Spinal Alignment decompression for pain alleviation in select patients is considered level U RYAN T. CREWS, CHRISTOPHER GIRGIS, RACHEL DOMIJANCIC, EMILY MOSHER, (Unproven). Presented is a seven year, controlled randomized double blinded SAI V. YALLA, North Chicago, IL, Lake Forest, IL, Chicago, IL prospective study determining the long term effect of neurolysis on pain Removable cast walkers (RCW) are commonly used to offload diabetic foot and quality of life in PDN patients. A multidisciplinary group of neurologists, ulcers (DFU) and promote healing; however, patient adherence with RCWs is endocrinologists, rehabilitation, pain, and surgery specialists performed poor. One suspected contributor to non-adherence is an induced limb length baseline pain (Likert 0-10) and quality of life SF36 exams. Patients were discrepancy (LLD) that the thick soled RCWs induce. It has been hypothesized randomized into surgical and non-surgical control groups (2:1 ratio, respec- that the LLD causes back and joint pain that patients try to alleviate by not using ORALS tively). Surgical patients underwent surgery bilaterally with each side ran- their RCW. The purpose of this study was to objectively evaluate the effect of domized to nerve decompression or sham surgery. Patient and final evalua- RCW upon spinal alignment and gait. Secondarily it investigated whether a con- tors were blinded to side with quarterly, one year, and four year evaluations. tralateral limb lift mitigated any RCW effects. Fifteen healthy subjects were Of 2987 screened patients, 138 enrolled: 92 randomized to surgery and 46 recruited. Exclusion criteria included previous diagnoses of scoliosis or limb as controls. 40 surgical and 27 controls completed the study. At one year length discrepancy. Participants were evaluated in three footwear conditions: the surgical group experienced a mean pain reduction of 5.70 in the surgical 1) control- standardized athletic shoes bilaterally, 2) RCW with standardized ath- leg (SD=2.09;p<0.0001) and 5.25 (SD=2.79;p<0.0001) in the sham leg while letic shoe on the contralateral foot, 3) RCW and athletic shoe plus lift on contra- the control group had no statistically significant reduction. A 54.5 month lateral foot. Under each condition, subjects’ 3D spinal alignment was assessed follow-up of 36 surgical patients revealed a mean pain reduction of 7.47 while standing via an optical non-radiation system (Formetric 4D, Diers). Addi- in the surgical leg (SD=2.54;p<0.0001) and 5.97 (SD=2.43;p<0.0001) in the tionally, subjects completed a walking trial under each footwear condition. The sham leg. The SF-36 General Health component score revealed a significant same optical system collected dynamic 3D spinal motion during walking trials. interaction for group by time, p=.0010; while group means at baseline, 3 mo, Kinematic gait data such as step length and knee range of motion were col- and 6 months (p=0.53, 0.24, and 0.10, respectively) were not significantly lected during the walking trials via body worn sensors (LEGSys, Biosensics). Dur- different, means at 9 months and 1 year were significant (p=0.01 and 0.02, ing standing sagittal imbalance was significantly (p=.026) altered in Condition 2 respectively). This data suggests a potential role for nerve decompression in in contrast to the Control Condition. During walking pelvic tilt and lordotic angles carefully selected patients. were significantly (p=.003 and p=.033) altered in Condition 2 in contrast to the Supported By: National Institutes of Health (UL1TR0011052); David M. Crowley Control Condition. Condition 3 did not differ (p>.05) from the Control Condition in Foundation regards to walking pelvic tilt and lordotic angles nor in standing sagittal imbal- ance. The RCW induced changes in spinal alignment could contribute to back pain and subsequently poor RCW adherence. However, a contralateral lift may improve RCW adherence by mitigating spinal alignment changes. Supported By: National Institute of Diabetes and Digestive and Kidney Diseases

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A27 SENDING THE BETA CELL MIXED SIGNALS

105‑OR SENDING THE BETA CELL MIXED SIGNALS Decreased Health-Related Quality of Life in Diabetes Patients with Foot Problems 107‑OR JIN SOTHORNWIT, ATCHARA SUWANNAKIN, GULAPAR SRISAWASDI, APIR- Inflammatory Cytokines Disrupt the Function of theβ -Cell Circadian ADEE SRIWIJITKAMOL, Bangkok, Thailand Clock: A Potential Mechanism of Obesity-Induced β-Cell Failure Aim: 1. To investigate health-related quality of life (HRQoL) in diabetes NAUREEN JAVEED, KUNTOL RAKSHIT, ALEKSEY V. MATVEYENKO, Rochester, patients with diabetic foot problems. 2. To compare HRQoL between 3 MN groups including 1) diabetes patients with diabetic foot problems (DF) includ- The circadian system plays a pivotal role in regulation of insulin secre- ing foot ulcer (DFU) or amputation (AMPU), 2) those who have other diabetic tion. In β-cells, clock-controlled genes regulate critical cellular pathways complications (COM) such as DR, ESRD, or CAD, and 3) diabetes patients (e.g., insulin secretion and mitochondrial function). Recent studies suggest without diabetic complication (CON). that obesity imparts deleterious effects on the circadian system, however Methods: 254 diabetes patients were studied in a cross-sectional setting. little is known about the molecular effects of obesity on the β-cell circadian Demographic and clinical characteristic were recorded. HRQoL was evalu- clock. In the current study we set out to: 1) delineate whether exposure to ated using Thai version of EuroQol five-dimensions questionnaire with five- diet-induced obesity (DIO) disrupts circadian regulation of insulin secretion, level scale (EQ-5D-5L). Subjects were asked to rate their level of impairment and 2) identify cellular mediators of DIO-induced circadian clock disrup- across 5 dimensions including mobility, self-care, usual activities, pain/dis- tion in β-cells. DIO was induced in mice by 8 week high fat diet (60%) and comfort, and anxiety/depression. Utility values (UV) were calculated using resulted in glucose intolerance associated with loss of circadian variations time-trade-off methods. in glucose disposal (P<0.05 vs. lean) and insulin secretion (P<0.05 vs. lean). Results: 141 DF (98 DFU and 43 AMPU), 82 COM (27 DR, 28 ESRD, 27 To delineate DIO-associated disruptors of β-cell circadian clock, we first CAD) and 31 CON subjects were completed the interview. The mean age examined whether glucotoxicity (24 mM glucose), lipotoxicity (0.5 mM pal- of subjects was 63.2+12.1 years, BMI of 24.9+4.7 kg/m2, mean HbA1c of mitate) and/or pro-inflammatory cytokines (IL-1β, TNF-α, IL-6) modulate gene 7.7+2.07%, the duration of diabetes was 13.1+9.9 years and the mean util- and protein expression of key circadian clock transcription factors (Clock ity scores was 0.799+0.25. There was no difference in age, BMI, HbA1c, and Bmal1) in INS-1 832/13 cells. Interestingly, exposure (24 hr) to IL-1β duration of DM, and diabetes treatment regimens between each group. (0.2-5 ng/ml) resulted in dose-dependent reduction in gene and protein 21% of diabetes subjects in DF group lost their job after had diabetic foot expression of Bmal1 and Clock in INS-1 832/13 cells which was also con- problems. UV of patients with complication were lower than those with- firmed in human islets. Next, we assessed the effects of IL-1β on islet cir- out complication. Among the complications, DF had the lowest mean UV as cadian clock function by tracking islet cell clock gene bioluminescence in compare to COM and CON (the mean UV of 0.703+0.28 in DF, 0.889+0.15 in islets isolated from Per2:luciferase knock-in mice. Exposure to IL-1β (2 ng/ml) CAD, 0.898+0.19 in ESRD, 0.924+0.1 in DR and 0.961+0.06 in CON, P < 0.01). almost completely abrogated β-cell circadian clock function through impair- There was no difference in the mean UV between DFU and AMPU. Patients ment in the amplitude (~70%, P<0.05), phase (P<0.05) and period (P<0.05) in DF group reported moderate to severe problem across all dimensions more of transcriptional oscillations. These data provide the first evidence of frequently than the other groups. cytokine-induced disruption of β-cell circadian clock function and suggest Conclusion: Diabetic foot problems had the greatest burden on health- a potentially novel mechanism mediating genesis of DIO-associated β-cell related quality of life. Therefore the diabetic foot care should be emphasized failure. in clinical practice to prevent diabetic foot problems. Supported By: National Institutes of Health (DK098468)

106‑OR 108‑OR Utilizing Nrf2 as a Biomarker for Diabetic Tissue Regeneration β-Arrestin 2 Is Essential for GIPR Signaling in β-Cells JOSHUA A. DAVID, TREVOR J. ELLISON, WILLIAM J. RIFKIN, ZACHARY M. MACKENZIE D. MARTIN, JONATHAN DOUROS, WILFREDO ROSARIO, REILLY BORAB, SOPHIA HAMEEDI, PIUL S. RABBANI, DANIEL J. CERADINI, New York, NY COCH, SARA ENCISCO, JINGJING NIU, BETELHME GEBRE, APRIL WITTMANN, Despite advances in management of diabetes, non-healing wounds pose DAVE D’ALESSIO, JONATHAN CAMPBELL, Durham, NC an expensive and unsolved clinical problem. We have previously implicated The incretin hormones, glucose-dependent insulinotropic peptide (GIP) defective signaling of the Nrf2/Keap1 anti-oxidative pathway in this dys- and glucagon-like peptide-1 (GLP-1), are released by the gut in response to function. Here, we investigate the mechanisms underlying this impaired nutrient intake and control glucose homeostasis in great part by enhancing healing in vivo. Excisional dorsal wounds were created in wild type (wt), glucose-stimulated insulin secretion (GSIS). This biology has been leveraged diabetic (db), and Nrf2-/- (KO) mice. Intact skin and tissue post-wounding in development of GLP-1 based therapies to control glucose homeostasis in were analyzed for gene expression of master redox transcription fac- type 2 diabetes (T2D). However, the GIP system has not been used for drug tor Nrf2, its physiologic repressor Keap1, and downstream anti-oxidant development because people with T2D fail to secrete insulin in response enzymes. Wounds were also analyzed for time to closure, epithelial gap, to GIP. It has become clear that G-protein coupled receptors rely on media- CD31+ density, and oxidative damage. Nrf2 expression in db mice at day tors other than cAMP, and recent findings have expanded the importance 10 was decreased by 58% as compared to wt. Keap1 was overexpressed in of β-arrestins. The role of these proteins for GIPR signaling is not known. db mice as compared to wt (253%) but not in KO mice (103%). Expression of ORALS We have recently described a novel GIPR signaling pathway in β cells that downstream anti-oxidant enzyme NQO-1 at day 5 was decreased in both db is independent of cyclic AMP, leading us to hypothesize that β-arrestin pro- and KO mice as compared to wt (5% and 4.6%, p<0.03), while there was no teins are essential for complete GIPR signaling. To test this, GIP was admin- difference between db and KO mice. Analysis of ROS end products showed istered to WT, β-arrestin 1 knockout (Arrb1-/-) and β-arrestin 2 knockout increases in db and KO wounds as compared to wt (657.5 and 517.9 ng/ml (Arrb2-/-) mice. Compared to injections of a vehicle control, GIP enhanced vs. 12.7). Gross and histological analysis showed delayed time to closure insulin secretion and reduced blood glucose during an IPGTT in both WT of wounds in db and KO mice as compared to wt (day 30 and day 21 vs. day and Arrb1-/- knockout mice. However, GIP did not improve glucose control 17). Db and KO wounds displayed larger epithelial gaps vs. wt mice at day in Arrb2-/- mice. Importantly, GLP-1 lowered glucose and enhanced GSIS 5 (8.76 and 9.36mm vs. 5.81, respectively). Furthermore, neovascularization comparably in all 3 groups. Stimulation of isolated islets with GIP enhanced was significantly lower in db and KO mice as compared to wt mice (8.25 and GSIS in WT and Arrb1-/- islets, but had no effect on insulin secretion from 17.33 blood vessels/high powered field vs. 37.6 at day 5). Arrb2-/- islets; similar to the findings in mice, GLP-1 was stimulatory in all In conclusion, we demonstrate the role of Nrf2 as a biomarker for diabetic three mouse lines. Finally, siRNA mediated knockdown of Arrb2 in INS1 tissue regeneration. Our findings further validate this pathway as a promis- 832/3 β cells abolished the effect of GIP to enhance insulin secretion. These ing therapeutic target for accelerating diabetic wound healing. findings identify an essential role forβ -arrestin 2 in mediating β-cell GIPR, Supported By: American Diabetes Association (1-16-ACE-08 to D.J.C.) but not GLP-1 R, stimulation of GSIS. This raises the possibility that signaling downstream of β-arrestin 2 may be involved in GIP insensitivity in diabetes, and that this pathway may be a fruitful drug target. Supported By: National Institutes of Health (T32DK007012)

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A28 SENDING THE BETA CELL MIXED SIGNALS

109‑OR betes (T2D). Supporting a role in AMPK action, treatment of hepatocytes Intraislet Glucagon-Like Peptide-1 Mediates GPR119 Agonist Insu- with the AMPK-agonist AICAR modulates miRNA expression. Our aim in the linotropic Effect present study was to identify miRNAs involved in AMPK function in mouse JULIA MATHIEU, GYSLAINE BERTRAND, JULIE VALLAGHE, FABIENNE CHAR- and human β-cells. RIER-SAVOURNIN, NATHALIE GREGOR, EMILIE VATEL, ANNE WOJTUSCISZYN, MiRNA profiling in islets of mice homozygous for floxed AMPKα1/α2 ERIC TRINQUET, MAGALIE RAVIER, STÉPHANE DALLE, Montpellier, France, alleles and expressing Ins1-Cre (AMPKdKO) or not (Control) identified 14 Codolet, France down- and 9 up-regulated miRNAs in AMPKdKO islets (FDR<0.15). The cor- Studies suggested that GLP-1 is produced not only in the intestinal L-cells responding pri-miRNAs were concomitantly modulated, indicating transcrip- but also in pancreatic alpha-cells, and that the dipeptidyl peptidase-4 (DPP- tional regulation. Gene ontology (GO) analysis of their predicted targets 4) is localized within the islets. GPR119 was reported to be both expressed revealed enrichment in pathways important for β-cell function and survival. in beta-cells and alpha-cells and its activation stimulates insulin secretion. MiR-184-3p (miR-184), the most down-regulated miRNA in the AMPKdKO Here, we investigated whether activation of GPR119 directly stimulates GLP-1 islets, is known to impact β-cell function and survival and its expression is release from alpha-cells, as it does in L-cells, and evaluated whether the regulated by glucose and reduced in murine models of diabetes in and human GPR119 insulinotropic effect is mediated in part through an intraislet secre- T2D islets. We demonstrate that treatment of human islets with highly spe- tion of bioactive GLP-1 from alpha-cells. Using a specific antibody reacting cific AMPK activators resulted in a significant increase in miR-184, indicating with the N-terminal part of GLP-1 (7-36/37), GLP-1 was detected in alpha-cells that AMPK-dependent regulation is conserved in humans. and not in beta-cells in mouse islets and pancreatic sections. In islets from Thus, our results suggest that AMPK (1) regulates the transcription of sev- nondiabetic human donors, immunostainings confirmed the expression of bio- eral miRNAs which may contribute to AMPK function in mouse and human active GLP-1 in alpha-cells only. Importantly, GLP-1 was not always found to islets and (2) mediates the effect of glucose on miR-184. Future work will be co-localize in the same granules than glucagon. Using mouse and human be aimed at identifying the AMPK-dependent processes in which miR-184 islets, no trace of GLP-1 in secretion media was detected in the absence is involved. of a DPP-4 inhibitor (DPP-4i). In contrast, in the presence of the DPP-4i Supported By: Medical Research Council, UK; Wellcome Trust UK (10 microM), a significant increase in the amount of bioactive GLP-1 in secre- tion media was observed in the islets treated with the GPR119 agonist, 112‑OR AS1269574 (100 microM), in the presence of glucose (11 mM), while glucagon Critical Role of Pdx1 for the Tsc1-mTOR Pathway in Beta Cells secretion was not affected by the AS1269574 treatment. The GLP-1 recep- JUAN SUN, LIQUN MAO, KENNETH S. POLONSKY, DECHENG REN, Chicago, IL tor antagonist, exendin 9-39 (100 nM) significantly reduced the insulinotropic Pdx1-haploinsufficient mice develop diabetes due to reducedβ -cell mass. effect of AS1269574. Since the addition of a DPP-4i protects GLP-1 from deg- To define the molecular link between Pdx1 deficiency and reducedβ -cell radation in islets, DPP-4i treatment significantly increased the potentiation mass, we knock down Pdx1 gene in MIN6 cells. Pdx1 suppression induced of insulin secretion by AS1269574. We report for the first time the involve- not only an increase in apoptotic cell death but also a decrease in cell pro- ment of an intraislet bioactive GLP-1 secretion in the insulinotropic effect of liferation. Pdx1 suppression induced an increase in Tsc1 mRNA and protein a GPR119 agonist, and that a GPR119 agonist and DPP-4i combination exerts levels by 49% and 140% (P<0.05), respectively, and had no effect on Tsc2 powerful effect on insulin secretion from pancreatic islets. mRNA levels but increased Tsc2 protein levels by 50% ( P<0.05). To determine the effects of Tsc1 deficiency onβ -cell proliferation in vivo, we used mice in 110‑OR which Tsc1 is deleted in islets using MIP-Cre/ERT. Compared to Tsc1F/FCre- +/- F/F - Targeted Deletion of Rheb1 in Pancreas Reduces β-Cell Prolifera- islets, β-cell proliferation was decreased in Pdx1 Tsc1 Cre islets, and was tion Partially Dependent on mTOR Signaling significantly improved by Tsc1 ablation in Pdx1+/-Tsc1F/FCre+ islets (P<0.05). The JINGJING ZHANG, ZHIPENG XU, FENG LIU, Changsha, China, San Antonio, TX Tsc1F/FCre+ mice showed an increase in β-cell mass by 138% compared to Aim: Identification of key regulators ofβ cell function and glucose metab- that in Tsc1F/FCre- mice (P<0.001). β-cell mass in Pdx1+/-Tsc1F/FCre+ mice was olism has significant therapeutic implications for diabetes. restored to the value in Tsc1F/FCre- mice and approximately doubled compared Results: Here we show that Ras homolog enriched in brain 1 (Rheb1), a to Pdx1+/-Tsc1F/FCre- mice (P<0.05). The blood glucose in Pdx1+/-Tsc1F/FCre+ mice direct upstream binding of mammalian target of rapamycin (mTOR), is highly was decreased by 34% compared with that in Pdx1+/-Tsc1F/FCre- mice. The expressed in pancreas and pancreatic islets, indicating a potential regula- Pdx1+/-Tsc1F/FCre+ mice demonstrated improved glucose tolerance and had tion role in β cell function. Our data show that pancreas-specific knockout normal glucose tolerance compared to Tsc1F/FCre- mice, indicating that Tsc1 of Rheb1 leads to inhibition of mTOR signaling in islets, subdued β cell mass ablation prevents diabetes in Pdx1+/-Tsc1F/FCre- mice. AUC of blood glucose and insulin content, and decreased insulin secretion in mice. Deletion of decreased by 51% in Pdx1+/-Tsc1F/FCre+ mice compared to Pdx1+/-Tsc1F/FCre- Rheb1 in the pancreas reduces the proliferation of β cell which was only mice (P<0.001). Moreover, both p-4E-BP and p-S6 were significantly increased partially dependent of mTOR. Furthermore, Pancreas-specific disruption of in islets from Pdx1+/-Tsc1F/FCre+ mice. Rapamycin-treated Pdx1+/-Tsc1F/FCre- and Rheb1 suppresses β cell transdifferentiation from other pancreatic cells Pdx1+/-Tsc1F/FCre+ mice showed impaired glucose tolerance, and glucose lev- and aggravates apoptosis of β cell induced by STZ. Interestingly, Rapamycin els were similar in these mice to Tsc1F/FCre- mice. ChIP assay showed that could not fully inhibits Rheb1-induced β cell proliferation, which indicates Pdx1 can directly regulate the expression of Tsc1 gene. that deletion of Rheb1 in pancreas reduces β cell proliferation only partially In conclusion, Pdx1 acts as a suppressor on the Tsc1 gene and then turns depending on mTOR signaling. on mTOR signaling in β-cells. Genetic ablation of Tsc1 preserves β-cell mass ORALS Conclusion: Our study has uncovered that knockout of Rheb1 in pancreas in Pdx1+/- mice. inhibits β cell proliferation via mTOR-dependent and independent mecha- nisms, which may provide novel therapeutic strategy for diabetes. 113‑OR Supported By: National Natural Science Foundation of China Protein Phosphatase 2A Regulates c-Myc and Glucose-Mediated Beta-Cell Replication 111‑OR CAROLINA ROSSELOT, JUAN CARLOS ALVAREZ-PEREZ, ANNA KALIS, JAYAL- AMP-Activated Protein Kinase (AMPK) Regulates β-Cell MicroRNA AKSHMI LAKSHMIPATHI, ROSEMARY LI, DONALD K. SCOTT, ADOLFO GARCIA- Expression OCAÑA, New York, NY AIDA MARTINEZ-SANCHEZ, JAMES SHAPIRO, PIERO MARCHETTI, KEI SAKA- Diabetes is associated with a progressive loss of functional beta-cells. MOTO, DAVID M. SMITH, ISABELLE LECLERC, GUY A. RUTTER, London, United Enhancing beta-cell proliferation and expanding beta-cell mass is one Kingdom, Edmonton, AB, Canada, Pisa, Italy, Lausanne, Switzerland, Cambridge, potential therapy to treat diabetes. A major current challenge is the iden- United Kingdom tification of intracellular mechanisms that regulate beta-cell proliferation AMPK, a target for antidiabetic drugs such as metformin, is critical in in pathological and physiological conditions. Glucose is a well-known beta- maintaining cellular energy balance. In the β-cell, AMPK activity is reduced cell mitogen that induces the upregulation of the key transcription factor by high glucose concentrations. Moreover, β-cell-specific AMPK-inactivation c-Myc. c-Myc is required for glucose-mediated beta-cell proliferation, but (AMPKdKO) in mice affects gene expression and cellular identity to impair the intracellular mechanisms that regulate c-Myc upregulation in beta-cells insulin secretion. The mechanisms responsible for these changes remain are unknown. Glucose (20mM) induces the phosphorylation of c-Myc at poorly understood. Serine 62 (pS62c-Myc) in beta-cells, increasing its stability and promoting MicroRNAs (miRNAs) are small non-coding RNAs processed from longer cell cycle activation and proliferation. Protein Kinase C-ζ (PKCζ) inactivation primary transcripts (pri-miRNAs) that silence gene expression. MiRNAs are decreases glucose-induced mTOR activation, c-Myc phosphorylation, and essential for β-cell development and function and are altered in type 2 dia- beta-cell replication. PKCζ inactivation also enhances activity of PP2A, a

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A29 LATEST IN DIABETIC NEUROPATHY—FROM MOUSE TO MAN, AND FROM MECHANISMS TO POTENTIAL TREATMENTS

critical negative regulator of c-Myc expression, by facilitating its dephos- Conclusion: Corneal confocal microscopy demonstrates an early and phorylation and degradation. Conversely, inhibition of PP2A activity with maintained improvement in small fibre structure after SPK, which was asso- endothal restores pS62c-Myc accumulation and glucose-mediated beta-cell ciated with an improvement in neuropathic symptoms and neurophysiology proliferation in mouse and human islets in the absence of PKCζ activity. at 36 months. These data provide further support for the use of CCM as an These data underline the importance of glucose-mediated downregulation early surrogate end-point in clinical trials of diabetic neuropathy. of PP2A activity to enhance c-Myc S62 phosphorylation and function as well Supported By: National Institutes of Health (R1-05991) as increase beta-cell replication. Selective inactivation of PP2A could be a therapeutic strategy to expand beta-cell mass in diabetes. 116‑OR A Reduction in Cortical Thickness May Explain the Somatosensory 114‑OR Shift in Pain Processing in Diabetic Neuropathy Contrast-Enhanced Ultrasound Noninvasively Measures Changes DINESH SELVARAJAH, FANG FANG, JENNIFER DAVIES, ELAINE CACHIA, in Islet Blood Flow Distribution Associated with Type 1 Diabetes ADITHYA SANKAR, RAJIV GANDHI, IAIN WILKINSON, III, SOLOMON TESFAYE, Progression Sheffield, United Kingdom, Shanghai, China JOSHUA R. ST. CLAIR, DAVID RAMIREZ, SAMANTHA PASSMAN, DALLAS HEN- We have previously demonstrated significant brain volume loss in DN, DERSON, RICHARD K. BENNINGER, Aurora, CO localised to the primary somatosensory cortex (S1). We also reported a shift Type 1 diabetes (T1D) results from immune-mediated destruction of insu- in functional organisation of S1 pain processing in painful DN who were also lin producing β-cells of the islets of Langerhans. Diagnosis of T1D typically insensate. This study aims to examine the relationship between the extent occurs at clinical manifestation of hyperglycemia, where considerable β-cell of structural volume change and the degree of functional reorganisation. death has already occurred. Insulitis and β-cell decline, however, occur for Methods: Clinical, neurophysiological and magnetic resonance imaging many years prior to disease onset and its identification could allow disease data were compared for 35 T1DM subjects [n=9 No DN (age 45.9+10.1), reversal. Thus, methods to noninvasively predict, diagnose and monitor 9 painless DN (46.3+12.0), 9 painful DN sensate (48.4+12.0) and 8 painful T1D progression are needed. The endocrine pancreas is highly vascularized DN insensate (44.5+12.1)] and 9 healthy volunteers (HV, 51.5+7.9)]. A 3T MR compared to the exocrine pancreas, and receives nearly 20% of the entire system and cortical reconstruction (FreeSurfer) were used. BOLD func- pancreatic blood flow. Moreover, changes in islet vasculature can be seen in tional MRI was used to examine functional organisation of the S1 cortex in type 1 and type 2 diabetes, including changes in diameter, number, and inter- response to right foot thermal stimulation. Linear regression analysis was actions of β-cells with the vascular epithelium. We have developed and veri- performed to examine the contribution of S1 cortical thickness, pain and fied a method for monitoring changes islet blood flow during the progression clinical parameters (age, neuropathy score, diabetes and pain duration) on of diabetes as a marker of disease progression. We used contrast enhanced observed S1 plasticity. ultrasound (CEUS) in mice to noninvasively identify significant increases in Results: Painful DN insensate subjects had significantly lower mean S1 islet perfusion rate associated with STZ-induced diabetes (p<0.01), and sig- cortical thickness [F(4,39)=5.78, p =0.001]. S1 plasticity was significantly nificant increases in perfusion rate and decreases in blood volume in non- correlated with neuropathic pain (r=-0.45, p=0.04), evoked pain (r=-0.46, obese diabetic (NOD) mice (p<0.001 and p<0.001, respectively). In NOD mice, p=0.03) and S1 cortical thickness (r=-0.57, p=0.01). The variable that was these changes were associated with histological confirmation of insulitis. most strongly associated with S1 plasticity was S1 cortical thickness Additionally, CEUS could identify and monitor efficacy of anti-CD4 T-cell (R2=0.32, F(1,14)=7.3, p=0.02; adjusted R2=0.28). therapy in NOD-RAG1-/- animals that underwent adoptive transfer of NOD Conclusions: Subjects with painful DN who had complete absence of sen- leukocytes. Our results show for the first time that CEUS can be used to sation in their feet had the greatest reduction in S1 cortical thickness. Lack measure and monitor changes in islet blood flow associated with insulitis of sensory input has a profound impact on cortical thickness and drives the and the progression of diabetes in vivo. Furthermore, we suggest that CEUS shift in S1 pain processing in those with “painful/painless foot.” The neuro- measurement of islet insulitis may hold a predictive value in identifying T1D pathic process in diabetes is clearly not only “peripheral” and longitudinal before clinical presentation of hyperglycemia, and could be used to predict studies are now required to study the natural history of central changes in and monitor efficacy in patients undergoing therapeutic intervention. relation to the various sensory phenotypes in DN. Supported By: National Institute of Diabetes and Digestive and Kidney Dis- Supported By: JDRF eases; Cooperative Study Group for Autoimmune Disease Prevention 117‑OR Protection of Neuropathy in Diabetic RAGE-Deficient Mice: Anti- LATEST IN DIABETIC NEUROPATHY—FROM MOUSE inflammatory Macrophage Predominance and Preserved Insulin TO MAN, AND FROM MECHANISMS TO POTENTIAL Sensitivity TREATMENTS EMI ISHIYAMA, HIROKI MIZUKAMI, SAORI OGASAWARA, KAZUNORI SANGO, 115‑OR KAZUHISA TAKAHASHI, YASUHIKO YAMAMOTO, HIROSHI YAMAMOTO, SOROKU YAGIHASHI, Hirosaki, Japan, Tokyo, Japan, Kanazawa, Japan Corneal Confocal Microscopy: A Viable Surrogate Endpoint for Neu- Although macrophage (MP) infiltration was reported in peripheral nerve ropathy following Simultaneous Pancreas Kidney Transplant

ORALS in patients with diabetic polyneuropathy (DPN), its implication in neuropathy SHAZLI AZMI, UAZMAN ALAM, MARYAM FERDOUSI, IOANNIS N. PETROPOU- development remains unsolved. The aim of this study is to clarify the role of MP LOS, GEORGIOS PONIRAKIS, HASSAN FADAVI, OMAR ASGHAR, ANDREW MAR- in DPN development and its relationship to insulin resistance (IR). In this study, SHALL, WENDY JONES, MITRA TAVAKOLI, MARIA JEZIORSKA, ANDREW J.M. RAGE-deficient mice (R-KO) were made diabetic for 8 weeks by streptozotocin. BOULTON, TITUS AUGUSTINE, NATHAN EFRON, RAYAZ A. MALIK, Manchester, Wild mice were also made diabetic for comparison (WT). Presence of DPN United Kingdom, Doha, Qatar, Queensland, Australia was confirmed by delay of nerve conduction velocity (NCV) and phenotype of Introduction: Despite normalization of glycemia after simultaneous infiltrated MF in the sciatic nerve (SN) was determined by qPCR. IR of SN was pancreas kidney transplantation (SPK), neuropathy shows minimal or no evaluated by pAKT expression. To address to the question whether MP influ- improvement. Although we have previously shown an improvement in cor- ences insulin sensitivity, Schwann cells (IMS32) were co-cultured in transwell neal nerve morphology 12 months after SPK, there was no effect on symp- chamber with M1 (proinflammatory) MP (R1) or M2 (anti-inflammatory) MP (R2) toms, quantitative sensory tests (QST) or neurophysiology. differentiated from RAW246 (R0). After 24 hour-co-incubation, we assessed Methods: We have undertaken detailed assessment of neuropathy at mRNA expression of M1 or M2 related molecules on MP by qPCR and phos- baseline, 6 months and annually over 3 years following SPK in 36 patients pho-AKT (pAKT) expression on Schwann cells. As results, diabetes induced with T1DM. significant NCV delay in WT, while diabetic R-KO were protected from NCV Results: HbA1c improved significantly (69·1±16·9 vs. 37.0±2.9 vs. 39.0±3.0 delay. Diabetic R-KO showed an increased mRNA expression of arginase-1, mmol/mol, p<0.0001). Corneal nerve fibre density (CNFD) (9.4±1.0 vs. marker of M2 type, in SN, while diabetic WT showed enhanced iNOS mRNA 12.2±1.7 no./mm2, p=0.005), corneal nerve branch density (CNBD) (9.8±0.05 (M1 marker) expression. pAKT expression in SN was attenuated in diabetic vs. 13.2±2.7 no./mm2, p=0.05) and corneal nerve fibre length (CNFL) (7.2±0.5 WT, whereas it was comparable between diabetic R-KO and nondiabetic coun- vs. 8.2±0.8 mm/mm2, p=0.05) improved significantly at 6 months with no terparts. In vitro studies demonstrated that Schwann cells co-cultured with R1 change in symptoms, QST or neurophysiology. However, at 36 months there exhibited 3-4 fold increases in the expression of iNOS and TNF- compared was a significant improvement in the neuropathy symptom profile (5.3±0.9 α to R0 and R2. On the other hand, the expression of arginase-1 was comparable vs. 3.1±1.2, p=0.04) and peroneal nerve conduction velocity (31.1±1.8 vs. among all pairs. pAKT expression was markedly attenuated in Schwann cells 38.7±2.7 m/s, p=0.05) and a further improvement in CNFD (9.4±1.0 vs. co-cultured with R1 compared to those with R0 or R2. Collectively, our find- 14.4±1.6 no./mm2, p=0.01) and CNFL (7.2±0.5 vs. 10.3±0.6 mm/mm2, p=0.001).

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A30 LATEST IN DIABETIC NEUROPATHY—FROM MOUSE TO MAN, AND FROM MECHANISMS TO POTENTIAL TREATMENTS ings suggest that proinflammatory processes by activated MP are implicated novel approach for use in clinical studies and clinical practice. Previous data in DPN development together with nerve IR. Correction of such processes may from our group was presented at the ADA 2016 Scientific Sessions. be beneficial for treatment of DPN. Supported By: Aarhus University; UNIK Partnerskabs Fonden; Novo Nordisk Foundation; Siemens A/S 118‑OR Increased Dermal Microvasculature in Painful Diabetic Peripheral 120‑OR Neuropathy Topical Delivery of Muscarinic Receptor Antagonists Prevents and PALLAI SHILLO, DINESH SELVARAJAH, MARNI GREIG, IAIN WILKINSON, YIAN- Reverses Indices of Neuropathy in Mouse Models of Type 1 and GOS YIANGOU, PHILIPPE DONATIEN, PRAVEEN ANAND, SOLOMON TESFAYE, Type 2 Diabetes Sheffield, United Kingdom, London, United Kingdom KATIE FRIZZI, CORINNE G. JOLIVALT, ANDRE J. MOTA, IVETTA GEDAREVICH, Aim: Painful diabetic peripheral neuropathy (painful-DPN) can be intrac- PAUL FERNYHOUGH, NIGEL A. CALCUTT, La Jolla, CA, Winnipeg, MB, Canada table with major impact, yet the underlying pain mechanisms remain uncer- Sensory neurons express muscarinic type 1 receptors (M1R) and M1R ago- tain. While distal leg intra-epidermal nerve fibre density is recommended nism constrains neuronal growth via suppression of mitochondrial function. for the diagnosis of small fibre neuropathy, we found that intra-epidermal Systemic delivery of M1R antagonists prevented and reversed peripheral nerve markers do not differentiate between painful-DPN and painless-DPN. neuropathy in rodent models of type 1 and type 2 diabetes. We extended However, as impaired skin microvascular reactivity has been described in exploration of the therapeutic potential of M1R antagonists by determining painful-DPN we investigated neuronal and vascular biomarkers in carefully efficacy following topical delivery. STZ-diabetic mice developed paw thermal phenotyped subjects with painful- and painless-DPN. hypoalgesia and loss of intra-epidermal nerve fibers. Topical delivery of the Methods: 42 T2DM subjects and 13 healthy volunteers (HV) underwent selective M1R antagonist pirenzepine (30 min/day for 8-12 weeks in hydrogel) detailed clinical and neurophysiological assessments and were subse- to the paw significantly prevented these indices of neuropathy at concentra- quently divided into three groups based on the neuropathy composite score tions of 2-10%, but not in the 0.2-1% dose range. Withdrawal of treatment of the lower limbs [NIS(LL)] plus 7 tests (16 Painful-DPN, 14 Painless-DPN and resulted in gradual progression to thermal hypoalgesia over 4-8 weeks. Estab- 12 No-DPN). All subjects underwent calf skin punch biopsy, and immunohis- lished thermal hypoalgesia in the db/db mouse model of type 2 diabetes was tochemistry was used to quantify intra-epidermal (IENF) and sub-epidermal gradually reversed over 4 weeks following instigation of daily topical delivery (SENF) nerve fibres with structural marker PGP9.5, regenerating fibres with of the muscarinic antagonists pirenzepine or oxybutynin (30 min of 2% drug in GAP43, sensory fibres with neuropeptide CGRP, and the dermal blood ves- hydrogel). Topical delivery of the non-selective muscarinic antagonist atropine sels with von Willebrand Factor (vWF). (30 min of 2% drug in hydrogel) to STZ-diabetic mice also prevented paw ther- Results: IENF density was severely decreased (p<0.001) in both DPN mal hypoalgesia and loss of IENF. Moreover, daily topical delivery of atropine groups, with no differences for PGP9.5, GAP43, CGRP, or GAP43/PGP9.5 (20µl of 2% in saline) to the eye prevented loss of sub-basal nerves of the ratio. There was significant increase of vWF in Painless-DPN and no-DPN cornea in STZ-diabetic mice, as measured by corneal confocal microscopy. No groups compared to controls, but this was markedly greater for painful-DPN, effect was seen in the contralateral untreated eye. Reduced corneal nerve and significantly higher than painless-DPN (p<0.0001). The ratio of SENF density in STZ-diabetic mice was reversed within 2 weeks by daily treatment CGRP:vWF showed a significant decrease in painful-DPN vs. Painless-DPN with the specific M1R antagonist MT7 (30µl of 25ng/ml in saline). These data (p =0.014). show local efficacy of diverse M1R antagonists against functional and struc- Conclusions: In established neuropathy increased dermal vasculature and tural indices of sensory neuropathy when applied to the skin or eye. The cur- its ratio to nociceptors may differentiate painful-DPN from painless-DPN. rent medicinal use of topical M1R antagonists for other conditions suggest Increased small blood vessels following tissue ischaemia/hypoxia associ- that rapid translation of these findings to clinical studies is viable. ated with disproportionate and abnormal nerve fibres (irritable nociceptors) Supported By: JDRF; National Institutes of Health may lead to a “painful vaso-neuropathy.” Supported By: Sheffield Teaching Hospitals 121‑OR Patterns of Small and Large Fiber Dysfunction in Painful and Pain- 119‑OR less Diabetic Polyneuropathy Novel MR-Neurography Detects Polyneuropathy in Type 1 Diabetes GIDON J. BOENHOF, ALEXANDER STROM, SONJA PUETTGEN, KÁLMÁN B. Related to Severity and Proximal/Distal Nerve Fibre Pathology BÓDIS, MICHAEL RODEN, DAN ZIEGLER, Düsseldorf, Germany MICHAEL VAEGGEMOSE, MIRKO PHAM, HATICE TANKISI, SABINE HEILAND, The distinguishing features contributing to the phenotype of diabetic NIELS EJSKJAER, PER POULSEN, HENNING ANDERSEN, Aarhus, Denmark, sensorimotor polyneuropathy (DSPN) as a painful (+p) or painless (-p) Heidelberg, Germany, Aalborg, Denmark entity are poorly understood. We hypothesized that DSPN+p and DSPN-p Objective: To evaluate if diffusion-tensor-imaging MR-Neurography (DTI- are characterized by predominant small and large nerve fiber dysfunction, MRN) can detect lesions of peripheral nerves in patients with type 1 dia- respectively. We assessed somatic, cardiac autonomic, and sudomotor betes. function in 332 patients with DSPN from the PROPANE study, 179 of whom Background: Diabetic peripheral neuropathy (DPN) often remains undiag- had DSPN+p and 153 had DSPN-p and 54 diabetes patients without DSPN

nosed until advanced stages. DPN causes irreversible damage to the periph- (DM) from the German Diabetes Study (DSPN-p/DSPN+p/DM [mean±SD]: ORALS eral nerves. Early diagnosis and sensitive diagnostic techniques are needed. age: 68.4±10.4/66.1±10.0/63.2±5.2 years, BMI: 29.5±5.3/30.9±5.6/30.1±4.9 Methods: Forty-nine type 1 diabetic patients (11 with severe polyneuropa- kg/m²; T2D: 83/86/87%, diabetes duration: 16.4±12.4/16.1±12.1/5.1±3.2 thy (sDPN), 13 with mild/moderate polyneuropathy (mDPN) and 25 without years, HbA1c: 7.3±1.1/7.7±3.3/6.8±0.9%). DSPN was diagnosed using modi- polyneuropathy (nDPN)) and 30 healthy controls (HC) were included. Clinical fied Toronto Consensus (2011) criteria, while DSPN+p and DSPN-p were examinations, nerve-conduction-studies and vibratory-perception-thresh- stratified using a cutpoint of 4 points on the Likert scale for chronic pain olds described the presence and severity of DPN. DTI-MRN (voxel size: (>1 year) in the distal lower limbs. After adjustment for sex, age, BMI, smok- 1.4x1.4x3mm3; b-values: 0, 800 s/mm2) covered proximal (sciatic nerve) and ing, diabetes type, diabetes duration, and HbA1c, compared to patients distal regions of the lower extremity (tibial nerve). FA and ADC were cal- with DSPN-p those with DSPN+p showed impaired warm thresholds (foot: culated and compared to T2 relaxometry and proton-spin-density obtained 46.0±4.4 vs. 45.3±4.4 °C), Coefficient of R-R interval variation during deep from a multi-echo TSE sequence. breathing (5.18±3.95 vs. 6.71±4.86%), and electrochemical skin conductance Results: DTI-MRN could accurately discriminate between DPN, nDPN and (ESC: hand: 56.1±17.8 vs. 60.9±17.3 µS, foot: 57.8±20.7 vs. 62.8±19.9 µS) (all HC. The proximal FA was lowest in sDPN (sDPN 0.38±0.04; mDPN 0.41±0.07; P<0.05). Large fiber function tests (nerve conduction, vibration threshold) did nDPN 0.47±0.02; HC 0.48±0.06; p<0.01). In addition, distal FA was lowest not differ between the DSPN groups. ROC analyses showed that both small in sDPN (sDPN 0.31±0.08; mDPN 0.34±0.06; nDPN 0.41±0.07; HC 0.42±0.07; and large fiber function tests were useful to detect DSPN+p (AUC vs. DM: p<0.01). Likewise, proximal ADC was highest in sDPN with lower values in 0.7-0.9) and DSPN-p, albeit to a slightly lesser degree (AUC vs. DM: 0.6-0.8). patients with mPDN and nDPN as well as in HC. The severity of neuropathy In conclusion, compared to painless DSPN, painful DSPN is characterized was correlated to DTI-MRN with a strong association of proximal (FA: R2 = by more pronounced small fiber dysfunction involving sudomotor, cardiac 0.49, p<0.01; ADC: R2 = 0.15, p = 0.01) and distal nerve lesions (FA: R2 = 0.32, autonomic, and cutaneous C fibers, while large fiber dysfunction is common p< 0.01; ADC: R2 = 0.19; p-value < 0.01). to both entities. Conclusions: DTI-MRN enables detection of DPN by decreasing nerve FA Supported By: German Ministry of Innovation, Science and Research of the and increasing ADC closely related to the severity of DPN. These findings may State of North Rhine-Westphalia; German Federal Ministry of Education and reflect proximal and distal nerve fibre pathology. We shall further develop this Research; European Union Seventh Framework Programme

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A31 DIABETES IN PREGNANCY—THE TAO TO UNDERSTANDING THE MECHANISMS

122‑OR 124‑OR Glutamic Acid Decarboxylase Autoantibody Is Associated with Augmented Islet Neogenesis during Pregnancy in a Mouse Model Peripheral Neuropathy in Autoimmune Diabetes in Adults of Insulin Resistance LEA DUVNJAK, KRISTINA BLASLOV, TOMISLAV BULUM, SANDRA VUCKOVIˇ C´ ERCUMENT DIRICE, ROHIT N. KULKARNI, Boston, MA REBRINA, JADRANKA KNEŽEVIC´ CU´ CA,´ Zagreb, Croatia The ability of β-cells to compensate for insulin resistance is an important Mechanisms implicated into the pathogenesis of autoimmune diabetes mechanism to prevent of diabetes. In this project we hypothesized that an (AI) may also play a role in the development of peripheral diabetic neuropathy organism with insulin resistance exhibits a dynamic reserve to further (PDN). A possible link between glutamic acid decarboxylase autoantibody enhance β-cell mass in response to physiological demands. To explore a β-cell (GAD Ab) and PDN in patients with type 1 diabetes was recently reported. compensatory reserve we superimposed pregnancy on a mouse model of insu- We investigated the association between GAD Ab, islet cell antigen (ICA lin resistance (MIR) that already exhibits robust β-cell hyperplasia. While both Ab) and insulinoma associated protein-2 (IA-2 Ab) with PDN in AI diabetes the control and MIR mice displayed increased β-cell proliferation and mass in in adults. Four hundred and 61 patient (mean age 42y) positive for at least response to the relative insulin resistance of pregnancy, the further increase in one diabetes related Ab at the time of diagnosis were included and divided β-cell mass and area in MIR suggested an additional reserve of β-cells. More- according to the presence of PDN into two groups. ICA was measured over, β-cell proliferation was also significantly increased in grafted human by indirect immunofluorescence while GAD and IA2 were detected with islets obtained from a pregnant NSG-MIR mouse model. Interestingly, a robust ELISA. Peripheral neuropathy was determined by electroneurography. PDN increase in serotonin + β-cells was observed during and after pregnancy (~60- was present in 76.1% patients. Patients with PDN were older (43 vs. 37 y, 85%) in the MIRs (n=3-4) suggesting a role for serotonin in β-cell proliferation. p=0.031), had longer disease duration (11 vs. 9 y, p=0.138), higher rate of We also observed increased insulin and glucagon + ductal epithelial cells, and hypertension (30.4 vs. 26.0, p=0.016) and statin use (18.8 vs. 15.3% p=0.046), increased numbers of islet clusters which were closely localized or adherent better glycaemic control (7.2 vs. 7.5% p=0.029) but increased C reactive pro- to pancreatic ducts during gestation in the MIR mice suggesting neogenesis. tein (5.7 vs. 4.9 mg/dL, p=0.6) and ferritin (296.6 vs. 195.9 µg/L, p=0.015) A majority of the MIR islets (~70%) showed a unique endocrine cell distribu- level. The Ab status in the group with PDN revealed significantly higher GAD tion characterized by accumulation of non-β endocrine cells at one pole of the Ab (430.9 vs. 96.65, p=0.001), lower ICA (27.5 vs. 150 JDF.p=0.001) and simi- islets that is in close apposition to pancreatic ductal cells. We are currently lar IA-2 titer (205.7 vs. 238.1 U/L. p=0.593). A significant correlation between pursing lineage trace analyses to identify the progeny of islet non-β-cell polar- GAD Ab titer and ferritin level was found (r=0.37, p=0.001). In the multinomi- ity by crossing CAII-CreERTM:R26R-eYFP mice with MIR animals. We are also nal regression including age, gender, disease duration, A1c, ICA, GAD and examining the human relevance of our findings by analyzing pancreas sections IA-2, GAD titer was independently associated with PDN (1.392 (1.113-1.198)). from pregnant humans and T2D patients. Together these results suggest that, In AI diabetes in adults GAD Ab titer is associated with presence of PDN and during increasing insulin demand, ductal cells contribute to the compensatory the relation seems to be independent of age, disease duration or glycaemic reserve by differentiation/neogenesis of β-cells that involve non-β endocrine control. The association between GAD Ab and serum ferritin as a marker of cells and have a potential pivotal role in islet compensation both in type 1 and cell stress might indicate GAD Ab mediated systemic inflammatory process type 2 diabetes. implicated in the pathogenesis of PDN that merits further investigation. 125‑OR Apolipoprotein A-I Protects against Pregnancy-Induced Insulin DIABETES IN PREGNANCY—THE TAO TO Resistance in Rats UNDERSTANDING THE MECHANISMS BEN J. WU, YIDAN SUN, SHUDI TANG, KWOK L. ONG, PHILIP J. BARTER, KERRY- ANNE RYE, Sydney, Australia 123‑OR Insulin resistance and inflammation play an important role in gestational Switching to Healthy Diet before Pregnancy Reduces Signs of diabetes mellitus (GDM). Increased plasma high density lipoprotein (HDL) Hypoxia and Improves Liver Metabolite Profile in Fetuses from and apolipoprotein (apo) A-I levels have been shown to improve glucose Mothers with Diet-Induced Obesity metabolism and inhibit inflammation in animals and humans. This study asks if STEPHANIE R. WESOLOWSKI, CHRISTOPHER M. MULLIGAN, BRYAN C. BERG- increasing plasma apoA-I levels improves insulin sensitivity and the inflamma- MAN, RACHEL C. JANSSEN, TYLER DEAN, DIANA TAKAHASKI, PAUL KIEVIT, tory profile in pregnancy in rats. Female Wistar rats were (pregnant) or were KEVIN L. GROVE, JACOB E. (JED) FRIEDMAN, Aurora, CO, Portland, OR not inseminated (virgin). Pregnant and virgin rats then received intravenous tail Non-human primate fetuses from mothers on a chronic high-fat diet (HFD) vein infusions of lipid-free apoA-I (8 mg/kg) or saline on days 6, 9, 12, 15 and 18 have increased hepatic steatosis and switching these obese HFD mothers of pregnancy. An intravenous glucose tolerance test was performed on day 19 to a healthy (CON) diet before pregnancy (DR) reduces steatosis in fetal off- or 20 of pregnancy. The area under the glucose response curve was reduced spring. The mechanisms responsible for reduced steatosis remain unknown. by 25±2.2% and the area under the insulin response curve was increased by Here, we collected umbilical venous and arterial cord blood samples at 106±14% in the saline infused pregnant rats relative to the saline infused vir- c-section (0.7 gestation) for blood gas measures and serum metabolites gin rats (p<0.05 for both). The area under the insulin response curve in the and fetal liver samples for triglycerides, diacylglyceride (DAG) species, apoA-I infused pregnant rats was reduced by 58±6.1% compared to the saline infused pregnant rats (p<0.05). Euglycemic-hyperinsulinemic clamps (Clamp)

ORALS and metabolites. Pregnant HFD mothers had 2-fold higher percent body fat and insulin AUC during an oral GTT compared to CON mothers. DR moth- were performed on day 19 or 20 of pregnancy. A bolus of [14C]2-deoxy-glucose ers remained obese, yet had improved insulin sensitivity similar to CON (2DG, 250 nmol) was injected intravenously following the Clamp. The 2DG uptake in red and white gastrocnemius muscle was increased by 37±8.3% and mothers. HFD fetuses had lower umbilical venous pO2, lower arterial pH, and increased lactate, hemoglobin, and hematocrit compared to CON and 42±14% in the apoA-I infused pregnant rats relative to saline infused preg- DR fetuses. HFD fetuses also had increased serum urate, uracil, citrate, and nant rats, respectively (p<0.05 for both). In addition, infusion of apoA-I also malate concentrations compared to CON and DR fetuses. HFD fetal livers inhibited pregnancy-induced increases in plasma inflammatory cytokines and had 3-fold increase in triglycerides compared to CON and DR livers. DAGs macrophage infiltration into adipose tissue. containing 14:0, 16:0, 16:1, 18:0, and 18:1 fatty acids were increased in HFD In conclusion, apoA-I protects against pregnancy-induced insulin resis- group (P<0.05 vs. CON) and normalized in DR group. HFD fetal livers had tance in rats by increasing insulin-sensitivity in skeletal muscle and inhibit- 3-fold increase in 2,3-phospho-glycerate levels (P<0.05 vs. CON and DR), ing pregnancy-induced inflammation. The findings also indicate that HDL and apoA-I raising agents that are currently being investigated in large scale car- which increases hemoglobin-O2 affinity and O2 delivery in tissues. HFD livers also had increased phosphoenolpyruvate, fructose 1,6-bisphosphate, and diovascular clinical outcome trials may have benefits in women with GDM. oxaloacetate concentrations (P<0.05 vs. CON and DR). These data support Supported By: Diabetes Australia Research Trust compensatory mechanisms in response to hypoxia, altered DAG composi- tion, and increased gluconeogenic flux in HFD fetal livers that is ameliorated in DR group. We speculate that reduced hepatic steatosis and improved metabolite profiles in DR fetuses may be due to improved maternal metabo- lism (decreased obesity, increased insulin sensitivity) and improved placen- tal function, oxygen transfer, and nutrient supply to the fetus. Supported By: National Institutes of Health (R24DK090964)

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A32 LANDSCAPE OF THERAPEUTIC TRIALS IN TYPE 2 DIABETES

126‑OR 128‑OR Sex-Specific Multigenerational Effects of Maternal Bisphenol A Maternal Diet and Body Composition-Associated Alterations in Gut Exposure on Offspring Pancreatic Islets Microbial Ecology in Pregnant Women AMITA BANSAL, CETEWAYO RASHID, FRANCES XIN, CHANGHONG LI, ERZSE- KARTIK SHANKAR, UMESH D. WANKHADE, DONALD TURNER, YING ZHONG, BET POLYAK, MARISA BARTOLOMEI, REBECCA A. SIMMONS, Philadelphia, PA SREE V. CHINTAPALLI, BRIAN D. PICCOLO, ALINE ANDRES, Little Rock, AR Exposure to the endocrine disruptor, Bisphenol A (BPA), is ubiquitous and Maternal body composition, GWG and diet quality influence offspring is associated with increased risk of multiple diseases including diabetes obesity risk. Among the hypothesized mechanisms are persistent changes and obesity. However, the underlying mechanisms remain largely unknown. in the maternal and infant microbiomes. Anthropometrics, body composi- We recently demonstrated that perinatal BPA exposure is associated with tion (BodPod), dietary intake (3 d food records) and ambulatory activity higher body fat, impaired glucose tolerance, and reduced glucose stimulated (accelerometry) were examined every 6 wk in a cohort of women enrolled insulin secretion in the first (F1) and second generation (F2) C57BL/6J male before gestation wk 10. Diet data were analyzed via NDSR and Healthy mice offspring. In the current study, we assessed the mechanisms that Eating Index (HEI) was calculated for each trimester. Stool samples were underlie these persistent changes across two generations. Islets were iso- collected at 12, 24 and 36 wk of pregnancy (n= 98, 98 and 106, respectively) lated from adult F1 and F2 offspring of F0 mothers exposed to physiologi- and utilized for microbial ecology analysis via 16S rRNA sequencing. Data cally relevant doses of BPA (10 μg/kg/day or LowerB, and 10 mg/kg/day or analyses were performed using standardized pipelines. α-diversity (number UpperB) from 2 weeks prior to mating until weaning. We found that both of observed OTUs, Chao1 or Shannon index) was unaltered by pregnancy doses of BPA altered multiple pathways in males, including reduced Esr1 and stage. α-diversity at 12 wk was positively associated with early pregnancy increased Igf2 gene expression, which were associated with increased islet maternal BMI, total dietary fiber and water intake. Likewiseα -diversity inflammation, leading to impaired insulin secretion across two generations. was positively associated with total protein intake (at 24 wk) and nega- Increased Igf2 expression was associated with altered DNA methylation at tively associated with glycemic index (both 12 and 24 wk). Regression of the Igf2 differentially methylated region 1. We also observed dose-specific taxonomic abundance with dietary data showed Firmicutes was negatively effects of BPA exposure on islets. UpperB exposure reduced mitochondrial associated with HEI (at 36 wk) and Verrumicrobia was positively associated driven insulin secretion, and basal and maximal mitochondrial oxygen con- with physical activity and inversely associated with % fat calories. Overall, sumption in islets. In contrast, LowerB exposure significantly reducedβ -cell we provide evidence for pregnancy-stage dependent interactions between mass and increased islet cell death. Transcriptome analyses also revealed lifestyle factors and maternal microbiome. alterations in pathways regulating inflammation and mitochondrial function Figure. in a dose-specific manner. Thus, the current study provides novel mechanis- tic evidence that developmental exposure to physiologically relevant doses of BPA impairs multiple β-cell pathways and therefore increases the risk of diabetes across two generations. These findings provide potentialβ -cell specific targets of BPA that if explored will help develop potential therapeu- tic strategies to prevent environment-induced diabetes. Supported By: National Institute of Environmental Health Sciences (ES023284, ES013508); March of Dimes; CEET-ES-013508-05; RO1DK098517; IDDRC- U54-HD086984

127‑OR Disruption of Pancreatic Prolactin Receptor Signaling Leads to Gestational Diabetes JACKSON NTEEBA, KAIYU KUBOTA, WENFANG WANG, HAO ZHU, GUOLI DAI, Supported By: U.S. Department of Agriculture (6206-51000-010-05S) MICHAEL J. SOARES, Kansas City, KS, Indianapolis, IN Gestational diabetes (GDM) afflicts 7% of all pregnancies in the USA; pre- disposing the mother and the developing infant to a high risk of developing LANDSCAPE OF THERAPEUTIC TRIALS IN TYPE 2 type 2 diabetes, obesity, and other chronic disorders. The cause of GDM is DIABETES unknown. Unsatisfactory adaptations of maternal beta cells to pregnancy is a hallmark of the disease. It is hypothesized that maternal pancreatic adaptations are driven by prolactin and placental lactogen acting through 129‑OR the prolactin receptor (PRLR) at the beta cells. To test this hypothesis, we The GLP-1 Analog Liraglutide Improves Glucose Tolerance and generated mice possessing Loxp sites flanking exon 5 of the Prlr gene (Prlrf/f) Reduces Body Weight in Schizophrenia Spectrum Disorder Patients and crossed them with mice expressing Cre recombinase under the control Treated with Clozapine or Olanzapine of the Pdx1 gene promoter to produce mice with a pancreas-specific Prlr LOUISE VEDTOFTE, JULIE R. LARSEN, MATHILDE S.L. JAKOBSEN, HANS R. gene null mutation (Prlrd/d). Prlrf/f or Prlrd/d females were mated to wild type JESPERSEN, MICHELLE I. JAKOBSEN, CAMILLA K. SVENSSON, KAMURAN males. Dams were euthanized on gestation day 15.5 to assess placental and KOYUNCU, OLE SCHJERNING, PETER S. OTURAI, ANDREAS KJAER, JIMMI ORALS fetal growth among genotypes. Body weight measurements and glucose NIELSEN, JENS J. HOLST, CLAUS T. EKSTRØM, CHRISTOPH U. CORRELL, TINA tolerance tests following 6 h of fasting were also performed. Loss of Prlr VILSBØLL, ANDERS FINK-JENSEN, Hellerup, Denmark, Copenhagen, Denmark, in the pancreas did not significantly impact body weight or blood glucose Aalborg, Denmark, Glen Oaks, NY levels in nonpregnant females. Pregnant Prlrd/d mice had elevated fasting Compared to the background population, patients with schizophrenia blood glucose and impaired glucose tolerance (P < 0.001). This inability to have two-to-three-fold higher mortality rates, primarily caused by cardio- sustain normal blood glucose balance during pregnancy worsened with age. vascular disease. So far, interventions designed to counteract antipsychotic- Prlrd/d dams returned to normal glycemic control 4 days postpartum. ELISA induced weight gain and cardiometabolic disturbances have had limited revealed that Prlrd/d dams had 40% lower serum insulin compared to age- success. In a 16-week, randomized, placebo-controlled, double-blinded trial, matched Prlrf/f dams (P < 0.01), indicating that the poor glucose homeostasis we investigated the effects of the GLP-1 analog liraglutide, 1.8 mg/day, during pregnancy in Prlrd/d dams was due to decreased insulin production. in 103 overweight/obese patients with prediabetes and schizophrenia- There were no significant differences in litter size or fetal weights among spectrum disorders on stable treatment with clozapine or olanzapine. Pri- Prlrd/d and Prlrf/f dams. Together, these results indicate that the PRLR, acting mary endpoint was change in glucose tolerance. The randomization (1:1) within the pancreas, is involved in maintaining normal blood glucose homeo- resulted in comparable groups. Drop-out rate was low and 97 participants 2 stasis during pregnancy and therefore its loss or dysfunction can predispose were included in the effect analyses (age: 43±11 years; BMI: 34±6 kg/m ). the mother to GDM. Glucose tolerance improved with liraglutide (P<0.001) compared to no Supported By: American Diabetes Association (1-16-PMF-012 to J.N.); National change with placebo (P=0.95) (between group P<0.001). Altogether, 63.8% Institutes of Health (HD020676) of the liraglutide-treated participants developed normal glucose tolerance compared to 16.0% of the placebo-treated participants (P<0.001, number- needed-to-treat=2). Body weight decreased with liraglutide (-4.7±0.5 kg) and increased with placebo (+0.5±0.7 kg) (P<0.001). Reductions in waist circumference (-4.0±0.6 vs. +0.5±0.7 cm, P<0.001), systolic blood pressure (-1.4±2.0 vs. +1.1±1.8 mmHg, P=0.04), visceral fat (-315.8±75.3 vs. -24.0±

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A33 LANDSCAPE OF THERAPEUTIC TRIALS IN TYPE 2 DIABETES

41.7 g, P=0.02), and LDL-cholesterol (-0.4±0.08 vs. -0.06±0.05 mmol/l, 131‑OR P<0.001) were significantly greater with liraglutide compared to placebo. The Long-Term Efficacy and Safety of Canagliflozin in Combination Adverse events with liraglutide were mainly gastrointestinal and serious with Insulin in Japanese Patients with T2DM adverse events were significantly lower in the liraglutide group (12 vs. 26%, SHINICHI HARASHIMA, NOBUYA INAGAKI, KOHEI KAKU, KAZUOKI KONDO, P=0.04). Liraglutide was well tolerated and significantly improved glucose NOBUKO MARUYAMA, MAKIKO OTSUKA, YUTAKA KAWAGUCHI, YUMI WATA- tolerance, body weight and other cardiometabolic disturbances in clozap- NABE, MAKI GODA, HIROAKI IIJIMA, Kyoto, Japan, Okayama, Japan, Tokyo, Japan ine- or olanzapine-treated patients with schizophrenia-spectrum disorders. Objective: To investigate the efficacy and safety of canagliflozin (CAN) Supported By: Novo Nordisk A/S administration in patients with T2DM who had inadequate glycemic control with insulin monotherapy. 130‑OR Methods: In the initial double-blinded 16-week period, patients were ran- Safety and Efficacy of Ertugliflozin plus Sitagliptin vs. Either Treat- domized to receive either CAN 100 mg (N = 76) or a placebo (P, N = 70). This was ment Alone after 52 Weeks in Subjects with T2DM Inadequately followed by a 36-week open-label period, in which all patients received CAN. Controlled on Metformin: VERTIS FACTORIAL Trial Extension Results: The placebo-adjusted changes in HbA1c, body weight, and RICHARD E. PRATLEY, ANNASWAMY RAJI, ROY ELDOR, SHEILA SUNGA, YAN- HOMA2-%B were −1.10% (95% CI, −1.33 to −0.87; p < 0.001), −2.37% (95% PING QIU, JEREMY JOHNSON, SUSAN HUYCK, GREGORY GOLM, STEVEN G. CI, −3.09 to −1.65; p < 0.001) (LS mean, LOCF), and 9.27% (95% CI, 5.35- TERRA, JAMES P. MANCUSO, SAMUEL S. ENGEL, BRETT LAURING, Orlando, FL, 13.19; p < 0.001) (LS mean), respectively. These effects, including body Kenilworth, NJ, Beijing, China, Andover, MA, Groton, CT weight, were sustained throughout the open-label period. The incidence of Ertugliflozin (ERTU) is an oral SGLT2 inhibitor in development for T2DM AEs was 64.8% and 68.0% in the P and CAN groups, respectively, during the treatment. In a double-blind Phase 3 trial, 1,233 subjects with A1C 7.5-11.0% double-blinded period, and 85.1% and 92.0% in the P/CAN and CAN/CAN on stable metformin monotherapy ≥1500 mg/day were randomized into 5 groups, respectively, during all treatment periods of CAN. The incidence per groups (Table). ERTU+sitagliptin (SITA) combinations were compared with subject-year exposure of hypoglycemia was 4.51 and 7.97 in the P and CAN corresponding ERTU doses (5 or 15 mg) or SITA alone. Primary outcome was groups, respectively, during the double-blinded period, and 4.85 during all at week 26; treatment was continued in a double-blind 26‑week extension treatment period of CAN. Hypoglycemic events in both groups were mild in phase. Mean A1C at baseline was 8.55%. After 52 weeks in the ERTU+SITA severity and dose-reduction of insulin decreased the incidence per subject- groups, greater reductions in A1C, FPG (vs. ERTU or SITA alone), body weight year exposure of hypoglycemic events. and systolic BP (vs. SITA alone) were observed (Table). The odds of having an Conclusions: The long-term efficacy and safety of CAN in combination A1C <7.0% were greater for ERTU+SITA vs. ERTU or SITA alone. Administra- with insulin was demonstrated. tion of ERTU alone or with SITA was well tolerated overall. Rates of genital Figure. mycotic infections with ERTU+SITA were similar to those observed with ERTU alone, and significantly higher than those observed with SITA alone (p<0.05, except ERTU 5 mg+SITA in females). Symptomatic hypoglycemia rates were not significantly different among groups but were highest in the ERTU 15 mg+SITA group. Overall the incidences of urinary tract infection and hypovolemia were similar across groups. Co-administration of ERTU+SITA resulted in effective glycemic control sustained over 52 weeks and was gen- erally well-tolerated. Table. Summary of Key Efficacy Endpoints at Week 52. ERTU ERTU SITA ERTU 5 mg + ERTU 15 mg + 5 mg 15 mg 100 mg SITA 100 mg SITA 100 mg (n=250) (n=248) (n=247) (n=243) (n=244) A1C (%) -0.96 -0.93 -0.82 -1.36 -1.39 (-1.10, -0.82) (-1.07, -0.79) (-0.97, -0.68) (-1.50, -1.22) (-1.53, -1.25) FPG (mg/dL) -28.7 -30.8 -15.2 -39.3 -41.8 Change from baseline, (-33.7, -23.6) (-36.1, -25.5) (-20.6, -9.8) (-44.3, -34.2) (-46.8, -36.8) LS mean (95% CI)† Body weight -2.4 -3.2 -0.1 -2.4 -2.8 (kg) (-2.9, -1.8) (-3.8, -2.7) (-0.7, 0.5) (-3.0, -1.8) (-3.4, -2.2) Systolic BP -2.7 -1.6 -0.2 -2.3 -2.2 132‑OR (mmHg) (-4.2, -1.2) (-3.1, 0.03) (-1.8, 1.5) (-3.8, -0.8) (-3.7, -0.7) Efficacy and Safety of Exenatide QW vs. Placebo Added to Insulin Glargine in Uncontrolled Basal-Insulin Treated Type 2 Diabetes: A1C <7.0% at Week 52, n (%) 64 (25.6) 56 (22.6) 66 (26.7) 99 (40.7) 97 (39.8) DURATION-7 Trial JUAN P. FRÍAS, JULIO ROSENSTOCK, ANIKO´ SOMOGYI, SERGE A. JABBOUR, HUI

ORALS ¶Excluding rescue approach; as the primary outcome was at Week 26, no WANG, ELISE HARDY, CRISTIAN GUJA, Los Angeles, CA, Dallas, TX, Budapest, formal statistical inference was performed for efficacy endpoints at Week Hungary, Philadelphia, PA, Gaithersburg, MD, Bucharest, Romania 52 to compare treatment groups. †Constrained longitudinal (cLDA) model with fixed effects for treatment, time, baseline eGFR (continuous), and the Exenatide BID added to insulin glargine (IG) improved glycemic control vs. interaction of time by treatment. IG alone in uncontrolled type 2 diabetes (T2D). DURATION-7 (NCT02229383) is the first study to assess efficacy and safety of adding exenatide QW (EQW) Supported By: Merck & Co., Inc.; Pfizer to IG ± metformin (MET) in 511 T2D patients (82.6% MET) with A1c 7.5-12.0% who underwent an 8-wk lead-in period for IG optimization with any prior SU use discontinued. Subsequently, 464 patients with continued hyperglycemia (A1c 7.0-10.5%) were randomized to EQW (n=233) or placebo (PBO) (n=231) added to IG±MET; IG titration continued over 28 wk. At randomization, mean baseline age was 57.7 yrs, T2D duration 11.3 yrs, A1c 8.5%, BMI 33.7 kg/ m2, and IG dose 51 U/day. EQW+IG significantly improved A1c and 2-hour PPG, with significant body weight loss vs. PBO+IG (Table) and with more patients achieving A1c <7.0% at wk 28 (32.5%) vs. PBO+IG (7.4%). Over 28 wk, IG dose increased slightly and did not differ between groups. Incidence of hypoglycemia was similar for EQW+IG (29.7%) and PBO+IG (28.6%); no major hypoglycemic episodes were reported. Gastrointestinal and injection site AEs were more common with EQW+IG (14.7%, 7.8%, respectively) than PBO+IG (10.8%, 3.0%). In conclusion, EQW+IG significantly improved A1c and induced weight loss, with no unexpected safety findings and similar hypoglycemia incidence vs. PBO+IG.

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A34 LANDSCAPE OF THERAPEUTIC TRIALS IN TYPE 2 DIABETES

Table. Treatment Responses from Baseline (Randomization) to Week 28. Table. Summary of Key Efficacy Endpoints at Week 52. Baseline, Week 28, LS mean Baseline, Week 28, LS mean PBO ERTU 5 mg ERTU 15 mg Pairwise Pairwise mean ± SD mean ± SD (95% CI) mean ± SD mean ± SD (95% CI) (n=153) (n=156) (n=153)# comparison:‡ comparison:‡ change from change from ERTU 5 mg ERTU 15 mg Baseline Baseline vs. PBO vs. PBO A1C (%) 8.5 ± 0.9 7.6 ± 1.2 -0.9 8.5 ± 0.9 8.3 ± 1.1 -0.2 -0.7 A1C, % 0.02 -0.75 -0.81 -0.76 -0.83 (-1.1, -0.8)* (-0.4, -0.1)* (-0.9, -0.5)* (-0.15, 0.19) (-0.90, -0.59) (-0.97, -0.66) (-0.98, -0.54) (-1.05, -0.61) P<0.001 FPG, mg/dL 3.2 -25.6 -26.4 -28.8 -29.6 LS mean change (-3.1, 9.5) (-30.9, -20.2) (-31.8, -21.0) (-36.4, -21.1) (-37.3, -21.9) 2-hour PPG after 235 ± 63 203 ± 66 -28 234 ± 64 230 ± 64 +0.4 -28 from baseline liquid MTT (mg/dL) (-39, -16)† (-11, +12)† (-39, -17)† (95% CI)† Body weight, -1.0 -3.5 -2.8 -2.5 -1.9 P<0.001 kg (-1.7, -0.3) (-4.1, -2.9) (-3.4, -2.2) (-3.4, -1.6) (-2.8, -1.0) Daily Insulin Dose 50 ± 21 52 ± 24 +2 51 ± 25 54 ± 27 +4 -2 Systolic BP, 0.8 -4.2 -4.1 -5.0 -4.9 (units) (+0.1, +3)* (+2, +5)* (-4, +0.2)* mmHg (-1.4, 3.1) (-6.0, -2.3) (-6.0, -2.2) (-7.8, -2.2) (-7.8, -2.1) P=0.070 Subjects with 21 (13.7) 52 (33.3) 50 (32.7) OR:§ OR:§ Body Weight (kg) 93.9 ± 20.2 92.8 ± 20.0 -1.1 94.3 ± 19.5 94.7 ± 19.8 +0.4 -1.5 A1C <7.0%, 3.6 (2.0, 6.6) 4.0 (2.2, 7.3) (-1.6, -0.6)* (-0.1, +0.9)* (-2.1, -0.8)* n (%) P<0.001 ¶Excluding rescue approach. #Two subjects randomized to ERTU 15 mg FPG (mg/dL) 148 ± 56 134 ± 46 -11 144 ± 46 142 ± 48 -2 -10 did not receive study medication and were excluded from the analysis (-18, -5)* (-8, +5)* (-18, -1)* ‡as the primary outcome was at week 26, no formal statistical inference P=0.021§ was performed to compare treatment groups for efficacy endpoints at week 52. †Constrained longitudinal (cLDA) model with fixed effects for *MMRM analysis; †ANCOVA analysis; §Nominal p value, not adjusted for treatment, time, prior antihyperglycemic medication (metformin + dipeptidyl multiplicity. FPG is an exploratory endpoint. Among randomized patients, peptidase-4 inhibitor/metformin + sulfonylurea), baseline eGFR (continuous) 232 EQW and 231 PBO patients received treatment and served as the basis and the interaction of time by treatment. §Adjusted odds ratio (OR) (95% CI) for safety analysis; 231 and 230 patients met ITT criteria and were ana- based on a logistic regression model fitted with fixed effects for treatment, lyzed for efficacy. ANCOVA, analysis of covariance; CI, confidence interval; prior antihyperglycemic medication, baseline A1C and baseline eGFR IG, insulin glargine; ITT, intent to treat; LS, least squares; MET, metformin; (continuous), with missing data imputed using the cLDA model. MMRM, mixed model repeated measures; MTT, meal tolerance test; PBO, placebo; PPG, postprandial glucose; SD, standard deviation. Supported By: Merck & Co., Inc.; Pfizer Supported By: AstraZeneca (NCT02229383) 134‑OR Effect of Sitagliptin in Type 2 Diabetes after Gastric Bypass 133‑OR ANKIT M. SHAH, ESMERALDA PIERINI, BETSY ROJAS, KIARRA LEVESQUE, MAR- Safety and Efficacy of Ertugliflozin after 52 Weeks in Subjects LENA HOLTER, SARAH STANO, MICHAEL AHLERS, SCOTT BELSLEY, JOHN HAR- with T2DM Inadequately Controlled on Metformin and Sitagliptin: VEY, NINAN KOSHY, JAMES MCGINTY, BLANDINE B. LAFERRERE, New York, NY Results from the Extension Phase of the VERTIS SITA2 Trial Background: Approximately 40% of patients do not experience type 2 dia- JIE LIU, ROY ELDOR, SAMUEL DAGOGO-JACK, GUILLERMO AMORIN, JEREMY betes (DM2) remission after gastric bypass (GBP) and 1/3 of patients who JOHNSON, YUQIN (ALICE) LIAO, SUSAN HUYCK, GREGORY GOLM, STEVEN G. go into remission relapse 5 to 8 years after the surgery. The release of glu- TERRA, JAMES P. MANCUSO, SAMUEL S. ENGEL, BRETT LAURING, Kenilworth, cagon-like peptide-1 (GLP-1) is enhanced after GBP. Dipeptidyl peptidase-4 NJ, Memphis, TN, Buenos Aires, Argentina, Beijing, China, Andover, MA, Groton, CT (DPP-4) inhibitors, which prolong the half-life of GLP-1, have not been studied Ertugliflozin (ERTU) is an oral SGLT2 inhibitor in development for T2DM to treat DM2 after GBP. treatment. Subjects (N=464) with A1C 7.0-10.5% on stable metformin Hypothesis: Sitagliptin (S) will lower glycemia compared to placebo (P) in ≥1500 mg/day and sitagliptin 100 mg/day were randomized to ERTU 5 mg, patient with DM2 after GBP. ERTU 15 mg, or placebo (PBO) in a double‑blind Phase 3 trial. The primary Methods: 4-week double-blind, randomized control trial to assess the effi- outcome was at week 26 and treatment was continued until week 52 in a cacy and safety of S in patients with persistent or relapsing DM2 after GBP. double-blind extension phase. Baseline characteristics were generally com- Subjects (n=32) completed a mixed meal tolerance test (MMT, Boost, 34g parable between groups (mean age 59.1 years, mean A1C 8.03%, mean body of CHO) and a 7-point home glucose monitoring (SPMG) before and 4 weeks weight 86.9 kg, mean eGFR 87.9 mL/min/1.73m2). After 52 weeks, greater after being randomized to S 100 mg (n=16) or P (n=16), with standardized reductions in A1C, FPG, body weight and systolic BP and a greater propor- questionnaires to assess gastro intestinal discomfort. Glucose, insulin and tion of subjects with an A1C <7.0% were observed in the ERTU groups vs. C-peptide were measured during the MMT. Insulin secretion rate (ISR) by PBO (Table), consistent with previously reported week 26 findings. Rates of C-peptide deconvolution method and β-cell glucose sensitivity (BCGS), or genital mycotic infections were higher in subjects receiving ERTU compared the slope between ISR and corresponding glycemia were calculated. with PBO at week 52 (males: 4.9% [ERTU 5 mg], 3.7% [ERTU 15 mg], 0 [PBO]; Results: Age (56.3 ± 8.2 years), BMI (34.4±6.7 kg/m2), HbA1c (7.21 ± ORALS females: 12.0% [ERTU 5 mg], 14.1% [ERTU 15 mg], 1.9% [PBO]; all p<0.05 vs. 0.77%), DM2 duration prior GBP (12.9 ± 10.0 years), years since GBP (5.6 ± PBO except ERTU 15 mg males). The incidences of urinary tract infections, 3.3 y), glycemia, ISR and BCGS, did not differ between P and S groups pre- symptomatic hypoglycemia and hypovolemia AEs were not meaningfully dif- intervention. S was well tolerated. S had no effect on glucose or ISR. Nei- ferent across groups. Addition of ERTU 5 mg or 15 mg to metformin and ther the post intervention glycemia: fasting (P=115 mg/dL vs. S=116 mg/dL, sitagliptin provided clinically meaningful glycemic control over 52 weeks and p=0.90), 120’ (P=125 mg/dL vs. S=122 mg/dL p= 0.75), AUC during MMT, and was well-tolerated. mean SPMG glucose, nor the delta change of any of these variables after either P or S, differed between groups. However S resulted in a small, albeit significant, increase in BCGS (+0.071±0.435 pmol∙kg-1∙min-1∙mM) compared to P (-0.291±0.409 pmol∙kg-1∙min-1∙mM, p=0.039). Conclusions: In patients with DM2 and mild hyperglycemia after GBP, a short course of sitagliptin resulted in a small improvement of β-cell function but did not provide any additional glucose-lowering. Supported By: Merck & Co., Inc.

135‑OR Triple vs. Dual Therapy with Saxagliptin plus Dapagliflozin vs. Sita- gliptin Added to Metformin-Failure Uncontrolled Type 2 Diabetes YEHUDA HANDELSMAN, CHANTAL MATHIEU, STEFANO DEL PRATO, EVA JOHN- SSON, RAISA KURLYANDSKAYA, NAYYAR IQBAL, JULIO ROSENSTOCK, Tarzana, CA, Leuven, Belgium, Pisa, Italy, Gothenburg, Sweden, Gaithersburg, MD, Dallas, TX Stepped-up therapy adding a single oral antidiabetic agent often fails to meaningfully improve glycemic control in patients with metformin-treated

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A35 INSULIN SIGNALING AND TRAFFICKING

type 2 diabetes (T2D) with significant hyperglycemia. We tested triple vs. (mental component summary) and TRIM-D (total scores) improved more with dual therapy in this randomized, double-blind, double-dummy, 26-week trial IDegLira vs. BB (p=0.0074 and p<0.0001 respectively). Adverse event rates (NCT02284893) that evaluated the efficacy and safety of adding saxagliptin were similar. (SAXA) 5 mg/day plus dapagliflozin (DAPA) 10 mg/day vs. sitagliptin (SITA) In conclusion, in pts with A1C >7% on metformin and IGlar, IDegLira vs. 100 mg/day in patients with T2D and metformin (MET) ≥1500 mg/day mono- BB resulted in similar A1C reductions, lower insulin dose, weight loss and therapy failure (A1C levels 8.0-10.5%). The primary end point was change lower risk of HEs. in A1C from baseline to week 26; secondary endpoints were the proportion of patients achieving A1C <7%, and the changes in body weight and FPG. Mean±SD baseline data were: age, 55.9±9.2 years; A1C, 8.8±0.9%; duration of T2D, 8.0±5.4 years; BMI, 33.1±6.2 kg/m2 and were similar between arms. SAXA + DAPA + MET resulted in significant decreases in A1C and weight vs. SITA + MET (Table). Incidences of AEs of interest with SAXA + DAPA + MET vs. SITA + MET were: hypoglycemia, 9.1% vs. 7.4%; urinary tract infections, 4.7% vs. 2.2%; genital infections 2.6% vs. 2.2%. In conclusion, triple therapy adding SAXA + DAPA provided greater improvement in glycemic control than dual therapy adding SITA alone in patients with poorly controlled metformin-failure T2D. Table. Results for Primary and Secondary End Points. Study end point SAXA + SITA + MET Difference P value DAPA + MET N=229 (95% CI) N=232 Mean±SD A1C (%) n=224 n=219 Baseline 8.8±0.8 8.9±0.9 — — Week 26 7.3±1.0 7.6±1.0 Adjusted mean±SE change in A1C from n=206 n=184 −0.3 baseline to week −1.4±0.1 −1.1±0.1 (−0.5, −0.1) 0.0008 26 (%) Supported By: Novo Nordisk Adjusted proportion±SE of n=224 n=219 12.2 patients with A1C 37.3±3.2 25.1±2.9 (4.0, 20.4) 0.0034 INSULIN SIGNALING AND TRAFFICKING <7% at week 26 (%) Adjusted mean±SE 137‑OR change in body n=207 n=184 −1.35 <0.0001 Carbohydrate Response Element Binding Protein (ChREBP) Regu- weight from baseline −1.86±0.20 −0.51±0.21 (−1.92, −0.79) lates Insulin-Stimulated Glut4 Exocytosis in Adipocytes Indepen- to week 26 (kg) dent of Akt Adjusted mean±SE ARCHANA VIJAYAKUMAR, JENNIFER WEN, PRATIK ARYAL, RACHEL J. PERRY, change in FPG from n=206 n=182 −21 <0.0001 JOAO-PAULO G. CAMPOREZ, GERALD I. SHULMAN, TIMOTHY E. MCGRAW, BAR- baseline to week 26 −32±3 −11±3 (−28, −14) BARA B. KAHN, Boston, MA, New York, NY, New Haven, CT (mg/dL) Altered glucose flux into adipocytes regulates systemic insulin sensitivity Adjusted at least partly through the transcription factor ChREBP, a major regulator proportion±SE of n=232 n=229 −3.7 of de novo lipogenesis (DNL). Adipose expression of glucose transporter patients requiring 2.7±1.0 6.4±1.6 (−7.4, 0.1) — Glut4, ChREBP and DNL enzymes strongly correlate with insulin sensitivity treatment in humans. We aimed to determine the mechanism by which adipose ChREBP intensification (%) regulates insulin sensitivity. We generated adipose-specific ChREBP KO A mixed statistical model was used to analyze between-group differences. (AdChREBP KO) mice and found they exhibit both hepatic and peripheral n is the number of randomized patients with non-missing baseline and insulin resistance. During a hyperinsulinemic-euglycemic clamp, insulin sup- week 26 values (last observation carried forward), except for mean baseline and week 26 A1C, where n is the number of randomized patients presses hepatic glucose production only 13% in AdChREBP KO vs. 64% in with non-missing baseline value and at least one post-baseline value. Controls. 2-deoxyglucose uptake in vivo is 44% lower in muscle and 29% lower in adipose tissue in KO mice. Insulin-stimulated glucose transport in Supported By: AstraZeneca isolated adipocytes from AdChREBP KO mice is also impaired. Glut4 protein levels and insulin-stimulated Akt phosphorylation are normal in adipose tis- ORALS 136‑OR sue in vivo and in isolated adipocytes from AdChREBP KO mice. Yet, insulin- Efficacy and Safety of Insulin Degludec/Liraglutide (IDegLira) vs. stimulated Glut4 translocation, measured with a dual labeled HA-Glut4-GFP Basal-Bolus (BB) Therapy in Patients with Type 2 Diabetes (T2D): reporter, is reduced by 50% in ChREBP KO adipocytes. This defect is cell DUAL VII Trial autonomous and is present in stromovascular-derived adipocytes from LIANA K. BILLINGS, ANKUR DOSHI, DIDIER GOUET, ALEJANDRA OVIEDO, HEL- AdChREBP KO mice. Rapid exocytosis of Glut4-containing vesicles to the ENA W. RODBARD, NIKOLAOS TENTOLOURIS, RANDI GRØN, NATALIE HALLA- plasma membrane is a critical step in insulin-stimulated Glut4 translocation. DIN, ESTEBAN JODAR, Evanston, IL, Houston, TX, La Rochelle, France, Buenos Aires, Adipocytes lacking ChREBP have slower insulin-stimulated Glut4 exocytosis Argentina, Rockville, MD, Athens, Greece, Søborg, Denmark, Madrid, Spain (half-time of ~21 min vs. ~7 min in Controls). The exocytosis rate constant is In a 26-wk open-label trial, 506 patients (pts) with T2D uncontrolled on >50% lower in ChREBP KO adipocytes. In sum, reduction of ChREBP in adi- metformin and 20-50 units (U) insulin glargine U100 (IGlar) were randomized pocytes which occurs in insulin resistant people, causes insulin resistance 1:1 to IDegLira or BB therapy (IGlar + insulin aspart up to 4 times a day). Mean in adipocytes, liver and muscle. Absence of ChREBP in adipocytes impairs A1C decreased from 8.2% at baseline to 6.7% at end of trial in both arms; insulin-stimulated glucose transport by slowing Glut4 exocytosis. Under- non-inferiority (by <0.3%) for IDegLira was confirmed (p<0.0001; Table). A standing the mechanisms for this could reveal new cellular pathways that similar proportion of pts achieved A1C targets with IDegLira vs. BB (66.0% cause insulin resistance and type 2 diabetes. vs. 67.0% for <7%/49.6% vs. 44.6% for ≤6.5% respectively). Total daily insu- Supported By: DK059635R01, DK098002 lin dose was lower for IDegLira (40.4 U) vs. BB (84.1 U) (p<0.0001). Body weight decreased with IDegLira and increased with BB (p<0.0001); the rate 138‑OR of hypoglycemic episodes (HEs) was lower with IDegLira vs. BB (p<0.0001). Phosphorylation of Tmod3 by AMPK Regulates GLUT4 Translocation More pts achieved a triple composite endpoint (A1C <7% with no HE in and Glucose Transport in L6 Myoblasts the last 12 wks and no weight gain) with IDegLira vs. BB (34.9% vs. 4.7%; MAN M. SHRESTHA, Singapore, Singapore odds ratio 12.56 [6.46; 24.45] p<0.0001). Mean pre- to postprandial plasma Insulin and muscle contractions mediate translocation of glucose trans- glucose increment decreased more with BB vs. IDegLira (p=0.0032). SF-36 porter 4 (GLUT4) to the plasma membrane for glucose uptake in skeletal mus-

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A36 INSULIN SIGNALING AND TRAFFICKING cles. It is well understood that insulin promotes GLUT4 translocation and glu- of insulin signaling might be achieved via direct effects on miRNA produc- cose uptake in muscles and adipocytes by the PI3K/Akt signaling pathway. We tion, a novel pathway affecting insulin sensitivity. recently identified Tropomodulin3 (Tmod3), an actin capping protein that blocks Supported By: Harold Hamm Diabetes Center the elongation and de-polymerization of actin filaments at the pointed end, as a novel Akt2 substrate, and showed that Tmod3 plays a vital role in GLUT4 141‑OR translocation and glucose uptake under insulin stimulation. Although AMPK Viral Insulin-Like Peptides Are New Ligands of Human Insulin and (5’ adenosine monophosphate-activated protein kinase) signaling regulates IGF-1 Receptors GLUT4 translocation during muscle contraction, the precise mechanisms gov- EMRAH ALTINDIS, WEIKANG CAI, MASAJI SAKAGUCHI, FA ZHANG, FA LIU, erning AMPK-medicated GLUT4 translocation are not clearly elucidated. Here RICHARD DIMARCHI, C. RONALD KAHN, Boston, MA, Bloomington, IN we report the identification of Tmod3 as an AMPK substrate and Ser25 as the The insulin gene family includes insulin, IGF-1, and IGF-2, and a number phosphorylation site on Tmod3 by AMPK signaling. We show that phosphory- of insulin-like molecules that have been identified in invertebrates and lation of Ser25 is required for AMPK-induced GLUT4 translocation and glucose nematodes. Using a comprehensive bioinformatics approach, we have now uptake in L6 myoblasts. Furthermore, Tmod3 phosphorylation by AMPK leads identified a new family of insulin-like molecules in viruses. We have named to actin re-modeling and promotes GLUT4 translocation and glucose uptake. these viral insulin/IGF1-like peptides or VILPs for short. Thus far, four VILPS We propose that Tmod3 is a key downstream effector of AMPK in the regula- have been found. All are in large dsDNA viruses of the Iridoviridae family, tion of GLUT4 translocation and glucose homeostasis in muscle cells. including one virus whose sequence was identified in the human gut. All Supported By: A*STAR Agency for Science, Technology and Research VILPs have the six conserved critical cysteines and show a very high homol- ogy to human insulin and IGF-1, to which they are ~ 30-45% identical. We 139‑OR have chemically synthesized these VILPs and functionally characterized their IRS1 Ser1101 Phosphorylation Impairs Insulin-Stimulated Muscle effects. Using brown preadipocyte cell lines with knockout of the endog- Glucose Metabolism enous insulin receptor (IR) and IGF-1 receptor (IGF-1R), we created new cell MAX C. PETERSEN, JOAO-PAULO G. CAMPOREZ, GERALD I. SHULMAN, New lines stably expressing individually either the mouse or human IR or IGF-1R to Haven, CT assess receptor binding and post-receptor signaling. We find that VILPs bind Phosphorylation of insulin receptor substrate 1 (IRS1) at serine 1101 has to both mouse and human receptors with higher affinity to the IGF-1 than been proposed to inhibit skeletal muscle insulin action. Two mechanisms for insulin receptor. These VILPS also activate receptor autophosphorylation IRS1 Ser1101 phosphorylation have been identified. In one, S6 kinase (S6K) and downstream signaling with increases in AKT and ERK phosphorylation, phosphorylation of IRS1 Ser1101 contributes to normal negative feedback albeit with lower potency. The VILPs also showed some bias in signaling of insulin signaling. In the other, diacylglycerol-induced protein kinase C-θ toward the AKT pathway compared with human insulin/IGF-1. In differenti- (PKCθ) phosphorylation of IRS1 Ser1101 mediates lipid-induced muscle insu- ated 3T3-L1 adipocytes, culture brown fat cells and freshly isolated white fat lin resistance. To test the physiological relevance of these mechanisms, we cells, VILPs are able to stimulate glucose uptake and lipogenesis. In human generated mice harboring a serine to alanine knock-in allele at the homolo- fibroblasts VILPs activated cell proliferation with potency similar to human gous residue to human IRS1 Ser1101 (Irs1S1097A). Skeletal muscle insulin insulin. The identification of VILPs and demonstration of their insulin and action in Irs1S1097A mice was evaluated using hyperinsulinemic-euglycemic IGF-1-like effects opens a new window on the mechanisms by which viruses clamp studies. On regular chow diet, Irs1S1097A mice displayed increased glu- and viral insulin-like peptides might modify host metabolism and contribute cose infusion rates and whole-body glucose disposal, indicative of enhanced to diseases, such as diabetes, through hormonal and possibly immunological skeletal muscle insulin action. However, Irs1S1097A mice were not protected effects. from whole-body or skeletal muscle insulin resistance induced by either Supported By: National Institutes of Health (5R01DK033201-32); Mary K. high-fat feeding or acute lipid infusion. Similarly, double knock-in (DKI) mice Iacocca Senior Postdoctoral Fellowship also harboring a homologous mutation on Irs2 (Irs1S1097A; Irs2S1138A) were not protected from high-fat diet-induced skeletal muscle insulin resistance. 142‑OR Conclusions: These data are consistent with a physiological role for IRS1 Unraveling the Regulation of Insulin Transport across the Brain Ser1101 phosphorylation in normal negative feedback of skeletal muscle insu- Endothelial Cell lin signaling, but provide evidence against a pathophysiological role for IRS1 SARAH M. GRAY, KEVIN W. AYLOR, EUGENE J. BARRETT, Charlottesville, VA Ser1101 phosphorylation in lipid-induced skeletal muscle insulin resistance. Insulin acts on the brain and is transported across the blood brain barrier (BBB). This route, not entry via CSF circulation, is the primary pathway for 140‑OR insulin’s entry to the brain. However, little is known regarding how circulat- Regulation of Akt Phosphorylation by Gamma-Secretase Inhibition ing insulin crosses the BBB’s highly restrictive brain endothelial cell (BEC). in Adipocytes Here, we examined mechanisms regulating BEC insulin uptake, signaling, and NILE MCCULLOUGH, DAVID P. SPARLING, Oklahoma City, OK BBB transcytosis and how transport is affected by high-fat diet (HFD) feed- The proximal cause of obesity-induced insulin resistance is excessive adi- ing and astrocyte activity. At physiologic insulin concentrations blocking the pose mass. Exploring new mechanisms that regulate adipose growth and insulin receptor (IR) not the IGF-1R inhibited BEC insulin uptake (p<0.0001)

insulin resistance is therefore vital. Recent work demonstrated adipocyte- and downstream signaling (p<0.01). Inhibiting lipid raft endocytosis (dynasore ORALS specific inhibition of theγ -secretase enzyme complex decreases adipose p<0.05, methyl-β-cyclodextrin, p<0.001, or filipin (p<0.05) inhibited insulin insulin sensitivity with a parallel decrease in Akt phosphorylation. The uptake while blocking the insulin signaling to PI3-kinase or MEK had no effect. γ-secretase complex targets type 1 transmembrane proteins, so we hypoth- Isolated BECs from rats fed HFD for 4 weeks had decreased insulin uptake esized that γ-secretase could directly affect activation of components of (p<0.01) and increased NFκB nuclear binding activity (p<0.05), yet had similar the insulin signaling cascade. In insulin-stimulated 3T3-L1 adipocytes pre- Akt and MEK phosphorylation, IR expression, and insulin degrading enzyme treated with a γ-secretase inhibitor (GSI), we found unaltered phosphoryla- expression compared to controls. Using an in vitro BBB, we found insulin was tion of upstream insulin signaling components, including the insulin receptor not degraded during BEC transcytosis and that stimulating astrocytes with and IRS1, suggesting an alternative mechanism to affect Akt activation. L-glutamate increased (p<0.05) and L-NAME decreased (p<0.001) insulin tran- As γ-secretase is also involved in a variety of pathways regulating gene scytosis. In aggregate we provide evidence for IR-specific, vesicle-mediated expression, we performed RNAseq on GSI-treated 3T3-L1 adipocytes. While transport of intact insulin across the BEC. The effects of HFD feeding, nitric transcription of components of the insulin signaling cascade do not appear oxide inhibition and astrocyte simulation suggests unique regulatory mecha- to be affected, we found significant down-regulation at the Dnm3os locus nisms govern BEC insulin uptake and transcytosis. after γ-secretase inhibition. Dnm3os produces three miRNAs, including Supported By: National Institutes of Health; American Heart Association miRNA-214, which can regulate PI3K/Akt signaling via down-regulation of Phosphatase and Tensin homolog deleted on chromosome 10 (PTEN) expres- 143‑OR sion. PTEN is the active PIP3 phosphatase in adipocytes in vitro, and altered Ankyrin-B Regulates the Interplay between BCAA and Lipid Metab- levels of PTEN are associated with changes in insulin sensitivity. Interest- olism in Adipocytes ingly, a polymorphism in miRNA-214 binding sites has been associated with DAMARIS N. LORENZO, VANN BENNETT, Chapel Hill, NC, Durham, NC increased susceptibility to type 2 diabetes mellitus. In GSI-treated adipo- Human variants in ankyrin-B (AnkB) have been implicated in hereditary cytes, qRT-PCR analysis revealed miRNA-214 levels decrease 19%; PTEN cardiac arrhythmia and type 2 diabetes (T2D).1-3 We reported that knock-in protein expression correspondingly increases 23% (p<0.05), correlating with mice bearing AnkB variants p.R1788W (present in 0.3% European Ameri- the loss of Akt phosphorylation. Therefore, γ-secretase-mediated regulation cans and enriched in T2D patients) and p.L1622I (present in over 7% African

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A37 CENTRAL NERVOUS SYSTEM REGULATION OF METABOLISM

Americans) develop pancreatic β-cell insufficiency combined with age- or post-prandial state. Eleven healthy obese (OB) (8F/3M, age 47±7 yrs, BMI diet-dependent obesity and insulin resistance (IR).4 Moreover, AnkB loss in 32.4±1.4) and 5 age- and BMI-matched subjects with type 2 diabetes (T2D) differentiated adipocytes and in white adipose tissue (WAT) from WAT-spe- (2F/3M, A1c 6.4±0.5%) underwent a simultaneous functional MRI (fMRI) cific AnkB knockout mice enhances adiposity and causes IR. However, how scan and hyperglycemic clamp (200mg/dL). Blood-oxygen-level-dependent AnkB modulates lipid metabolism and insulin sensitivity remains unclear. signal was obtained while viewing high calorie (HC), low calorie, and non- Further studies in WAT-KO and knock-in AnkB mice suggest that AnkB regu- food pictures. CNS regions associated with eating behavior were chosen lates glucose uptake by promoting endocytosis of the glucose transporter for a region of interest brain analysis: executive control (ventromedial pre- 4 (GLUT4) in adipocytes and skeletal muscle. Biochemical and proximity frontal cortex (VmPFC)) and reward motivation (insula, caudate, and puta- ligation assays show that AnkB simultaneously interacts with clathrin and men). Hunger was rated before and after the scan. The fMRI-clamp study GLUT4. Thus, lack of AnkB reduces clathrin-GLUT4 association in adipocytes, was repeated after an 8 week reduced calorie diet. Participants achieved which leads to internalization deficits, persistent elevation in cell surface a 3.4±3.2% weight loss (p<0.05). Before the diet, hunger before and after GLUT4, and increased lipid accumulation. Interestingly, downregulation of the scan was not different, but this change increased after diet (p<0.05). BCAA oxidative metabolism in WAT and elevated BCAA levels have been After the diet, VmPFC activity decreased in hyperglycemia in both groups. associated with obesity and IR in humans.5, 6 Here, we show that AnkB In OB but not T2D, caudate activity (reward-motivation) after weight loss deficiency downregulates BCAA catabolism in WAT through transcriptional negatively correlated with hunger change (p<0.05). The amount of weight mechanisms that synergize with hyperlipidemia to contribute to the develop- loss correlated with the changes in caudate activity in hyperglycemia while ment of obesity and IR. Loss of AnkB in WAT significantly reduced expres- viewing HC pictures (R2=0.599, p<0.05). sion of main BCAA catabolic enzymes and led to elevations in BCAA and In summary, weight loss influenced brain responses to hyperglycemia, related acylcarnitines levels. Accumulation of catabolic intermediates and with decreased VmPFC activity and an increase in hunger. In OB but not T2D, lipids trigger endoplasmic reticulum stress and impaired insulin signaling. greater reductions in weight correlated with decreased caudate activity. Thus, AnkB is a novel regulator of the cross-talk between BCAA, fatty acid, These results suggest that increased inhibitory control for food cues in the and glucose metabolism in adipocytes. post-prandial state may be important for a successful weight loss diet in nondiabetic OB; and different eating patterns may affect diet adherence in 144‑OR T2D. A Loss of STAT5 Signaling in Adiponectin-Expressing Cells In Supported By: National Institutes of Health Vivo Leads to Metabolically Healthy Adiposity Accompanied by Improved Glucose and Lipid Metabolism 146‑OR HARDY HANG, ALLISON J. RICHARD, RANDALL L. MYNATT, CARRIE M. ELKS, Obesity and Diabetes Alter Human Brain Glucose during Hypergly- JACQUELINE M. STEPHENS, Baton Rouge, LA cemia STATs are a family of transcription factors that have cell- and tissue- JANICE J. HWANG, LIHONG JIANG, MUHAMMAD HAMZA, ELIZABETH SAN- specific functions by enabling hormone- and cytokine-induced changes in CHEZ RANGEL, RENATA BELFORT-DEAGUIAR, LISA PARIKH, FENG DAI, GRAEME gene expression. STAT5A and 5B are known to facilitate adipocyte develop- MASON, DOUGLAS ROTHMAN, ROBERT S. SHERWIN, New Haven, CT ment and regulate adipose function in vitro and in vivo. To further elucidate Chronic hyperglycemia is associated with cognitive decline and neurovas- the role of STAT5 proteins in fat cells, we used adiponectin-Cre and floxed cular dysfunction. However, how obesity and diabetes alter glucose entry STAT5 A/B mice to generate mice that lack both STAT5A and 5B in mature into the human brain and cerebral glucose metabolism remains incompletely adipocytes (STAT5AKO). Notably, studies on 3 cohorts of mice have revealed understood. To address this question, 25 participants including 8 healthy that STAT5AKO mice have an adiposity phenotype on chow diet. However, lean control subjects (4F/4M, age 28.8 ± 2.2 yrs (mean±SEM), BMI 23.4 ± STAT5AKO mice lose this phenotype upon high-fat or high-fat/high sucrose 0.9 kg/m2, HbA1c 5.0 ± 0.1), 6 obese subjects (4F/2M, age 38.0 ± 4.4, BMI feeding. It is well established that levels and signaling of growth hormone 37.3 ± 1.4, HbA1c 5.2 ± 0.2), 6 T1DM patients (4F/2M, age 28.2 ± 3.0, BMI (GH), a primary STAT5 activator, are diminished in mammals with excess 27.5 ± 2.8, HbA1c 8.5 ± 0.2, duration of DM 16.3 ± 4.0), and 5 T2DM patients adiposity. Moreover, there is no additional glucose intolerance or insulin (3F/2M, age 46.6 ± 3.4, BMI 32.4 ± 1.3, HbA1c 10.0 ± 1.0, duration of DM resistance observed in STAT5AKO mice on high fat diet relative to floxed con- 9.2 ± 4.1) underwent 1H magnetic resonance spectroscopy (MRS) at 4 Tesla trols. When obese high fat-fed STAT5AKO female mice are switched to chow to measure intracerebral (IC) glucose in the occipital lobe during a 2-hour diet, they are highly resistant to weight loss as compared to floxed control hyperglycemic clamp (~220 mg/dl). Spectra were subtracted from baseline mice that exhibit significantly enhanced weight loss and reduced adiposity. to eliminate overlap from other brain metabolites not directly affected by Despite the maintained obesity, STAT5AKO mice have reduced inflammation glucose levels. At 120 minutes, IC glucose was markedly different across in adipose tissue and less liver steatosis. Although additional phenotypic the 4 groups (P=0.01) despite nearly identical plasma glucose levels (P=0.16). characterization is ongoing, the STAT5AKO mice have an adiposity phenotype Our finding that diabetes and obesity are associated with diminished human that is uncoupled from insulin resistance and metabolic dysfunction. It is brain glucose content suggests that cerebral glucose metabolism may be well known that chronic elevation of GH is associated with insulin resis- altered in these metabolic diseases. This finding may have important impli- tance. Yet, most mammals with altered GH signaling have altered levels of cations for understanding how obesity and diabetes lead to cognitive and IGF-1. Since STAT5AKO only have reduced GH signaling in fat, and not in liver, neurovascular dysfunction. ORALS it is not surprising that our mice do not have alterations in plasma IGF-1. Figure. In summary, we have generated a novel animal model of metabolically healthy adiposity that may provide insight into our understanding of factors that protect against type 2 diabetes. Supported By: National Institutes of Health (R01DK52968)

CENTRAL NERVOUS SYSTEM REGULATION OF METABOLISM

145‑OR Brain Responses to Postprandial Glucose Levels Influence Weight Loss SAMUEL ROSENBERG, MARY SAVOYE, DONGJU SEO, CHRISTIAN SCHMIDT, Supported By: National Institutes of Health; Endocrine Fellows Foundation WAI LAM, HAI HOANG, MUHAMMAD HAMZA, LISA PARIKH, CHERYL LACADIE, JANICE J. HWANG, TODD CONSTABLE, RAJITA SINHA, ROBERT S. SHERWIN, RENATA BELFORT-DEAGUIAR, New Haven, CT, Branford, CT, Guilford, CT Changes in blood glucose levels have been shown to modulate eating behavior, but the effect of modest increases in glucose levels on the central nervous system (CNS) control of eating behavior remains unclear in weight loss. The purpose of this study was to evaluate the effect of weight loss on brain activation and food preferences during hyperglycemia, simulating the

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A38 CENTRAL NERVOUS SYSTEM REGULATION OF METABOLISM

147‑OR 149‑OR Reduced Renal Sympathetic Nerve Activity Improves Glucose Tol- Melanocortin-4 Receptor Regulates Energy Homeostasis through erance in Hypothalamus-Specific POMC Knockout Mice by Elevat- ROCK1 ing Glycosuria SANG SOO KIM, INES S. LIMA, MIN CHEOL KANG, SUNG WAN CHUN, YOSSI KAVALJIT H. CHHABRA, DONALD A. MORGAN, KAMAL RAHMOUNI, MALCOLM DAGON, WENJING LI, YOUNG BUM KIM, Boston, MA J. LOW, Ann Arbor, MI, Iowa City, IA Melanocortin signaling is essential for the maintenance of body weight We recently reported that obese and insulin-resistant, hypothalamus- and energy balance. Neurons expressing MC4R in the hypothalamus act as specific proopiomelanocortin knockout (hsPOMC KO) mice exhibit improved a key mediator of melanocortin action, but knowledge of the critical intra- glucose tolerance associated with glycosuria and reduced levels of the glu- cellular transduces of melanocortin signaling remains incomplete. Here we cose transporter Glut2, but not SGLT2, in renal proximal tubules. Because show that α-melanocyte-stimulating hormone (MSH) stimulates Rho-kinase POMC neurons innervate and excite sympathetic preganglionic neurons in 1 (ROCK1) activity in the hypothalamus, indicating that ROCK1 could function the spinal cord, we hypothesized that reduced basal renal sympathetic nerve as a downstream component of melanocortin signaling. Deficiency of ROCK1 activity (RSNA) could explain the elevated glycosuria and improved glucose in MC4R expressing neurons results in increased in body weight under a nor- tolerance in hsPOMC KO mice. We measured RSNA by multifiber recording mal chow diet (control 36.4±2.3g vs. MC4R-ROCK1 deficient mice 45.1±1.2g, directly from the nerves innervating the kidney in conscious freely moving p<0.01, respectively). This is most likely due to increased daily food intake mice. hsPOMC KO mice exhibited a 41% reduction in RSNA (1.05 ± 0.08 vs. in MC4R-ROCK1 deficient mice (control mice 5.1±0.2g vs. MC4R-ROCK1 0.62 ± 0.03 v*sec/min, P<0.0001) compared to control mice. To further vali- deficient mice 6.1±0.2g, p<0.05). Concurrently, CLAMS analysis indicates date the function of RSNA in glucose reabsorption, we denervated kidneys that oxygen consumption in MC4R-ROCK1 deficient mice is significantly in WT and db/db mice before determining their glucose tolerance. Oral glu- decreased by ~20%, compared with control mice. Importantly, activation of cose tolerance tests revealed that renal-denervated WT mice (8-10 week ROCK1 in MC4R expressing neurons is required for the regulation of normal old) exhibited improved glucose tolerance (AUC: 33,183 ± 920.7 vs. 41,468 ± melanocortin action, as evidenced by the fact that α-MSH’s ability to sup- 1,142 mg/dl*min, P<0.05), without any changes in insulin sensitivity, com- press food intake is impaired in mice lacking ROCK1 in MC4R neurons. In pared to sham-operated littermates. Moreover, the renal-denervated db/db vitro studies in cultured hypothalamic cells demonstrate that α-MSH pro- mice demonstrated lower fasting blood glucose levels (310.4 ± 8.2 vs. 459 ± motes the physical interaction of MC4R and ROCK1, thereby increasing acti- 14.5 mg/dl, P<0.05) and improved glucose tolerance (∆AUC: 17,147 ± 959 vation of ROCK1 and its downstream signaling PI3K and FOXO1. vs. 23,038 ± 1,251 mg/dl*min, P<0.05) than sham-operated db/db mice. The In conclusion, our data identify ROCK1 as a novel regulator of melanocor- improvement in glucose tolerance in renal-denervated WT and db/db mice tin action on food consumption and energy expenditure and establish a new was due to elevated glycosuria (WT: 1.07 ± 0.2 vs. 0.47 ± 0.05; db/db: 938 ± MC4R→ROCK1→PI3K→FOXO1 signaling for melanocortin. Targeting Rho- 35 vs. 504 ± 47 mg/24 h, P<0.05). Altogether, these data indicate that hypo- kinase in the hypothalamus could provide a new strategy to combat obesity thalamic POMC is critical in maintaining basal RSNA, which in turn, controls and its related complications. renal glucose reabsorption in mice. Thus, our study provides a mechanism Supported By: National Institutes of Health to explain the clinical observation that renal denervation improves glucose metabolism in patients with drug resistant hypertension. 150‑OR Supported By: National Institute of Diabetes and Digestive and Kidney Diseases Deletion of Lipoprotein Receptor LRP1 in GABAergic Neurons Pro- (5R01DK066604, 5R01DK068400) motes Obesity and Insulin Resistance MINCHEOL KANG, JI A. SEO, SANG SOO KIM, SUNG WAN CHUN, YOSSI DAGON, 148‑OR YOUNG-BUM KIM, Brookline, MA, Seoul, Republic of Korea, Boston, MA Diabetes Remission Induced by Central FGF1 Is Associated with Low-density lipoprotein receptor-related protein 1 (LRP1) is a member Improved β-Cell Function of LDL receptor family that plays a key role in systemic glucose and lipid JENNY M. BROWN, JARRAD SCARLETT, JENNIFER ROJAS, MILES MATSEN, homeostasis. Recent studies have implicated hypothalamic LRP1 in the NICK ACHARYA, CAMILLA INGVORSEN, TRISTA HARVEY, KEVIN VELASCO, regulation of feeding and leptin signaling, yet the underlying neurocircuitry ANNA SECHER, RASMUS JØRGENSEN, GREGORY J. MORTON, MICHAEL W. involved in LRP1 action is unclear. Because GABAergic neurons are a major SCHWARTZ, Seattle, WA, Måløv, Denmark mediator of leptin’s anorexigenic action, we addressed the question of Recently, our lab reported that sustained diabetes remission is induced whether deleting LRP1 from GABAergic neurons can affect adiposity and by a single intracerebroventricular (icv) injection of fibroblast growth fac- energy balance. Here we show that LPR1 deficiency in GABAergic neurons tor 1 (FGF1) in both mouse and rat models of T2D, but not in rodents with results in increased body weight in mice fed a normal chow diet both in severe insulin-deficient diabetes induced by streptozotocin. We also showed males and females (Male, control 30.7±2.2g vs. GABA-LRP1 deficient mice that in the Zucker Diabetic Fatty (ZDF) rat model of T2D, 1) diabetes remis- 45.1±3g; Female, control 27.9±0.8g vs. GABA-LRP1 deficient mice 41.1±3.6g, sion induced by a single icv FGF1 injection lasts ~4wk, and 2) the subse- p<0.01, respectively). This is most likely due to increased daily food intake in quent return of hyperglycemia coincides with onset of β-cell dysfunction GABA-LRP1 deficient mice (control mice 4.6g±0.2g vs. GABA-LRP1 deficient and severe insulin deficiency. We therefore hypothesized that in ZDF rats, mice 5.7±0.3g, p<0.05). Concurrently, MRI analysis indicated that fat mass FGF1 action in the brain transiently preserves β-cell function, and that the in GABA-LRP1 deficient mice was significantly increased by ~120% without disappearance of this protective effect is heralded by diabetes relapse. changes in lean mass, compared with control mice. Adiposity in GABA-LRP1 ORALS To test this hypothesis, we sought to determine if either basal or glucose- deficient mice is accompanied by increased blood glucose and insulin lev- induced insulin secretion is increased in ZDF rats during diabetes remission els. In addition, GABA-LRP1 deficient mice exhibited insulin resistance, as induced by icv FGF1. We therefore measured plasma insulin levels both at evidenced by the fact that blood glucose levels blunted to decreased after baseline and during a hyperglycemic clamp (induced by iv glucose infusion) insulin injection (0.5U/kg body weight), whereas in control mice, glucose designed to match blood glucose levels (~400 mg/dl) between icv vehicle- decreased about 40%. Furthermore, LPR1 deficiency in GABAergic neurons and FGF1-treated rats. We found that despite much lower blood glucose leads to glucose intolerance. levels in icv FGF1-treated animals, basal plasma insulin levels were ~3-fold In conclusion, our data demonstrate that hypothalamic LRP1 regulates higher (p<0.05) and the rate of glucose infusion during the clamp was ~15- systemic energy balance through GABAergic neurons, by modulating food fold higher (p<0.05) than in icv vehicle-treated controls. In the basal state, intake and insulin sensitivity. These effects could be due to LRP1 action on therefore, both insulin secretion and the rate of glucose disposal were mark- GABAergic leptin signaling and neuronal activity. edly increased by icv FGF1. Interestingly, insulin secretion did not increase Supported By: National Institutes of Health further during clamped hyperglycemia (p=n.s.) in FGF1-treated animals, sug- gesting that their glucose-induced insulin secretion is maximal in the basal 151‑OR state. We conclude that in a rat model of T2D, diabetes remission induced Suppression of Ghrelin Receptor in AgRP Neurons Mitigates Diet- by icv FGF1 is accompanied by, and may result from, increased basal, but not Induced Obesity by Activating Thermogenesis glucose-stimulated insulin secretion. CHIA SHAN WU, GEETALI PRADHAN, SHAODONG GUO, YONG XU, YUXIANG Supported By: National Institutes of Health; Novo Nordisk SUN, College Station, TX, Houston, TX Hypothalamus senses various signals to control food intake and energy expenditure in the body. Ghrelin, an orexigenic hormone released mainly from the gut, signals the hypothalamus of the brain to stimulate growth hor- mone release, enhance appetite, and promote weight gain. Ghrelin receptor,

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A39 HYPOGLYCEMIA—MECHANISMS OF ALERTED BRAIN FUNCTION AND VASCULAR RESPONSES

aka Growth Hormone Secretagogue Receptor (GHS-R), is highly expressed unknown whether exercise-induced hyperlactatemia alters cerebral lactate in the brain, with highest expression found in Agouti-related protein (AgRP) handling during subsequent hypoglycemia. neurons in the hypothalamus. We recently reported that deletion of GHS-R Methods: Patients with T1DM and IAH, patients with T1DM and normal in all neurons in the brain completely prevents mice from diet-induced obe- awareness of hypoglycemia (NAH) and healthy controls (HC) (n=6 per group) sity (DIO) due to activated non-shivering thermogenesis and enhanced physi- underwent a hyperinsulinemic hypoglycemic (2.8 mmol/L) clamp in the MR cal activity. To further decipher the specific neuronal circuits mediating the system, directly after performing a bout of HIIT, consisting of 3 30s all-out effects of GHS-R on metabolic control, we generated AgRP neuron-specific sprints. Before HIIT and during hypoglycemia, cerebral lactate levels were GHS-R knockout mice (Agrp-Cre;Ghsrf/f). Our data showed that GHS-R in measured continuously with J-editing 1H-MRS. Cerebral lactate time curves AgRP neurons is required for ghrelin’s stimulatory effects on growth hor- were fitted with an exponential decay function. mone secretion, feeding initiation, and adiposity, but interestingly not for Results: Plasma lactate levels peaked markedly after HIIT in all groups long-term total food intake. Importantly, deletion of GHS-R in AgRP neurons (mean increase 14.7±2.6 mmol/L), then fell, but remained elevated during attenuated obesity, increased energy expenditure and enhanced cold-resis- subsequent hypoglycemia. Cerebral lactate levels did not differ between tance in mice fed with high fat diet (HFD). Moreover, the HFD-fed knockout groups before HIIT. Fitted cerebral lactate levels after HIIT increased more mice showed enhanced thermogenic activation in both brown and subcuta- in T1DM IAH (0.76±0.04 µmol/g ww) than in T1DM NAH (0.68±0.04 µmol/g neous fat, implying altered neuronal activity in the AgRP neurons and subse- ww) or in HC (0.61±0.04 µmol/g ww, p<0.05 between all groups). During quently enhanced sympathetic outflow. hypoglycemia, cerebral lactate levels gradually returned to baseline levels in In summary, we have identified AgRP neurons as key site for GHS-R medi- HC and T1DM NAH, but the steady-state level of cerebral lactate fell below ated thermogenesis and demonstrated that GHS-R in AgRP neurons plays a baseline in T1DM IAH (-0.19±0.08 µmol/g ww, p<0.05). crucial role in the brain-fat integration of physiology, which contribute novel Conclusion: HIIT causes cerebral lactate concentrations to increase most insights to pathogenesis of DIO. in T1DM IAH, which indicates enhanced cerebral lactate transport capacity. Supported By: American Diabetes Association (1-15-BS-177 to Y.S.); American The fall in cerebral lactate levels below baseline in T1DM IAH during sub- Heart Association (12IRG9230004, 14GRNT18990019); U.S. Department of Agricul- sequent hypoglycemia is compatible with increased lactate oxidation. Both ture (3092-5-001-059); U.S. Department of Agriculture/National Institute of Food alterations in cerebral lactate handling may contribute to IAH by maintaining and Agriculture (1010840) brain fuel supply during hypoglycemia. Supported By: European Foundation for the Study of Diabetes; Dutch Diabetes 152‑OR Research Foundation Implications of Hypothalamic Gliosis for Appetite and Glucose Regulation 154‑OR SUSAN J. MELHORN, MARY ROSALYNN DE LEON, VIDHI TYAGI, MARY WEBB, Altered Responses to Hypoglycemia in Brain Regions Involved in THOMAS GRABOWSKI, KENNETH MARAVILLA, ELLEN SCHUR, Seattle, WA Arousal, Executive Function, and Memory in Type 1 Diabetes with Hypothalamic inflammation, or gliosis, has been documented in rodent Impaired Awareness of Hypoglycemia models and humans within key regions that regulate energy and glucose MUNACHISO NWOKOLO, STEPHANIE A. AMIEL, FERNANDO O. ZELAYA, BULA homeostasis and impairs these processes in rodents. To test if gliosis M. WILSON, LOUISA GREEN, ANDREW PERNET, PRATIK CHOUDHARY, London, is related to impaired central satiety processing in humans, monozygotic United Kingdom twin pairs (N=40 pairs), oversampled for obesity (mean BMI 30.1±5.9 kg/m2, To investigate the impact of impaired awareness of hypoglycemia (IAH) on mean age 29.9±9.4 y), completed serial appetite ratings, a DXA scan, a cerebral responses to hypoglycemia in adults with type 1 diabetes (T1D), we structural magnetic resonance imaging (MRI) scan to assess gliosis via used functional MRI (fMRI) to measure changes in cerebral blood flow (CBF) mean bilateral T2 relaxation time in the mediobasal hypothalamus (MBH), as a surrogate marker of brain activation. functional MRI with visual food cues before and after a standardized meal, 15 hypoglycemia aware (HA) T1D participants (age 39±13.5 years, dia- and an ad libitum buffet meal. Within-pair analyses of twin differences betes duration 24±12.8 years, Gold score 1.5±0.5, 6 male) and 16 T1D par- were completed with linear regression. Because twins are compared to ticipants with IAH (age 37±10.5 years, diabetes duration 22±7.6 years, Gold each other, analyses control for sex, age, familial factors and genetics and score 5.6±1.4, 7 male) underwent fMRI scans during two-step, hyperinsulin- were further adjusted for fat mass. Twins with longer MBH T2 relaxation emic clamps (90mg/dL and 47mg/dL). Symptoms were quantified using visual time reported less reduction in subjective hunger by a standardized meal analogue scales. Global and regional CBF were examined using SPM12 and (β=1.29; P=0.04), and, using a global measure of activation across satiety- region of interest (ROI) analysis. related regions, had greater brain activation by high- vs. low-calorie food Symptom scores increased in HA, euglycemia vs. hypoglycemia; 18.9±6.9 cues following the meal (β=1.41, P<0.01). Region-specific effects were found vs. 37.4±10.8, (p<0.0001), but not in IAH, 17.8±5.4 vs. 18.7±5.7, (p=0.4). Global in the ventral striatum (β=1.41, P=0.03), dorsal striatum (β=1.37, P=0.02) and CBF increased similarly (∆ global CBF HA vs. IAH p=0.7) and significantly in the mOFC (β=3.99, P<0.01). The twin with a longer MBH T2 relaxation time HA (6.3% p=0.01) and IAH (8.0% p=0.03). In response to hypoglycaemia, ROI demonstrated less meal-induced suppression of global brain activation by analysis revealed significantly increased activation of the thalamus, p=0.019 high-calorie food cues (β=2.04, P=0.001), with similar regional specificity for (arousal, vigilance and coordination of the stress response), orbitofrontal the ventral and dorsal striatum (β=2.05, P=0.03; β=2.28, P=0.01) and mOFC cortex, p=0.005, and dorsolateral prefrontal cortex p=0.034 (emotional ORALS (β=4.87, P=0.003), but did not consume significantly more total calories or salience and executive function) in HA. Greater deactivation of the hippo- different macronutrients at the buffet meal. However, fasting insulin con- campus (memory) was also noted in HA, p=0.04. centrations were higher in the twin with the longer T2 relaxation time in the Our data do not support increased CBF during hypoglycemia as a mecha- left MBH (β=0.28, P=0.01). Hypothalamic gliosis appears to have functional nism for IAH. Instead we show reduced thalamic activation may contrib- consequences for appetite and glucose regulation in humans, independent ute to the loss of the stress response in IAH. Altered responses in regions of adiposity or genetics. involved in executive function, motivation, emotional salience and memory Supported By: National Institutes of Health (DK089036) may account for the different behavioural responses to hypoglycemia in IAH. These adaptations may create barriers to effective behavioural changes that would reduce risk of future hypoglycemia. HYPOGLYCEMIA—MECHANISMS OF ALERTED Supported By: Diabetes UK BRAIN FUNCTION AND VASCULAR RESPONSES 155‑OR 153‑OR Exposure of Astrocytes to Recurrent Hypoglycemia In Vitro Alters Altered Effect of High-Intensity Interval Training on Cerebral Gliotransmission and Purinergic Signaling Lactate Levels during Subsequent Hypoglycemia in Patients with JULIA M. VLACHAKI WALKER, PAUL G. WEIGHTMAN POTTER, JOSEPHINE Type 1 Diabetes and Impaired Awareness of Hypoglycemia ROBB, KATE L.J. ELLACOTT, CRAIG BEALL, Exeter, United Kingdom HANNE M. ROOIJACKERS, EVITA C. WIEGERS, CEES J. TACK, AREND HEERSC- Recurrent hypoglycemia leads to an impaired counter-regulatory response HAP, MARINETTE VAN DER GRAAF, BASTIAAN E. DE GALAN, Nijmegen, Neth- (CRR) to hypoglycemia, mediated by changes in the brain. AMP-activated pro- erlands tein kinase (AMPK) is a central energy regulator believed to be involved in the Background: Alterations in cerebral lactate handling are thought to play a development of impaired CRR, yet little is known about the role of AMPK in role in the development of impaired awareness of hypoglycemia (IAH). High- astrocytes, which make up approximately 50% of the cells in the brain. Astro- intensity interval training (HIIT) acutely increases plasma lactate levels. It is cytes release gliotransmitters, ATP and lactate, to act as a stress signal and

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A40 HYPOGLYCEMIA—MECHANISMS OF ALERTED BRAIN FUNCTION AND VASCULAR RESPONSES energy substrate, respectively. To investigate whether astrocytic function is enumerated using flow cytometry. Platelet aggregation increased following altered following RH, in vitro we exposed U373 human astrocytoma cells to hypoglycemia vs. euglycemia (AUC mean ± SEM: 74 ± 7 vs. 53 ± 4; P<0.05). 4 episodes of low glucose (LG; 0.1mM) over 2 or 4 days and measured AMPK Total MPA (median [IQR] cells/μL: 106 [41-135] vs. 51 [27-71]; P<0.05) and NPA phosphorylation, lactate release, total ATP and ATP/ADP ratios. Purinergic (626 [471-820] vs. 237 [71-786]; P<0.05) increased following hypoglycemia signalling was examined by application of exogenous ATP and intracellular vs. euglycemia. Hypoglycemia increased intermediate monocyte specific calcium levels measured. AMPK phosphorylation increased during LG expo- MPA (P<0.01, Figure 1) and non-classical monocyte MPA [4 cells/μL [1-7] vs. sure compared to control (2.5mM), which was blunted following recurrent LG 0.4 [0.1-1.4] P<0.01) with no significant change in classical monocyte MPA. (RLG). Lactate release, per mol of glucose available, increased during LG, and Hypoglycemia increases platelet reactivity, MPA and NPA levels and this was not altered following RLG. ATP/ADP ratio was not altered during 3 hr leads to increased interaction between pro-inflammatory monocyte subsets LG or following RLG, nor did total ATP (tATP) change during acute LG. Follow- and platelets. These novel data reveal mechanisms that may contribute to ing RLG, U373s had increased basal tATP and increased basal metabolism, CV risk associated with diabetes and its therapy. suggesting increased capacity for ATP production. Stimulation of astrocytes with exogenous ATP increased intracellular Ca2+ in a concentration-depen- dent manner, which was blunted following RLG, suggesting a diminished response to an important universal danger signal. These data show that astrocytes are intrinsically altered by RLG, even in the absence of neuronal stimuli and that ATP-mediated purinergic signalling is altered following RLG. Altered purinergic signalling may be a component of defective CRR. Supported By: Diabetes UK

156‑OR Cerebral Blood Flow Responses to Hypoglycemia in the Whole Cor- tical Grey Matter of Nondiabetic Subjects and Patients with Type 1 Diabetes HEIDI GROHN, DANIELE MASCALI, XIUFENG LI, AMIR MOHEET, PETR BEDNARIK, ANJALI KUMAR, NATHAN RUBIN, KRISTINE KUBISIAK, LYNN EBERLY, ELIZA- BETH R. SEAQUIST, SILVIA MANGIA, Minneapolis, MN, Rome, Italy Patients with type 1 diabetes (T1D) are often exposed to hypoglycemia (HG), and can ultimately manifest impaired awareness of HG (IAH). To iden- tify the brain substrates of IAH in T1D, here we sought to determine the cerebral blood flow (CBF) response to HG in the whole cortical grey matter of a group of 21 nondiabetic subjects (10F/11M, age = 35 ± 15 years) and 21 T1D patients (13F/8M, age = 35 ± 11 years, A1c = 7.2 ± 0.7%, diabetes duration = 20 ± 12 years), 6 of whom were classified as HG-unaware based on the Cox questionnaire. We aimed to test the following hypotheses: 1) Supported By: Medical Research Council, UK (to A.I.) the cortical grey matter CBF response to HG is similar between nondiabetic and HG-aware T1D subjects; 2) HG-unaware subjects present a blunted CBF 158‑OR response to HG compared to nondiabetic and to HG-aware T1D subjects. The Effects of Differing Levels of Hypoglycemia on Vascular Biologic CBF was measured by state-of-the-art arterial spin labeling MRI during a Mechanisms in Healthy Individuals 2-step hyperinsulinemic clamp [step 1 = 95 mg/dL normoglycemia (NG) and MAKA HEDRINGTON, MAIA MIKELADZE, NINO JOY, DONNA TATE, LISA YOUNK, step 2 = 50 mg/dL (HG)]. The comparison of the cortical grey matter CBF dur- EVAN THAYER, STEPHEN N. DAVIS, Baltimore, MD ing HG vs. NG did not demonstrate significant differences in the nondiabetic The effects of differing levels of hypoglycemia on in-vivo vascular biologic subjects (2 ± 10%, p=0.42). In contrast, cortical grey matter CBF increased by mechanisms have not been studied. Therefore the aim of this study was to 11 ± 15% (p=0.01) and 12 ± 12% (p=0.07) in HG-aware and HG-unaware T1D determine the effects of mild to moderate hypoglycemia on pro-coagulant, subjects, respectively. Findings did not qualitatively change when classify- pro-inflammatory and pro-atherothrombotic responses. ing the HG-awareness status based on the epinephrine HG-response rather Thirty two healthy individuals (16M/16F) (34±3 yrs, BMI 26±3kg/m2) partici- than the Cox questionnaire. Overall, these observations do not support our pated in four separate one-day studies. Experiments consisted of 2-hour hyperin- initial hypotheses, and are only in partial agreement with previous findings sulinemic glucose clamps of 90±1, 70±2, 61±1 or 53±1 mg/dL. 2D Doppler imaging reported in the literature. In the current study, the T1D status determined the was used to determine flow mediated dilation (FMD) of the brachial artery. cortical grey matter CBF response to HG more than the HG-awareness per Insulin levels were similar (122±2µU/ml) in all four protocols. Changes se, suggesting that diabetes exposure and perhaps glycemic variability are from baseline in TNF-α, P-selectin, E-selectin, ICAM-1, VCAM-1 and PAI-1 key players in modulating the brain responses to HG. Future studies includ- were higher and reduction in FMD greater during hypoglycemia of 61±1 and ing larger cohorts exposed to greater extremes in glycemia before HG will be 53±1 mg/dL as compared to 90±1mg/dL (p<0.05) (Table). ORALS needed to fully evaluate the impact of diabetes on the CBF responses to HG. In summary, blood glucose levels of 53±1 and 61±1 mg/dL activated pro- Supported By: National Institutes of Health (P41EB015894, P30NS076408, coagulant, proinflammatory and pro-atherothrombotic mechanisms while R01DK099137) impairing nitric oxide mediated vasodilator endothelial function. In conclusion, both moderate hypoglycemia of 53±1 mg/dL and mild hypo- 157‑OR glycemia of only 61±1 mg/dL can acutely result in deleterious in-vivo vascu- Effect of Hypoglycemia on Platelet Reactivity and Platelet-Leuko- lar biologic changes in healthy humans. cyte Kinetics Table. Changes from Baseline to Final 15 Min. of Glucose Clamps. AHMED IQBAL, MARK THOMAS, PETER NOVODVORSKY, ALAN BERNJAK, 53±1 mg/dL 61±1 mg/dL 70±2 mg/dL 90±1mg/dL LEWIS BIRCH, DANIELLE LAMBERT, LINDA KAY, FIONA WRIGHT, LYNNE PRINCE, TNF- (pg/ml) 0.49±0.4* 0.42±0.3* -0.6±0.5 -0.39±0.2 SHEILA FRANCIS, ROBERT STOREY, IAN SABROE, SIMON R. HELLER, Sheffield, Δ α United Kingdom Δ P-selectin (pg/ml) 15.2±10.2* 4.7±2* -3.6±1.8 -20.4±8.2 Hypoglycemia is emerging as a trigger for cardiovascular (CV) events Δ E-selectin (ng/ml) 1±0.9* 1.7±0.7* -1.9±1 -2.3±1.4 observed in intensive glycemic control of T2DM. Potential mechanisms include Δ VCAM-1 (ng/ml) 64.1±26.8* 23.9±7* -38.1±9.7 -83.9±39.1 inflammation-induced thrombosis. High levels of circulating monocyte and neutrophil platelet aggregates (MPA and NPA) strongly increase CV risk. Δ ICAM-1 (ng/ml) 4.8±1.7* 7.5±6.5* -14.5±9 -10.5±5 We hypothesized that hypoglycemia increases platelet reactivity and Δ PAI-1 (ng/ml) 5.3±3.5* -1.6±0.7* -3.1±0.9 -4.1±0.9 MPA and NPA levels. Δ FMD (mean maximum%) -3.8±1* -3.2±1.1* 1.2±1.2 0.9±0.8 Sixteen healthy volunteers underwent a hyperinsulinemic hypoglycemic Mean±SEM * - p<0.05 compared to 90±1 mg/dL. (2.5 mmol/L) or euglycemic (6.0 mmol/L) clamp. Blood was sampled at base- line and 60 minutes. Platelet aggregation induced by ADP 6.45 μM was mea- Supported By: National Institutes of Health/National Heart, Lung, and Blood sured using impedance aggregometry. MPA and NPA were phenotyped and Institute (P01HL056693)

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A41 THINKING AND WORKING OUTSIDE THE BOX—PREVENTION AND INTERVENTION APPROACHES

159‑OR THINKING AND WORKING OUTSIDE THE BOX— Stress Perception and Parietal Lobe Connectivity in Type 1 Diabetes PREVENTION AND INTERVENTION APPROACHES MUHAMMAD A. HAMZA, JANICE J. HWANG, CHERYL LACADIE, DONGJU SEO, LISA PARIKH, CHRISTIAN SCHMIDT, RENATA BELFORT-DEAGUIAR, WAI LAM, 161‑OR SAMUEL ROSENBERG, TODD CONSTABLE, RAJITA SINHA, ROBERT S. SHER- PREVENT-DM Comparative Effectiveness Trial of Lifestyle Inter- WIN, New Haven, CT vention and Metformin T1DM patients who report higher stress levels display increased glycemic MATTHEW J. O’BRIEN, ALBERLY PEREZ, ADAM SCANLAN, VICTOR A. ALOS, variability and increased severity and frequency of hypoglycemia. Whether ROBERT C. WHITAKER, GARY D. FOSTER, RONALD T. ACKERMANN, JODY D. T1DM patients who are aware of hypoglycemia (AW) or unaware (UA) expe- CIOLINO, CAROL J. HOMKO, Chicago, IL, Philadelphia, PA, New York, NY rience stress differently has not been closely studied. To investigate, we While the Diabetes Prevention Program (DPP) and other clinical trials dem- administered the Perceived Stress Scale (PSS), which measures the degree onstrated the efficacy of intensive lifestyle interventions (ILI) and metformin to which individuals judge different life situations as stressful, to 10 healthy 2 to prevent type 2 diabetes, no studies have tested their comparative effects controls (HC) (7F/3M, age 35±10 years, BMI 23.1±1.8 kg/m , HbA1c 5.0±0.2), in pragmatic settings. This randomized controlled trial was designed to com- 15 AW by Clarke score (10F/5M, age 30±7, BMI 24.5±3.1, HbA1c 7.1±0.9), and pare the real-world effectiveness of ILI, metformin, and standard care among 10 UA, (7F/3M, age 44 ±12, BMI 26.5±4.2, HbA1c 7.1±0.8). Hispanic women (Latinas) with prediabetes. Ninety-two Latinas, who had a PSS scores were different across groups (HC: 22.1±2.7, AW: 24.1±1.6, UA: mean HbA1c of 5.9%, BMI of 33.3kg/m2, and waist circumference of 97.4cm, 14±2.0, P=0.004). Notably, UA patients had lower PSS scores compared to HC were recruited from an urban community and randomly assigned to ILI, met- (P=0.001) and AW patients (P=0.03). Further, a subset of participants (n=24) formin, or standard care. The 12-month ILI was adapted from the DPP’s ILI underwent BOLD fMRI scanning for analysis of the Intrinsic Connectivity and delivered by community health workers (promotoras) over 24 sessions. Distribution (ICD), which is a measure of synchronous regional brain activity, Metformin participants received 850mg twice daily. Those randomized to during a two-step euglycemic-hypoglycemic clamp (90-60 mg/dl). Significant standard care continued their regular medical care. The primary outcome was connectivity changes were noted in the angular gyrus (AG) of the inferior weight and secondary outcomes were waist circumference, blood pressure, parietal lobe which plays a role in conscious awareness via multisensory HbA1c, fasting plasma glucose, insulin, and lipids, each assessed at base- integration to give meaning to the external world. Consistent with the PSS, line and 12 months. ILI participants demonstrated significantly greater mean UA patients had lower connectivity in AG at euglycemia and hypoglycemia weight loss (-4.0kg, 5.0%) than metformin (-0.9kg, 1.1%) and standard care compared to HC (P=0.039, P=0.005) and AW patients (P=0.001, P=0.027). participants (+0.8kg, 0.9%) (p<0.001). The difference in weight loss between Moreover, PSS scores positively correlated with increased activity in the 2 2 metformin and standard care was not significant. The ILI group experienced AG at euglycemia (r =0.594, P=0.002) and hypoglycemia (r =0.542, P=0.006). a greater reduction in waist circumference than standard care (p=0.001), and The ability to sense stress is crucial for protective and regulatory pro- a marginal improvement in HbA1c compared to metformin and standard care cesses. Compared to AW patients, UA patients have a blunted perception of (p=0.063). In the first comparative effectiveness trial of diabetes prevention stress which can be detected via altered brain connectivity in interoceptive treatments, a 12-month ILI produced significantly greater weight loss than and sensory neurocircuits. These findings may have implications for under- metformin and standard care among Latinas with prediabetes. These data standing how hypoglycemia unawareness may impact patients’ abilities to suggest that ILI delivered by promotoras is an effective strategy for prevent- sense and thus respond appropriately to stress. ing diabetes in this high-risk group, which may be superior to metformin. Supported By: National Institutes of Health Future pragmatic trials involving larger samples should examine differences in diabetes incidence associated with these treatments. 160‑OR Supported By: National Institute of Diabetes and Digestive and Kidney Dis- Human Primary Astrocyte (HPA) Metabolism Is Altered Following eases; National Institutes of Health (K23DK095981) Exposure to Recurrent Hypoglycemia In Vitro PAUL G. WEIGHTMAN POTTER, JULIA M. VLACHAKI WALKER, ANA M. CRUZ, 162‑OR RITCHIE WILLIAMSON, ANDREW RANDALL, CRAIG BEALL, Exeter, United Kingdom, Effects of a Gamified Mobile Application to Support a Lifestyle- Bradford, United Kingdom Change Program in Adults: A Controlled Pilot Astrocytes play important roles in regulating brain metabolism by provid- SAM ODDSSON, Palo Alto, CA ing the metabolic substrate lactate in response to stress, such as during Background: About one in three adults in the United States and the UK hypoglycemia. Little is known about metabolism within these cells following has prediabetes; increasing risk of heart attack, stroke, and type 2 diabetes. recurrent hypoglycemia. Using human primary astrocytes (HPA; non-trans- As smartphone ownership continues to grow, mobile applications will have formed), in vitro, we tested the hypothesis that mitochondrial metabolism an increasing role in combatting the epidemic of lifestyle-related conditions and glycolytic function are altered following recurrent low glucose exposure such as diabetes and prediabetes. We hypothesized that a mobile health- (RLG), which was measured using the Seahorse Extracellular Flux Analyser. engagement platform could be used to significantly augment a structured HPA cells were exposed to 3 hour bouts of 2.5 or 0.1 mM glucose over 4 days lifestyle change program, as measured primarily by weight loss and adher- and cells assayed for mitochondrial and glycolytic metabolism and lactate ence to the program. release. Following RLG, the baseline oxygen consumption rate was elevated, ORALS Methods: We randomly assigned 153 overweight or obese individuals to indicating increased mitochondrial oxygen consumption. Following addition a standard program (in-person, weekly group meetings over 4 months), or of mitochondrial uncoupling drug, FCCP, which stimulates maximal respira- to the same program supported by a mobile application. The mean age of tion (MR), RLG-treated cells had decreased MR, indicating reduced spare participants was 47 years, and the mean body-mass index was 36.2. respiratory capacity. Addition of rotenone and antimycin A (complex I and Results: The addition of a mobile platform was associated with a 2.97- III inhibitors, respectively, to block all other mitochondrial O consumption) 2 fold increase in the achievement of a 5% weight-loss goal (95-percent con- indicated no difference in non-mitochondrial respiration between control fidence interval 1.07-9.72), as compared with the standard in-person-only and RLG. The extracellular acidification rate (ECAR), a marker for glycoly- program. Adherence to the program was significantly higher in the mobile- sis, was also elevated following RLG. Addition of oligomycin, to inhibit ATP supported group. synthase increased ECAR and this increase was attenuated following RLG, Conclusions: The findings provide strong support for adding a mobile indicating reduced glycolytic reserve. These changes did not translate to application to augment structured lifestyle modification. altered lactate release, however, taken together these data suggest that, in human primary astrocytes, mitochondrial and glycolytic metabolism are altered following RLG, suggesting an intrinsic adaptation to RLG to better prepare astrocytes for future metabolic stress, such as hypoglycemia. Supported By: Mary Kinross Charitable Trust; Diabetes UK; Society for Endocri- nology; British Society for Neuroendocrinology

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A42 THINKING AND WORKING OUTSIDE THE BOX—PREVENTION AND INTERVENTION APPROACHES

163‑OR 165‑OR Frequent Self-Weighing Delays or Prevents the Development of Two for One: Effects of a Couples Intervention on Partners of Type 2 Type 2 Diabetes in a Real-World Setting: A Subanalysis of Japan Diabetes Patients Diabetes Outcome Trial-1 PAULA M. TRIEF, JONATHAN SANDBERG, DONALD CIBULA, LAWRENCE FISHER, NAOKI SAKANE, YOSHITAKE OSHIMA, SHINSUKE NIRENGI, KAZUHIKO KOTANI, JACQUELINE DIMMOCK, DANIELLE M. HESSLER, RUTH S. WEINSTOCK, Syracuse, KENTARO OKAZAKI, JUICHI SATO, SADAO SUZUKI, SATOSHI MORITA, KAZUO NY, Provo, UT, San Francisco, CA IZUMI, MASAYUKI KATO, NAOKI ISHIZUKA, MITSUHIKO NODA, HIDESHI KUZUYA, Family interventions for adults with diabetes typically focus on family Kyoto, Japan members supporting patients to effect patient change. Diabetes affects Objective: The aim of this study was to investigate whether frequent self- partners too, negatively (e.g., high distress) and positively (e.g., enhanced weighing can effectively prevent the development of type 2 diabetes (T2D) closeness). We know little about how couples interventions affect partners. in high-risk individuals. In the Diabetes Support Project, a telephonic couples intervention was Research Design and Methods: The prospective, pragmatic cluster- compared to an equivalent individual intervention and to individual diabe- randomized, controlled trial included 43 health checkups centers (cluster) tes education (DE). Partners completed assessments at baseline, 4 (post- across the country. Subjects identified as having impaired fasting glucose, program), 8 and 12 months: BMI, blood pressure (BP), depressive symptoms aged 20-65 years, were randomized to an intervention arm (n=1,240) or a (DS), diabetes distress (DD), relationship satisfaction (Dyadic Adjustment self-directed control arm (n=1,367). A weight scale with a storage function Scale, DAS) and conflict management styles (Conflict Resolution Inventory, was provided to each participant in both arms during the first year. They CRI). In this RCT, 268 type 2 diabetes patients (A1c ≥ 7.5%) and their partners could send accumulated data to the lifestyle support center via a transmit- were randomly assigned to DE (2 calls), individual call (IC) or couples call (CC) ter. Based on these data, subjects in the intervention arm received one-year interventions (2 DE + 10 behavioral modules, weekly). A majority of partners goal-focused lifestyle support by healthcare providers via telephone while were female (64.6%), white (70.1%) and overweight (mean BMI=32.2 ±11.1 the control arm did not. The primary outcome was the development of inci- kg/m2), mean age=55.8 (± 11.7) yrs. Mixed linear model regression was used dent diabetes in the annual health checkups. to analyze the effects of treatment and time for group mean differences Results: Seventy seven % of the participants in the intervention and 81% among partners, adjusted for baseline values. Mean relationship satisfac- in the control arm sent self-weighing data. During a median follow-up period tion (DAS) in the CC partner group was marginally and significantly higher of 4.9 years, a total of 177 subjects developed diabetes. The incidence was than IC (p=.067 @ 4 mos; p=.043 @ 8 mos), and DE (p=.005@ 4 mos; p=.009 reduced by 16% in the intervention arm compared with the control, with @ 8 mos) partner groups; IC and DE did not differ; no differences were found no significant difference (hazard ratio (HR): 0.84). The subjects were then @ 12 mos. For DD, results also favored the CC arm. The CC partners mean divided into 3 groups based on frequency of self-weighing (low frequency: DD score was lower than IC and DE partner means @ 4, 8 and 12 months (all <2 times/week, middle frequency: 3-4 times/week, and high frequency: 5-7 p’s significant); IC and DE did not differ. No significant between group dif- times/week). Subjects with “high frequency” showed a greater reduction of ferences were found for partner weight, BP, DS or CRI styles. Thus, couples body weight and a lower incidence of diabetes compared with those with interventions can have significant positive effects on partners’ diabetes dis- “low frequency” of self-weighing (reference, HR: 1.00) both in the interven- tress and relationship satisfaction. Future research should explore how to tion and control arms (HR: 0.43 and 0.65, respectively). prolong relationship satisfaction change, and better understand the underly- Conclusions: Adding frequent self-weighing to lifestyle modification pro- ing dynamics of change. grams could be an effective strategy to delay or prevent diabetes in a real- Supported By: National Institutes of Health/National Institute of Diabetes and world setting. Digestive and Kidney Diseases (R18DK080867)

164‑OR 166‑OR Shared Decision Making (SDM) to Engage Patients with Prediabe- Stepped-Care Behavioral Intervention Reduces Regimen-Related tes in Type 2 Diabetes Prevention: The Prediabetes Informed Deci- Distress sion and Education (PRIDE) Study DOYLE M. CUMMINGS, LESLEY LUTES, BERTHA HAMBIDGE, MARISSA CAR- TANNAZ MOIN, NORMAN TURK, CAROL M. MANGIONE, JACQUELINE MAR- RAWAY, SHIV PATIL, ALYSSA ADAMS, CHELSEY SOLAR, KERRY LITTLEWOOD, TIN, SUSAN ETTNER, KEITH C. NORRIS, CHI HONG TSENG, KENRIK DURU, Los SHEILA EDWARDS, PEGGY GATLIN, Greenville, NC, Kelowna, BC, Canada, Tampa, Angeles, CA FL The growing number of U.S. adults with prediabetes reinforces the Elevated regimen related distress (RRD) in type 2 diabetes (T2D) is associ- urgency of implementing effective action to prevent type 2 diabetes. Life- ated with poor glycemic control and lower medication adherence but the style intervention (i.e., DPP) and metformin can reduce diabetes risk, but impact of reducing RRD is unclear. This randomized clinical trial evaluated real-world uptake of these therapies remains low. In a practice level, cluster- the effect of a stepped care behavioral intervention on RRD in primary care randomized, intention-to-treat trial in one large academic health system, we patients with uncontrolled T2D and co-morbid distress and/or depressive tested the effectiveness of using trained pharmacists embedded in primary symptoms. Patients with uncontrolled T2D and screener-based behavioral care to deliver a shared decision-making (SDM) intervention to engage co-morbidity [n = 139; age = 52.6 yr.; 77.6% female; 71% African American] patients in diabetes prevention, using a prediabetes decision aid. Uptake were randomized to a stepped-care cognitive behavioral intervention [n = of DPP and/or metformin and weight change at 4 months were assessed 67; based on Diabetes Distress Scale (DDS-17) and Patient Health Question- ORALS among overweight patients with prediabetes (i.e., BMI > 24 kg/m2 and A1c naire (PHQ-9) scores] delivered by trained behavioral providers or to usual 5.7-6.4%), as compared to 3:1 propensity-matched control patients receiv- care (n = 72). Patients in the lowest tertile of distress or depression scores ing usual care. Data from electronic medical records (EMR) and two main received behaviorally anchored lifestyle coaching by a trained nurse; those local DPP vendors were used for outcome assessment. A generalized lin- in the middle tertile received problem-solving therapy by a trained psycholo- ear model was used to estimate weight change at 4 months, using clinic gist; and those in the highest tertile received cognitive behavioral therapy as a fixed effect. Between November 2015 and July 2016, a total of 262 by a trained psychologist. All patients were evaluated at baseline and at eligible patients completed the SDM visit within 10 of 20 randomly selected 6-months of follow-up. There were no differences between arms at base- intervention clinics. Among these, 54% (n=141) chose DPP, 19% (n=49) chose line in mean age, race, gender, or mean values for glycosylated hemoglobin DPP + metformin, 10% (n=26) chose metformin only, and 18% (n=46) chose no (A1c), body mass index (BMI), or RRD. Although the overall change in A1c at action. Among intervention patients choosing DPP +/- metformin, 5% and 6 mo. was not significantly different between intervention and control arms, 24% attended 4-8 and >9 DPP sessions respectively. Weight loss among patients in the behavioral intervention arm had significantly greater reduc- the 200 intervention patients with available 4-month weight data was sig- tion in RRD than those in the control arm [-1.1 ± 1.3 vs. -0.66 ± 1.0, p = 0.049]. nificantly higher as compared to 411 propensity-matched control patients Among intervention group patients, those with improvement in RRD scores (-3.37 lbs., p<.0001). These findings indicate that a prediabetes SDM inter- (n = 42) had significantly greater improvement in (A1c) [-1.4 ± 1.6 vs. -0.30 ± vention can be used to enhance patient engagement in evidence-based 1.9; p = 0.05] and those with a 6-month RRD score of ≤ 3.0 had significantly therapies to prevent diabetes and weight loss at 4 months. Prediabetes SDM greater improvement in medication adherence [Morisky Medication Adher- care models can be disseminated to enhance type 2 diabetes prevention ence Score (MMAS) = +0.72 vs. -1.1; p = 0.01]. A stepped-care behavioral efforts among patients at highest risk. intervention reduces RRD in patients with uncontrolled T2D and co-morbid Supported By: National Institutes of Health/National Institute of Diabetes and behavioral problems. Digestive and Kidney Diseases (R18DK105464-01) Supported By: Bristol-Myers Squibb Foundation

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A43 TRANSLATING THERAPEUTICS TO THE REAL WORLD

167‑OR TRANSLATING THERAPEUTICS TO THE REAL WORLD Occupational Therapy (OT) Intervention Improves Glycemic Control and Quality of Life in Young Adults (YAs): Main Outcomes of the 169‑OR Resilient, Empowered, Active Living (REAL) Randomized Controlled Effect of Metformin on Diabetes Prevention at 15 Years: Identifica- Trial (RCT) tion of Subgroups Most Likely to Benefit, Diabetes Prevention Pro- ELIZABETH A. PYATAK, KRISTINE CARANDANG, CHERYL L.P. VIGEN, JESUS gram (DPP) Research Group DIAZ, ALYSSA CONCHA-CHAVEZ, JEANINE BLANCHARD, ROBIN WHITTEMORE, DAVID M. NATHAN, JILL P. CRANDALL, DANA DABELEA, SHARON L. EDELSTEIN, DONNA SPRUIJT-METZ, ANNE L. PETERS, Los Angeles, CA, New Haven, CT RONALD B. GOLDBERG, STEVEN E. KAHN, WILLIAM C. KNOWLER, KIEREN J. Introduction: YAs with diabetes experience poor glycemic control and psy- MATHER, XAVIER PI-SUNYER, MARINELLA TEMPROSA, GILDA TRANDAFIRESCU, chosocial well-being, particularly YAs with low socioeconomic status (SES). ELIZABETH A. WALKER, DIABETES PREVENTION PROGRAM RESEARCH GROUP, We developed a manualized OT intervention, REAL, to address diabetes self- Boston, MA, Bronx, NY, Aurora, CO, Rockville, MD, Miami, FL, Seattle, WA, Phoenix, care and psychosocial well-being in this population, and evaluated REAL in a AZ, Indianapolis, IN, New York, NY two-arm parallel group RCT. In the DPP, metformin (MET) reduced the 3-year development of diabetes Methods: Inclusion criteria were age 18-30, low SES, T1D or T2D for ≥1 (DM) by 31%, compared with the randomly assigned placebo (PLA) group. year, and A1C ≥8%. Participants were randomly assigned to the REAL inter- At baseline, the cohort was at high risk to develop DM by having IGT, FPG vention (Intervention Group, IG) or an attention control group (CG). Over 6 95-125 mg/dl, and overweight or obesity. The subset of participants who months, IG participants received biweekly OT sessions using the REAL man- 2 at baseline were younger than 60 years, had a BMI ≥35 kg/m , and women ual composed of 7 content modules; CG participants received standardized with a prior history of GDM had the greatest responses to MET with 44, 53, educational materials and biweekly follow-up calls. The primary outcome and 51% reductions in DM development, respectively. During the DPP Out- was A1C; secondary outcomes included diabetes self-care, diabetes-related comes Study, PLA was stopped and open-label metformin was provided to quality of life (DQoL), diabetes distress, depressive symptoms, and life the original MET group. All participants were offered a group lifestyle inter- satisfaction. Blinded assessors collected data at baseline and 6 months in vention. We report the results of MET compared with PLA on DM develop- participants’ homes or community settings. Overall intervention adherence ment, defined by FPG or 2-hr OGTT criteria, or by A1C≥ 6.5%, over a total of was 71%. 15 years (Table). After 15 years, MET continued its beneficial effects in sub- Results: Recruitment was completed in December 2015. 81 participants groups defined by younger age and greater BMI. In addition, MET decreased were randomized (41 IG, 40 CG); follow-up data were available for 72 partici- DM development in women with a prior history of GDM (n=233) by 40.6% pants (35 IG, 37 CG). Participants were 22.6 ( 3.5) years old, 78% Hispanic, ∓ (95% CI: 16, 58), compared with 9.7% (-6, 23) in parous women with no his- 63% female, 75% T1D, with A1C of 10.8% ( 1.9%). The only between-group ∓ tory of GDM (n=1223). With A1C used to define DM, hazard rates were lower difference at baseline was a stronger family history of diabetes in the CG yet MET effects were generally stronger and similar across all subgroups (p=0.01). Intention-to-treat analysis showed that at follow-up, IG as com- studied. These results should inform the discussion whether and in whom to pared to CG participants had improved A1C (-0.53% vs. +0.36%; p=0.02) use metformin for DM prevention. and DQoL (+0.7 vs. +0.15, p=0.04); these effects did not differ by gender, ethnicity, or diabetes type. No study-related serious adverse events were Table. reported. Baseline Subgroup and Glucose-based Glucose-based A1C-based A1C-based Discussion: Overall, our findings indicate that OT intervention improves characteristic sample size DM* incidence DM* risk DM# incidence DM# risk clinical and psychosocial well-being among low-SES YAs with diabetes. (n = subjects rates reduction rates reduction Supported By: National Institutes of Health/National Institute of Diabetes and evaluated for (MET, PLA) MET vs. PLA (MET, PLA) MET vs. PLA DM development in % per year (95% CI) in % per year (95% CI) Digestive and Kidney Diseases (1K01DK099202-01A1) based on glucose; A1C) 168‑OR All (n=2155; 1837) 5.9, 7.1 17 (7, 27) 2.9, 4.5 36 (25, 45) The Effect of the Patient-Centered, Smartphone-Based, Diabetes Age (years) 25-44 6.0, 8.2 27 (9, 42) 3.5, 5.2 32 (10, 48) Care System in Patients with Uncontrolled Type 2 Diabetes: A Ran- (n=642; 564) domized Controlled Trial for 24 Weeks EUN KY KIM, SOO HEON KWAK, HYE SEUNG JUNG, BO KYUNG KOO, MIN 45-59 5.7, 7.0 18 (4, 31) 2.7, 4.3 35 (19, 48) (n=1098; 936) KYONG MOON, SOO LIM, HAK CHUL JANG, KYONG SOO PARK, YOUNG MIN CHO, Seoul, Republic of Korea ≥60 6.3, 5.9 -4 (-38, 22) 2.2, 4.3 45 (18, 63) We developed a comprehensive smartphone-based, patient-centered (n=415; 337) diabetes care system (PSDCS) containing modules of glucose monitoring, BMI (kg/m2) 22 to <30 5.2, 5.8 10 (-13, 28) 2.1, 3.6 40 (19, 56) diet monitoring, exercise monitoring, education materials, a bulletin board (n=689; 605) for social communication, and a clinical decision support. For patients using 30 to <35 5.6, 6.8 17 (-3, 34) 2.7, 4.4 38 (18, 54) insulin, the system provided guidance for insulin dosing. A multicenter, ran- (n=658; 575) domized controlled trial for 24 weeks was conducted to confirm its thera- ORALS ≥35 6.8, 8.7 22 (6, 35) 3.9, 5.7 30 (11, 45) peutic efficacy and safety. Total 172 patients with type 2 diabetes were ran- (n=808; 657) domized to either the PSDCS or standard care group. After 24 weeks, HbA1c * FPG≥126 or 2hPG ≥ 200 mg/dl; # A1C ≥ 6.5%; p<0.05 noted in bold. reduction from baseline was greater in the PSDCS group (-0.4 ± 0.1%) than in the standard care group (-0.1 ± 0.1%). The difference of adjusted mean Supported By: National Institute of Diabetes and Digestive and Kidney Diseases changes was 0.35% (95% CI: 0.14-0.55, p = 0.001). The reduction of HbA1c was more evident in the patients whose baseline HbA1c was 8.0% or higher 170‑OR (-0.9 ± 0.2% vs. -0.3 ± 0.2%, p = 0.016) and who used insulin (-0.7 ± 0.2% The Value Index Favors Using GLP-1 More than DPP-4, Saving Medi- vs. -0.2 ± 0.2%, p = 0.014). The proportion of patients whose HbA1c reached care $200 Million below 7.0% was 41.1% for the PSDCS group and 20.7% for the standard care SAAD SAKKAL, Mason, OH group (OR = 2.01, 95% CI: 1.24-3.25, p = 0.003). The proportion of the patients Introduction: The yearly bill for diabetes is $340 billion; while less the 14% whose HbA1c reached 6.5% or lower was 14.4% and 2.4%, respectively (OR achieve all targets together. NHANES and HEDIS, show that over the last = 5.78, 95% CI: 1.40-23.86, p = 0.004). The patients who attained HbA1c decade, the percentage of patients achieving HgA1c< 7% goal alone has below 7.0% without hypoglycemia was 31.1% in the PSDCS group and 17.1% decreased from 56% to 50%. We asked in this abstract: What is the value in the standard care group (OR = 1.82, 95% CI: 1.03-3.21, p = 0.024). In the index for DPP-4 and GLP-1 medications in Medicare patients? insulin users, glucose excursion of PSDCS group was significantly reduced Design: We compared the value index by finding how much money ($) was compared to that of the standard care group (-54.4 ± 14.9 mg/dL vs. 8.0 ± spent on improving HgA1c by 1% in three months. This calculation takes 14.9 mg/dL, p = 0.007). There was no difference in numbers of hyper- and quality and cost to estimate the value of each medication. We took the price hypoglycemia between the groups. System-related adverse events did not Medicare pays from the Medicare spending data for 2015. From the litera- occur during the study. ture, we assumed % 0.66 HgA1c drop for DPP-4 and 1%.1 drop for GLP-1. In conclusion, our smartphone-based PSDCS improved glucose control Results: 1) DPP-4 annual cost were (Januvia: $2572, Onglyza: 2304, Trad- with tolerable safety profile, which can be applied for patients with type 2 jenta: 2105, Nesina:1769), average annual cost $2447. The total patients diabetes. were 1197066 and total spending $2929750365. 2) GLP-1 Annual costs were

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A44 TRANSLATING THERAPEUTICS TO THE REAL WORLD

(Victoza: $3617, Bydureon: $2572, Trulicity: $1769, and Tanzeum: $1654. 172‑OR The average cost per patient of $3303. The total patients were 216692 and Dapagliflozin in Renal Impairment: The Association of British Clini- spending $715830403. 3) Diabetes care value index: for DPP-4 was calcu- cal Diabetologists Nationwide Dapagliflozin Audit lated at $927, for GLP-1 was $750 per 1% HgA1 c drop. 4) Comparing direct MAHENDER YADAGIRI, STEPHEN C. BAIN, TONY ROBINSON, JOHN P.H. WILD- observed annual price difference was: $856 per patient, but real actual ING, TERENCE PANG, BARBARA MCGOWAN, PETER WINOCOUR, VICTOR OGUN- effective difference based on the value index was $177 favoring GLP-1. If TOLU, JAMES CLARK, HELEN PARTRIDGE, IAN W. GALLEN, KAREN ADAMSON, this cost advantage, based on the value index, of $177 was projected to- ROBERT E.J. RYDER, ABCD NATIONWIDE DAPAGLIFLOZIN AUDIT CONTRIBU- patients using the lower value DPP-4 preparations (1197066), the savings TORS, Birmingham, United Kingdom, Swansea, United Kingdom, Bath, United King- adds to $211880682 per year. 5) From the perspective of value index, it dom, Liverpool, United Kingdom, Dudley, United Kingdom, London, United Kingdom, appears there are Two tiers: The first was more effective and economical Welwyn Garden City, United Kingdom, Wolverhampton, United Kingdom, Redhill, (GLP-1) and the second is higher priced/ less effective (DPP-4). Convenience United Kingdom, Bournemouth, United Kingdom, Reading, United Kingdom, Livings- and side effect need further analysis. ton, United Kingdom Conclusion: The value index in Medicare ($ spent to bring HgA1c by 1%) Using data from UK nationwide audit of dapagliflozin in real clinical use favors GLP-1 agents over DPP-4, with a difference of $177 per patient per 2014-2016 (n=2027), we evaluated the efficacy of dapagliflozin in mild and year. A Projection for the 1197066 patients on high expense DPP-4 prepara- moderate renal impairment. Including only pts with baseline and follow-up tions shows annual savings of $211880682. HbA1c and eGFR, pts were categorized into CKD grp 1 (normal, eGFR > 90 ml/ min), grp 2 (mild renal impairment, eGFR 60-90 ml/min) and grp 3 (moderate 171‑OR renal impairment, eGFR 30-59ml/min). In 880 patients [age 57.2±10.0 yrs, Predictors and Clinical Outcomes of Treatment Intensification in 58.4% males, diabetes duration 7.0 (1.9-13.0) yrs, weight 99.0 (87.5-116.3) Patients (Pts) with T2D Uncontrolled on Basal Insulin (BI) in Real- kg, BMI 35.1 (30.9-39.9) kg/m2 and HbA1c 9.3 (8.4-10.5)%] over 4.3 (3.0-7.0) World Settings mths, comparing grps, mean (± SE) HbA1c fell by 1.1 ± 1.1% from 9.7±1.4 LEE KALLENBACH, FEN YE, TAO FAN, WENLI HU, PHILLIP A. LEVIN, San Francisco, to 8.6±1.5% (p=0.000) grp 1, 0.9±1.4% from 9.4±1.5 to 8.5±1.4% (p=0.000) CA, King of Prussia, PA, Bridgewater, NJ, Baltimore, MD grp2 but did not change significantly in grp 3 (9.3±1.4 to 9.1±1.8% (p=0.510)). Failure to intensify treatment despite non-achievement of glycemic Weight fell by 3.2±5.2 kg from 106.8±22.1 to 103.5±22.0 (p=0.000) grp 1, goals is a major barrier to optimal T2D care. Predictors of, and outcomes 2.1±4.8 kg from 101.1±22.4 to 99.0±22.0kg (p=0.000) grp 2 and 3.5±7.7kg associated with, treatment intensification using injectable therapies were from 105.9±18.3 to 102.4±18.1kg (p=0.003) grp 3. Dapagliflozin reduced ALT assessed in pts with T2D uncontrolled on BI (i.e., A1C > 7.0% 1-6 months in all grps but reduced systolic BP only in grps 1 and 2 (Figure). Dapagliflozin after BI initiation, defined as the index date) from the Practice Fusion Data- reduces HbA1c, weight, BMI, systolic BP and ALT by similar statistically and base, which includes > 25 million pts (6.7% of all U.S. ambulatory care). clinically significant amounts in normal and mild renal impairment. In mod- Data from January 2011 through December 2015 were used. Of 14,653 pts erate renal impairment, dapagliflozin reduces weight and ALT but has no identified, BI regimen was intensified in 2,121 pts within 6 months after the significant impact on HBA1c or systolic BP in the grp sizes studied. index date. Intensification was with a rapid-acting insulin (RAI), glucagon- Figure. like peptide-1 receptor agonist (GLP-1 RA), or other injectable. Intensification with either a RAI or GLP-1 RA was significantly associated with having an endocrinologist as prescribing physician. Higher BMI and lower age were also significantly associated with GLP-1 RA intensification. Treatment inten- sification resulted in a greater A1C drop at 12 months vs. no intensification (Table). Hypoglycemia rate increased with RAI and other injectable, but not GLP-1 RA, use. Intensification with a GLP-1 RA led to greater A1C reduction and lower hypoglycemia rate vs. RAI. Therapy intensification led to better outcomes in T2D pts; BI + GLP-1 RA use was associated with the greatest A1C reduction and lowest hypoglycemia rate. Table. A1C at Baseline, Change from Baseline in A1C, and Hypoglycemia Rate by Intensification Strategy. RAI GLP-1 RA Other No injectablea intensification n (%) 1,459 341 321 12,532 (10.0) (2.3) (2.2) (85.5) Baseline A1C, mean (SD) 9.3 9.0 9.5 8.9 (1.7) (1.6) (1.7) (1.6) Changeb in A1C, least −0.276 −0.311 −0.22 −0.139

Supported By: Association of British Clinical Diabetologists ORALS squares mean (95% CI) (−0.421, −0.131) (−0.535, −0.087) (−0.459, 0.02) (−0.251, −0.028) Hypoglycemic eventsc 11.5 6.6 10.0 7.0 per 100 patient years, 173‑OR mean aOther injectable includes: amylin mimetic, short-acting, or premixed insulin. WITHDRAWN bAdjusted linear regression for absolute change from baseline to 12 months post intensification. Adjusted for: age, race/ethnicity, endocrinologist, internal medicine, primary care, BMI (continuous), smoking status, A1c (%) last observed at or prior to intensification date, biguanides, sulfonylureas, thiazolidinediones, dipeptidyl peptidase 4 inhibitors, combination pills, cardiovascular disease, obesity, osteoarthritis, Charlson Comorbidity Index, and Diabetes Complications Severity Index. cOn or after intensification. Supported By: Sanofi U.S.

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A45 TRANSLATING THERAPEUTICS TO THE REAL WORLD

2015 using the claim database of the Korean National Health Insurance Sys- tem, which is the single-payer healthcare system covering all Korean citi- zens and residents. Cox’s proportional hazard models were used to estimate hazard ratios for major CVD event (coronary artery disease, heart failure, stroke, or transient ischemic attack) between users of different DPP-4i. Sex, age, hypertension, dyslipidemia, peripheral vascular disease, microvascular complications, and Charlson’s comorbidity index were adjusted as potential confounders. Results: The observed numbers of CVD events (total observed person- time) were 13,627 (291,363 person-years) for sitagliptin, 6,676 (122,529 person-years) for vildagliptin, 2,353 (52,028 person-years) for saxagliptin, 18,972 (402,492 person-years) for linagliptin, and 4,027 (79,904 person- years) for gemigliptin users. Compared to sitagliptin, the fully adjusted hazard ratios for CVD events were 1.05 (95% CI: 1.02-1.08; p = 0.001) for vildagliptin, 0.93 (95% CI: 0.89-0.97; p = 0.001) for saxagliptin, 0.93 (95% CI: 0.91-0.95; p< 0.001) for linagliptin and 0.96 (95% CI: 0.93-1.00; p = 0.039) for gemigliptin. Conclusions: In comparison with sitagliptin therapy, saxagliptin, lina- gliptin, and gemigliptin therapies were associated with lower risk of car- diovascular events, whereas vildagliptin therapy might be associated with higher risk of cardiovascular events. Supported By: Korean Ministry of Health and Welfare (HI13C0715); LG Life Sci- ences Ltd

176‑OR Trends in Glycemic Medication and Control in Youths with Type 2 174‑OR Diabetes (T2D): The SEARCH for Diabetes in Youth Study DANA DABELEA, CATHY A. PINTO, TONGTONG WANG, RAVI SHANKAR, JEA- A Prospective, Pragmatic Clinical Trial to Compare the Real-World NETTE M. STAFFORD, RALPH B. D’AGOSTINO, JR., JEAN M. LAWRENCE, GRACE Use of V-Go in Type 2 Diabetes Patients KIM, CATHERINE PIHOKER, SEARCH FOR DIABETES IN YOUTH STUDY GROUP, SCOTT ABBOTT, MATTHEW NGUYEN, POUL STRANGE, MARK CZIRAKY, Aurora, CO, Rahway, NJ, Upper Gwynedd, PA, Winston-Salem, NC, Pasadena, CA, THOMAS WASSER, KAY LARHOLT, Zionsville, IN, Bridgewater, NJ, Princeton Junc- Seattle, WA tion, NJ, Wilmington, DE There are limited data on temporal changes in pharmacologic treatment This prospective pragmatic clinical trial evaluated V-Go compared to a of T2D youths. standard treatment optimization control (STO) in a community-based prac- Using data from the U.S. SEARCH for Diabetes in Youth Study, we con- tice setting. The trial utilized cluster randomization where study sites rather ducted 1) a cross-sectional comparison of medication use for 646 incident than individual patients were randomized to V-Go or STO. Patients with T2D cases (age 15.4 [±2.7] years, 62% female, 18.9% Non-Hispanic white) type 2 diabetes taking insulin were enrolled and treated according to routine who completed a SEARCH baseline visit in two periods (2002-2005 vs. 2008 practice for up to 4 months. Patients initializing V-Go stopped other insu- and 2012), and 2) a longitudinal analysis for a subset of 322 participants who lin therapy while diabetes treatments were continued in STO patients. All also had a follow-up visit on average after 7.1 ± 2.1 years. treatments, medications and supplies were obtained by usual care utilizing The majority of incident cases in each period received metformin (64.9% patient insurance and co-pays. The primary outcome was the difference in vs. 70.4%) and/or insulin (38.1% vs. 38.4%), while fewer were treated with the change in A1c from baseline to end of study (EOS). The analysis popula- sulfonylurea (5.6% to 3.6%), with non-significant changes over time. There tion included 415 patients, 246 STO and 169 V-Go across 52 sites. Mean age was a significant reduction in thiazolidinedione (TZD) use (5.0% vs. 2.0%, was 59.8 years and weight was 220.7 lbs. The population was 62.4% Cau- p<0.05). casian and 25.8% African American. Baseline A1c ranged from 7.9 to 14.2%. At baseline, participants on metformin monotherapy had a lower unad- Nearly all patients (96.4%) had at least one comorbid condition. There were justed A1C (6.4±1.4%) compared to those on insulin monotherapy (8.4±2.2%, significant A1c decreases from baseline with V-Go (-0.95%, p<0.001) and p<.0001) or insulin plus an oral diabetes medication (ODM) (7.7±2.2%, STO (-0.46%, p<0.001) and for V-Go vs. STO (p<0.002) despite a significant p<.0001). Among participants on metformin monotherapy at baseline reduction (p<0.001) in mean total daily insulin dose (TDD) with V-Go. V-Go (n=138), 29.7% reported metformin monotherapy at follow-up, with the baseline TDD was 71.3 U/day (0.76 U/Kg) which decreased to 54.03 U/day remainder either adding (19.6%) or switching (8.0%) to insulin, an ODM (0.57 U/Kg) at EOS. STO baseline TDD was 72.2 U/day (0.72 U/Kg) which (15.9%), or no medication (26.8%). Of those receiving insulin (±ODM) at base-

ORALS was unchanged at EOS (71.8 U/day; 0.72 U/Kg). Baseline A1c was higher for line (n=129), 76% were on insulin (±ODM) at follow-up. V-Go vs. STO (9.88% vs. 9.34%; p<0.001) possibly indicating a selection bias Overall, 35% of the 322 patients were at goal (A1C <7.0%) at the follow-up of more advanced diabetes patients initiating V-Go given the a priori ran- visit including 44.1% of those on metformin monotherapy at baseline, 20.6% domization of treatment sites. Utilizing a diabetes device treatment satis- of those on insulin (±ODM) baseline, and 64.5% of those with no reported faction questionnaire at baseline and EOS, patient satisfaction significantly medication use at baseline. improved for V-Go compared to baseline and STO. 93.5% of patients used Despite the growing number of medications available for T2D adults, V-Go as directed. This trial demonstrated improved A1c and patient treat- youths with T2D are still largely being treated with metformin and/or insulin, ment satisfaction, with decreased insulin dose, in patients initiating V-Go which are the only medications approved for pediatric use in the U.S., with in a real-world setting. a recent decline in TZD use as seen in adults. We found that a majority of Supported By: Valeritas, Inc. youths with T2D receiving treatment for an average of 7 years were not at the ADA-recommended A1C goal. 175‑OR Supported By: National Institutes of Health; National Institute of Diabetes and Subclasses of Dipeptidyl Peptidase-4 Inhibitors and Cardiovascu- Digestive and Kidney Diseases; Centers for Disease Control and Prevention lar Risk: Analysis of Real-World Data for 747,392 Patients Type 2 Diabetes KYOUNG HWA HA, BONGSEONG KIM, HANSOL CHOI, DAE JUNG KIM, HYEON CHANG KIM, Suwon, Republic of Korea, Seoul, Republic of Korea Objective: To compare the risk of cardiovascular disease (CVD) associ- ated with five different dipeptidyl peptidase-4 inhibitors (DPP-4i) in Korean patients with type 2 diabetes. Methods: We identified 747,392 patients who used sitagliptin (n = 232,855), vildagliptin (n = 98,368), saxagliptin (n = 44,422), linagliptin (n = 299,294) or gemigliptin (n = 72,453) between January 2013 and June

For author disclosure information, see page A751. ADA-Supported Research

A46 THE GENETIC ARCHITECTURE OF DIABETES

THE GENETIC ARCHITECTURE OF DIABETES 179‑OR Expanding the Spectrum of Type 2 Diabetes Risk Alleles through 177‑OR Genome-Wide Association Study Imputed Up to Haplotype Refer- A Meta-analysis of Genome-Wide Association Studies for Type 2 ence Consortium Panel Diabetes in Africans ANUBHA MAHAJAN, DANIEL TALIUN, DIAMANTE, AMP-T2D, DIAGRAM CON- ADEBOWALE A. ADEYEMO, MENG SUN, JI CHEN, ELEANOR WHEELER, ANUBHA SORTIA, Oxford, United Kingdom, Ann Arbor, MI MAHAJAN, FRASER PIRIE, AYO DOUMATEY, MANJ SANDHU, ANDREW MOR- We are conducting the largest genome-wide association study (GWAS) RIS, AYESHA MOTALA, INÊS BARROSO, MARK I. MCCARTHY, CHARLES N. of type 2 diabetes (T2D) susceptibility to date in Europeans, aggregating ROTIMI, Bethesda, MD, Oxford, United Kingdom, Cambridge, United Kingdom, Dur- 50,152 cases and 465,263 controls, interrogating a comprehensive cata- ban, South Africa logue of variation across allele frequency spectrum after imputation up to Aims/Hypothesis: GWAS for type 2 diabetes (T2D) have uncovered over Haplotype Reference Consortium panel. Analysis of ~20M variants, including 100 risk loci primarily in populations of European and Asian ancestry. Stud- ~14M that are rare or low-frequency (minor allele frequency [MAF] <0.5% ies in populations of African ancestry provide the opportunity to discover and 0.5-5%, respectively], identified 105 loci at genome wide significance -8 novel T2D loci (including African-specific variants) and fine map variants at (p<5x10 ), of which 38 did not overlap regions previously implicated in known loci. T2D. Only 5 lead variants had MAF<5%, including one novel association -8 Methods: A meta-analysis of two GWAS was conducted in 4344 Africans: near CCND1 (rs11820019, MAF=2.7%, p=4x10 , 1.17 [1.11-1.23]). Conditional (i) 1602 cases and 976 controls of Zulu ethnicity (Durban Diabetes Study); (ii) analyses revealed 44 additional (3 rare and 12 low-frequency) distinct asso- -5 1029 cases and 737 controls from Nigeria, Ghana and Kenya (Africa America ciation signals (p<10 ) across the loci including 2 at TCF7L2 (rs182771291, -8 -6 Diabetes Mellitus Study - AADM). Association between T2D and each vari- MAF=0.4%, p=1x10 , 1.64 [1.40-1.93] and rs142511108, MAF=1.1%, p=3x10 , ant was tested using linear mixed model to account for cryptic relatedness 1.24 [1.14-1.35]). Collectively, these variants captured ~16% of overall T2D and population structure. liability scale variance. Applying LD score regression to publically available Results: Most significant variant was the widely-replicated rs7903146 at GWAS summary statistics for a range of phenotypes, we confirmed the previ- TCF7L2 (p = 2.0×10-13). One novel locus (rs73284431 near AGMO and DGKB) ously observed genetic correlations between T2D, obesity, fasting glucose, reached genome-wide significance (p = 4.6 × 10-9, MAF = 9.5%; MAF=0 in birth weight, lipids, and cardiovascular disease. In addition, we found novel -28 Europeans and Asians). A second African-specific variant (rs12277475, inverse genetic correlations with age of first birth (Rg=-0.38, p=1x10 ), -13 11:2206933, MAF = 21.9%) near the index variant INS-IGF2 rs3842770 age at menarche (Rg=-0.26, p=3x10 ), and father’s age at death (Rg=-0.43, -7 -6 reached moderate significance (p=1.7× 10-7. SNP rs73987668 near CA10 p=3x10 ). By contrast, metabolites such as isoleucine (Rg=0.44, p=3x10 ) and -5 (locus associated with the metabolic syndrome in Africans) showed glycoprotein acetyls (Rg=0.48, p=3x10 ) showed positive correlations with genome-wide significance in AADM study only (p=3.94X10-9). Using direct T2D risk. Our observations highlight the potential for discovery of additional and local replication approaches, we replicated with directionally consistent T2D-risk alleles across the frequency spectrum by continued increases in effects, over 50% of the 87 established T2D loci tested in this study. Within sample size and the diversity of variants with new resources for genotype replicated loci, variants other than the reported index SNPs often showed imputation, providing important novel clues to T2D pathophysiology. smaller P-values highlighting the fine-mapping capability of the reduced link- age disequilibrium present in African genomes. 180‑OR Conclusions/Interpretation: We found two (rs73284431 and rs73987668) Whole-Genome Sequence Association Analysis of Fasting Glucose novel susceptibility loci for T2D in Africans and replicated over half of loci and Fasting Insulin from 7,121 Nondiabetic Individuals in Trans- found in other populations. Results demonstrate the importance of perform- omics for Precision Medicine (TOPMed) ing GWAS in Africans for better understanding of the genetic architecture of ALISA K. MANNING, BRIAN CADE, BERTHA HIDALGO, XIAOCHEN LIN, QING LIU, T2D and provide a resource to larger consortia for further discovery, replica- LAURA RAFFIELD, KATHLEEN RYAN, CHLOÉ SARNOWSKI, JENNIFER WESSEL, tion and fine-mapping. HUICHUN XU, Cambridge, MA, Boston, MA, Birmingham, AL, Providence, RI, Chapel Hill, NC, Baltimore, MD, Indianapolis, IN 178‑OR The majority of genetic variants significantly associated with glycemic Meta-analysis of 93,838 East Asians Identifies New Loci Associ- traits reside in the non-coding genome, with many causal variants still ated with Type 2 Diabetes unknown. Whole genome sequence association (WGSA) analysis allows XUELING SIM, MOMOKO HORIKOSHI, AGEN CONSORTIUM, Singapore, Singa- us to (1) fine-map known and novel loci without depending on imputation, pore, Yokohama, Japan (2) assess enrichment of sub-significant associations across non-coding To identify new T2D susceptibility loci in East Asians, we conducted annotations, and (3) discover novel rare variant associations. Here, we genome-wide meta-analysis in 35,955 T2D cases and 57,883 controls from present an initial WGSA of fasting insulin (FI) and fasting glucose (FG) lev- 21 studies collected from China, Japan, Korea, Philippines, Singapore, and els in phase 1 TOPMed data (N=7121) with deep (>30x) sequence coverage Taiwan and imputed to 1000 Genomes reference panels. We performed asso- in five cohorts, three European-ancestry (EA): Framingham Heart Study, ciation analyses with and without adjustment for body mass index (BMI), N=3209; Old Order Amish Studies, N=980, Cleveland Family Study, N=197, and two African-American (AA): Jackson Heart Study, N=2487, Cleveland and combined study-specific association statistics using a fixed effects ORALS effective sample-size weighted meta-analysis approach assuming an addi- Family Study, N=248. For each cohort, we used linear mixed effects mod- tive genetic model. We analysed 6,952,153 variants, and identified 48 loci els (as implemented in EMMAX or MMAP software) adjusting for sex, age at genome-wide significance (P<5x10-8), of which 9 are new. The strongest and BMI, with empirical kinship for relatedness and population structure. novel association map to an intronic variant at KSR2 (rs7305424, P=2.0x10-9, We restricted to variants with minor allele count > 5 in more than 1 cohort and meta-analyzed within and across ancestry with METAL. In EA+AA Phet=0.84). KSR2 regulates energy intake and expenditure, and rare variants in KSR2 have been implicated in early-onset obesity and severe insulin resis- analysis, common (minor allele frequency [MAF]>5%) variant associations -8 tance. Two of the new signals near SIX2-SIX3 and TMEM18 map to loci previ- (P<5x10 ) were identified for FG at known loci: MTNR1B (rs10830963, -16 -8 -10 ously reported to be associated with T2D related quantitative traits such as P=2.5x10 ; rs12792753, P=1.4x10 ), GCK (rs4607517, P=1.2x10 , and 13 -10 fasting glucose (FG) and obesity. The lead variant rs12712928 (P=3.0x10-8, additional variants), and G6PC2 (rs560887, P=5.4x10 ). At MTNR1B, multi- 2 ancestry fine-mapping reduced the significant FG associations from 46 (EA) Phet=0.39) at SIX2-SIX3 was in high linkage disequilibrium (r =0.91) with the East Asian FG associated variant rs895636 (P=6.9x10-8, P =0.42). The to 2 (AA+EA). Novel FI associations were seen in rare (MAF<1%) variants: het -9 -8 allele associated with higher FG at rs895636 was associated with increased 18q12.1 (rs146884135, P=2.1x10 ), 4p12 (rs193168677, P=1.2x10 ), 1q25.3 -8 -8 T2D risk. Associations at TMEM18 attained genome-wide significance in (rs550837507, P=3.8x10 ), and DCLK3 (rs573417731, P=4.8x10 ). These -8 -5 results, which are being extended with phase 2 TOPMed cohorts (expected analyses without BMI adjustment only (PwoBMI=1.2x10 , PBMI=1.8x10 ), sug- gesting mediation effects of BMI on T2D. Allele frequencies at two other total N=27830), highlight the value of multi-ancestry WGSA to refine known lead variants near PTPN11 (rs77753011, P=4.6x10-8, MAF=0.23) and ZNF257 and discover novel associations for complex traits. (rs142395395, P=6.5x10-9, MAF=0.04) were higher in East Asians compared Supported By: National Institutes of Health (5K01DK107836) to the other ancestries (MAF<0.0014 in 1000 Genomes non-East Asians). Taken together, we identified new T2D loci in East Asians that highlight biol- ogy candidates.

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A47 THE GENETIC ARCHITECTURE OF DIABETES

181‑OR In conclusion, this is the first study systematically describing that approxi- First Genome-Wide Association Study of Latent Autoimmune Dia- mately one third of patients with a multigenerational diabetes, routinely betes in Adults Provides Novel Insights defined as T2D among adult patients, carry, in fact, mutations in MODY- or DIANA L. COUSMINER, RAJASHREE MISHRA, EMMA AHLQVIST, METTE ND-genes. Conversely, the genetic defect in most of the remaining 2/3 of ANDERSEN, ALESSANDRA CHESI, JONATHAN BRADFIELD, RICHARD E. PRAT- such patients is still unraveled, thus leaving them in the limbo of FDA. As our LEY, MICHAEL R. RICKELS, ADRIAN VELLA, FERNANDO OVALLE, RONALD HAR- recent successful whole exome sequencing (WES) study - pointing APPL1 RIS, STEVEN VARVEL, PHILIPPE FROGEUL, JOHN LONSDALE, DIDAC MAURICIO, as a new diabetogenes in one of such families - suggests, it is likely that NANETTE SCHLOOT, BENJAMIN F. VOIGHT, HAKON HAKONARSON, KAMLESH additional WES studies presently ongoing in our laboratory will identify new KHUNTI, CARLA J. GREENBAUM, BJORN ASVOLD, KNUD YDERSTRAEDE, EWAN diabetogenes which are responsible for hyperglycemia in FDA, a bin of per- R. PEARSON, STANLEY SCHWARTZ, TORBEN HANSEN, TIINAMAIJA TUOMI, sisting ignorance we need to empty. BERNHARD BOEHM, LEIF GROOP, R. DAVID LESLIE, STRUAN F.A. GRANT, Phila- Supported By: Italian Ministry of Health; Ricerca Corrente 2016 delphia, PA, Malmö, Sweden, Copenhagen, Denmark, San Diego, CA, Orlando, FL, Rochester, MN, Birmingham, AL, Wilkes-Barre, PA, Richmond, VA, Lille, France, Bar- 183‑OR celona, Spain, Cologne, Germany, Leicester, United Kingdom, Seattle, WA, Trond- Genome-Wide Effect of Variants in Specific Classes of Pancreatic heim, Norway, Odense, Denmark, Dundee, United Kingdom, Helsinki, Finland, Ulm, Islet Accessible Chromatin on Type 2 Diabetes Risk Germany, London, United Kingdom BILL GREENWALD, NAOKI NARIAI, ALLEN WANG, NICK VINCKIER, FRAUKE Latent autoimmune diabetes in adults (LADA) presents with clinical fea- DREES, BING REN, MAIKE SANDER, KELLY FRAZER, KYLE GAULTON, San Diego, tures of both T1D and T2D and is often misclassified as T2D. By conducting CA the first GWAS for LADA, we aimed to investigate the genetic architecture T2D risk variants are enriched in pancreatic islet regulatory elements. of this poorly characterized form of diabetes. In a European ancestry meta- To further define islet regulatory processes involved in T2D, we created analyses, we included up to 2,713 LADA cases (>20 yrs, 6 months w/o insulin an integrated epigenome map of 16 chromatin states in primary islets by after presentation, GADA+) and 5,439 population controls. We also included combining available histone modification and transcription factor ChIP-seq 971 T1D and 9,749 T2D cases for subsequent comparisons. Following impu- with ATAC-seq generated in four islet samples. We then interrogated this tation to the HRC panel, each center used logistic regression in SNPTEST, map using whole-genome T2D association and islet eQTL data in a Bayesian followed by inverse variance weighted meta-analysis in GWAMA for SNPs framework. We determined the effect of variants in islet epigenome states with MAF > 5%. In LADA vs. controls, and vs. T2D, all 4 genome wide sig- on T2D in a joint model of 5.7M common (MAF>.05) variants using fgwas. We nificant signals were at T1D loci (LADA vs. controls, rs9273368 (MHC): OR = observed strong enrichment of variants in active enhancer (ln(enrich)=2.51, 3.1, P = 2.2x10-146; rs2476601 (PTPN22): OR = 0.58, P = 5.7x10-22; rs689 (INS): CI=0.82,3.54) and flanking promoter (ln(enrich)=3.34, CI=1.59,4.50) acces- OR = 1.5, P = 1.0x10-19; rs7310615 (SH2B3): OR = 0.77, P = 2.9x10-12). When sible chromatin on T2D risk, with no enrichment in other states. We used contrasting LADA vs. T1D, only the MHC locus was significantly different, the effects from this model as priors on variants in fine-mapping 81 known being weaker in LADA (OR = 0.34, P = 8.1 x 10-40). T1D loci were also observed T2D signals, identifying 16 signals with likely causal variants (probability in the suggestive tier (P < 10-6), including BACH2, TNFRSF11B and MEG3. [PPA]>.50) in islet accessible chromatin. We further applied priors to vari- In contrast to previous reports, the TCF7L2 locus was not associated with ants in fine-mapping all 1MB windows genome-wide, and identified 6 novel LADA in this study. We imputed HLA alleles and haplotypes using SNP2HLA windows containing putative T2D risk variants in islet accessible chromatin. and observed a significantly weaker role for known T1D high risk haplotypes We then tested known and novel T2D signals for effect on islet gene expres- in LADA, including DRB1*0301-DQA1*03-DQB1*0201 and DRB1*0301- sion using 118 RNA-seq samples. Seven known signals were co-localized DQA1*05-DQB1*0201. Further, LD Score Regression excluding the MHC (Pqtl>.9) with an islet eQTL as well as two novel signals, 6q25 for RGS17 region revealed a high genetic correlation between LADA and autoimmune and 11p15 for TH. Direct integration of eQTL data increased fine-mapping traits beyond T1D, including rheumatoid arthritis (rG = 0.45 (0.16), P = 0.005). resolution for shared signals, in several cases down to a single variant such Interestingly, LADA also had a high correlation with T2D (rG = 0.31 (0.1), as rs11708067 (ADCY5; PPA=0.99) and rs11257655 (CAMK1D; PPA=0.97), and P = 0.003) and related traits. revealed these signals are caused by variants in active enhancer accessible In conclusion, LADA is similar genetically to T1D, albeit as a less pro- chromatin. We found no evidence that T2D variants in flanking promoter nounced form. These findings further emphasize the need to distinguish chromatin are eQTLs. Our results reveal that T2D risk in islets is broadly LADA from T2D to aid appropriate treatment. mediated by variants in active enhancer and flanking promoter accessible Supported By: American Diabetes Association (1-17-PDF-077 to D.L.C.); National chromatin, the former through direct effects on islet gene expression. Institutes of Health (R01DK085212) Supported By: National Institutes of Health

182‑OR 184‑OR Expanding the Knowledge on the Spectrum of Familial Diabetes in Human, Mouse, and Rat Multitissue Integrative Chromatin State Adult Patients and eRNA Maps Reveal Conserved Stretch Enhancer Landscapes at SERENA PEZZILLI, ORNELLA LUDOVICO, TOMMASO BIAGINI, LUANA MERCURI, Diabetes and Related Trait Loci FEDERICA ALBERICO, ELEONORA LAURICELLA, HAMZA DALLALI, GIORGIO

ORALS ARUSHI VARSHNEY, JONATHAN HALDEMAN, MICHAEL ERDOS, RICARDO BASILE, ELIDE MICCINILLI, PAMELA PISCITELLI, SALVATORE DE COSMO, MAS- ALBANUS, PETER ORCHARD, ROMY KURSAWE, JOHN HENSLEY, HANS-EWALD SIMO CARELLA, TOMMASO MAZZA, VINCENZO TRISCHITTA, SABRINA PRU- HOHMEIER, CHRISTOPHER B. NEWGARD, FRANCIS S. COLLINS, MICHAEL L. DENTE, Rome, Italy, San Giovanni Rotondo, Italy, Tunis, Tunisia, Boston, MA STITZEL, STEPHEN C.J. PARKER, Ann Arbor, MI, Durham, NC, Bethesda, MD, Farm- We recently reported that 3% of adults defined as having type 2 dia- ington, CT betes (T2D) are, in fact, affected by a multigenerational (> 3 consecutive Genome-wide association studies (GWAS) have identified >100 single generations) form of diabetes. In 13% of such families, hyperglycemia was nucleotide polymorphisms (SNPs) that modulate risk for type 2 diabetes caused by mutations in one of the 6 most common MODY-genes (HNF4A, (T2D) and related traits. Using functional genomic profiling, we and others GCK, HNF1A, PDX1, HNF1B and NeuroD1), as identified by Sanger sequenc- have shown that T2D GWAS SNPs are significantly enriched to overlap pan- ing. We here address the hypothesis that diabetes, in the remaining fami- creatic islet stretch enhancer chromatin states, implicating these regulatory lies which were negative to the previous screening, from now defined as elements as biological mediators of disease risk. Given the importance of “Familial Diabetes of the Adulthood” (FDA) was due to either i) mutations rodent model organism systems to inform human disease research, it was in uncommon MODY-genes we did not investigated previously or ii) muta- of interest to identify functionally conserved regulatory signatures in analo- tions in neonatal diabetes (ND)-genes. This was studied using targeted gous cell types. We generated histone modification (H3K4me1, H3K4me3, next-generation sequencing of 26 MODY and/or ND-genes. Mutations were H3K27ac, H3K27me3, H3K36me3) ChIP-seq and open chromatin (ATAC-seq) classified as such by a mixed filtering/prioritization strategy and tested for profiles from human, mouse, and rat islets and beta cell lines. Computational co-segregation in the families. Among 55 FDA study probands, 11 carried integration with existing human and mouse data from diverse tissues allowed heterozygous mutations in MODY- (N=6) and ND- (N=5) genes, respectively. us to observe extensive tissue-specific conservation of regulatory chromatin When possible, co-segregation was tested and it was confirmed in most of state architecture in analogous islet tissues across species, including signifi- such families. cant enrichment (P<10-5) for regions harboring SNPs associated with islet When present data where combined with those of our previous screening, dysfunction and T2D in humans. High resolution chromatin accessibility pro- 23.9% and 9.1% family probands carried, in fact, mutations in MODY- and filing using ATAC-seq enabled us to identify specific transcription factor (TF) ND-genes, respectively. footprints embedded in the regulatory chromatin states. We investigated

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A48 OBESITY PATHOGENESIS AND TREATMENT—INSIGHTS FROM MOUSE MODELS enhancer RNA (eRNA) profiles across human, mouse, and rat beta cell mod- observed for ChREBP-/- livers. Increased Dio2 (3.8-fold) and Ucp1 (3.5-fold) els, which revealed bidirectional signatures of intergenic eRNA transcription gene expression indicate that ChREBP-/- BAT may be under increased adren- at T2D GWAS loci. Two different examples show (1) novel eRNA regulatory ergic stimulation, suggesting that ChREBP deficiency compromises normal biology embedded in a lincRNA near the known FOXA2 locus and (2) regu- BAT activity. Taken together, our results indicate that ChREBP function is latory grammar conservation at the newly-implicated ABCB9 locus. These critical for BAT homeostasis. integrated genome, epigenome, and transcriptome results form a valuable Supported By: U.S. Department of Agriculture-Agricultural Research Service resource for reciprocally mapping human and rodent T2D enhancer biology (3092-51000-060-03S) and inform translational strategies for maximizing model organism diabetes research. 187‑OR Supported By: American Diabetes Association (1-14-INI-07 to S.C.J.P.); National Glucagon-Receptor Signaling Regulates Thermogenesis via Institutes of Health/National Institute of Diabetes and Digestive and Kidney Dis- Hepatic Farnesoid X Receptor eases (R00DK099240) TEAYOUN KIM, CASSIE L. HOLLEMAN, SHELLY R. NASON, RUTH E. MCDOWELL, MARTIN E. YOUNG, HUBERT M. TSE, RICHARD D. DIMARCHI, DIEGO PEREZ- TILVE, KIRK M. HABEGGER, Birmingham, AL, Bloomington, IN, Cincinnati, OH OBESITY PATHOGENESIS AND TREATMENT— Glucagon, an essential regulator of glucose and lipid metabolism, also INSIGHTS FROM MOUSE MODELS promotes weight loss. Thus, novel therapeutics that include glucagon recep- tor (GcgR) agonism have emerged as promising candidates for obesity and 185‑OR diabetes. Notably, chronic GcgR agonism restored circulating bile acids O-GlcNAc Transferase Inhibits Visceral Fat Lipolysis and Is a while also stimulating expression of hepatic farnesoid X receptor (FXR). We Potential Risk Factor for Obesity hypothesized that GcgR agonism regulates energy metabolism, at least in YUNFAN YANG, MINNIE FU, MINDIAN LI, KAISI ZHANG, BICHEN ZHANG, part, through FXR signaling. To test this hypothesis, we utilized whole body liver SIMENG WANG, WEIMING NI, XIAOYONG YANG, New Haven, CT and liver-specific FXR knockout (FXR∆ ) mouse models. Chronic administra- Excessive visceral fat accumulation is a primary risk factor for metaboli- tion of a GcgR agonist (IUB288) predictably induced hyperglycemia and glu- cally unhealthy obesity, which is closely related to a variety of metabolic cose intolerance regardless of genotype, yet reduced diet-induced obesity dysfunctions such as diabetes and cardiovascular diseases. Reducing vis- (DIO) in wild type (WT), but not FXR∆liver mice. IUB288-reduced body weight ceral fat is an effective strategy to combat obesity-related diseases. The in WT mice was primarily due to fat mass loss and was associated with visceral white adipose tissue is highly susceptible to the availability of increased core body temperature, which was not observed in FXR∆liver mice. external nutrients. Nutrient fluxes into the hexosamine biosynthetic path- IUB288 substantially increased energy expenditure (p<0.01) and respiration way led to the posttranslational modification of nuclear, cytoplasmic, and (p<0.05) in DIO WT mice, but not FXR∆liver mice. [14C]-Palmitate oxidation in mitochondrial proteins by O-linked β-N-acetylglucosamine (O-GlcNAc) moi- hepatocytes isolated from WT mice was increased in a dose-dependent eties. O-GlcNAc transferase (OGT) is responsible for the addition of GlcNAc manner (p<0.01), an effect reduced in hepatocytes from FXR∆liver mice. moieties to target proteins. Here, we report that the nutrient-sensing Likewise, FXR∆liver hepatocytes showed lower oxygen consumption rate O-GlcNAc signaling is essential for adipose tissue homeostasis. Constitu- (OCR) than WT hepatocytes. Beyond hepatic metabolism, adipocyte size tive deletion of OGT in mouse adipose tissue leads to a dramatic reduction was reduced in WT, but not FXR∆liver mice. Consistently, differentiated X9 of white fat mass. Inducible deletion of adipose OGT causes a rapid, specific beige adipocytes increased FA-oxidation when stimulated with conditioned loss of visceral adipose tissue. The loss of visceral adipose tissue is asso- WT, but not FXR∆liver hepatocyte media after IUB288 treatment. Our data ciated with fasting-induced elevation of serum free fatty acid levels and clearly demonstrate that GcgR agonism, in a hepatic FXR-dependent man- lipid droplet shrinkage in visceral, but not subcutaneous, adipocytes. In vitro ner, enhances energy expenditure and fatty acid oxidation in vivo via its lipolysis assay shows that loss of OGT promotes adrenergic agonist-induced regulation of cellular energy metabolism in liver and adipose tissues. This lipolysis specifically in visceral adipose tissue. Mechanistically, loss of OGT heretofore-unappreciated aspect of glucagon biology has implications for decreases O-GlcNAcylation of lipid droplet-associated perilipin 1, which the use of GcgR agonism in therapeutic strategies for multiple components leads to elevated perilipin 1 phosphorylation and enhanced lipolysis. These of the metabolic syndrome. findings establish an essential role for OGT in the regulation of visceral adi- Supported By: American Diabetes Association (1-13-JF-21 to K.M.H.); National pose tissue lipolysis and indicate a unique potential for targeting O-GlcNAc Institutes of Health/National Institute of Diabetes and Digestive and Kidney Dis- signaling in the treatment of metabolically unhealthy obesity. eases (K01DK098319) Supported By: National Institutes of Health 188‑OR 186‑OR Adipose CREB3L3 Mediates Obesity-Induced Metabolic Dysfunc- ChREBP Deficiency Dysregulates BAT Homeostasis in Mice tion ALLI NUOTIO-ANTAR, MAHMOUD MOHAMMAD, MIAO HSUEH CHEN, Houston, MAXIMILIAN MCCANN, GUIFEN QIANG, VICTORIA GIL, HYERIM WHANG KONG, TX KEZHONG ZHANG, STEPHEN DUNCAN, CHONG WEE LIEW, Chicago, IL, Detroit,

Increasing whole-body energy expenditure and glucose disposal through MI, Charleston, SC ORALS activation of brown adipose tissue (BAT) has been suggested as a therapy A “metabolically healthy obese” subpopulation makes up an estimated to counter obesity and type 2 diabetes. However, mechanisms governing 10-30% of the total obese population. While the preserved metabolic health BAT metabolism and function have not been fully elucidated. In mammals, of these individuals is attributed to having more subcutaneous fat accumula- cold exposure increases the expression of genes in BAT that regulate both tion, smaller adipocytes, reduced visceral fat inflammation, and low ectopic glycolysis and beta-oxidation, as well as glucose and fatty acid uptake, facil- fat accumulation, the cellular mechanisms underlying this phenotype remain itating increased glucose and lipid substrate utilization for mitochondrial unclear. We have discovered that the fat-specific ablation (KO) of cyclic-AMP uncoupling that generates heat. Carbohydrate response element binding Responsive Element Binding Protein 3-like-3 (CREB3L3), a transcription fac- protein (ChREBP) is a glucose-responsive transcription factor that regulates tor that we have found to be selectively downregulated in obese subcutane- the expression of glycolytic and lipogenic genes. Although ChREBP is highly ous fat, creates a phenotype strikingly similar to metabolically healthy obe- expressed in BAT, its function in that tissue is not well defined. We analyzed sity when KO mice are fed a high-fat diet (HFD). The KO mice become more gene expression and de novo synthesis of fatty acids in BAT taken from obese than floxed wild type (WT) controls, with significantly larger visceral ChREBP-/- mice. Despite showing no significant differences with regard to epididymal and subcutaneous inguinal fat depots, but do not exhibit any body weight, total fat mass, or liver weights, ChREBP-/- mice fed a standard signs of metabolic dysfunction. These mice do not exhibit the impaired glu- chow diet and housed at normal room temperature had 42% decreased BAT cose tolerance or insulin sensitivity expected with their larger body weight. weights at 20 weeks of age in comparison to wild type littermate controls Surprisingly, despite significant enlargement of their epididymal fat depot (p<0.005). In ChREBP-/- BAT, expression of lipogenic genes Acc1 and Fasn and adipocytes, these mice have a downregulation of visceral inflammatory was reduced 11-fold (P<0.001), while Scd1 was decreased by 7-fold (P<0.01). markers. While the KO mice have significantly larger visceral adipocytes, the Furthermore, expression of genes that mediate fatty acid and glucose subcutaneous adipocytes are significantly smaller, and both the KO epidy- uptake in BAT, Cd36 and Glut1, were increased 1.6- and 2-fold, respectively dymal and inguinal fat depots trend towards having more total adipocytes. (P<0.05), in ChREBP-/- BAT. Although fractional synthesis of glycerol was not Despite their enhanced adiposity, KO mice do not have increased circulat- altered, C4:0 (short-chain), C6:0, C10:0, and C12:0 (medium-chain) fatty acid ing free fatty acids, triglycerides, cholesterol, or hepatic lipid accumulation. synthesis was significantly reduced in ChREBP-/- BAT, an effect that was not This reduction in circulating lipids despite the KO mice being more obese

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A49 OBESITY PATHOGENESIS AND TREATMENT—INSIGHTS FROM MOUSE MODELS

suggests that ablation of CREB3L3 in adipose tissue can reduce circulating 191‑OR lipids, which was confirmed in our chow-fed KO mice. Taken together, our Site 3 FFAR1 Agonism Improves Glucose Metabolism and Reverses data suggest that the ablation of CREB3L3 in adipose tissue can preserve Obesity in Mice metabolic homeostasis during obesity by improving lipid handling and reduc- SEUNGHUN LEE, TONYA MARTIN, BRIAN RADY, SANATH MEEGALLA, HUI ing visceral inflammation. HUANG, MIKE WINTERS, LISA NORQUAY, JUNE ZHI XU, JENSON QI, JIANY- Supported By: American Heart Association (16PRE30190011); National Institutes ING LIU, FUYONG DU, THOMAS KIRCHNER, NATHANIEL WALLACE, YIN LIANG, of Health (R00DK090210, R01DK109015) MARK PLAYER, ALESSANDRO POCAI, Spring House, PA The free fatty acid receptor 1 (FFAR1, also referred to as GPR40) medi- 189‑OR ates fatty acid-induced insulin secretion from pancreatic β-cells. At least Fractalkine-CX3CR1 Signaling Deficiency Exacerbates Obesity- 3 distinct binding sites exist on the FFAR1 receptor and numerous ligands Induced Inflammation and Insulin Resistance have been investigated for their antidiabetic actions. The most advanced, MAYUMI NAGASHIMADA, YINHUA NI, KAZUKI SAWAMOTO, TSUGUHITO OTA, fasiglifam, is a site 1 binder that stimulates IPone and improves glycemic Kanazawa, Japan control in diabetic patients. Recently, small molecule FFAR1 agonists were Fractalkine-CX3CR1 is a chemokine system that exerts both negative and discovered which bind to site 3, stimulate IPone and cAMP and result in positive consequences on disease pathogenesis and progression. Here, we both insulin and glucagon-like peptide-1 (GLP-1) secretion. Here, we tested show that fractalkine-CX3CR1 plays a crucial role in obesity-induced adi- the hypothesis that this novel pharmacology would lead to robust glucose pose tissue inflammation and whole-body insulin resistance. Fractalkine lowering and weight loss and that a fixed-dose combination (FDC) with a (Cx3cl1) mRNA expression was persistently downregulated in epididymal dipeptidyl peptidase-4 inhibitor (DPP-4i), would result in enhanced efficacy. white adipose tissue (eWAT) of high-fat diet (HFD)-induced obese (DIO) mice, A novel selective FFAR1 agonist (JNJ-A) was discovered that binds to site 3 as compared to expression in lean controls. Consistently, DNA microarray and stimulates GLP-1 secretion in mice and monkeys (~2-3-fold elevation in analysis in eWAT of DIO mice demonstrated that fractalkine gene expres- plasma GLP-1). Because JNJ-A restored insulin secretion in islets obtained sion decreased despite increased expression of other chemokine systems, from type 2 diabetic human donors, an oral glucose tolerance test was per- such as MCP-1-CCR2. Interestingly, downregulation of fractalkine preceded formed in diabetic monkeys (12-14 yr-old). Consistent with the human islet adipose tissue macrophage (ATM) recruitment in DIO mice. To determine the data, JNJ-A (2 mg/kg, p.o.) restored insulin secretion in diabetic monkeys effect of fractalkine-CX3CR1 signaling on obesity-induced ATM recruitment leading to improvement of glucose metabolism (P<0.05 vs. vehicle). Chronic and insulin resistance, we examined the metabolic phenotype of Cx3cr1-/- treatment with JNJ-A dose-dependently reduced food intake and body mice. Cx3cr1-/- mice fed normal chow developed slightly worsened glucose weight (-7% and -15% vs. vehicle and baseline, at 10 and 30 mg/kg respec- tolerance. On an HFD, Cx3cr1-/- mice had increased macrophage infiltration tively, n=8/group; P<0.05 JNJ-A vs. vehicle) in diet-induced obese mice. and formation of crown-like structures in eWAT compared with those of In the same study, superior body weight reduction was observed in mice wild type (WT) mice, despite the fact that weight and adipocyte size were treated with the FDC DPP-4i/JNJ-A vs. JNJ-A alone (-14 and -22%, at 10 and similar. HFD-induced glucose intolerance, hyperinsulinemia (Cx3cr1-/- vs. WT; 30 mg/kg, P<0.05) suggesting that GLP-1 contributes to the effect of JNJ-A 1.3 ± 0.2 ng/ml vs. 0.5 ± 0.1 ng/ml, P < 0.05), and insulin signaling were on body weight. These data demonstrate that JNJ-A engages the enteroin- exacerbated in eWAT of Cx3cr1-/- mice. These findings were associated sular axis in rodents and higher species leading to improvement in glucose with increased plasma TNFα, amplification of JNK and activation of NF-κB metabolism and energy homeostasis. Site 3 FFAR1 agonism represent a new in eWAT, as well as progression of hepatic steatosis. Furthermore, HFD- potential approach for obesity and type 2 diabetes. induced adipose inflammation and hyperinsulinemia were aggravated in chimeric mice lacking CX3CR1 in bone marrow (BM) cells (BM transplant of 192‑OR Cx3cr1-/- into WT), as compared to BM transplant of Cx3cr1+/+ into WT mice. Epigenomic Analysis of Temperature-Responsive Cellular Plastic- Thus, loss of fractalkine-CX3CR1 signaling increased ATM recruitment, ity of Beige Adipocytes thereby exacerbating obesity-induced inflammation and insulin resistance. HYUN CHEOL ROH, MANJU KUMARI, LINUS TSAI, ANNA LYUBETSKAYA, DANI- ELLE E. TENEN, EVAN D. ROSEN, Boston, MA 190‑OR Fat cells are normally classified as white adipocytes or brown adipocytes, PB-718, a Dual GLP-1/Glucagon Receptor Agonist Demonstrates but a distinct type of fat cell called the beige adipocyte has recently been Superior Weight-Loss Effect and Ameliorates Nonalcoholic Steato- identified. These cells support thermogenesis and dissipate calories like hepatitis (NASH) in Animal Models brown adipocytes but have unique temperature-responsive cellular plas- WEI LU, CHUNMEI WANG, XIAOSU LUO, YINGHUI ZHANG, LIANG HONG, ticity. Because the thermogenic adipocytes of adult humans are similar to MICHAEL XU, Suzhou, China murine beige adipocytes, there has been particular interest in the biology of Obesity remains a primary health and economic threat for modern soci- these cells as a new therapeutic target for metabolic diseases. The molecular eties. However pharmacological treatment of obesity has limited efficacy. basis for the unique cellular plasticity of beige adipocytes is poorly defined, Nonalcoholic fatty liver disease (NAFLD) is one of the main hepatic complica- in part because the cellular heterogeneity of the adipose depot complicates tions associated with obesity. Nonalcoholic steatohepatitis (NASH), a more the isolation and analysis of this minority cell type. To elucidate mechanisms underlying beige adipocyte plasticity, we developed a methodology using a

ORALS severe form of NAFLD, is the commonest cause of chronic liver disease and liver transplantation. Despite this, there are no universally accepted phar- new transgenic mouse, called ‘NuTRAP’, and generated transcriptomic and macological therapies for NASH. The strong association of NASH with met- epigenomic profiles of beige, brown, and white adipocytes in a cell-type spe- abolic syndromes provides a strong rationale for investigating therapies that cific manner in vivo. Genome-wide profiling showed that while brown adi- induce weight loss and improve insulin sensitivity. Here, we investigated pocytes display a relatively stable epigenomic landscape, beige adipocytes the effects of PB-718, a pegylated dual GLP-1/Glucagon receptor agonist in display a distinct epigenomic plasticity; these cells interconverts between animal models of obesity and NASH. We have shown in DIO (diet-induced a brown-like and a white-like state depending on ambient temperature. Our obesity) mice that PB-718 treatment achieved much more potent effect on subsequent analysis identified transcriptional pathways in beige adipocytes weight loss compared to GLP-1 receptor agonist alone. PB-718 treatment that may mediate this plasticity. Furthermore, distinct from regular white also resulted in reduced serum cholesterol and serum and liver triglyceride adipocytes, warming-induced whitened beige adipocytes display poised in these mice. Meanwhile, PB-718 treatment also reduced fasting glucose enhancer activity at thermogenic genes, suggesting that beige adipocytes level and improved glucose tolerance in DIO mice. PB-718 treatment has also may retain an epigenomic memory of brown states. This study advances been proved safe and efficacious in obese monkeys. 11%-15% body weight our understanding of molecular mechanisms of beige adipocyte plasticity. loss were seen in three dose groups after 30-day treatment. And the dual Supported By: American Diabetes Association (1-17-PDF-133 to H.C.R.); Charles agonist treatment apparently improved insulin sensitivity in obese monkeys. H. Hood Foundation In a mice STZ/HFD model of NASH, PB-718 treatment for 3-weeks signifi- cantly reduced blood glucose level and NAFLD activity scores. Our results suggested that the dual GLP-1/Glucagon receptor agonist may have clinical potential for the treatment of obesity and NASH.

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A50 MECHANISMS AND MODULATORS OF CARDIOVASCULAR COMPLICATIONS

MECHANISMS AND MODULATORS OF 195‑OR CARDIOVASCULAR COMPLICATIONS Empagliflozin Suppresses the Progression of Atherosclerosis in Diabetic apoE-Deficient Mice 193‑OR SAIKO MURAKAMI, TAKESHI MATSUMURA, TAKAFUMI SENOKUCHI, NORIO What STIMulates Ca2+ Dependent Kinase Activity in the Mouse ISHII, KAZUKI FUKUDA, SHUHEI NISHIDA, TATSUYA KONDO, EIICHI ARAKI, Heart? Kumamoto, Japan A recent clinical study demonstrated that empagliflozin (EMPA), one of HELEN E. COLLINS, JOSHUA ANDERSON, JOHN C. CHATHAM, Birmingham, AL Hyperglycemia and diabetes have been shown to impair hypertrophic sig- the selective sodium-glucose cotransporter 2 inhibitors (SGLT2is), reduced naling in cardiomyocytes. Recent studies have suggested that stromal inter- cardiovascular events in patients with type 2 diabetes (T2D). In this study, action molecule 1 (STIM1), plays a role in regulating cardiomyocyte hyper- we investigate whether EMPA suppresses progression of atherosclerosis trophy, however the function of STIM1 in the heart is poorly understood. We in high-fat diet-fed apolipoprotein-E-deficient (apoE KO) (HFD-apoE-KO) mice have shown that mice with a cardiomyocyte deletion of STIM1 (crSTIM1-KO) and streptozotocin-injected apoE KO (STZ-apoE-KO) mice. HFD-apoE-KO develop ER stress, mitochondrial abnormalities, and dilated cardiomyopa- mice (n=18) or STZ-apoE-KO mice (n=20) were treated with EMPA (5 mg/ thy. Currently, the knowledge of kinases and signaling processes affected by kg/day; n=9 and 10, respectively) or vehicle (control: n=9 and 10, respec- STIM1 is lacking. Therefore, we used a discovery based kinomics approach to tively) for 8 weeks. The whole aorta or 6-µm-thick frozen sections of the identify kinases differentially regulated by STIM1. 12-week male control and aortic sinus were obtained from these mice and were stained with Oil red crSTIM1-KO mice were injected with saline or phenylephrine (PE, 15mg/Kg, O. Detection of reactive oxygen species and macrophages in plaques were s.c), after 15 min hearts obtained for analysis. 2ug lysates were loaded on performed using anti-4-HNE and anti-F4/80 antibodies. Expression of MCP-1 to a Serine/threonine kinome chip. Primary analysis performed using Bion- and TNFalpha in aorta were performed by real-time PCR. Measurement of avigator 6.0 (PamGene) and subsequent analysis performed using Kinexus intracellular reactive oxygen species (ROS) was performed using H2DCF-DA. PhosphoNET database and GeneGo Metacore and confirmed using standard In both two models, there were no significant differences on dietary intake, immunoblotting. Pathway analysis revealed significantly lower PKC and PKG body weight and lipid profile between control group and EMPA group. How- signaling in KO hearts at baseline. Immunoblotting confirmed that activation ever, glucose levels at all time points by meal tolerance test were lower in ema group than in control group. Oil-Red-O staining in the aortic sinus and en of the Ca2+-dependent PKCα at pThr497 (1.00 ± 0.03 vs. 0.75 ± 0.06, p < 0.05) and one if its downstream targets MARKCS at pSer158/162 were lower in face of aorta revealed that size of atherosclerotic lesions was decreased on KO hearts. Similar reductions were found for MEK1/2 at pSer217/221, AMPK ema group in both two models. In STZ-apoE-KO mice, 4-HNE-positive area, at pThr172 (1.00 ± 0.04 vs. 0.57 ± 0.09, p < 0.05) and PDPK1 at pSer241 number of macrophages and mRNA expression of MCP-1 and TNFalpha in (1.00 ± 0.06 vs. 0.75± 0.03, p < 0.05). Additional analysis identified L-type aorta were lower in ema group. Moreover, 30 mM glucose-induced intracel- Ca2+ channel and delayed rectifier +K channels, as target downstream pep- lular ROS generation in peritoneal macrophages was significantly lower in tide sequences of the identified kinases. In support, EKG analysis revealed STZ-apoE-KO mice treated with EMPA. significantly lower HR (461.7 ± 0.73 vs. 428.7 ± 1.98 bpm, p < 0.05) and pro- In conclusion, EMPA suppresses the progression of atherosclerosis in longed QT interval (23.2 ± 0.00 vs. 47.6 ± 0.00 ms, p < 0.05) in KO. These HFD- or STZ-apoE KO mice, and reduced ROS generation in macrophages and data highlight for the first-time that Ca2+ dependent kinases are regulated atherosclerotic lesions. These findings may indicate the beneficial effects of by STIM1 in the heart. This may have important implications in understand- SGLT2is for the prevention of diabetic macrovascular complications. ing how STIM1 contributes to signaling in the diabetic heart. Supported By: American Diabetes Association (1-16-PDF-024 to H.E.C.); National 196‑OR Institutes of Health (R21HL110366); American Heart Association (15POST25260004) Protective Effect of Liraglutide against Vascular Restenosis via Enhancement of Endothelial Nitric Oxide Production 194‑OR HIDEKI KUSHIMA, YUSAKU MORI, MUNENORI HIROMURA, KYOKO KOHASHI, Insulin, Not IGF1, Accelerated Intima Hyperplasia in Diabetes by MASAKAZU KOSHIBU, MICHISHIGE TERASAKI, TOMOYASU FUKUI, TSUTOMU Induction of Hyaluronan Synthase 2 HIRANO, Tokyo, Japan Background: Diabetes is a risk for failure of revascularization after percu- QIAN LI, WEIER QI, YU XIA, KYOUNGMIN PARK, ATSUSHI ISHIKADO, JIALIN FU, taneous transluminal angioplasty. A recent clinical trial showed that a GLP-1 CHRISTIAN RASK-MADSEN, C. RONALD KAHN, GEORGE L. KING, Boston, MA, receptor agonist (GLP-1RA) reduced revascularization in diabetic patients. Osaka, Japan Elevated insulin or IGF1 levels are associated with accelerated arterial We investigated mechanisms for the vasoprotective effect of GLP-1RA in intima hyperplasia (AIH) and restenosis after angioplasty in diabetes. To vivo and in vitro. determine the definitive role for each, we deleted either insulin receptor (IR) Method: Male nondiabetic C57BL6 and diabetic db/db mice (7 weeks) or IGF1 receptor (IGF1R), specifically, in arterial smooth muscle cells (SMC) were subcutaneously implanted with osmotic pumps releasing saline or and assessed AIH after wire injury in regular (RD) or high fat diet (HFD). After liraglutide (lira), and 2 days later, they underwent wire injury of the femoral injury, AIH was worse when mice were on HFD than RD. However, AIH was artery. Injured arteries were corrected 28 days after treatment. attenuated in SMC specific IR knockout (SMIRKO) mice compared to WT mice Results: In C57BL6 mice, lira dose-dependently reduced the neointimal area (25, 49, and 60% by 5.7, 17, and 107 nmol/kg/day, respectively) without even in HFD. In contrast, SMC specific IGF1R knockout mice (SMIGF1RKO) ORALS exhibited increased AIH on HFD. Signaling studies showed that SMC lacking affecting metabolic parameters including HbA1c, but did not induce medial IGF1R had greater responses to insulin for pAKT and proliferation than WT thinning or arterial dilation. Lira also reduced proliferating cells in the neo- SMC, whereas SMC lacking IR responded less well to insulin than WT SMC, intima and media. These effects were abolished by the coadministration strongly indicating that homo-IR has much greater mitogenic signaling and of a nitric oxide (NO) synthase inhibitor. We also investigated a different effects than hetero-IR/IGF1R or homo-IGF1 R in SMC. To determine specific intervention period via treatment only for the first 14 days (F) or 14 days later insulin targeted genes that accelerated AIH, RNA-seq were performed in (L). The F group suppressed neointimal formation similar to the mice treated aortic SMC from WT, SMIGF1KO or SMIRKO mice stimulated with or without for 28 days, whereas the suppression was blunted in the L group. In db/db insulin (100nM). There are only 19 genes which were increased by insulin by mice, lira similarly suppressed neointimal formation and cell proliferation. more than 1.8 fold with p<0.1 in SMIGF1RKO vs. WT VSMC and not increased In human umbilical vein endothelial cells, lira concentration-dependently by insulin in SMIRKO VSMC. Among these genes, only hyaluronan synthase increased NO production, and this effect was preserved in high-glucose 2 (Has2), a critical enzyme for blood vessel development and integrity, was (25 mmol/L) incubation. In contrast, lira did not affect cell proliferation. In confirmed to be decreased in the aorta of SMIRKO compared to WT mice, human aortic smooth muscle cells, lira did not suppress cell proliferation whereas Has2 was increased in the artery of SMIGF1RKO mice after wire stimulated by platelet-derived growth factor. injury vs. WT mice in parallel with increased AIH in SMIGF1RKO mice. Mech- Conclusion: Liraglutide directly suppresses restenosis via the enhance- anistically, insulin induced the expression of Has2 by both PI3K/Akt and Erk ment of endothelial NO production, and this protective effect is preserved pathways in SMC. Thus, accelerated restenosis in obesity and diabetes is under hyperglycemia. Earlier intervention with GLP-1RA may lead to more due to enhanced insulin signaling via homozygous IR in SMC partly due to favorable vascular outcomes. increased expression of Has2 and hyaluronan, indicating the importance of extracellular matrix abnormalities in causing diabetic vascular diseases. Supported By: National Institute of Diabetes and Digestive and Kidney Diseases

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A51 VALID MIXED RESULTS—HETEROGENEITY OF RESPONSES TO NUTRITION INTERVENTIONS

197‑OR VALID MIXED RESULTS—HETEROGENEITY OF Non-GLP-1 Peptide Substrates of DPP-4 Improve Cardiac Function RESPONSES TO NUTRITION INTERVENTIONS in Young Mice but Not Obese Diabetic Mice SRI N. BATCHU, GOLAM KABIR, THOMAS KLEIN, KIM A. CONNELLY, ANDREW 199‑OR ADVANI, Toronto, ON, Canada, Biberach, Germany Body Shape Genetic Risk Score Modifies Effects of Weight-Loss Although DPP-4 inhibitors are now widely employed in the management Diets on Two-Year Changes of Central Adiposity and Body Composi- of people with type 2 diabetes a number of questions remain unanswered. tion: POUNDS Lost Trial Firstly, whereas the glucose-lowering actions of DPP-4 inhibitors are attrib- YORIKO HEIANZA, DIANJIANYI SUN, TIANGE WANG, TAO HUANG, STEVEN R. utable to heightened GLP-1 activity, the effects of GLP-1 or non-GLP-1 peptide SMITH, GEORGE A. BRAY, FRANK M. SACKS, LU QI, New Orleans, LA, Winter Park, substrates of DPP-4 on cardiac function are uncertain. Secondly, whereas FL, Baton Rouge, LA, Boston, MA DPP-4 inhibitors have been repeatedly observed to improve cardiac function A genome-wide study identified genetic variants associated with body shape in pre-clinical models, their effects on cardiovascular outcomes in patients based on a combination of multiple anthropometric traits. We investigated have been largely neutral. Here we explored the GLP-1-independent actions whether the variants characterizing body shape might affect long-term changes of the DPP-4 inhibitor linagliptin whose cardiovascular outcome trials are yet of adiposity in response to low-calorie weight-loss diets. This study included to report. Pointing to a GLP-1-independent mechanism of action, linagliptin 692 obese individuals who were randomly assigned to 1 of 4 diets varying in (0.083g/kg in chow for 8 weeks) preserved cardiac contractility equivalently macronutrient contents. Two-year changes in adiposity measures were evalu- in wild type and GLP-1 receptor knockout mice subjected to pressure over- ated in response to low- or high-protein diets according to body shape genetic load (ejection fraction, fractional shortening, cardiac output and stroke vol- risk score (GRS) based on previously identified 31 variants. We found signifi- ume each p<0.05 vs. normal chow). In isolated perfused hearts, linagliptin cant interactions between the GRS and dietary protein on 2-year changes in in chow for one week or perfusion with the DPP-4 substrates substance waist circumference (WC) and body fat. Higher GRS was associated with a less P or SDF-1α improved post-ischemic cardiac contractility (LVDP, p<0.05 vs. reduction in WC (β [SE] per one point increase in the GRS=0.28 [0.12]; Pinteraction control), whereas other DPP-4 substrates (GLP-1, GLP-2 or GIP) did not. Post- =0.02), whole body fat % (β=0.14 [0.1]; Pinteraction =0.02), and trunk fat % (β = 0.15 ischemic recovery was reduced by ~50% in the hearts of aged, high fat diet- [0.12]; Pinteraction =0.02) in response to high-protein diet. Conversely, higher GRS fed streptozotocin-diabetic mice compared to nondiabetic chow-fed animals was associated with decreases in these outcomes in the low-protein diet and neither substance P nor SDF-1α improved LVDP recovery in these obese group. Our data suggest that obese individuals with distinct levels of the body diabetic hearts. Collectively, these results indicate that i) the DPP-4 inhibi- shape GRS may respond differently to weight-loss diet interventions, and those tor linagliptin has GLP-1 receptor-independent cardiac effects; ii) some of carrying the higher body shape GRS may achieved greater benefits of improving these effects can be mimicked by non-GLP-1 peptide substrates of DPP-4; adiposity by consuming low-protein weight-loss diet. and iii) the cardiac effects of non-GLP-1 DPP-4 substrates are altered by the obese diabetic state. This altered response may contribute to discrepancies Figure. between the effects of DPP-4 inhibitors in experimental models and in car- diovascular outcome trials. Supported By: Boehringer Ingelheim GmbH

198‑OR Increased Compensatory GLP-1 Secretion after Myocardial Infarc- tion in Mice Is Amplified by Linagliptin and Leads to Improved Left Ventricular Function and Mitochondrial Respiratory Capacity SEBASTIAN DIEBOLD, FLORIAN KAHLES, JULIA MOELLMANN, ALEXANDER NICKEL, CHRISTOPH MAACK, NIKOLAUS MARX, MICHAEL LEHRKE, Aachen, Ger- many, Homburg, Germany The incretin hormone GLP-1 holds cardioprotective efficacy and was recently found to be increased by inflammatory stimuli. This study was performed to characterize the secretion of GLP-1 in response to myocardial infarction in mice and investigate its functional relevance. Myocardial infarction (MI) was induced by permanent LAD ligation in 6 weeks old, male C57BL/6J mice, which led to a significant increase of cir- culating GLP-1 concentrations (from 7.9 pM to 20.8 pM after 6 hours; n=6; p<0.05 in comparison to baseline and control). Prevention of GLP-1 degra- dation by pretreatment with the dipeptidylpeptidase-4 (DPP-4) inhibitor linagliptin (3 mg/kg p.o., for 3 days) increased left ventricular contractility (10101± 1690 dp/dt by Millar catheter) relative to control (7830 ± 1445 dp/dt; ORALS Supported By: National Heart, Lung, and Blood Institute; National Institute of p<0.05 n=8) 6 h post MI, while antagonism of the GLP-1 receptor (exendin-9; Diabetes and Digestive and Kidney Diseases; Boston Obesity Nutrition Research 100 nM/kg i.p., 1 day pretreatment) worsened contractility (6469 ± 944 dp/ Center; United States–Israel Binational Science Foundation (2011036) dt; p< 0.05 n=7). Further, linagliptin failed to improve left ventricular func- tion in GLP-1 receptor KO mice demonstrating a GLP-1 receptor-dependent effect. 200‑OR Mechanistically we found that GLP-1 pretreatment (100 nM/kg i.p., 1 day A High-Glycemic-Index Diet may Lower Insulin Sensitivity in White before MI; n=8) and DPP-4 inhibition by linagliptin similarly increased myo- but not Black Americans cardial AMPK-phosphorylation in non-infarcted tissue (1.5 fold induction by JEANNIE TAY, AMY M. GOSS, BARBARA A. GOWER, Birmingham, AL GLP-1; p<0.04 n=4; 1.6 fold induction by DPP-4 inhibition; p< 0.01 n=6), which Background: Compared to Caucasian Americans (CA), African Americans was associated with improved respiratory capacity of isolated mitochondria (AA) have a greater burden of type 2 diabetes (T2D). High glycemic index from non-infarcted tissue (2 fold induction by GLP-1; p<0.04 n=6; 1.7 fold (GI) diets are associated with higher T2D rates according to meta-analyses. induction by DPP-4 inhibition; p< 0.04 n=7). Whether dietary GI is associated with skeletal muscle insulin sensitivity (SI) as In conclusion, MI is a GLP-1 compensatory secreting stimulus, which assessed by the gold standard euglycemic clamp is less clear. Further, whether improves left ventricular function in a GLP-1 receptor dependent manner. associations between diet and SI are similar in CA and AA is not known. This is further amplified by linagliptin dependent DPP-4 inhibition leading Objective: To test the hypothesis that dietary GI would be inversely asso- to AMPK-activation and improved mitochondrial respiration in non-infarcted ciated with SI assessed with euglycemic clamp, and that this relationship tissue. would be similar in CA and AA adults without diabetes. Methods: Skeletal muscle SI was measured by hyperinsulinemic-eug- lycemic clamps at an insulin dose of 120 mU/m2/min in 61 weight- stable adults (56% African Americans, 36% males, mean ± SD: age 29 ± 8 yrs, BMI 27.6 ± 5.9) without diabetes. Dietary intake was assessed by 4-day food records that included 1 weekend day. Lean body mass (LM) was measured by DXA and used to normalize glucose disposal rate.

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A52 VALID MIXED RESULTS—HETEROGENEITY OF RESPONSES TO NUTRITION INTERVENTIONS

Results: In analyses with all participants combined, SI was inversely regained only 1.44 kg (P=0.003) more. Consequently, a 4.39 kg (P=0.001) dif- associated with GI (r= -0.32), and positively associated with intakes of who- ference in responsiveness to the diets were found between normoglycemic legrains (r=0.32), vegetable protein (r=0.27), monounsaturated fat (r=0.31), and prediabetic participants. Prediabetic participants with below median FI and soluble and insoluble dietary fiber (r=0.3; p≤0.04 for all). Diets high in regained 7.78 kg (P<0.001) more on the high than low GL diet, whereas no refined grains (r=-0.24) and glycemic load (r=-0.25) tended to be inversely difference was observed for normoglycemic participants with above median associated with SI (P=0.06). In multiple linear regression analysis, the race x FI [1.17 kg (P=0.19)]. GI interaction was significant (P=0.04, R2 32%), indicating that diet was more Conclusions: Low GL ad libitum diet is an effective strategy for maintenance strongly associated with SI in CA than in AA. of weight loss among prediabetic individuals particular among those also hav- Conclusions: These cross-sectional observations suggest that a high GI ing lower FI. The results are important for a dietary strategy to manage weight diet may have an adverse effect on SI in CA, but not AA. Prospective and maintenance in prediabetic individuals and to prevent type 2 diabetes. interventional studies are needed to clarify whether dietary GI affects SI or diabetes risk in both CA and AA. 203‑OR Supported By: National Institutes of Health/National Institute of Diabetes and Vitamin D Supplementation Has No Effect on Insulin Sensitivity or Digestive and Kidney Diseases (R01DK096388); Nutrition Obesity Research Center Secretion in Vitamin D-Deficient and Overweight or Obese Adults: (P30DK56336); Diabetes Research Center (P60DK079626) A Randomized, Placebo-Controlled Trial BARBORA DE COURTEN, AYA MOUSA, NEGAR NADEPOOR, ROBERT SCRAGG, 201‑OR MAXIMILIAN DE COURTEN, Melbourne, Australia, Clayton, Australia, Auckland, Pretreatment Fasting Plasma Glucose and Insulin as Determinants New Zealand of Weight Loss Success: The NUGENOB Study Objective: Vitamin D supplementation has been proposed as a potential YISHAI ZOHAR, MADS F. HJORTH, CHRISTIAN RITZ, THORKILD I.A. SØRENSEN, strategy for diabetes prevention. However, clinical trials to date have been ARNE ASTRUP, NUGENOB GROUP, Boston, MA, Frederiksberg, Denmark, Copen- limited by the use of low doses of vitamin D supplemented for short dura- hagen, Denmark tions in individuals without vitamin D deficiency, and use of surrogate mea- Background: Which diet is optimal for weight loss and weight mainte- sures of insulin sensitivity and secretion. This double-blind randomized trial nance remains controversial. We studied levels of fasting plasma glucose aims to fill these knowledge gaps. (FPG) and insulin (FI) as determinants of successful weight loss by diets vary- Research Design and Methods: Sixty-five overweight or obese and vita- ing in fat and carbohydrate content. min D deficient (25-hydroxyvitamin D (25OH)D)≤ 50 nmol/L) adults were ran- Methods: A total of 771 primarily obese participants were randomly domized to receive either a bolus oral dose of 100,000 IU followed by 4,000 assigned to receive a low-fat/high-carbohydrate or high-fat/low-carbohy- IU daily of cholecalciferol, or matching placebo for 16 weeks. Before and drate hypocaloric diet (-600 kcal/day) for 10 weeks. Modifications of dietary after intervention, participants had gold standard assessment of body com- effects of pre-treatment FPG and FI were examined by linear mixed models. position (dual X-ray absorptiometry), insulin sensitivity (hyperinsulinemic- Results: Median (interquartile range) BMI was 34.7 (31.8; 38.0) kg/m2. The euglycemic clamps) and insulin secretion (intravenous glucose tolerance low-fat/high-carbohydrate had a 15 E% lower fat and 15 E% higher carbo- test). Fifty-four participants completed the study (35M/19F; age= 31.9±8.5 hydrate content compared to the high-fat/low-carbohydrate diet (P<0.001). years; BMI= 30.9±4.4 kg/m2 (mean±SD)). Normoglycemic participants (n=460 completers) lost 0.43 kg (P=0.03) more Results: 25(OH)D increased in the vitamin D group compared to placebo on the 10 week low-fat/high-carbohydrate than high-fat/low-carbohydrate (57.0±21.3 vs. 1.88±15.1nmol/L, p<0.001). Vitamin D and placebo groups did diet, whereas no difference was observed for prediabetic participants not differ in changes in % body fat (-0.4±1.6 vs. -0.3±1.7%, p=0.9), insulin (n=168 completers) (P=0.41) and diabetic participants (n=15 completers) sensitivity (0.02±2.0 vs. -0.03±2.8 mg/kg/min, p=0.9) or first phase insulin tended to lose 2.04 kg (P=0.07) more on the high-fat/low-carbohydrate secretion (-21.38±212 vs. 24±184 mlU/L, p=0.4). Results remained not sig- diet. Consequently, a 2.47 kg (P=0.03) difference in responsiveness to the nificant after adjustment for age, sex, % body fat, sun exposure, physical diets were found between normoglycemics and diabetics. Participants with activity, and dietary vitamin D intake (p>0.1). FPG≥115 mg/dL (6.4 mmol/L) and below median FI lost 3.06 kg (P=0.02) more Conclusions: Vitamin D supplementation does not improve obesity, insu- on the high-fat/low carbohydrate than the low-fat/high-carbohydrate diet. lin sensitivity or secretion in vitamin D-deficient and overweight or obese Participants with FPG<115 mg/dL and below median FI lost 0.49 kg (P=0.02) adults. It is therefore unlikely that vitamin D supplementation would be an more on the low-fat/high-carbohydrate diet. effective strategy for reducing diabetes risk. Conclusions: Diabetic participants and those with elevated pre-treat- Supported By: Australian National Health and Medical Research Council ment FPG and lower FI benefit more from high-fat/low-carbohydrate diets (1047897) whereas participants with lower FPG and lower FI benefit more from low- fat/high-carbohydrate diets. The results are important for developing a more 204‑OR effective personalised dietary strategy for weight management of diabetic Can Baseline Vitamin D Levels Predict Type 2 Diabetes Remission and prediabetic individuals. following Sleeve Gastrectomy? ALANOUD ALADEL, SAHAR AZHARIAN, PHILIP G. MCTERNAN, MILAN PIYA,

202‑OR VINOD MENON, Coventry, United Kingdom, Derby, United Kingdom ORALS Pretreatment Fasting Plasma Glucose and Insulin as Determinants Background: Vitamin D deficiency contributes to insulin resistance and of Weight Maintenance Success: The DiOGenes Study glucose dysregulation, and subjects with obesity and vitamin D deficiency MADS F. HJORTH, CHRISTIAN RITZ, ELLEN E. BLAAK, WIM H.M. SARIS, DOMI- have an increased future risk of type 2 diabetes mellitus (T2DM). However, NIQUE LANGIN, THOMAS M. LARSEN, YISHAI ZOHAR, ARNE ASTRUP, Frederiks- the effect of baseline physiological Vitamin D levels as a predictor of T2DM berg, Denmark, Maastricht, Netherlands, Toulouse, France, Boston, MA remission following bariatric surgery is unknown. Sleeve gastrectomy (SG) as Background: Which diet is optimal for weight loss and weight mainte- a bariatric procedure is becoming increasingly popular in the UK and world- nance remains controversial. We studied levels of fasting plasma glucose wide. Therefore, the aim of this study was to analyze whether pre-bariatric (FPG) and insulin (FI) as prognostic markers for successful weight mainte- operative vitamin D levels may predict T2DM outcomes 12 months post-SG. nance by diets differing in glycemic load (GL). Method: A cohort of 100 obese patients with T2DM (age: 43±6.5yr, BMI: Methods: Following successful loss of ≥8% body mass during an 8-week 32±12Kg/m2) and without T2DM (age: 47±4.5yr, BMI: 34±11Kg/m2; 73% female) low-calorie-diet (LCD) weight-loss phase 316 overweight and obese partici- undergoing SG participated in an ethics approved study in a single bariatric pants were randomly assigned to an ad libitum low GL (low carbohydrate and centre in the UK. Patient anthropometric and biochemical data including vita- low glycemic index) or high GL (high carbohydrate and high glycemic index) min D were collected at baseline and 12 months post-SG. Patients taking vita- weight maintenance diet for 26 weeks. Modifications of dietary effects of min D supplementation at baseline were excluded from the study. pre-treatment FPG and FI were examined by linear mixed models. Results: In total, 71% of patients had vitamin D deficiency at baseline, Results: The low GL diet had a 5.4 E% lower carbohydrate content and a levels inversely correlated with baseline BMI (P= 0.005, r=-0.330). Pre-op 4.5 glycemic index unit lower content compared to the high GL diet result- weight loss and vitamin D levels were negatively correlated with HbA1c 12 ing in a 32 g/10MJ difference in GL (P<0.001). Initial median (interquartile months post-surgery (P=0.027, r=-0.225 and P=0.020, r=-0.280). Baseline range) body mass index was 33.3 (30.7;37.0) kg/m2. After a median weight vitamin D levels predicted levels of HbA1c post-surgery following adjust- loss of 10.3 kg in the LCD period, prediabetic participants (n=30 completers) ment for pre-op weight loss, HDL and age. Within the group with T2DM regained 5.83 kg (P<0.001) more on the 26 weeks ad libitum high than low (n= 47), patients with T2DM remission (n=21, 44.7%) 12 months post-surgery, glycemic-load diet, whereas normoglycemic participants (n=179 completers) had significantly higher vitamin D at baseline compared with patients who

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A53 DIABETES IN PREGNANCY—BABY, BABY, NO SUGAR MOMMA FOR ME

remained in a T2DM state (44.4±17.16 vs. 33.86±21.4 nmol/L; p=0.026); not- B consumption or omission on glucose homeostasis and clock gene, AMPK, ing that there was no significant differences in the distribution of hyperten- and Sirt mRNA expression in healthy and type 2 diabetes (T2D) individuals. sion (P=0.324), mean pre-op weight loss, excess weight loss (EWL) and other In a crossover design, 18 healthy and 18 T2D volunteers with 14.5±1.5 yr dia- anthropometrics for both groups in all time points. betes, BMI 30.7±1.1 kg/m2 and HbA1c: 7.6 ± 0.1% were randomly assigned to Conclusion: Baseline Vitamin D levels appear to be an important indicator a test day with B and lunch (YesB) and a test day with only lunch (NoB). Post- for T2DM outcomes, 12 months following SG. prandial clock genes (Clock, Bmal1, Per1, Per2, Cry1, Rev-erbα, Rorα) AMPK Supported By: King Saud University and Sirt1 mRNA expression, in white blood cells (WBC), and plasma glucose, insulin, intact glucagon-like peptide-1 (iGLP-1) and dipeptidyl peptidase IV 205‑OR (DPP-4) plasma activity were assessed after B and lunch. In healthy people, Metabolic Effects and Safety of Weight Loss via Intermittent Fast- YesB day led to 26% upregulation of Bmal1, the positive loop of clock gene ing vs. Continuous Energy Restriction in Patients with Type 1 Diabe- expression (p<0.005), to 34-43% increase of AMPK and Sirt1 (p<0.005), and tes and Overweight or Obesity to 30% downregulation of negative feedback loop Per2 after lunch (p<0.05). JANE OVERLAND, KRISZTINA TOTH, JANET FRANKLIN, ALICE GIBSON, LINDA In the diabetic group, YesB day led to 25-42% upregulation of Bmal1, AMPK, MOLYNEAUX, AMANDA SAINSBURY, JENCIA WONG, Sydney, Australia Per1, Cry1 and Rev-erbα (p<0.005). B skipping (NoB day) in healthy and Over 50% of people with type 1 diabetes are overweight or obese. Data type 2 diabetic individuals, led to downregulation of Bmal1 and AMPK is lacking to support a particular dietary approach to weight loss in this high (p<0.005) and it was associated with ~15% elevation of AUC of glucose risk cohort. We conducted a pilot study to examine the metabolic effects response after lunch and impaired insulin and iGLP-1 responses to lunch and safety of weight loss via intermittent fasting (IF) vs. continuous energy (p<0.0001). Breakfast skipping adversely affects the expression of clock, restriction (CER). clock-related genes and AMPK mRNA expression after lunch and was cor- Ten people with type 1 diabetes and overweight or obesity were randomised related with reduced insulin, iGLP-1 and increased postprandial glycemic to IF or CER for 12 weeks. IF involved consuming three meal replacement response after lunch in both healthy and diabetic individuals. These results shakes (600 kcal/day) for two 24-hour periods/week. CR participants were suggest that intake of breakfast is important for maintaining the clock gene given individualised diet plans with a 500 kcal deficit/day. Weekly contact was regulation of the overall glucose metabolism both in healthy and in type 2 maintained for insulin dose adjustment, and monitoring of blood ketone and diabetes. glucose levels. Outcomes were measured at baseline and 13 weeks. Relative to baseline, body weight, waist circumference and trunk fat were reduced in both groups at week 13 (Table 1). Between group analysis DIABETES IN PREGNANCY—BABY, BABY, NO SUGAR showed greater weight loss in IF participants (p<0.1). Blood ketones reached MOMMA FOR ME 1.6 mmol/L in one IF participant, but fell to 0.4 mmol/L after the next meal. Hypoglycaemia was unchanged but participants’ total daily insulin was 207‑OR reduced by 14% and 18% respectively. HbA1c in the First Trimester and Risk of Gestational Diabetes, IF was equally effective in this cohort as CER but close monitoring of insu- 2012-2015 lin requirements and ketosis is required. JEAN M. LAWRENCE, XIA LI, DAVID A. SACKS, Pasadena, CA Table 1. The International Association of Diabetes in Pregnancy Study Groups (IADPSG) recommends early HbA1c testing to assess glycaemia. As data on Intermittent Fasting Continuous Energy Restriction st (IF n=5) (CER n=5) associations between 1 trimester HbA1c and GDM are limited, we exam- ined these associations in our diverse obstetric population. Our health plan’s Baseline 13 weeks Baseline 13 weeks prenatal clinics began universal HbA1c testing as part of initial obstetric Weight (kg) * 75.6 (70.9-103.2) 71.6 (65.3-97.6) α § 80.2 (78.1-103.6) 77.7 (73.0-94.6) α laboratory tests in 2012. Clinical information and lab test results were BMI (kg/m2) 30.1 (2.5) 28.1 (2.4) 33.3 (5.0) 31.8 (3.6) from medical records; maternal race/ethnicity was from birth certificates. HbA1c (%) 8.4 ( 0.9) 8.4 (0.9) 8.6 (1.2) 8.1 (1.5) GDM was identified by applying IADPSG or C&C criteria to 75- or 100-g OGTT results, respectively. Relative risks (RR) and 95% CI were reported Total daily insulin dose (units)* 56 (40-133) 49 (32-132) 68 (29-93) 42 (38-62) for the log binomial models. There were 91,855 deliveries from 2012-2015 Waist circumference (cm) * 90 (84-115) 86 (80-110) α 101 (90-122) 94 (87-108) α to women with 1st trimester HbA1c screening (mean age 30.8 [±5.6] yrs, DEXA Trunk fat (kg) 16.5 (3.0) 14.9( 3.1) α 20.7(4.6) 18.5( 4.2) α mean pre-pregnancy BMI 26.8 [±6.2], 51% Latina). HbA1c was above nor- Mean Arterial Pressure 87.7 (84.7-91.3) 83.0 (78.3-91.3) 81.7 (74.0-97.3) 76.7 (76-82.7) mal for 16.8%; 16.7% were 5.7-6.5% (prediabetes) and 0.1% ≥6.5% (overt (mmHg) * diabetes). After excluding n=105 with HbA1c ≥6.5% due to different follow- up protocols, 95.2% (n=87,373) had testing for GDM, of which 11.6% had Cholesterol (mmol/L) 4.5 (1.0) 5.1 (0.4) 4.3 (0.9) 6.1 (3.8) GDM. Women with HbA1c of 5.7-6.4% had a 50% greater risk (RR=1.54) of HDL cholesterol (mmol/L) 1.5 (0.4) 1.7 (0.3) 1.8 (0.5) 1.3 (0.8) GDM than women with normal HbA1c after adjusting for age, race/ethnicity, Triglycerides (mmol/L) 1.0 (0.5) 0.9 (0.2) 1.0 (0.2) 1.6 (1.7) pre-pregnancy BMI, GDM test (C&C vs. IADPSG), and delivery year. Being obese, age 40 yrs, and Asian each had similar RR as elevated HbA1c (data ORALS Resting Energy Expenditure 1598 (1329-2160) 1614 (1329-2224) 1753 (1505-1997) 1617 (1537-1787) ≥ (Kcal/day)* not shown). HbA1c screening early in pregnancy can identify women at Low Blood Glucose Index * 5.1 (2.3-16.3) 8.7 (2.4-9.9) 6.1 (4.1-11.9) (2.6 (0.5-6.1) increased risk of GDM. Hypoglycaemia 0 (0-3) 0.9 (0.5-1.3) 1 (0-7) 0.9 (0.8-2.3) Table. Association between 1st Trimester HbA1c Category and Risk of GDM (episodes/patient/week)* in a Diverse Obstetric Population. Nocturnal hypoglycaemia 0 (0-1) 0 (0.1-0.2) 0 (0-1) 0.4 (0-0.5) First N (%) N w/ N (%) Unadjusted Adjusted (episodes/patient/week)* Trimester testing for with RR RR HbA1c GDM GDM (95% CI) (95% CI) Mean (SD); * median (range). § p<0.01 ANOVA time*treatment. α p< 0.01 compared to baseline. <5.7% 76,428 (83.2) 74,094 6,822 (9.2) 1.00 1.00

Supported By: Novo Nordisk 5.7-6.4% 15,322 (16.7) 13,279 3,354 (25.3) 2.74 1.54 (2.64-2.85) (1.51-1.57) 206‑OR ≥6.5% 105 (0.1) — — — — Influences of Breakfast on Clock Gene and AMPK mRNA Expression Total 91,855 87,373 10,176 (11.6) — — and Postprandial Glycemia in Healthy and Type 2 Diabetes DANIELA JAKUBOWICZ, JULIO WAINSTEIN, ZOHAR LANDAU, ITAMAR RAZ, BO GDM testing method based on prenatal clinic preferences. IADPSG=75- gram OGTT, 1 abnormal value=GDM, C&C=Carpenter and Coustan=50g AHRÉN, NAVA CHAPNIK, TALI GANZ, MIRIAM MENAGED, MAAYAN BARNEA, ≥ challenge±100-g OGTT, ≥2 abnormal values=GDM. YOSEFA BAR-DAYAN, OREN FROY, Tel Aviv, Israel, Holon, Israel, Jerusalem, Israel, Lund, Sweden, Rehovot, Israel Supported By: Kaiser Permanente Southern California The circadian clock regulates glucose metabolism. Meal timing not aligned with the circadian clock i.e., breakfast (B) skipping and/or eating at hours assigned to sleep, have been associated with high HbA1c and postprandial hyperglycemia after lunch and dinner. Our aim was to explore the effect of

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A54 DIABETES IN PREGNANCY—BABY, BABY, NO SUGAR MOMMA FOR ME

208‑OR 210‑OR GLP-1 Profile during Glucose Tolerance Test in Gestational Diabe- Sex Differences in the Association of Maternal Phenotype with tes: A Prospective Case-Control Study Maternal and Newborn Metabolites in the Hyperglycemia and NITHYA SUKUMAR, CHRISTOS BAGIAS, ILONA GOLJAN, JENS JUUL HOLST, Adverse Pregnancy Outcome (HAPO) Study European Cohort PONNUSAMY SARAVANAN, Coventry, United Kingdom, Nuneaton, United King- VICTORIA SANDLER, JAMES R. BAIN, MICHAEL J. MUEHLBAUER, ALAN KUANG, dom, Copenhagen, Denmark ROBERT D. STEVENS, OLGA ILKAYEVA, LYNN P. LOWE, WILLIAM L. LOWE, JR., Glucagon-like peptide-1 (GLP-1) concentrations are reduced by 20 to 50% in BOYD E. METZGER, CHRISTOPHER B. NEWGARD, DENISE M. SCHOLTENS, HAPO type 2 diabetes but studies in women with gestational diabetes mellitus (GDM) STUDY COOPERATIVE RESEARCH GROUP, Chicago, IL, Durham, NC are inconclusive. Our aim was to study the GLP-1 profile during a 75g glucose Maternal obesity, hyperglycemia and insulin resistance impact fetal tolerance test (GTT) at GDM diagnosis. A prospective study of selectively metabolism and have implications for chronic disease in offspring. Given sex screened women was conducted. Plasma GLP-1 was measured at 30 minute differences in newborn anthropometrics, it is important to understand how intervals during the 2-hour GTT. GDM was diagnosed according to UK NICE fetal sex differences affect the association of maternal BMI and glycemia guidelines (glucose0min ≥5.6mmol/l or glucose120min ≥7.8mmol/l). 145 women with maternal metabolites and fetal traits. Using phenotype data and tar- were recruited and 19 developed GDM (glucose120min range 7.8 to 12.1mmol/l). geted and non-targeted metabolomic assays from 400 European ancestry 19 controls, with the lowest glucose120min values in our cohort (range 4.0 to mother-baby pairs from the HAPO Study, we investigated sex-specific differ- 4.5mmol/l), were identified. GDM women had significantly lower mean GLP- ences in the associations of maternal phenotypes and maternal metabolites 30min concentrations than controls after adjusting for age, ethnicity, smoking at the time of oral glucose tolerance test (OGTT) at 28 weeks gestation and and BMI (Figure). GLP-1 total area under the curve (AUC) was reduced by 13% newborn cord blood metabolites at birth. After adjusting for maternal age, in GDM (adjusted p<0.05) but mean GLP-1 and incremental AUC were similar. mothers of boys had higher BMI, fasting and 1-hour glucose and C-peptide, Aside from glucose0min, GLP30min was a predictor of glucose120min in regression and mean arterial pressure. Mean maternal metabolite levels did not dif- models that adjusted for the above confounders and gestational weight gain fer for women carrying boys vs. girls; however, some maternal phenotype/ (β-coefficient -0.31, p=0.02). There were no associations between GLP-1 at metabolite associations did vary by newborn sex according to statistical other time points and any glucose parameters. Our findings suggest that early interaction tests. In mothers of boys, maternal BMI and fasting plasma GLP-1 response, measured by GLP30min, is reduced by 20% in GDM and it is an glucose (PG) were associated with medium- and long-chain acylcarnitines independent negative predictor of glucose levels during GTT. (AC), 3-hydroxybutyrate, and tricarboxylic acid (TCA) cycle intermediates. In mothers carrying girls, maternal BMI and fasting PG were highly associated Figure. with specific amino acids (AA). 1-hour PG was associated with AC in mothers with girls and TCA cycle intermediates and simple sugars in mothers with boys. Insulin sensitivity was associated with AC and lipid intermediates in mothers carrying girls, in comparison to AA and fatty acids (FA) in mothers with boys. Similar to maternal metabolites, mean newborn metabolite levels did not differ for boys and girls after adjustment for fasting PG and BMI. Sex differences in the associations of AA, AC, and FA with maternal phenotypes may shed light on how the sex of the fetus may impact maternal metabolism. Supported By: National Institute of Diabetes and Digestive and Kidney Diseases; Eunice Kennedy Shriver National Institute of Child Health and Human Development

209‑OR 211‑OR Lipid Predictors of Infant Adiposity in Early and Late Pregnancy, Maternal Hyperglycemia and Children’s Arterial Stiffness Fasting and Fed WING H. TAM, RONALD C.W. MA, CONNIE L.Y. YUEN, JULIANA C.N. CHAN, Hong LINDA A. BARBOUR, TERI L. HERNANDEZ, NICOLE M. HIRSCH, MELANIE S. Kong, China REECE, CATHERINE CHARTIER-LOGAN, JACOB E. FRIEDMAN, RACHAEL E. VAN 482 boys and 444 girls born to mothers who had joined the HAPO study PELT, Aurora, CO, Denver, CO were assessed at 7 years of age for their blood pressure (BP) and carotid- The role of lipids, their timing in gestation, and relationship to the fed vs. femoral pulse wave velocity (cf-PWV). We performed linear regression fasted state as a contributor to fetal fat accrual in normal weight (NW) and analysis to study the associations of maternal plasma glucose (PG) levels obese (OB) women are poorly defined. To test the hypothesis that fasting (F) at OGTT between 24 and 32 weeks of the index pregnancy with children’s and postprandial (PP) triglycerides (TG) contribute to infant adiposity (% fat), BP and cf-PWV. Maternal 1-h and 2-h PG were associated with children’s we studied 25 NW (BMI 22±2) and 18 OB (BMI 31±3) women in early (E=14-16 BP, after adjustment for maternal hypertensive status and children’s age wks) and late (L=28 wks) pregnancy. Fasting (F) and PP (liquid mixed meal) and sex. For each standard deviation (SD) increase in the maternal fasting, glucose (GLU), insulin (INS), TG, and free fatty acids (FFA) were measured. 1-hr and 2-hr glucose levels at OGTT between 24 and 32 weeks of the index Infant % fat was assessed by DXA at 2 wks. Fasting and PP area under the pregnancy, there was corresponding increase in the risk of arterial stiffness ORALS curve over 4 hr (PP ) for GLU, INS and TG were higher in OB vs. NW both in the offspring, after adjustment for confounding variables as shown in the AUC E and L (all p<0.05) and FFA decreased in NW (p<0.05). Insulin resistance Table. The associations were independent of children’s blood pressure. The (INS X GLU ) was higher in OB vs. NW both E and L. Wt gain (15±7 vs. association between cord blood C-peptide levels and children’s cf-PWV was AUC AUC 14±4 kg) and infant % fat (10.9±5 vs. 9±4%) were NS higher in OB. In the evident only in girls, but not boys, independent of their blood pressure. pooled cohort, % fat correlated (all p<0.01) with both E and L FTG (r=0.53; Conclusions: Maternal hyperglycemia in pregnancy and fetal hyperinsu- 0.55), PPTG (r=0.53; 0.58) and PPGLU (r=0.45; 0.41). In OB moms, E FTG linemia are independently associated with offspring’s cardiovascular risk at AUC AUC (r=0.69) and E PP TG and GLU predicted % fat, but only the change from 7 years of age. AUC E to L in FTG and PPTGAUC predicted % fat in NW (r=0.58; 0.57). These data support that while F and PP TG and GLU drive infant adiposity, early exposure is more predictive in OB while the increase in TG over gestation is better in NW. These unique findings may inform earlier interventions in OB vs. NW women that also target both fasted and PP lipids to prevent excess infant adiposity.

Supported By: Research Grants Council of Hong Kong

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A55 HOT TOPICS—ADAPTIVE AUTOIMMUNITY AND TYPE 1 DIABETES

Figure. baseline, 24-28 weeks, 35-37 weeks of gestation and at delivery. Results from 5 sites (n=200) above the overall mean GWG difference (2.02 kg) between intervention (HE&PA) and control women at 35-37 weeks were re-analyzed separately in a post-hoc analysis. Gestation at entry was 15.3 ± 2.3 weeks, past GDM 3%, and pre-pregnancy BMI 33.2 ± 3.5 kg/m2. Mean intervention GWG was 3.2 kg (1.1-5.3) less than the control group in the HE&PA limb by 35-37 weeks, with a reduced HOMA (-0.13 (-0.26, -0.001)) at 24-28 weeks, but no associated difference in FBG (0.03 (-0.10, 0.15)) mmol/l or GDM incidence (OR 1.06 (0.41; 2.73)). There were no significant differences in GWG, FBG or HOMA in HE or PA limbs. No significant differences were found between Supported By: National Institutes of Health (R01DK078645) groups in birth weight or proportion of babies born small or large for gesta- tional age. We conclude that limiting GWG by an additional 3 kg with HE&PA 212‑OR by 35-37 weeks gestation reduces insulin resistance. However, this is insuf- Association between Glycemic Variability and Large-for-Gesta- ficient to reduce FBG or impact on GDM development. tional-Age Neonates in Women with Type 1 Diabetes Supported By: European Union Seventh Framework Programme (FP7/2007-2013) RACHEL T. MCGRATH, SARAH J. GLASTRAS, SEAN K. SEEHO, EMMA S. SCOTT, GREGORY R. FULCHER, SAMANTHA L. HOCKING, Sydney, Australia 214‑OR Objective: Type 1 diabetes (T1D) in pregnancy is associated with an Exposure to Maternal Diabetes In Utero and Offspring Eating increased risk of large-for-gestational-age (LGA) neonates (birth weight >90th Behavior: The EPOCH Study centile for gender and gestational age). Debate remains regarding the optimal ALLISON L.B. SHAPIRO, KATHERINE A. SAUDER, CHRISTINE HOCKETT, EMILY approach for monitoring glycemic control in T1D pregnancy and which time LENZINI, STEPHANIE GRAVITZ, DANA DABELEA, Aurora, CO period during pregnancy contributes most to fetal overgrowth. Our aim was The risk of becoming overweight among offspring exposed to gestational to prospectively and longitudinally determine the ability of HbA1c or glycemic diabetes (GDM) in utero is two-fold higher than in the general population. The variability (GV) to predict LGA neonates in a cohort of women with T1D. responsible mechanisms are likely multifactorial, with some evidence that Design and Methods: 21 women with T1D had continuous glucose moni- GDM exposure alters brain satiety signaling and eating behavior. We investi- toring (CGM) to assess GV at 14-18, 24-28 and 32-36 weeks’ gestation. HbA1c gated the relationship between GDM exposure and altered eating behavior in was measured at CGM device insertion. Indices of GV (Standard Deviation 268 offspring (mean age = 16 yrs, range: 12-19 yrs) from the Exploring Perinatal [SD], J-index) were calculated. The association between HbA1c or GV and Outcomes among Children (EPOCH) cohort who were exposed (n=50) or not LGA was determined. exposed (n=218) to GDM in utero. Adolescent eating behavior was measured Results: 8 neonates were born LGA. Higher GV indices (J-index, SD) at by the Eating in the Absence of Hunger (EAH-C) questionnaire. EAH-C behavior 24-28 weeks’ gestation predicted LGA at birth (p = 0.0001 and p = 0.0001 subscale scores (range: 1-5) for Negative Affect, External Stimuli, and Fatigue/ respectively). These associations retained significance after adjustment Boredom were derived by averaging responses across items corresponding to for gestational weight gain, duration of diabetes and insulin pump use (p = each subscale. The association between GDM exposure and scores for each 0.039 and p = 0.007 respectively). GV indices at 32-36 weeks’ gestation were behavior subscale was evaluated in multivariate linear models, controlling not predictive of LGA neonates. Women having LGA neonates had higher for a priori covariates (maternal pre-pregnancy BMI, offspring birth weight, HbA1c at each time point in pregnancy, however these associations were not age, race, and Tanner stage), and including an interaction term between GDM statistically significant after adjustment for confounders. J-index at 24-28 exposure and sex. In univariate analyses, female adolescents scored signifi- weeks was more strongly correlated with birth weight centile than HbA1c cantly higher on negative affect (score = 1.6 vs. 1.4, p = 0.03) compared to (r = 0.708; p = 0.0001 vs. r = 0.613; p = 0.003). Furthermore, the combination their male counterparts. Sex significantly modified the association between of J-index and HbA1c at 24-28 weeks resulted in substantial predictability GDM exposure and Fatigue/Boredom eating behavior (p = 0.02), indicating that of LGA neonates (AUC = 0.99; p = 0.0003). Combined, HbA1c > 6% (42mmol/ female offspring exposed to GDM in utero (vs. those unexposed) were more mol) and J-index of > 30 at 24-28 weeks had a sensitivity of 100% and a likely to eat in response to feeling bored or tired, even when already satiated specificity of 100% for predicting LGA neonates. (B = 0.64, 95% CI: 0.08, 1.20). The interaction between GDM exposure and sex Conclusions: Elevated GV at 24-28 weeks’ gestation is more predictive on Negative Affect eating also approached significance (p = 0.07), suggesting of LGA neonates than HbA1c. Minimising GV in the second trimester may that GDM-exposed female adolescents may be more likely to eat in response reduce the risk of fetal overgrowth in T1D pregnancy. to anger or sadness (vs. those unexposed). Our findings highlight the need for Supported By: Novo Nordisk Australia; Australia Regional Diabetes Support further investigation into the possible early life programming of brain satiety Scheme; Australia Ramsay Research and Teaching Fund signals and eating behaviors by GDM exposure. Supported By: National Institute of Diabetes and Digestive and Kidney Diseases 213‑OR Does Limiting Gestational Weight Gain Reduce the Risk of GDM? HOT TOPICS—ADAPTIVE AUTOIMMUNITY AND

ORALS The DALI Randomised Controlled Trial Post-hoc Analysis DAVID SIMMONS, MIREILLE VAN POPPEL, GERNOT DESOYE, ROSA CORCOY, TYPE 1 DIABETES ROLAND DEVLIEGER, ALEXANDRA KAUTZKY-WILLER, PETER DAMM, ELISA- BETH R. MATHIESEN, DORTE M. JENSEN, FIDELMA DUNNE, ANNUNZIATA 215‑OR LAPOLLA, EWA WENDER-OZEGOWSKA, AGNIESKA ZAWIEJSKA, ALESSAN- Costimulatory Molecule CD226 Impacts Lymphocyte Frequency and DRA BERTOLOTTO, LISE-LOTTE TORVIN ANDERSON, DAVID J. HILL, DALI CORE CD8+ T-Cell Function during Type 1 Diabetes INVESTIGATOR GROUP, Campbelltown, Australia, Amsterdam, Netherlands, Graz, WEN-I YEH, HOWARD R. SEAY, BRITTNEY N. NEWBY, CLAYTON E. MATHEWS, Austria, Barcelona, Spain, Leuven, Belgium, Vienna, Austria, Copenhagen, Denmark, TODD M. BRUSKO, Gainesville, FL Odense, Denmark, Galway, Ireland, Padova, Italy, Poznan, Poland, Pisa, Italy, London, Investigations into the pathogenesis of type 1 diabetes (T1D) implicate ON, Canada antigenic priming and costimulation as key pathways in disease develop- With few exceptions, lifestyle interventions have not prevented GDM. One ment. A non-synonymous polymorphism in the costimulatory molecule CD226 possible reason has been insufficient gestational weight gain (GWG) limita- (rs763361) has been linked to genetic risk for T1D. This activating pathway is tion. We compared the effect of 3 lifestyle interventions (Healthy eating (HE), constrained by the co-inhibitory receptor T-cell immunoreceptor with Ig and Physical activity (PA) and both HE and PA (HE&PA)) on fasting glucose (FBG) ITIM domains (TIGIT) that competes with CD226 for ligands CD112/CD155. and HOMA in sites with the greatest GWG limitation in a European multicen- We have previously showed that CD226 facilitates CD4+ T effector function, tre randomised trial (n=436) (ISRCTN70595832). Pregnant women at risk of whereas TIGIT potentiates regulatory T (Treg) cell activity. Here, we report GDM (BMI≥29 kg/m2) were invited to undertake a 75g oral glucose tolerance the susceptible variant at rs763361 (T/T) leads to increased total circulating test before 19+6 weeks gestation. Those without GDM (based on IADPSG/ lymphocyte count by 1.3-fold (N=82; nT/T=34; p=0.018). Moreover, we report WHO 2013 criteria) were randomized to HE, PA or HE&PA, pre-stratified by site. a novel function of CD226 in controlling CD8+ T-cell activity. Both CD226 and Women received 5 face-to-face, and 4 telephone coaching sessions based on TIGIT are upregulated upon human CD8+ T-cell activation and remain highly the principles of motivational interviewing. Each intervention included discus- expressed in memory subsets. Interestingly, TIGIT is co-expressed with the sion about the risks of GDM and 7 HE and/or 5 PA ‘messages’ depending on transcription factors T-bet and EOMES, whereas ~80% of cytokine produc- randomization. A GWG target <5kg was emphasized. Data were collected at ing cells express CD226, demonstrating the coordinated expression of these

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A56 HOT TOPICS—ADAPTIVE AUTOIMMUNITY AND TYPE 1 DIABETES factors with differentiated T-cell lineages. We next sorted CD8+ T-cells ing dysregulation in naïve CD4 T-cells since NOD CD4 T-cells show a skewing based on CD226 and TIGIT expression and assessed effector activity as well toward memory cell formation upon polyclonal stimulation which is rescued by as gene expression profile following in vitro activation. Using a multiplex 2-DG. Finally, we show that treatment of mice with 2-DG delays hyperglycemia assay, we showed that CD226+ cells produced cytokines, chemokines, and in an adoptive transfer model of T1D (median delay 2.5 days, p < 0.05). Over- cytolytic proteins (e.g., IFNγ, MIP-1α, granzyme B, and perforin) in a manner all, our findings support the hypothesis that metabolic reprogramming of CD4 independent of TIGIT. We further discovered over 160 genes differentially T-cells by inhibiting glycolysis is a viable therapeutic target in T1D. regulated by CD226 or TIGIT in CD8+ T-cells. Based on these observations, Supported By: American Diabetes Association (7-12-CD-11 to H.M.T.); JDRF we expect CD226 and TIGIT will impact CD8+ T-cell cytotoxicity to human (1-SRA-2015-42-A-N); National Science Foundation (DMR 1306110); National β-cells, which express high levels of the ligands CD112 and CD155. These Institutes of Health (R01DK099550, T324T90DE022736-05) data support this co-stimulatory axis as a potential therapeutic pathway in T1D that could either attenuate CD226 co-stimulation of effector T-cells, or 218‑OR inversely support tolerance induction by TIGIT signaling on Tregs. Stem Cell Derived Tissue-Associated Regulatory T-Cells Suppress Supported By: American Diabetes Association (1-16-PDF-131 to W-I.Y.); National Autoimmune Diabetes Institutes of Health; JDRF MOHAMMAD HAQUE, JIANXUN SONG, Hershey, PA Pluripotent stem cells (PSCs) can be utilized to obtain a renewable source 216‑OR of healthy regulatory T-cells (Tregs) to treat autoimmune diabetes as they have + Killers with a Sweet Tooth: CD8 T-Cells Require Glucose to Destroy the ability to produce almost all cell types in the body, including Tregs. Auto β-Cells Ag-specific PSC-Tregs can be programmed to be tissue-associated and infil- SCOTT E. STIMPSON, JING CHEN, ASHLEY ZUNIGA, ADRIAN JOHNSTON, trate to local inflamed tissues (e.g., islets) to suppress autoimmune responses BRITTNEY N. NEWBY, RAM KHATTRI, MATTHEW MERRITT, CLAYTON E. after adoptive transfer, thereby avoiding potential overall immunosuppres- MATHEWS, Gainesville, FL sion from non-specific regsT . In this study, we developed a new approach to Insulitis, the presence of adaptive immune cells (including autoantigen- generate functional Ag-specific regsT from induced PSC (iPSCs), i.e., iPSC-Tregs, specific cytotoxic CD8+ T-cells (CTL)), in the pancreatic islets represents the which have the ability to suppress autoimmunity in a murine model of autoim- pathological lesion of type 1 diabetes (T1D). Identifying a means to restrain mune diabetes in Ag-associated fashion. We retrovirally transduced murine autoreactive CTL could provide a novel therapeutic avenue to prevent T1D. iPSCs with a DsRed reporter construct containing genes of major histocom- We hypothesized that by identifying the energy substrate requirements of patibility complex (MHC) II (I-Ab)-restricted ovalbumin (OVA)-specific T-cell activated CTL we could block the cytotoxic effects on β-cells. To test this receptor (TCR) and the transcriptional factor FoxP3. We in vitro differentiated + hypothesis, we used Glucose-6-Phosphatase Catalytic Subunit 2 (IGRP) the DsRed iPSCs into OVA-specific iPSC-Tregs with an OP9 stromal cell line reactive CTL from three donors. These IGRP-CTL were used in cytotoxic- expressing Notch ligands DL1, DL4 and I-Ab in the presence of recombinant ity assays against human β cells under conditions of substrate limitation/ cytokines of rIL-7 and rFlt3L. We visualized the expression of CD3, TCR, CD4, excess as well as in the presence of metabolic inhibitors. CTL cytotoxicity CD25, and CTLA-4 on OVA-specific iPSC-Tregs. We also in vivo differentiated capability was equal in media containing 11, 5.5, 2.7 or 1mM glucose. When the TCR and FoxP3 gene-transduced iPSCs into functional OVA-specific regsT , using 0mM glucose media, CTL activity dropped to approximately 50% of which had the ability to produce TGF-beta, following OVA stimulation. More- the level observed with 5.5mM glucose. Addition of equal concentrations over, adoptive transfer of such Tregs dramatically suppressed autoimmunity of glucose and the competitive inhibitor 2-deoxyglucose (2DG: 2.7mM ea) in a well-established OVA-induced model of autoimmune diabetes, including resulted in no CTL activity. CTL activity in 0mM glucose media could not be the inflammation and prevents the insulin secreting pancreatic beta cells rescued by addition of galactose (5.5mM) or excess mitochondrial (mt) sub- from destruction. Of note, we demonstrated that the adoptive transfer sig- strates (pyruvate or methyl succinate (20mM ea)), suggesting that glycoly- nificantly reduced the higher ratio of CD8+ to CD4+ T-cells in diabetic mice. Our sis is required for CTL activity with no mt bioenergetic input. CTL cytolytic results indicate that stem cells can be used to develop auto Ag-specific regsT , activity remained when inhibiting mt electron transport complexes or ATP which have a therapeutic potential for autoimmune diabetes. translocation, establishing that mt were unnecessary in effector CTL activ- Supported By: American Diabetes Association (1-16-IBS-281 to J.S.); National ity. 1H NMR studies supported that CTL produced high levels of lactate and Institutes of Health (R01AI121180, R21AI109239) that CTL do not utilize glutaminolysis, Leloir pathway, or mt ATP production as a bioenergetic source during effector function. To test whether 2DG has + 219‑OR the ability to modulate T1D onset we used an accelerated NOD-CD8 T-cell Redirected Regulatory T-Cells that Target Antigen-Specific T-Cells receptor transgenic model with 2DG supplemented in the drinking water. Are Highly Immunosuppressive Mice receiving 2DG were protected against T1D development. DIMITRI KAKABADSE, SIGAL FISHMAN, MARK D. LEWIS, SHIRA PEREZ, LI WEN, In conclusion, glucose as the sole energy substrate used by activated GIDEON GROSS, F. SUSAN WONG, Cardiff, United Kingdom, Kiryat Shmona, Israel, effector CTL and inhibiting glycolysis in CTL can block T1D onset. New Haven, CT Supported By: University of Florida Regulatory T-cells (Treg) play an important role in modulating the develop- ment of type 1 diabetes in both humans and the Non Obese Diabetic (NOD)

217‑OR mouse. In order to enhance regulatory T-cell activity, we have developed ORALS CD4 T-Cell Metabolism as a Therapeutic Target in Type 1 Diabetes genetic constructs encoding the MHC class II I-Ag7 α- and β-chains, carry- RUTH E. MCDOWELL, HUBERT M. TSE, Birmingham, AL ing a mimotope peptide recognised by the highly diabetogenic CD4 T-cell CD4 T-cells must engage specific metabolic programs to efficiently undergo BDC2.5 in the NOD mouse, supplemented with CD3-ζ intracellular activation activation, differentiation, proliferation, and effector responses. Inhibiting CD4 domain. We have used these constructs to redirect CD4+CD25+FoxP3+ Treg T-cell metabolism can ameliorate autoimmune and inflammatory diseases such cells against BDC2.5 T-cells that recognise the specific class II/peptide con- as lupus, asthma, experimental autoimmune encephalomyelitis, and arthritis. struct. CD4+CD25+ FoxP3+Treg cells were enriched from young female NOD Therefore, immuno-metabolic reprogramming demonstrates potential as a mice that express FoxP3 with a red fluorescent protein (RFP) reporter gene. novel strategy to rectify aberrant T-cell responses in type 1 diabetes (T1D), an The cells were co-transfected with the I-Ag7-BDC2.5mimotope peptide- autoimmune disease culminating in the destruction of insulin-secreting pan- CD3-ζ RNA constructs by electroporation. BDC2.5 transgenic T-cells were creatic β cells. We hypothesize that dysregulated CD4 T-cell metabolism is labelled with CFSE and used as responders in a proliferation assay, assess- a driver of T1D and that metabolic reprogramming can dampen exacerbated ing the dilution of CFSE in response to the peptide recognized by the BDC2.5 inflammatory T-cell responses to delay T1D. To test this hypothesis, we investi- T-cells. The transfected Tregs and control Tregs were used to test suppres- gated the effect of the glycolysis inhibitor 2-deoxy-glucose (2-DG) on CD4 T-cell sion of the BDC2.5 T-cells. In-vitro, transfected Tregs redirected towards effector responses and adoptive transfer of T1D. We show that 2-DG inhibits BDC2.5 T-cells, exhibited greater suppression of BDC2.5 T-cell prolifera- IFNγ and IL-17A production by 3 and 2.5-fold (p < 0.001), respectively, from dia- tion to their cognate peptide, compared to control Treg cells. Suppression betogenic NOD. BDC-2.5 CD4 T-cells stimulated with their cognate autoantigen was tested at different Treg:BDC responder ratios and the higher Treg:BDC while slightly increasing IL-10 production (1.5-fold, p < 0.05) at a dose which responder ratios, the greater the suppression. Our experiments show that does not compromise viability or proliferation. Furthermore, we show that the Treg cells electroporated with mRNA encoding the antigen-specific peptide exacerbated effector cytokine production seen in stimulated NOD CD4 T-cells can target diabetogenic CD4+T-cells and are more suppressive than control compared to CD4 T-cells from T1D-resistant B6.H2g7 mice can be rescued by Treg cells. These Tregs that selectively target diabetogenic T-cells that will treatment with 2-DG. Our data suggest that metabolic dysregulation may occur be tested for ability to prevent diabetes in the NOD mouse. in the CD4 T memory or effector cell compartments rather than an underly- Supported By: BIRAX Regenerative Medicine Initiative; JDRF; Diabetes UK

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A57 LIPID MODIFYING INTERVENTIONS AND THEIR CONSEQUENCES

220‑OR 222‑OR Hybrid Insulin Peptides as Biomarkers in Type 1 Diabetes Islet Autoantibodies Are Associated with Insulitis but Not Beta Cell ROCKY L. BAKER, THOMAS DELONG, PETER A. GOTTLIEB, KATHRYN HASKINS, Loss in Type 1 Diabetes Aurora, CO, Denver, CO LAURA M. JACOBSEN, DESMOND A. SCHATZ, STEPHANIE L. FILIPP, MATTHEW We recently established that hybrid insulin peptides (HIPs), formed spon- J. GURKA, MICHAEL J. HALLER, MARK A. ATKINSON, MARTHA CAMPBELL- taneously in islet beta-cells by fusion of insulin C-peptide fragments to THOMPSON, Gainesville, FL peptides of Chromogranin A (ChgA) or Islet Amyloid Polypeptide (IAPP), are Type 1 diabetes (T1D) is a presumptive autoimmune disease characterized ligands for diabetogenic CD4 T-cell clones. The goal of this study was to histologically by a T cell insulitis and serologically by the presence of islet investigate whether HIP-reactive T-cells were indicative of ongoing autoim- autoantibodies (AAb) that notably wane with diabetes duration, presumably munity in mice and in human T1D patients. due to loss of antigen as β cell mass declines. We therefore sought to uti- We used MHC class II tetramers loaded with HIPs to investigate the lize samples from the Network for Pancreatic Organ donors with Diabetes presence of HIP-reactive T-cells by flow cytometry in the islets, spleen and (nPOD) to evaluate relationships between AAb, insulitis, and residual β cells. peripheral blood of nonobese diabetic (NOD) mice. Using a 10-color, multi- nPOD T1D pancreas samples (n=118) with immunohistochemical staining, two parameter, flow cytometric assay, we assessed the phenotype of tetramer- blocks per head, body and tail, were analyzed. Testing for GADA, IA-2A, and positive cells. Both ChgA/HIP and IAPP/HIP tet+ cells were present in the ZnT8A via RIA was performed on sera. mIAA was excluded due to long term islets of NOD mice starting at 6 weeks of age, and continued to accumu- insulin use in donors. Associations between variables were assessed via chi- late throughout disease progression. A longitudinal analysis in the blood of square and Fisher’s exact tests; Cochran-Mantel-Haenszel tests were used NOD mice demonstrated that T-cells specific for a HIP containing a ChgA for ordinal variables. Donors with insulitis plus residual β cells had an aver- sequence are activated very early (before 8 weeks of age) whereas T-cells age age of onset of 13.7±5.7 years with short duration of diabetes (3.9±3.2 specific for an IAPP/HIP are activated at a later time point. NOD mice that years). Donors without insulitis but with residual β cells were older at onset went diabetic had a high frequency of tetramer-positive cells that were char- (17.7±10.3 years) compared to those with complete loss of β cells (10.5±7.8) acterized by an antigen-experienced phenotype. and a similar disease duration. Those with insulitis (n=28) had a greater To investigate their relevance to human disease, we used IFN-gamma number of AAb than those without insulitis (n = 90; p=0.02). There was a ELISPOT to determine whether HIP-reactive T-cells with an inflammatory significant trend of multiple AAb observed among those with insulitis who phenotype were present in PBMCs of new onset T1D patients. We observed had longer duration (>5 years) of diabetes (p<0.01). AAb presence, stratified that PBMCs from new onset T1D patients responded to 8 of 16 HIPs tested. by number, type, or duration of disease did not show a significant difference Furthermore, nearly half of the patients tested responded to one or more between those with and without residual β cells. Notably, AAb were present HIPs, indicating that HIP-reactive T-cells can potentially serve as a bio- in 34/69 cases (49%) with complete loss of insulin staining (mean T1D dura- marker of disease in a subset of patients. tion 23 years). Our findings support the hypothesis that HIP-reactive T-cells are critical In summary, the presence of insulitis is associated with multiple AAb players in the pathogenesis of T1D in mice and in humans. regardless of duration of T1D. Persistence of β cells is associated with older Supported By: American Diabetes Association (1-15-JF-04 to R.L.B.); National age of onset supporting the notion that younger onset of T1D is a different Institutes of Health; JDRF and more severe disease. Finally, AAb are not associated with the presence or absence of residual β cells. 221‑OR Antibodies to Posttranslationally Modified Insulin for Prediction of Type 1 Diabetes in Children LIPID MODIFYING INTERVENTIONS AND THEIR ROCKY STROLLO, CHIARA VINCI, NICOLA NAPOLI, PAOLO POZZILLI, JOHNNY CONSEQUENCES LUDVIGSSON, AHUVA NISSIM, Rome, Italy, London, United Kingdom, Linköping, Sweden 223‑OR Background: We have shown that autoimmunity to insulin in type 1 MicroRNA-30c Reduces Plasma Cholesterol in Different Hypercho- diabetes (T1D) may result from neo-epitopes induced by oxidative post- lesterolemic and Hyperglycemic Mouse Models translational modifications (oxPTM). Antibodies specific to oxPTM-insulin SARA IRANI, JAHANGIR IQBAL, MAHMOOD HUSSAIN, Brooklyn, NY, Mineola, NY (oxPTM-INS) are present in the majority of newly-diagnosed T1D subjects High plasma cholesterol levels are found in several metabolic disorders and are more prevalent than autoantibodies to native insulin. We investi- and their reductions are advocated to reduce risk of atherosclerosis. A way gated whether oxPTM-INS-antibodies (oxPTM-INS-Ab) are present before to lower plasma lipids is to curtail lipoprotein assembly and secretion; how- T1D clinical onset, and evaluated the ability of oxPTM-INS-Ab to identify ever, this is associated with steatosis. We have shown that microRNA-30c children progressing to T1D in comparison to other islet-autoantibodies. (miR-30c) reduces Western diet-induced hypercholesterolemia and athero- Methods: We used serum samples collected longitudinally from the ‘All sclerosis in C57BL/6J and Apoe-/- mice with no adverse effects by reducing Babies In Southeast Sweden (ABIS)’ cohort tested for the gold standard hepatic lipoprotein production and lipid synthesis. Here, we tested the effect islet-autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA), of miR-30c on plasma lipids, transaminases and hepatic lipids in five mouse tyrosine phosphatase 2 (IA-2A). We studied 23 children who progressed to

ORALS models. Hepatic delivery of miR-30c reduced MTP activity but did not affect T1D (progr-T1D) and 63 children who did not progress to T1D after a median plasma lipids and glucose in chow-fed C57Bl6J and streptozotocin-induced follow-up of 11 years. Of the latter group, 32 were positive to one or more diabetic, normolipidemic mice. However, miR-30c reduced cholesterol in islet-autoantibodies (AAB+). Antibodies to insulin modified by• OH or HOCl total plasma and VLDL/LDL by ~ 28% and ~ 25%; respectively in chow fed (oxPTM-INS) were measured by our developed ELISA. leptin deficient (ob/ob) and leptin receptor deficient (db/db) hypercholesterol- Results: •OH-INS-Ab were present in 82% of progr-T1D children vs. emic and hyperglycemic type 2 diabetic mice, without affecting glucose lev- 19% of AAB+ who did not progress and 0% of AAB- controls, respectively els. Interestingly, these mice had lower plasma transaminases and creatine (p<0.001). oxPTM-INS-Ab detected 17.4%, 26.1% and 44.4% of progr-T1D kinases indicating possible beneficial effects. Mechanistic studies showed children who were negative to GADA, IA-2A or IAA, respectively. Among that miR-30c reduced hepatic MTP activity and lipid synthesis. Moreover, children positive to at least one autoantibody, oxPTM-INS-Ab displayed miR-30c significantly lowered plasma cholesterol and atherosclerosis in 74% sensitivity and 91% specificity. GADA and IAA were less sensitive Western-diet fed low density lipoprotein receptor knockout mice with no (39% and 44%, respectively) and specific (68% and 84%, respectively) than effect on plasma triglyceride, glucose and transaminases, suggesting that oxPTM-INS-Ab. The oxPTM-INS-Ab accuracy for progr-T1D was higher than miR-30c can be a potential therapeutic agent for homozygous familial hyper- GADA (AUC 0.862±0.06 vs. 0.566±0.09; p=0.003) or IAA (AUC 0.862±0.06 vs. cholesterolemia. In all these studies, hepatic lipid levels were similar in con- 0.624±0.08; p=0.017) and similar to IA-2A (AUC 0.871±0.05). trol and miR-30c injected mice. These studies indicate that miR-30c reduces Conclusions: oxPTM-INS-Ab are present before T1D clinical onset. Mea- plasma cholesterol in diet-induced and diabetic hyperholesterolemic mice surement of oxPTM-INS-Ab alone may identify children progressing to T1D but not in normocholesterolemic mice. Thus, miR-30c may be beneficial in with better accuracy than GADA and IAA. lowering plasma cholesterol in different metabolic disorders independent of Supported By: European Foundation for the Study of Diabetes; JDRF; Swedish the origin of hypercholesterolemia. Research Council; Swedish Child Diabetes Foundation; Wallenberg Foundation; Supported By: American Heart Association; National Institutes of Health Medical Research Council of Southeast Sweden; Swedish Council for Working Life and Social Research

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A58 LIPID MODIFYING INTERVENTIONS AND THEIR CONSEQUENCES

224‑OR 226‑OR Pirfenidone Prevents and Reverses Hepatic Insulin Resistance and Efficacy and Safety of Alirocumab in Persons with Type 1 or Type 2 Steatohepatitis by Polarizing M2 Macrophages in Mice Diabetes Mellitus and Atherosclerotic Cardiovascular Disease in 10 GUANLIANG CHEN, YINHUA NI, NAOTO NAGATA, LIANG XU, MAYUMI ODYSSEY Phase 3 Trials NAGASHIMADA, SHUICHI KANEKO, TSUGUHITO OTA, Kanazawa, Japan OM P. GANDA, JORGE PLUTZKY, SANTOSH K. SANGANALMATH, MAJA BUJAS- Excessive hepatic lipid accumulation promotes the activation of macro- BOBANOVIC, ANDREW KOREN, JONAS MANDEL, LAWRENCE A. LEITER, Boston, phage/Kupffer cells, resulting in exacerbation of insulin resistance and non- MA, Tarrytown, NY, Paris, France, Bridgewater, NJ, Chilly-Mazarin, France, Toronto, alcoholic steatohepatitis (NASH). Pirfenidone is an antifibrotic agent used in ON, Canada the treatment of pulmonary fibrosis. Pirfenidone also suppresses bleomycin- Introduction: Individuals with diabetes mellitus (DM) and atherosclerotic induced increases in the pulmonary influx of T-cells and macrophages. How- cardiovascular disease (ASCVD) are at high risk for future cardiovascular ever, less attention has been focused on its anti-inflammatory effects. Here, events. We report the efficacy and safety of alirocumab (ALI) in 984 persons we investigated the effect of pirfenidone in a lipotoxicity-induced NASH with DM and ASCVD in 10 ODYSSEY Phase 3 trials. model. C57BL/6 mice were fed a high-cholesterol, high-fat (CL) diet with or Methods: Persons with DM and ASCVD (defined in Table) were pooled without 0.2% pirfenidone. After 12 weeks, pirfenidone treatment reduced from 5 placebo- and 5 ezetimibe-controlled trials (24-104 week [W] duration). hepatic TG, TC, and NEFA levels by 24%, 23%, and 50%, respectively (all Results: Baseline characteristics in ALI (n=638) vs. control (n=346) groups p < 0.05), as well as lipid peroxidation, which was assessed by TBARS. Pir- were comparable. Overall, ~96% were on statin therapy. On ALI, significant fenidone improved glucose intolerance and hyperinsulinemia in the CL group reductions from baseline in LDL-C and non-HDL-C were observed, and a and enhanced the insulin signal, assessed by IRβ and Akt phosphoryla- higher % achieved LDL-C levels <50 mg/dL, at W24 vs. control (Table). Mean tion, in the liver, which is associated with the attenuation of MAPK (ERK/ differences in % change from baseline at W24 with ALI vs. control ranged p38MAPK) and NF-kB activation. Flow cytometry analysis revealed that from +3.6 to +10.7% for HDL-C, -46.0 to -20.0% for Lp(a) and -15.2 to +2.1% pirfenidone reduced total hepatic macrophages, particularly CD11c+CD206− for triglycerides in the analyzed pools. ALI did not affect FPG or HbA1c lev- (M1), whereas it increased CD11c-CD206+(M2), with subsequent reduction els compared with control. Overall safety was generally similar between of CD4+ and CD8+ T-cell contents, which contributed to the improvement treatment groups. Injection site reactions, reported in 5.0% vs. 2.7% (ALI vs. of insulin resistance and steatohepatitis. Moreover, pirfenidone downregu- control) and 2.5% vs. 0.8% in the placebo- and ezetimibe-controlled trials, lated LPS-induced M1 marker mRNA expression in RAW264.7 macrophages respectively, were mostly mild and few led to ALI discontinuation. but augmented IL-4-induced M2 marker mRNA expression in a dose-depen- Conclusion: ALI significantly reduced LDL-C, Lp(a) and non-HDL-C, and was dent manner. Additionally, pirfenidone reduced the activation of hepatic generally well-tolerated, vs. placebo or ezetimibe in persons with DM and stellate cells and inhibited fibrosis, lowering hydroxyproline content by 40% ASCVD. (p < 0.05). Importantly, pirfenidone reversed insulin resistance, as well as Table. Percent Change From Baseline in Calculated LDL-C and Non-HDL-C, hepatic inflammation and fibrosis, in pre-existing advanced NASH. and Percent Achieving LDL-C Levels <50 mg/dL, at Week 24 in Persons with In conclusion, pirfenidone might be a novel and promising treatment for DM† and ASCVD‡ (Intention-to-Treat Analysis with Mixed-Effect Model with NASH. Repeat Measures). Supported By: Japan Ministry of Education, Culture, Sports, Science and Tech- LDL-C Non-HDL-C nology % LS mean (SE) ALI Control Difference % achieving ALI Control Difference (PBO or vs. control LDL-C <50 mg/dL (PBO or vs. control 225‑OR EZE) (95% CI) at W24 EZE) (95% CI) Apolipoprotein C-III Proteoform Distribution Is Associated with Insulin Resistance in Prediabetes ALI 150 (n=340) -61.5 -1.0 -60.5 67.4% ALI vs. -50.8 -1.0 -49.8 vs. PBO (n=172), (1.6) (2.2) (-65.9 0.2% PBO (1.4) (1.9) (-54.4 JURAJ KOSKA, OLGICA TRENCHEVSKA, DOBRIN NEDELKOV, RALPH A. with statins to -55.2) to -45.2) DEFRONZO, DAWN C. SCHWENKE, PETER D. REAVEN, ACT NOW INVESTIGA- TORS, Phoenix, AZ, Tempe, AZ, San Antonio, TX, Sacramento, CA ALI 75/150 (n=92) -46.4 +6.3 -52.7 54.3% ALI vs. -36.8 +9.2 -46.0 Apolipoprotein C-III (apoC-III) is considered a major contributor to dys- vs. PBO (n=45), (3.0) (4.5) (-63.5 2.5% PBO (2.9) (4.3) (-56.5 lipidemia in insulin resistance (IR). In our previous studies, higher relative with statins to -41.9) to -35.5) amounts of a distinct disialylated apoC-III (apoC-III2) proteoform improved ALI 75/150 -48.7 -20.6 -28.1 56.0% ALI vs. -40.9 -16.0 -24.9 lipid metabolism in hepatocytes in vitro and was inversely associated with (n=173) vs. EZE (2.6) (3.3) (-36.6 18.2% EZE (2.4) (3.1) (-32.6 plasma triglycerides (TG) in humans. It remains unknown whether relative (n=110), with to -19.6) to -17.1) statins amounts of apoC-III2 are modified by insulin sensitivity and thus contribute to IR-related dyslipidemia. ALI 75/150 (n=23) -54.9 +4.0 -58.9 22.4% ALI vs. -45.6 -10.9 -34.7 ApoC-III proteoform distribution (by mass spectrometry immunoassay), vs. EZE (n=11), (6.0) (8.8) (-80.9 0% EZE (4.6) (6.9) (-52.3 and IR or insulin sensitivity (SI) indices derived from fasting (HOMA-IR) and without statins to -36.8) to -17.1) OGTT (SIMatsuda) glucose and insulin values were measured in participants of Pool of alirocumab 150 mg Q2W vs. placebo studies (with statins): LONG ACT NOW - a placebo controlled trial of pioglitazone in prediabetes. TERM, HIGH FH. Pool of alirocumab 75/150 mg Q2W vs. placebo studies At baseline, the ratio of apoC-III (12% of total) to the most abundant (with statins): COMBO I, FH I, FH II. Alirocumab was initiated at 75 mg Q2W ORALS 2 with possible Week 12 dose increase to 150 mg Q2W depending on Week monosialylated apoC-III1 (53% of total) was associated inversely with HOMA-IR (r=-0.16, p=0.0005) and positively with SI (r=0.18, p<0.0001) 8 LDL-C levels (17.4% with alirocumab dose increase). Pool of alirocumab Matsuda 75/150 mg Q2W vs. ezetimibe studies (with statins): COMBO II, OPTIONS (both n=486). After adjusting for age, sex, ethnicity and BMI, apoC-III2/C-III1 I, OPTIONS II (16.5% with alirocumab dose increase). Pool of alirocumab remained associated with HOMA-IR (p=0.008) and SIMatsuda (p=0.0006). Vari- 75/150 mg Q2W vs. ezetimibe studies (without statins): MONO, ALTERNA- † ation in apoC-III2/C-III1 also accounted for 14 and 17% of the associations TIVE (44.4% with alirocumab dose increase). DM: Type 1 or 2 diabetes ‡ between IR (HOMA-IR and SIMatsuda, respectively) and plasma TG. Longitudi- reported in the medical history as reported by the investigator. ASCVD nally, adjusted for follow-up duration (median 2.8 years) and treatment arm, was defined as coronary heart disease (including acute MI, silent MI, lower HOMA-IR (p=0.03) and higher SI (p=0.003) at baseline predicted unstable angina, coronary revascularization procedure and other clinically Matsuda significant coronary heart disease diagnosed by invasive or non-invasive higher apoC-III2/C-III1 at follow-up (n=293). Longitudinal change in apoC- III /C-III accounted for 12% of the associations between baseline HOMA-IR testing), ischemic stroke, and peripheral arterial disease. For FH II, ALTER- 2 1 NATIVE, OPTIONS I and OPTIONS II studies, ASCVD also included ischemic and SIMatsuda, and change in plasma TG. stroke, transient ischemic attack, carotid endarterectomy, carotid artery Our data indicate that greater IR in prediabetes patients is associated stent procedure or renal artery stent procedure. ALI, alirocumab; ASCVD, with lower relative amounts of a more favorable form of apoC-III, which may atherosclerotic cardiovascular disease; CI, confidence interval; DM, diabe- partly account for IR-related dyslipidemia. This is consistent with our prior tes mellitus; EZE, ezetimibe; HDL-C, high-density lipoprotein cholesterol; report of increased relative apoC-III2 with the insulin sensitizer pioglitazone LDL-C, low-density lipoprotein cholesterol; LS, least squares; MI, myocar- in this cohort. dial infarction; PBO, placebo; SE, standard error; Q2W, every 2 weeks. Supported By: National Institutes of Health; American Heart Association; Supported By: Sanofi; Regeneron Pharmaceuticals, Inc. Takeda Pharmaceutical Company Limited

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A59 LIPID MODIFYING INTERVENTIONS AND THEIR CONSEQUENCES

227‑OR 229‑OR Effects of Leptin on Regulators of Lipoprotein Lipase in Patients Intestinal Cholesterol Absorption Is Increased by Acute Adminis- with Lipodystrophy tration of Glucagon, but Is Not Altered by Acute Sodium-Glucose MARISSA LIGHTBOURNE, BRENT ABEL, MARY WALTER, ROBERT SHAMBUREK, Cotransporter 2 Inhibition with Dapagliflozin in Dyslipidemic RANGANATH MUNIYAPPA, REBECCA J. BROWN, Bethesda, MD Golden Syrian Hamsters Lipodystrophy (LD) syndromes involve selective loss of fat tissue and FRANCOIS BRIAND, MARJOLAINE QUINSAT, EMMANUEL BROUSSEAU, THI- leptin deficiency, complicated by severe insulin resistance and high triglyc- ERRY SULPICE, Labège, France erides (TG). Leptin replacement with recombinant human methionyl leptin We previously showed that chronic SGLT2 inhibition (SGLT2i) alters (metreleptin, ML) improves glycemic control and TG. Mechanisms by which cholesterol metabolism in dyslipidemic hamsters, with increased LDL-cho- leptin lowers TG may include changes in lipoprotein lipase (LPL) activity lesterol plasma levels and reduced intestinal cholesterol absorption (ICA). causing increased breakdown of TG-rich lipoproteins. Certain apoproteins SGLT2i may stimulate glucagon secretion in response to hypoglycemia (Apo) and angiopoietin-like (ANGPTL) proteins regulate LPL activity and may induced by urinary glucose loss, and glucagon may impact intestinal motil- mediate TG reductions with ML. We hypothesized that ML in patients with ity and cholesterol metabolism. We thus tested whether the reduction in LD would increase levels of proteins that increase LPL activity (ApoC2, Apo ICA by SGLT2i could be acutely induced and linked to glucagon secretion. A5), and decrease those that decrease LPL activity (ApoC3, ANGPTL3, ANG- Diet-induced dyslipidemic Golden Syrian hamsters were treated, acutely PTL4, ANGPTL8). Patients with LD received ML 5 mg Q12 h for 2 weeks (wks), and subcutaneously, with vehicle, dapagliflozin 10mg/kg (DAPA) or glucagon then 4.5 ± 1.0 mg Q12h for 6 months (m). Patients were hospitalized with 50µg/kg. Hamsters were then gavaged with radiolabeled olive oil containing food intake controlled at pre-ML levels for the first 2 wks, then continued 3H-cholesterol to assess ICA after i.p. injection of Poloxamer-407 (plasma ML at home on ad libitum diet. ApoA5 (Antibodies-Online), apoC2 (Abcam), lipase inhibitor) over 6 hours after olive oil gavage. After an acute treatment apoC3 (Abcam), ANGPTL3 (R&D), ANGPTL4 (R&D), the ANGPTL8 (Phoenix) and olive oil gavage, DAPA reduced blood glucose levels by up to 34% over were measured by ELISA prior to ML, and after 2 wks and 6 m of ML. Time- 6 hours, leading to a reduction in blood glucose area under the curve (AUC) points were compared by paired t-test or Wilcoxon signed rank test based by 16% (p<0.05 vs. vehicle). Compared with vehicle, DAPA did not change on distribution of data. At 2 wks (n=14), there were decreases in TG (median plasma glucagon levels. Compared with vehicle, subcutaneous injection of [25th,75thCI]: -171 mg/dL [-1178,-56], P=.0017), ApoC3 (-284 ± 474 mcg/mL glucagon increased blood glucose levels by up to 63% over 6 hours after (P=.002) and ApoC2 (-175 ± 299 mcg/mL, P=.0085). At 6 m (n=11), there were olive oil gavage, leading to a 33% higher blood glucose AUC (p<0.05 vs. vehi- decreases in TG (-112 [-477,-9], P=.032), ApoC3 (-187 mcg/mL ± 265, P=.041), cle). Compared with vehicle, plasma 3H-cholesterol appearance over 6 hours and ANGPTL8, (-45 ng/mL ± 44, P=.0071). There was no significant change after olive oil gavage remained unchanged with DAPA, while it significantly in ApoA5, ANGPTL3 or ANGPTL4 at 2 wks or 6 m, ANGPTL8 at 2 wks, or increased by up to 81% with glucagon administration. These data indicate ApoC2 at 6 m. Improved TG in LD patients treated with ML may be mediated that ICA was unaltered by DAPA, but increased by glucagon. by decreased ApoC3 and ANGPTL8, causing increased breakdown of TG by In conclusion, the present study suggest that reduction in ICA under LPL. Counter to our hypothesis, ApoC2, also decreased at 2 weeks. ApoC2 SGLT2i may not be induced acutely, but rather chronically. Our results also is present on TG-rich particles and HDL, and is known to correlate well with exclude a possible role of glucagon, which indeed increased ICA by unknown TG, thus reductions in ApoC2 with ML may simply reflect reductions in TG- mechanisms to be further investigated. rich particles. 230‑OR 228‑OR Is Statin Use Associated with Increased Albuminuria and Worsen- Effect of High-Potency Statins on Cognitive Function in Patients ing Glycemic Control in Type 1 Diabetes (T1D)? with Type 2 Diabetes RACHEL G. MILLER, TREVOR J. ORCHARD, Pittsburgh, PA NUNTAKORN THONGTANG, JIRASAK PIYAPROMDEE, SUTIN SRIUSSADAPORN, While the benefits of statin use in preventing atherosclerotic cardiovascu- Bangkok, Thailand lar disease have been well-established in clinical trials, statin use has also Statin use has been reported to be a potential risk of cognitive impair- been associated with increased risk of type 2 diabetes and greater albumin- ment, and too low plasma LDL level is associated with worse cognitive uria. Thus our objective was to examine the associations between statin use performance. We assessed the effect of high potency statin treatment and and glycemic control, insulin sensitivity, and albuminuria in a cohort with low plasma LDL levels on cognition. This was a randomized controlled study. long-duration T1D. Type 2 diabetic (DM) patients who had no atherosclerosis cardiovascular dis- The Pittsburgh Epidemiology of Diabetes Complications (EDC) Study is an ease, and were taking simvastatin up to 20 mg/day (N=76) were randomized ongoing prospective cohort study of childhood-onset T1D diagnosed 1950- to continue using the same dosage of simvastatin (low potency statin group; 1980. Baseline exams of 658 participants took place 1986-88 and bienni- LP) for 12 weeks or change to atorvastatin 40 mg/day for 6 weeks, and if tol- ally thereafter for the first 10 yr of follow-up and at 18 and 25 yr. Question- erable increased to atorvastatin 80 mg/day for 6 weeks (high potency statin naires were administered biennially throughout. Statin use was ascertained group; HP). Montreal Cognitive Assessment (MoCA) test and Trail Making through self-reported medication lists. HbA1c was measured at each study Test part B (TMT) were assessed at baseline, 6 weeks, and 12 weeks, 73 exam and aligned to DCCT values. Pre-post statin changes in HbA1c, esti- patients completed the study. Mean age was 59±9 years, 72.6% female. mated glucose disposal rate (eGDR) a previously validated measure of insu- ORALS Mean baseline plasma LDL level on simvastatin was 70.6 ±14 mg/dl. There lin sensitivity derived from euglycemic clamps, albumin excretion rate (AER), was no significant difference in mean age and plasma LDL levels at baseline and estimated glomerular filtration rate (eGFR) were examined and com- between the LP (n=38) and HP group (n=35). Mean plasma LDL levels at 12 pared to age- and sex- matched non-users over a comparable time period. weeks were significantly lower in the HP group than in the LP group; LDL Overt nephropathy (ON) is the first instance of AER>200 μg/min. 72.8 ± 22 mg/dl vs. 59.5 ± 18.4 mg/dl; p=0.007. Mean MoCA score in the 40.3% (n=265) reported any statin use during follow-up. Pre-post statin low potency statin group was 21.0, 22.8, and 23.7 at baseline, 6 weeks and changes in HbA1c, eGDR, AER, and eGFR did not differ from background. 12 weeks, respectively while mean MoCA score in the HP group was 20.8, In Cox models where statin use was entered as a time-varying covariate, 22.3, and 23.7, respectively. TMT results were 118.9 seconds, 114.8 seconds, statins were not significantly associated with ON (HR=1.5, p=0.4) or inci- and 117.8 seconds at baseline, 6 weeks and 12 weeks, respectively in the dence of eGFR<75ml/min/1.73m2 (HR=0.9, p=0.7), after adjustment for most LP group, while they were 125.5 second, 130.9 seconds, and 114.9 seconds, recent risk factor profile prior to statin initiation, including age, sex, non-HDL respectively in the HP group. There were no significant differences in MoCA cholesterol, HbA1c, blood pressures, and white blood cell count. score and TMT between the two groups in all 3 phases including patients These results suggest that, in this cohort of long-standing T1D, statin use with plasma LDL levels <40 mg/dl. is not associated with worsening glycemic control or adverse renal disease In summary, increasing statin potency from low potency to high potency outcomes. statins resulted in significant lower plasma LDL levels without causing cog- Supported By: National Institutes of Health nitive decline. Supported By: Siriraj Hospital

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A60 HOSPITAL-BASED CARE AND DIABETES—ADHERENCE TO DIABETIC CARE STRATEGIES

HOSPITAL-BASED CARE AND DIABETES— Conclusion: Transitions of care for T2DM patients from the hospital to ADHERENCE TO DIABETIC CARE STRATEGIES home can be difficult. These preliminary data suggest RPM programs hold particular promise for improving T2DM outcomes, readmission rates, and cost of care after hospital discharge. 231‑OR Supported By: U.S. Department of Health and Human Services/Centers for A Randomized Trial of a Proactive Inpatient Diabetes Service Medicare and Medicaid Services (1C1CMS331344) (RAPIDS) Demonstrates Decreased Adverse Glycemia and Hospi- tal-Acquired Infections MERVYN KYI, PETER G. COLMAN, PAUL R. WRAIGHT, JANE REID, ANNA GAL- 233‑OR LIGAN, SHANAL KUMAR, LOIS M. ROWAN, ALISON NANKERVIS, ALEXANDRA Effect of Continued Follow-Up by a Hospital Diabetes Care Team on GORELIK, KATIE A. MARLEY, DAVID M. RUSSELL, SPIROS FOURLANOS, Mel- Diabetes Control at 1 Year after Discharge bourne, Australia RAJESH GARG, RAQUEL REIN, SHELLEY HURWITZ, BROOKE SCHUMAN, PATRI- We hypothesized that a proactive inpatient diabetes service (IDS) which CIA UNDERWOOD, CHEYENNE METZGER, SHREYA BHANDARI, Boston, MA electronically identifies inpatients with diabetes and provides more immedi- Patients with poorly controlled diabetes admitted to the hospital are ate management will decrease the incidence of adverse glycemia and hos- often discharged back to their outpatient diabetes care providers. We con- pital complications. ducted a randomized controlled study to evaluate the effect of continued RAPIDS (ACTRN12616000265471) is a cluster-randomized trial on 8 wards care (CC) by a hospital diabetes team as compared to the usual care (UC) of a tertiary hospital. Consecutive inpatients with diabetes or new-onset on HbA1c at 1 year after discharge. Adults with HbA1c ≥8% admitted for an hyperglycemia (random blood glucose [BG] ≥11.1 mmol/L without known dia- elective surgery were enrolled into the study. All patients were managed betes) were recruited. Connectivity meters were used to record capillary BG by the diabetes team during their hospital stay, achieved optimal glycemic results from admission until discharge, or day 14 for long-stayers. control and received instructions for diabetes management at discharge. There was a 10-wk baseline observational phase followed by a 12-wk However, patients randomized to the CC group continued to be followed by active phase where the wards were cluster-randomized into 4 interven- the hospital team while the UC group patients were advised to follow with tion and 4 control wards. Intervention wards received proactive IDS (endo- their pre-admission providers. Patients in the CC group received weekly to crinologist or nurse practitioner who aimed to see patients within 24 h of monthly phone calls from a diabetes specialist nurse practitioner (NP). Dur- admission), while control wards continued usual care (a referral-based con- ing these calls, the NP reviewed the patients’ home monitored blood glucose sult service). Primary outcome (incidence of adverse glycemic days [AGD]: values, counseled about diet and exercise and discussed their medications. patient-day with any BG <4.0 or >15.0 mmol/L) and secondary outcome The NP also communicated with patients’ established care providers for any (hospital-acquired infections) were compared between baseline and active medication changes, and arranged follow-up visits and laboratory tests. Out phases within each group. of 184 participants enrolled into the study, follow-up HbA1c at 1 year was We recruited 1002 patients (87% type 2 diabetes; 29% insulin-treated; available for 151 patients, 77 in the CC group (65±9 years, 45% men) and 74 A1c: 7.5±1.7%) totaling 5447 patient-days and 19062 BG results. Incidence in the UC group (63±10 years, 59% men). There were no differences in demo- of AGD decreased significantly in the intervention wards (243 vs. 186 per graphic characteristics, duration of diabetes, complications of diabetes or 1000 patient-days [23% decrease], p < 0.001), but there was no significant the number of antidiabetic medications at baseline. Baseline HbA1c (%) was change in the control wards (291 vs. 261 per 1000 patient-days, p= 0.08). 8.9 ± 1.0 in the CC group and 9.1 ± 1.1 in the UC group (p=NS). HbA1c at 1 year When adjusted for patient clinical factors, proactive IDS was independently after discharge was 8.2 ± 1.4 in the CC group and 8.5 ± 1.5 in the UC group associated with lower AGD. There was also a decrease in hospital-acquired (p=NS). Change in HbA1c from baseline was significant within each group infections (9% vs. 3%, p=0.01) in the intervention wards but not in the con- but not different between the groups; -0.71 ± 1.3 in the CC vs. -0.67 ± 1.5 in trol wards (9% vs. 10%). the UC group (p=NS). This study shows that post-discharge follow-up by a This randomized trial of a proactive inpatient diabetes service decreased hospital team has no effect on HbA1c at 1 year after discharge in patients the incidence of adverse glycemia and hospital-acquired infections. with high preadmission HbA1c. Supported By: Australian Diabetes Society; Royal Melbourne Hospital Supported By: Health Resources and Service Administration; U.S. Department of Health and Human Services (UD7HP25059) 232‑OR Remote Interventions Improving Specialty Complex Care (RIISCC) 234‑OR for Patients with Type 2 Diabetes Patient and Hospital Characteristics Contributing to Disparities in LESLIE A. EILAND, MOHAMMAD SIAHPUSH, ROBERT J. SCHWAB, DEJUN SU, 30-Day Hospital Readmission among Patients with Diabetes TZEYU L. MICHAUD, GERI M. TYSON, MARY E. DEVANY, JENNIFER L. LARSEN, RENE RODRIGUEZ-GUTIERREZ, JEPH HERRIN, KASIA LIPSKA, VICTOR M. MON- Omaha, NE TORI, NILAY D. SHAH, ROZALINA G. MCCOY, Rochester, MN, New Haven, CT Background: The increasing cost of care is of great concern to all. This Racial/ethnic minorities often experience worse health outcomes, including CMS-funded project evaluated the impact of implementing remote patient higher risk of hospital readmission. Such disparities are particularly appar- monitoring (RPM) services on type 2 diabetes (T2DM) outcomes for patients ent among people with chronic diseases, including diabetes. The degree to transitioning from an academic hospital to home. which this is caused by clinical factors, socioeconomic barriers, or disparities ORALS Methods: This prospective RPM health outcome 90 day intervention in the places where they receive care is uncertain. We analyzed data from included: 1) daily remote blood pressure, weight, pulse and glucose monitor- OptumLabs, a national dataset of over 100 million racially, geographically, and ing, 2) weekly coaching and education phone calls by an assigned nurse, and socioeconomically diverse commercial and Medicare Advantage beneficiaries, 3) 90 day remote interactive video visit for diabetes education. A1c, Patient to evaluate all-cause 30-day readmissions experienced by 301,464 adults with Activation Measure (PAM 13), blood pressure, and weight were assessed at diabetes who were hospitalized 523,872 times between January 1, 2009 and the beginning and at the final visit, along with patient satisfaction, hospital December 31, 2014. Overall, 301,464 adults experienced 63,017 readmissions. readmissions and cost of care. Inclusion criteria included T2DM at time of All cause readmission rate was 11.6% in whites, 13.6% in African Americans, discharge and living within 20 miles of the hospital, except those listed or 11.5% in Asians, and 12.2% in Hispanics (p<0.001). Heart failure was the most post-transplant, discharged to intermediate or long term care, or unable to common reason for readmission among all races. After adjustment for age understand or use the technology. Results of RPM group were compared and sex, Asians had a lower odds of readmission compared to whites (OR to eligible patients who declined to participate or could not be contacted 0.92, 95% CI 0.86-0.98); African Americans had higher odds (OR 1.13, 95% within the time window after discharge (Compare). CI 1.11-1.16); and Hispanics had a similar rate. Upon adjustment for comorbidi- Results: Over 21 months (12/14-8/16), 905 patients completed the RPM ties, readmission risk remained elevated only among African Americans. This (55% F/45% M), with mean age 59 y (±12 SD), and 35% non-white. Compare disparity among African Americans persisted after further adjustment for (n=1198) was older (62 vs. 59; p<0.001), 49% F (p=0.016), and 24% non-white socioeconomic status and hospital characteristics (location, size, teaching (24%; p<0.001) than RPM. Those with A1c > 9% decreased (24% to 12%; status, for-profit status) of the discharging facility. This increase in readmis- p<0.001), mean A1c decreased (8 to 7%; p<0.001), and PAM-13 increased (63 sion risk among African Americans was especially high upon discharge from to 69; p<0.001). Satisfaction was high with RPM (94%). Mean 90 d health- large (greater risk in larger hospitals), urban, and teaching hospitals. Our study care costs/patient was $11,737 vs. $15,054 in RPM vs. Compare (p= 0.1074). reinforced the higher risk of readmission among African American patients, The probability of readmission for any condition was 34% lower in RPM than and demonstrated that this disparity is due to a combination of race, clinical, Compare (P=<0.001), controlling for age, sex, race, and insurer type. socioeconomic, and hospital characteristics. All of these factors need to be addressed to improve the equity and quality of diabetes care.

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A61 HOSPITAL-BASED CARE AND DIABETES—ADHERENCE TO DIABETIC CARE STRATEGIES

235‑OR 237‑OR How Much Does Adherence to Insulin Influence Glycemic Control? Insulin Decline by Patients with Diabetes and Glucose Control JULIE C. LAUFFENBURGER, WENHUI WEI, JENNIFER LEWEY, ALAN CHANT, NAOSHI HOSOMURA, HUABING ZHANG, ALEXANDER TURCHIN, Boston, MA, SAIRA JAN, NITEESH K. CHOUDHRY, Boston, MA, Bridgewater, NJ, Newark, NJ Beijing, China Optimal glycemic control for individuals with diabetes requires adherence Provider experience shows that many patients decline insulin therapy. to medication and lifestyle. This is particularly true for those on insulin, yet However, systematic data on the consequences of insulin decline are lack- the relative contribution of adherence to insulin on diabetes outcomes has ing. In absence of prescriptions or insurance claims, information on insu- not previously been quantified in real-world practice. lin decline is only available in narrative provider notes, typically requiring Enrollment data from the ongoing TARGIT-Diabetes pragmatic trial pro- manual chart review for analysis. vide the unique opportunity to examine the influence of insulin adherence on We utilized a high-fidelity (sensitivity 100%; positive predictive value glycemic control. This trial is evaluating three equivalently-priced strategies 95%) informatics tool to abstract insulin decline information from electronic on adherence and glycosylated hemoglobin (HbA1c) among insulin-treated provider notes of adults with diabetes and A1c ≥ 7.0% treated at primary patients with type 2 diabetes insured by a large health insurer. For this anal- care practices affiliated with two academic medical centers who were rec- ysis, we identified subjects with≥ 1 HbA1c before randomization who main- ommended insulin between 2000 and 2014. Among 13,128 study patients, tained insurance eligibility in the year before this test. Using administrative 4,296 (32.7%) initially declined insulin. In multivariable analysis patients who claims data, we measured 30 non-modifiable factors such as age, gender were older (OR 1.10; 95% CI 1.06 to 1.14; p < 0.0001), female (OR 1.18; 95% CI and comorbidities and 14 potentially modifiable factors such as copayments, 1.09 to 1.28; p < 0.0001), non-English speakers (OR 1.15; 95% CI 1.04 to 1.28; provider visits, and adherence, or continued use of, insulin in pharmacy p = 0.008) or were taking more non-insulin diabetes medications (OR 1.56; claims. We then used multivariable logistic regression to identify predictors 95% CI 1.54 to 1.66; p < 0.0001) were more likely to decline insulin. Patients of good control (HbA1c<8) and quantify the variation explained by adherence who declined insulin took longer to achieve A1c < 7.0% (median time 21 vs. and the modifiable factors (using C-statistics). 13 months; p < 0.0001; Figure). This finding was confirmed in multivariable The study cohort consisted of 1,745 patients with a mean HbA1c of 8.4 analysis (HR = 0.83; 95% CI 0.80 to 0.86; P < 0.0001). (SD: 1.8). Of these, 47.1% were at goal (HbA1c<8), and 81.0% were adherent Insulin decline is common and is associated with poor glycemic control. to basal insulin. Good adherence (Odds Ratio (OR): 1.35, 95% CI: 1.04-1.77), This important clinical phenomenon must be addressed to improve care and hypertension (OR 1.46, 1.13-1.88) and mail order use (OR 1.54, 1.18-2.01) were outcomes of patients with diabetes. independent predictors of good control. The 14 modifiable characteristics Figure. contributed 51.4% of the explained variation in good control. Adherence to insulin accounted for 14.9% of that variation. Adherence is significantly associated with good glycemic control and accounted for a substantial amount of modifiable variation in whether sub- jects’ diabetes is controlled. Given its ability to be intervened upon as a risk factor, effort should focus on insulin adherence to improve diabetes outcomes. Supported By: Sanofi

236‑OR Association between Oral Diabetes Agent Adherence, Age, Comor- bidities, and A1C among Elderly Patients GREGORY A. NICHOLS, MARSHA A. RAEBEL, WENDY DYER, JULIE A. SCHMITT­ DIEL, Portland, OR, Denver, CO, Oakland, CA The Medicare STAR program provides monetary incentives for health plans to achieve good adherence to oral antidiabetes agents (OADs). The effect of adherence on A1C among elderly diabetes patients with varying number of comorbidities is unknown. We studied 56,629 diabetes patients aged >65 from the Colorado, Northwest, and Northern California regions of Kaiser Permanente receiving only OADs in 2010. We calculated adherence using the Proportion of Days Covered (PDC) method where PDC > 0.8 was considered adherent. We defined good glycemic control as A1C < 8%, poor control as A1C > 9%, and used modified Poisson regression to assess the relationships between age, comor- bidities, adherence, and A1C control adjusting for sociodemographics, days’ Supported By: Sanofi-Aventis supply of dispensings and copayment. Mean age was 74+7 years, 48% were women, and mean number of comorbidities was 1.6+1.5. 82% of patients were 238‑OR adherent with OADs. Age and comorbidities were modestly associated with ORALS The Health-Care Resource Waste Associated with Patient Nonad- adherence and risk of good glycemic control but strongly associated with risk of herence and Early Discontinuation of Specialized Continuous Glu- poor control. Among patients with diabetes aged > 65, multiple comorbidities cose Monitoring: A Multi-country Analysis impact adherence, but age and comorbidities have little effect achieving good SHENGSHENG YU, BIJU VARUGHESE, Alameda, CA glycemic control. Although strongly associated with poor control, adherence Specialized continuous glucose monitoring (CGM) provides real-time glu- shows little variation across age/comorbidity strata suggesting that health cose feedback and glycemic trends to inform daily diabetes management for plan case mix may not impact the Medicare STAR adherence metric. patients who require such features as alarms due to hypoglycemia unaware- Table. ness. Despite the recent developments in technology and patient support programs, a substantial amount of patient effort is still required to maintain sufficient usage of this technology to achieve clinical benefits. This study aims to assess the impact of patient non-adherence (NA) and early discontinuation (ED) on healthcare resource use from a healthcare payer perspective. A cost calculator was designed to evaluate monthly healthcare waste on specialized CGM within the first year of initiation. The healthcare resource waste is defined as CGM spending which occurred when the patient was either NA or ED. The CGM cost was defined by the wholesale acquisition cost of the current technology in the U.S., or its equivalent in other countries. The NA and ED rates were obtained through a literature search. The estimated annual cost for the specialized CGM was $9,501 per patient in the U.S. based on the 27% 1-year discontinuation rate reported by the T1D Exchange Clinical Registry and the adherence rates reported by Pichard et al., the healthcare resource waste associated with NA and ED was $209,807

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A62 BEYOND GLYCEMIC IMPACT and $20,738, respectively, for every 100 patients initiating specialized CGM. reduced with lixisenatide vs. placebo (p=0.046), but VLDL-TG pool size was In combination, NA and ED wasted 24.3% of resources within the first year not different. CM-TG fractional catabolic rate tended to be higher after lix- of initiation. Similar results were observed using the local costs in Sweden, isenatide than placebo (14.3±1.3 vs. 10.5±1.0 pools/d; P=0.05) but CM-TG Germany, Norway, Belgium, and the Netherlands. production rate was not different. Lixisenatide reduced CM-oleate (TG) The healthcare resource waste associated with specialized CGM NA and AUC-60-480min tracer-to-tracee ratio*min. vs. placebo; p=0.048. VLDL-apoB100 ED warrants deliberate consideration from HCPs when selecting suitable and CM-apoB48 concentrations were not different. CM-apoB48 production patients for this technology. rate was 160±26 and 320±100 mg/kg/d (lixisenatide vs. Placebo; P=0.077). Conclusion: Lixisenatide improved postprandial TG concentrations by reducing circulating CM-TG concentration and increasing CM-TG fractional BEYOND GLYCEMIC IMPACT catabolic rate. Reduced meal-derived oleate tracer-to-tracee ratio in CM-TG confirms reduced gastric emptying by lixisenatide. 239‑OR Supported By: Sanofi-Aventis Double-Blind, Placebo-Controlled, Randomised Trial to Assess the Effect of Liraglutide on Left Ventricular Diastolic Dysfunction in 241‑OR Type 2 Diabetes Mellitus Patients GLP-1 Receptor Agonism Preserves Hippocampal Glucose Metabo- MAURICE B. BIZINO, INGRID M. JAZET, JAN W. SMIT, HILDO J. LAMB, Leiden, lism in Alzheimer’s Disease Netherlands, Nijmegen, Netherlands MICHAEL GEJL, BIRGITTE BROCK, LÆRKE EGEFJORD, KIM VANG, ALBERT Background: Asymptomatic left ventricular diastolic dysfunction (LVDD) GJEDDE, JOERGEN RUNGBY, Aarhus, Denmark, Copenhagen, Denmark caused by impaired myocardial relaxation is an early reversible sign of dia- T2D increases the risk of Alzheimer’s disease (AD) and vice versa, but betic cardiomyopathy. Preclinical studies suggest beneficial effects of GLP-1 the understanding of underlying mechanisms is poor. Animal models point RA on LVDD. The aim of this study is to test if GLP-1 RA improves LVDD in to hippocampus (HC) and parahippocampus (PHC) as sites of insulin resis- DM2 patients. tance (IR) leading to cognitive dysfunction in T2D and Alzheimer disease Methods: In this 26 week double-blind, placebo-controlled trial, DM2 (AD). A major feature of AD is the steady decrease of cerebral metabolic patients without cardiovascular disease were randomly assigned to liraglutide rate of glucose (CMRglc). The decline of CMRglc is closely related to cogni- (LIRA) or placebo (PLCB). LV diastolic function was assessed using MRI derived tive impairment as a marker of neuronal activity and disease progression. indices: early (E) and late (A) transmitral peak flow rate, E/A ratio, peak mitral In experimental models, GLP-1 receptor agonism alleviates several features annular septal velocity (e’) and LV filling pressure estimate E/e’. Intention-to- of neurodegeneration. We predicted that treatment with liraglutide would treat analysis of between group differences was performed using ANCOVA. raise CMRglc measured with PET in AD patients. Results: Patients were randomised to LIRA (n = 23) or PLCB (n = 26). As In this 26-week, double-blind, placebo-controlled trial, we randomized 38 shown in Table, LIRA significantly reduced E, E/A ratio and E/e’ as compared patients with AD to treatment with liraglutide (n=18) or placebo (n=20). We with PLCB. A and e’ did not change significantly. mapped HC and PHC values of CMRglc and volume from regional radioac- Conclusion: GLP-1 RA reduces early diastolic filling and LV filling pressure. tivity, and we scored changes of cognition with the WMS-IV scale during As such, GLP-1 RA might slow progression of diabetic cardiomyopathy by the observation period. With placebo, CMRglc declined significantly in PHC unloading the left ventricle. Conversely, patients with symptomatic LVDD (P=0.048) and insignificantly in HC (P=0.17) but remained unchanged with might be exposed to increased risk of decompensated heart failure with liraglutide. Overall cognition did not change in either group, with significant GLP-1 RA therapy. Future studies need to assess long-term effects of GLP-1 impairment of orientation with placebo vs. liraglutide (P = 0.041). In PHC at RA in patients with LVDD. baseline, we confirmed the predicted positive correlations between CMRglc and cognition (P=0.008, r=0.5), CMR and volume (P=0.039, r=0.37), and Table. glc volume and cognition (P=0.008, r=0.5). We also confirmed the negative cor- Liraglutide (n = 23) Placebo (n = 26) relation between values of CMRglc and duration of AD (P=0.004, r=-0.5). PHC Baseline 26 weeks Baseline 26 weeks p value volume decreased with increasing BMI (P=0.01, r=-0.44) and increasing age Heart rate (bpm) 72 ± 9 75 ± 10 77 ± 13 76 ± 13 0.041 (P=0.04, r=-0.36). Volumes remained constant within and between groups. In AD, liraglutide prevented the decline of CMR in PHC seen with pla- E (ml/s) 331 ± 99 294 ± 78 325 ± 96 349 ± 111 0.002 glc cebo, signifying cognitive impairment and disease evolution. As sites of A (ml/s) 367 ± 79 392 ± 73 371 ± 70 397 ± 81 0.88 imaging, the cognitively relevant PHC and HC regions are easily identified E/A 0.95 ± 0.44 0.77 ± 0.22 0.90 ± 0.31 0.90 ± 0.30 0.003 targets of determination of cerebral glucose metabolism. e’ (cm/s) 6.0 ± 1.6 6.3 ± 1.7 6.0 ± 1.8 5.9 ± 2.2 0.401 Supported By: Health Research Fund of Central Denmark Region; Novo Nordisk Scandinavia AB; Aarhus University E/e’ 7.4 ± 3.0 6.4 ± 2.1 8.0 ± 2.9 8.6 ± 2.9 0.005 Supported By: Novo Nordisk A/S 242‑OR Double-Blind, Placebo-Controlled, Randomised Trial to Assess the

240‑OR Effect of Liraglutide on Ectopic Fat Accumulation in Type 2 Diabetes ORALS Effect of Lixisenatide (Lyxumia) on Postprandial Lipoprotein Kinetics Mellitus Patients FARIBA SHOJAEE-MORADIE, MARTIN B. WHYTE, SHARAF SHARAF, NICOLA MAURICE B. BIZINO, INGRID M. JAZET, HILDO J. LAMB, JAN W. SMIT, Leiden, JACKSON, BARBARA FIELDING, DAVID RUSSELL-JONES, MARGOT UMPLEBY, Netherlands, Nijmegen, Netherlands Guildford, United Kingdom Background: Ectopic fat accumulation (EFA) can be characterized by Introduction: Hypertriglyceridaemia is a feature of type 2 diabetes. Recent excess abdominal visceral adipose tissue (VAT), hepatic steatosis and myo- data suggest that GLP-1 receptor signalling may regulate postprandial lipo- cardial steatosis. EFA plays an important role in DM2 complications and can protein synthesis and secretion. We studied the effect of lixisenatide (GLP-1 be reversed by weight loss. The aim is this study is to test if GLP-1 RA associ- agonist) on postprandial hepatic (VLDL-tiglyceride (TG) and apolipoproteinB ated weight loss also reduces EFA. (apoB)100) and intestinal (chylomicron (CM)-TG and apoB48) kinetics in the Methods: In this 26 week double-blind, placebo-controlled trial, DM2 patients TG-rich lipoproteins (TRL). (BMI > 25 kg/m2) were randomly assigned to liraglutide (LIRA) or placebo (PLCB), Methods: Eight males with type 2 diabetes (age 57.3±1.9 years; BMI added to standard care. Visceral and subcutaneous (SAT) adipose tissue were 30.0±1.2kg/m2) were randomised to 4-weeks lixisenatide/placebo (double- measured using MRI; hepatic (HTGC) and myocardial triglyceride content (MTGC) blind cross-over) with 4-weeks washout. At the end of each arm, the trial were quantified with MR spectroscopy. Within group and between group differ- drug was taken at -270 min.; hourly high-fat meals were given from -240 min. ences were analysed with paired t-test and ANCOVA respectively. for 11 h. TG uptake was evaluated by examining the postprandial response Results: Patients were randomised to LIRA (n = 23) or PLCB (n = 26). LIRA 13 2 of [ C] triolein given with a meal at -120 min. At 0 min., an iv bolus of [ H5] significantly reduced body weight as compared with PLCB. SAT but not VAT glycerol (75µmol/kg) and primed constant infusion of [1-13C] leucine (1mg/kg; was significantly reduced in LIRA. Although LIRA reduced HTGC and MTGC, 1mg/kg/h) were given to measure TG and apoB kinetics in VLDL and CMs. this reduction was not significantly greater than with PLCB (Table 1). Results are mean±SEM. Conclusion: GLP-1 RA therapy added to standard care reduces hepatic and Results: Postprandial plasma TG and TRL-TG concentrations from -60 to myocardial steatosis, comparable to placebo. GLP-1 RA preferentially reduces 120 min. were lower with lixisenatide vs. placebo (p<0.05), with no differ- subcutaneous adipose tissue. Therefore, GLP-1 RA associated weight loss ence (at plateau) from 240 to 480 min. Postprandial CM-TG pool-size was might be less beneficial than weight loss ensuing lifestyle modification.

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A63 BEYOND GLYCEMIC IMPACT

Table 1. 244‑OR Liraglutide (n = 23) Placebo (n = 26) Long-Acting GLP-1 Receptor Agonists Semaglutide and Liraglutide Protect against Development of Atherosclerosis in Animal Models Baseline 26 weeks p Baseline 26 weeks p p between Independent of Body-Weight-Lowering Effects groups GÜNAJ RAKIPOVSKI, BIDDA ROLIN, RIKKE KIRK, IB V. KLEWE, JANE NØHR, Weight (kg) 98.4± 13.8 94.3 ± 14.9 <0.001 94.5 ± 13.1 93.9 ± 13.2 0.81 <0.001 KLAUS S. FREDERIKSEN, ROBERT AUGUSTIN, LOTTE B. KNUDSEN, Måløv, BMI (kg/m2) 32.6 ± 4.4 31.4 ± 4.2 <0.001 31.6 ± 3.4 31.6 ± 3.9 0.72 <0.001 Denmark HbA1c (mmol/mol) 66.7 ± 11.5 55.0 ± 13.3 <0.001 64.7 ± 10.2 56.9 ± 6.9 <0.001 0.27 Recently, semaglutide (SEMA) and liraglutide (LIRA) have demonstrated beneficial effects on CV outcomes in addition to their known antidiabetic 2 VAT (cm ) 207 ± 87 203 ± 88 0.26 204 ± 63 200 ± 55 0.997 0.41 and weight lowering effects. Here, the effect of SEMA and LIRA on the SAT (cm2) 361 ± 142 339 ± 131 0.004 329 ± 107 333 ± 125 0.67 0.007 development of atherosclerosis in mouse-models is reported. HTGC (%) 18.1 ± 11.2 12.0 ± 7.7 0.001 18.4 ± 9.4 14.7 ± 10.0 <0.001 0.17 Study 1: LDLr KO mice (n=23) on Western diet (WD) were treated with MTGC (%) 1.45 ± 0.57 1.23 ± 0.56 0.038 1.29 ± 0.55 1.19 ± 0.62 0.668 0.39 vehicle (VEH) or SEMA daily subcutaneously (SC), at three doses (4, 12 or 60 µg/kg) for 17 weeks. Study 2: ApoE KO mice (n=15) on WD were treated Supported By: Novo Nordisk A/S with LIRA (1.0 mg/kg), or a weight loss comparator (COMP) at two doses (0.2 or 0.8 mg/kg) or VEH, SC for 12 weeks. In study 1 inflammatory markers on 243‑OR aortic tissue were assessed by NanoString analyses. In both studies plasma Semaglutide Provides Superior Body Weight Reduction across cholesterol (CHL) and triglycerides (TG) were determined by HPLC and aortic SUSTAIN 1-5 Clinical Trials plaques by En Face. ILDIKO LINGVAY, JÖRG LÜDEMANN, MICHEL MARRE, KARI UUSINARKAUS, Study 1: SEMA attenuated aortic plaque development to a similar degree VINCENT WOO, HENRIK F. THOMSEN, NELUN WIJAYASINGHE, MELANIE at all doses (4 µg/kg: 4.5±0.8%, 12 µg/kg: 4.0±0.8% and 60 µg/kg: 4.6±1.1% DAVIES, Dallas, TX, Falkensee, Germany, Paris, France, Colorado Springs, CO, Win- vs. VEH 13.1±1.3%; p<0.0001). All doses of SEMA were associated with nipeg, MB, Canada, Aalborg, Denmark, Søborg, Denmark, Leicester, United Kingdom reduced inflammation in the plaques, where 87 genes related to inflamma- The SUSTAIN 1-5 trials evaluated s.c. semaglutide, a GLP-1 analog, in sub- tion were significantly regulated, compared to VEH. Specifically, leukocyte jects with T2D vs. placebo, sitagliptin, exenatide ER, insulin glargine and as add recruitment, adhesion and migration were beneficially regulated. This was on to insulin. The primary endpoint was HbA1c. Pre-specified analyses included independent of BW as only SEMA at 60 µg/kg significantly reduced BW (VEH: change from baseline in body weight (BW), proportion of subjects with ≥5% 35.9±1.1 vs. 60µg/kg: 30.5±0.7g; p<0.0001). Study 2: Compared to VEH, the and ≥10% BW loss from baseline, change in BMI and waist circumference. COMP at 0.8 mg/kg had a 27% (p<0.0001) and LIRA a 19% (p<0.0001) lower A mean BW loss of 3.5-6.4 kg from baseline was observed with QW sema- BW. However, only LIRA prevented plaque development (VEH: 17.1±1.9% vs. glutide vs. 1.9 kg reduction to 1.2 kg increase for comparators (p<0.0001; Fig- LIRA: 11.1±1.9%; p<0.05) and neither COMP group had effect on plaques ure). Semaglutide treatment led to greater proportions of subjects achieving (0.2 mg/kg: 17.2±1.6%; 0.8 mg/kg: 19.6±1.5%). Plasma CHL was not affected ≥5% and ≥10% BW loss vs. comparators, and significant reductions in BMI and only SEMA at 60 µg/kg reduced plasma TG (VEH: 6.8±0.8mM vs. 60µg/ and waist circumference (p<0.05; Table). kg: 4.4±0.4mM; p<0.05). Semaglutide provided clinically meaningful reductions in BW, BMI and In mouse models of atherosclerosis, long acting GLP-1 RAs SEMA or LIRA waist circumference vs. comparators in a broad range of subjects with T2D. protect against atherosclerosis, independent of BW. The mechanism likely comprises anti-inflammatory effects. Supported By: Novo Nordisk A/S

245‑OR Is Treatment of Nonalcoholic Steatohepatitis with Pioglitazone Equally Effective in Patients with Prediabetes Compared with Type 2 Diabetes (T2DM)? FERNANDO BRIL, ROMINA LOMONACO, BEVERLY ORSAK, JOAN HECHT, FERMIN TIO, KENNETH CUSI, Gainesville, FL, San Antonio, TX Nonalcoholic steatohepatitis (NASH) is a major public health problem and the 2nd cause of cirrhosis in the U.S. Results from a prior RCT with pio- glitazone (PIO) in patients with NASH without T2DM reported controversial results (Sanyal et al, NEJM 2010), while our group reported that PIO resolved NASH in ~60% of patients with prediabetes or T2DM (Cusi et al. Ann Intern Med 2016). The aim of this study was to compare the histologic response to PIO in patients with vs. without T2DM. A total of 101 patients with NASH (50±1 years, 70% male, 51/49% with ORALS T2DM/prediabetes, BMI: 34.4±0.5 kg/m2) were randomized for 18 months to placebo or PIO 45 mg/day. The primary outcome was defined as improve- ment in the NAFLD activity score ≥2 points without worsening of fibrosis in liver histology. Secondary outcomes included resolution of NASH on histol- ogy, intrahepatic triglyceride (IHTG) content by 1H-MRS, and insulin sensitiv- ity during a 2-step euglycemic insulin clamp with glucose turnover. Both groups were well matched at baseline. Treatment effect was compa- rable among patients with vs. without T2DM for the primary outcome (48% vs. 46%), although resolution of NASH appeared to be greater in patients with T2DM (44% vs. 26%). Significant improvement in fibrosis was observed only in T2DM patients (p=0.035). Reduction of IHTG content (-11±2% vs. -9±2%, p=0.62) and plasma ALT (-50±10 vs. -36±5 U/L, p=0.22) were similar in both groups, as well as improvement in hepatic (suppression of EGP: from 35 to 52% and from 46 to 59%, p=0.49) and muscle insulin sensitivity (Rd: +3.9±0.9 vs. +2.8±0.6 mg/kgLBM/min, p=0.32). Conclusion: Pioglitazone treatment results in beneficial histologic and metabolic effects in both patients with prediabetes or T2DM, suggesting to be largely independent of its glucose-lowering properties. Its greater effect on fibrosis in patients with T2DM deserves further exploration as a potential intervention for the prevention of advanced fibrosis. Supported By: American Diabetes Association (1-08-CR-08 to K.C.); Burroughs Supported By: Novo Nordisk A/S Wellcome Fund

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A64 RISK FACTORS ASSOCIATED WITH DIABETES

246‑OR Model 2 + waist circumference 1.19 (0.96 - 1.47) 1.03 (0.70 - 1.50) 1.04 (0.74 - 1.45) 2.27 (1.32 - 3.90) Secretory Capacity of Pancreatic Beta Cells Is Enhanced 6 Months after Renal Denervation in Hypertensive Patients Model 2 + log SI 1.14 (0.92 - 1.42) 1.04 (0.71 - 1.53) 1.01 (0.72 - 1.41) 1.89 (1.10 - 3.23) ROLAND E. SCHMIEDER, IRIS KISTNER, AXEL SCHMID, FELIX MAHFOUD, STE- Model 2 + log CRP 1.17 (0.92 - 1.50) 1.01 (0.65 - 1.57) 0.98 (0.66 - 1.47) 1.96 (1.15 - 3.34) FANIE FRIEDRICH, TILMANN DITTING, ROLAND VEELKEN, MICHAEL BÖHM, MICHAEL UDER, CHRISTIAN OTT, Erlangen, Germany, Homburg, Germany Model 2 + smoking + waist + log 1.08 (0.84 - 1.41) 0.98 (0.61 - 1.59) 0.95 (0.63 - 1.45) 1.85 (1.03 - 3.34) Objective: A high sympathetic tone increases not only blood pressure SI + log CRP (BP) but also decreases pancreatic β-cell insulin secretion. Renal denerva- OR expressed × 1SD unit increase. tion (RDN) lowers BP by decreasing sympathetic nerve activity. Hence, the Supported By: National Heart, Lung, and Blood Institute (HL-47887, HL-47889) objective of the study was to analyze whether RDN improves beta cell secre- tory capacity. Design and Method: In this observational prospective study with blind 248‑OR endpoint evaluation of glucose homeostasis patients with normal or If ADA Criteria Accepted 1-Hour Glucose Value in OGTT as a Diag- impaired glucose metabolism and treatment resistant hypertension (diagno- nostic Criteria for T2DM: What Would Change? RISK Study Results-V TEMEL YILMAZ, NAZLI OKUMUS, HAYDAR SUR, MEHMET SARGIN, GUN- sis confirmed with 24-h ambulatory BP≥ 130/80 mmHg), were consecutively included if they agree to the study protocol. Glucose homeostasis as well as DUZ INCESU, BEGUM DEMIRCAN, SEHNAZ KARADENIZ, RISK STUDY GROUP, insulin secretion was measured before and 6 months after RDN (Simplicity Istanbul, Turkey flex catheter, Medtronic) by glucagon test. At each time point blood was The RISK Study was designed to evaluate the efficacy of 1-h and 2-h 75-g sampled prior to glucagon administration and 6 minutes after intravenous OGTT results in the screening of IGT and diabetes according to the Ameri- injection of 1mg glucagon for measurement of C-peptide, insulin and proin- can Diabetes Association (ADA) criteria. This study comprises 6620 subjects sulin (by ELISA). (mean age: 52.9±11.5 years) from 191 centers, who were at increased risk of Results: In 35 patients (office BP 155±22mmHg/89±14mmHg and 24-h T2DM according to the ADA criteria. Subjects were grouped as IFG (100-125 ambulatory BP 151±12mmHg/91±11mmHg while on 5.0 (4.0-6.0) antihyper- mg/dl), Impaired Glucose Tolerance (IGT) (140-199 mg/dl) and Diabetes Group tensive drugs) office and 24-h ambulatory BP was significantly reduced (DG) (>200 mg/dl) according to fasting glucose and OGTT. 1-h OGTT results 6 months after RDN (all p<0.005). In parallel fasting plasma glucose and were grouped as IGT1 and DG1, and 2-h OGTT results as IGT2 and DG2. The HbA1c level were significantly reduced 6 months after RDN (both p<0.01). In OGTT results revealed IGT1 in 43.7%, DG1 in 21.9%, IGT2 in 26.4%, DG2 in addition, the homeostasis model assessment-insulin resistance decreased 11.2% of the subjects. IFG prevalence was 41.7% and 54.2% in IGT1 and 6 months after RDN (p=0.001). Finally, the increase of C-peptide concen- IGT2 groups respectively. Sensitivity of 1-h/2-h OGTT for DM diagnosis was tration and insulin concentration after glucagon injection was significantly 62.4% and 51.2%, and specificity was 83.9% and 93.2% respectively. higher 6 months after RDN than before RDN (both p<0.05). Figure. Conclusions: Thus, our data indicate an improved glucose homeostasis, insulin resistance and pancreatic β-cell function after RDN in patients with treatment resistant Hypertension.

RISK FACTORS ASSOCIATED WITH DIABETES

247‑OR GlycA, a Protein Glycan-Derived Marker of Systemic Inflammation as a Predictor of Type 2 Diabetes: The Insulin Resistance Athero- sclerosis Study (IRAS) CARLOS LORENZO, ANDREAS FESTA, ANTHONY J. HANLEY, MARIAN REWERS, STEVEN M. HAFFNER, San Antonio, TX, Korneuburg, Austria, Toronto, ON, Canada, Aurora, CO N-acetylglucosamine/galactosamine (GlycA) moieties of acute phase pro- teins predict future type 2 diabetes. However, it is unclear whether GlycA carries complementary information to C-reactive protein (CRP). We exam- ined the 5-year risk of developing diabetes associated with GlycA in IRAS participants without diabetes (321 non-Hispanic whites, 209 African Ameri- cans, and 280 Hispanics). GlycA was measured by NMR spectroscopy and insulin sensitivity index (SI) by the frequently sampled intravenous glucose tolerance test. The risk of diabetes related to GlycA was similar in men and ORALS women (p for interaction = 0.197), but was more relevant in African Ameri- cans (p for interaction = 0.040) (Table). GlycA added discriminatory value (net reclassification improvement: 23.1%, p = 0.027; integrated discrimination improvement: 0.056, p <0.001) and properly reclassified more than a third of individuals with moderate and strong risks of diabetes in African Americans. In addition, the risk related to GlycA was not explained by adjustment for In conclusion, if only 2-h glucose levels were considered, 61% of subjects smoking, adiposity, SI, and CRP. In summary, there are ethnic differences in the risk of future diabetes with IGT and 18.6% of those with DM according to 1-h OGTT would be associated with GlycA, even after accounting for the effect of CRP. Future missed. Furthermore, 42% of DM cases according to 1-h results would be confirmation needs to be done in other populations. GlycA may be a valuable treated as prediabetes. IFG was more correlated with 2-h OGTT levels when tool to improve prediction in African Americans. compared to 1-h. These results show that evaluation of 1-h glucose levels in addition to 2-h results should be opened to discussion as an important factor Table. Five-Year Risk of Developing Type 2 Diabetes Associated with GlycA that could increase sensitivity and specificity of ADA diagnostic criteria for by Logistic Regression Analysis. IGT and diabetes. Adjustment model All Non-Hispanic Hispanics African OR (95% CI) whites OR (95% CI) Americans OR (95% CI) OR (95% CI) Model 1: Unadjusted 1.40 (1.17 - 1.67) 1.25 (0.93 - 1.68) 1.27 (0.94 - 1.72) 1.84 (1.28 - 2.67) Model 2: Age, sex, ethnicity, clinic, 1.27 (1.04 - 1.56) 1.16 (0.81 - 1.64) 1.11 (0.80 - 1.54) 2.03 (1.26 - 3.28) family history of diabetes, and glucose tolerance status Model 2 + current smoking 1.24 (1.01 - 1.52) 1.11 (0.78 - 1.58) 1.10 (0.79 - 1.54) 1.97 (1.23 - 3.17)

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249‑OR Figure. The Risk of Progression to Type 1 Diabetes (T1D) in Individuals of Diverse Ages with Multiple Autoantibodies LAURA M. JACOBSEN, JAY M. SOSENKO, CARMELLA EVANS-MOLINA, LINDA A. DIMEGLIO, ROBIN S. GOLAND, DARRELL M. WILSON, MARK A. ATKINSON, TANDY AYE, WILLIAM RUSSELL, JOHN M. WENTWORTH, SUSAN GEYER, DAVID BOULWARE, Gainesville, FL, Miami, FL, Indianapolis, IN, New York, NY, Stanford, CA, Palo Alto, CA, Nashville, TN, Parkville, Australia, Tampa, FL Young children with multiple autoantibodies (≥2 Abs) are at high risk for the development of T1D with reported 5 and 10-year risks of 0.44 and 0.70. However, the risk in individuals of diverse ages with multiple Abs has not been studied in depth. We thus examined the impact of age, the Diabetes Prevention Trial Risk Score (DPTRS), and types of Abs upon the risk of T1D in TrialNet Pathway to Prevention (PTP) participants with ≥2 Abs (IAA, GADA, IA-2A, ICA, ZnT8), a cohort with a wide age range [n=1896; mean±SD age: 13.5±10.7 years (range 1-45 years); ZnT8A measured in 1119]. Findings are shown for the full cohort, since they were similar with or without ZnT8A. Based on the hazard ratio (HR) from a Cox regression analysis, there was 4.5% (95% CI: 3.3%, 5.6%) less risk for T1D per year increase in age (p<0.001). In the analysis of the DPTRS (based upon age, BMI, log fasting C-peptide, glucose and C-peptide sums from 30 to 120 minutes during 2-hr Supported By: Gunnar and Ingmar Jungner Foundation for Laboratory Medicine OGTTs), among PTP participants with normal glucose levels, the cumulative incidence for T1D was higher for values ≥6.5 than values <6.5 (p<0.001), both 251‑OR among individuals with 2 Abs [5-year risks: 49% (n=184) vs. 12% (n=429)] The Influence of Visceral Adipose Tissue Accumulation on the and >2 Abs [(5-year risks: 57% (n=397) vs. 21% (n=368)]. In the Ab analysis, Accuracy of Surrogate Indices for Insulin Sensitivity adjusting for Ab number, those with GADA as one of the ≥2 Abs had less LAUREN A. FOWLER, JEANNIE TAY, LAURA L. GOREE, AMY M. GOSS, NIKKI C. risk than the others [HR: 0.337 (0.281, 0.505); p<0.001]. In contrast, those BUSH, W. TIMOTHY GARVEY, BARBARA A. GOWER, Birmingham, AL with IA-2A as one of the ≥2 Abs were at higher risk [HR: 1.78 (1.33, 2.38); Disparities in the accuracy of surrogate indices of insulin sensitivity have p<0.001]. 10-year risks for 2 Abs with DPTRS values <6.5 (n=429), or ≥2 Abs been observed for both race and gender. Surrogate measures of insulin sen- with GADA in the absence of IA-2A (n=556), were approximately 20% and sitivity may reflect hepatic processes to a greater extent than does the eug- 40% respectively. lycemic clamp, the accepted criterion method for evaluating insulin sensitiv- In summary, the risk for T1D in a diversely aged population with ≥2 Abs ity. Greater visceral adipose tissue (VAT) is associated with hepatic insulin becomes quite low as individuals age. A lower risk is also evident among sensitivity and may contribute to race-gender differences in the accuracy those with normal glucose levels and DPTRS values <6.5, and among those of surrogate indices. We tested the hypothesis that associations between with GADA as one of the ≥2 Abs in the absence of IA-2A. direct and surrogate measures of insulin sensitivity would be higher among In conclusion, the findings suggest that a considerable proportion of individuals with high vs. low VAT. Participants were 65 nondiabetic adults diversely aged individuals with ≥2 Abs appear unlikely to progress to T1D. (26 men, 39 women, 36 African Americans, and 27 European Americans), classified as having low or high VAT using sex-specific criteria. Insulin sen- 250‑OR sitivity was measured with the euglycemic-hyperinsulinemic clamp, which Subtle Elevations of Metabolic Risk Factors Prognosticate Type 2 reflects primarily skeletal muscle glucose disposal. HOMA-IR and Matsuda Diabetes 20 Years or More before Diagnosis—A Study with 47,997 indexes were calculated from fasting and OGTT values. VAT was measured Cases with DXA. Associations between surrogate indices and clamp-derived insu- HÅKAN MALMSTRÖM, GÖRAN WALLDIUS, SOFIA CARLSSON, VALDEMAR lin sensitivity were stronger in the high VAT group (Matsuda, r2=0.4724; GRILL, INGMAR JUNGNER, SOFFIA GUDBJÖRNSDOTTIR, MIKHAIL N. KOSI- HOMA-IR, r2=0.3857) vs. the low VAT group (Matsuda, r2=0.1609; HOMA-IR, BOROD, NIKLAS HAMMAR, Stockholm, Sweden, Trondheim, Norway, Gothenburg, r2=0.2194). Inclusion of race and gender in the models differentially affected Sweden, Kansas City, MO associations in the high vs. low VAT groups, suggesting that the influence of Background: Risk factors for T2D may be present long before diagnosis race and gender may be altered by VAT. Our findings indicate that associa- but few studies have documented more than a ten years long period. Here tions between measures of insulin sensitivity are influenced by VAT accumu- we describe metabolic risk factors for T2D up to 25 years prior to diagnosis. lation, which may reflect the extent to which hepatic and peripheral insulin Methods: In the Swedish AMORIS cohort (n=537,119) we identified new sensitivity are correlated. Thus in general, surrogates would be expected T2D cases (n=47,997) in 1985-2012. In a nested design, five controls were to perform better in individuals and groups with greater VAT, such as Cau- randomly selected and matched to each case by sex, age and calendar with casians and men. Differences in VAT should be considered when choosing ORALS incidence density sampling. Risk factors were measured at clinical examina- methods to evaluate insulin sensitivity. tions in 1985-96. Trajectories for fasting glucose (fGlu), triglycerides (TG), Supported By: National Institutes of Health/National Institute of Diabetes and total cholesterol (TC), and body mass index (BMI) were evaluated by yearly Digestive and Kidney Diseases (P30DK56336, R01DK096388, P60DK079626) means for cases and controls. The 20-year risk for T2D based on age, sex, BMI, fGlu and TG was estimated in the full cohort using logistic regression. 252‑OR Results: Cases of T2D (•) had higher mean fGlu and TG compared to Con- Pathways to Type 2 Diabetes: Hypothesis-Free Discovery through trols (▲) long before the diagnosis (Figure). The 20-year risk of T2D was high Integration of Large-Scale Metabolomic and Genomic Data in obese subjects even at low to moderate glucose levels. TG ≥124 mg/dL LUCA LOTTA, PAUL NEWCOMBE, KAY TEE KHAW, NICK WAREHAM, CLAUDIA increased the risk irrespective of BMI and fGlu and women showed at least LANGENBERG, Cambridge, United Kingdom the same risk as men at corresponding risk factor levels (data not shown). Background: Discovery of type 2 diabetes [T2D] pathways has been lim- Conclusions: T2D is associated with subtle elevations of glucose and ited by partial coverage of the blood metabolome, small size and/or cross- lipids many years before diagnosis. This suggests that diabetogenic pro- sectional design of earlier studies. Clinical utility and causal relevance of cesses tied to chronic insulin resistance may operate for decades prior to previously identified metabolites remain largely unexplored. T2D diagnosis. Methods: Baseline plasma samples were used for untargeted metabolite measurement (DiscoveryHD4® platform, Metabolon Inc.) in 7,496 partici- pants of the EPIC-Norfolk cohort, including 716 incident T2D cases. Multi- variate Cox regression, Bayesian sparse logistic regression, and pathway enrichment analyses were used to identify metabolites associated with incident T2D. The Area Under the Receiver Operating Characteristic curve [AUC] and Mendelian randomisation analyses were used to assess predic- tive performance and causal relevance of identified pathways.

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A66 REGULATION OF DIFFERENTIATION AND METABOLISM IN BROWN ADIPOSE TISSUE

Results: A total of 57 metabolites from 23 biochemical classes were ml/min/1.73 m2 during 4 years of follow-up compared to those who did not identified (Bonferroni corrected p<0.0001), with strongest associations for (127±42 vs. 180±79ng/ml, p=0.003). It was inversely associated with declin- carbohydrate metabolism. Bayesian analyses highlighted 6 independent ing eGFR even after full adjustment including ACR, baseline CAD and the metabolites (posterior probability >0.35 and Bayes factor >250): mannose presence of T2DM (OR=0.354 [95% CI 0.131-0.957], p=0.041). The inclusion (adjusted odds ratio per 1-SD: 2.42), 1,5-anhydroglucitol (0.61), glutamate of uromodulin to a basic prediction model for CKD increased the model per- (1.38), N-acetylglycine (0.63), 2-hydroxystearate (0.66), and 1-palmitoyl- formance (C-statistic 0.844 vs. 0.804, p=0.049). glycerol 16:0 (1.66). We observed significant enrichment for 11 pathways, In conclusion, we for the first time show that serum uromodulin predicts strongest for alanine and aspartate metabolism (4,900-fold enrichment, a decline in kidney function independently from conventional risk factors p=4.6x10-9). Independent metabolites predicted future diabetes (AUC 0.86), including T2DM. and added marginally but significantly to models including HbA1c and other risk factors (0.91 vs. 0.93). Mendelian randomisation analyses based on genome-wide significant SNP-metabolite associations highlighted likely REGULATION OF DIFFERENTIATION AND non-causal associations. METABOLISM IN BROWN ADIPOSE TISSUE Conclusions: Integration of data from large-scale metabolomic and genomic discovery studies detects pathways to T2D and helps identify causal associations. 255‑OR NFIA Controls the Brown Fat Gene Program by Colocalizing with Supported By: Medical Research Council, UK PPARgamma at Cell-Type-Specific Enhancers YUTA HIRAIKE, HIRONORI WAKI, JING YU, MASAHIRO NAKAMURA, KANA 253‑OR MIYAKE, KEN SUZUKI, RYO NAKAKI, GAKU NAGANO, HARUYA OHNO, KENJI DGLA Is Associated with HOMA-IR and Risk of Incident but Not OKI, MASAYASU YONEDA, SHUICHI TSUTSUMI, HIROYUKI ABURATANI, TOSHI- Prevalent Type 2 Diabetes in the Multiethnic Study of Atheroscle- MASA YAMAUCHI, TAKASHI KADOWAKI, Tokyo, Japan, Hiroshima, Japan rosis Brown fat dissipates energy in the form of heat by means of the uncou- NATALIE L. WEIR, BRIAN T. STEFFEN, WEIHUA GUAN, RONALD KLEIN, BARBARA pling protein-1 (UCP1) on the mitochondrial inner membrane. In humans, E.K. KLEIN, MARY-FRANCES COTCH, MICHAEL Y. TSAI, Minneapolis, MN, Madi- brown fat activity is inversely correlated with body mass index. Therefore, son, WI, Bethesda, MD stimulating development and/or function of brown fat would be a novel The omega-6 fatty acid dihomo-gamma-linolenic acid (DGLA) has been strategy for the treatment of obesity and its complications. However, global shown to have anti-inflammatory and anti-proliferative effects in vitro landscape of brown fat development is not entirely understood. Here, we and was shown to reduce symptoms of atopic dermatitis and rheumatoid identified nuclear factor I-A (NFIA) as a novel transcriptional regulator of arthritis. Furthermore, we previously demonstrated an association of DGLA brown fat. The binding motif for Nuclear factor I (NFI) transcription factor with reduced risk of diabetic retinopathy. Paradoxically, DGLA has also been is enriched within brown-fat-specific open chromatin regions. Of the four shown to be associated with increased risk of incident type 2 diabetes isoforms of NFI family, NFIA is highly expressed in brown fat compared to (T2D). The present study aimed to evaluate whether DGLA is associated white fat or muscle. Introduction of NFIA into myoblasts results in lipid accu- with HOMA-IR, risk of incident and prevalent T2D in a large cohort of 5,326 mulation, activation of the brown-fat-specific gene program and suppression adult participants from the Multi-Ethnic Study of Atherosclerosis (MESA). A of muscle genes. Conversely, the brown fat of NFIA knockout mice displays multivariable linear regression model adjusted for age, sex, BMI, education impaired expression of the brown-fat-specific genes and reciprocal eleva- status, smoking, alcohol intake, and race/ethnicity was used to determine tion of muscle genes. Moreover, human perirenal brown fat of patients with associations between baseline DGLA levels (quartiles) and HOMA-IR; a Cox pheochromocytoma show concurrent increase in NFIA and UCP1 expres- proportional hazards model estimated risk of incident T2D over a median sion. Mechanistically, NFIA selectively co-localize with PPARgamma at the 12 year follow-up. At baseline, individuals in the three upper quartiles of brown-fat-specific enhancers, and co-localization of NFIA facilitates the DGLA had a significantly higher HOMA-IR compared to those in the refer- binding of PPARgamma, leading to increased chromatin accessibility and ence quartile (Q1) (coefficient, [p-value]): Q2: 0.084 [p=5.3x10-6]; Q3: 0.157 active transcription. Collectively, these results indicate that NFIA is a novel [p=1.2x10-16]; Q4: 0.237 [p=3.9x10-32]. Similar results were seen at year 10. key transcription factor that co-localizes with PPARgamma and activates the Risk of incident T2D significantly increased with increasing levels of DGLA brown-fat-specific gene program. (Hazard Ratio, [p-value]): Q2: 1.13 [p=0.37]; Q3: 1.404 [p=0.006]; Q4: 1.712 [p<0.001]. However, DGLA levels were not associated with prevalent T2D. We hypothesize that DGLA is a marker of insulin resistance because its level 256‑OR is determined by the regulatory actions of insulin on delta-5 and delta-6 Paracrine FGF6 Activates Thermogenic Program through Induction desaturases. Thus DGLA level, like insulin resistance, predicts incident T2D of Prostaglandin E2 but is not associated with prevalent T2D. However, it is not known what role, FARNAZ SHAMSI, RUIDAN XUE, MORTEN LUNDH, ELENA KEMPF, TIAN LIAN if any, DGLA plays in the pathogenesis of T2D. Further studies are required HUANG, LUIZ LEIRIA, SR., MATTHEW D. LYNES, C. RONALD KAHN, YU-HUA to reconcile the purported beneficial effects of DGLA with its paradoxical TSENG, Boston, MA, Copenhagen, Denmark, Leipzig, Germany association with insulin resistance. Brown and beige adipose tissues play a central role in the regulation

of energy expenditure in response to environmental changes such as cold ORALS and diet. Therapeutic approaches targeting brown and beige adipose tis- 254‑OR sues, and modulating its energy-dissipating capacity, hold great promise Serum Uromodulin Predicts Decline in Kidney Function Indepen- for the treatment of obesity-related disorders. The thermogenic capacity of dently from the Presence of Type 2 Diabetes brown fat is enabled by the selective expression of uncoupling protein 1 KATHRIN GEIGER, ANDREAS LEIHERER, AXEL MUENDLEIN, CHRISTOPH H. (UCP1), which executes thermogenesis by uncoupling cellular respiration and SAELY, EVA M. BRANDTNER, PETER FRAUNBERGER, HEINZ DREXEL, Dornbirn, mitochondrial ATP synthesis. To discover protein(s) that can regulate UCP1 Austria, Feldkirch, Austria, Philadelphia, PA expression, we performed a proprietary high-throughput screen using a pro- Uromodulin is the most abundant protein excreted in urine. Low uro- tein library containing more than 5,000 mammalian secreted proteins in a modulin has been found to be associated with type 2 diabetes (T2DM) as murine brown preadipocytes cell line. The screen identified a number of hits well as with chronic kidney disease (CKD). Whether it also predicts a future that can induce UCP1 expression in the committed brown preadipocytes. decline in kidney function is not known and is addressed in the present Among those, fibroblast growth factor 6 (FGF6) could increase UCP1 expres- study. We measured serum uromodulin in 529 patients undergoing coro- sion through a mechanism that does not involve activation of the adipogen- nary angiography for the evaluation of established or suspected coronary esis program. Mechanistically, FGF6’s effects on UCP1 expression were artery disease (CAD). Uromodulin was lower in patients with T2DM than mediated through binding to FGFR3 and via induction of inducing PTGS2 in nondiabetic subjects (148±70 vs. 171±79; p=0.001) and significantly cor- (COX2) and PTGES1 expression to promote prostaglandin E2 biosynthesis. related with estimated glomerular filtration rate (eGFR; r=0.242, p<0.001) Inhibition of Prostaglandin E2 production, using genetic loss of function and and, inversely, with the albumin creatinine ratio (ACR; r=-0.120, p=0.012). It pharmacologic approaches, attenuated FGF6-induced UCP1 expression. was significantly lower in patients with CKD (eGFR <60 ml/min/1.73 m2) than AAV-mediated delivery of FGF6 into white adipose tissue of mice resulted in in those with normal kidney function (72±29 vs. 169±76 ng/ml; p<0.001), and induction of UCP1 and ameliorated the detrimental effects of high fat diet- also in patients with albuminuria than in patients without increased albu- induced obesity. min excretion (149±72 vs. 168±78 ng/ml; p=0.008). Further, uromodulin at In conclusion, these data reveal a previously unknown paradigm for regu- baseline was significantly lower in patients who developed an eGFR <60 lation of energy expenditure, in which induction of UCP1 expression and

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A67 REGULATION OF DIFFERENTIATION AND METABOLISM IN BROWN ADIPOSE TISSUE

mitochondrial activity are dissociated from adipocyte differentiation and 259‑OR lipid accumulation. These findings may offer a new therapeutic opportunity Regulation of Brown Fat Progenitor Cells by Insulin Activation of to combat obesity and insulin resistance through increasing whole body Enos on the Vascular Endothelium energy expenditure. KYOUNGMIN PARK, QIAN LI, MATTHEW D. LYNES, HISASHI YOKOMIZO, CHRIS- Supported By: National Institutes of Health (R01DK077097, R01DK102898) TIAN RASK-MADSEN, ERNESTO MADDALONI, YU HUA TSENG, GEORGE L. KING, Boston, MA 257‑OR Brown Adipose Tissue (BAT) development is important for body energet- CRISPR-Engineered Human Brown-Like Adipocytes Display ics, insulin sensitivity and weight gains. BAT is densely vascularized and yet Enhanced Mitochondrial Activity and Facilitate Glucose Metabo- the interactions between BAT and endothelium, especially with endothelial lism In Vivo dysfunction, a key manifestation of insulin resistance and obesity, have not CHIH HAO WANG, MORTEN LUNDH, ROKUS KRISZT, FARNAZ SHAMSI, TIAN been explored. We characterized endothelial specific IRS1 overexpression LIAN HUANG, YU HUA TSENG, Boston, MA, Copenhagen, Denmark, Singapore, transgenic mice, ECIRS1, which exhibited lower body weight and improved Singapore systemic insulin sensitivity in parallel with dramatic insulin enhanced Brown and brown-like beige adipocytes dissipate energy for thermo- nitric oxide (NO) production via activation of PI3K/eNOS pathway. At room genesis and have been proposed to combat obesity and metabolic disor- temperature and cold exposure (5°C), ECIRS1 mice developed greater BAT ders. Uncoupling protein 1 (UCP1), a mitochondrial ion carrier, is uniquely mass at interscapular and subcutaneous sites. Analysis of isolated BAT expressed in brown and beige adipocytes, and facilitates fuel utilization precursors in vivo showed that BAT progenitor cells as marked by Lin-:CD31- and energy expenditure. Ectopic UCP1 overexpression improves obesity and :CD34+:Sca1+:CD140b+:CD146+ were increased in the ECIRS1 mice by 1.7 fold insulin resistance in mice. In humans, however, whether induction of endog- vs. WT mice, confirmed by immunohistochemistry and qRT-PCR analysis enous UCP1 leads to brown-like phenotype and benefits metabolism has not measuring UCP1+ cells and Ucp1 mRNA. To determine the lineage of the yet been addressed. In this study, we utilized the CRISPR/Cas9 synergistic BAT progenitors in the ECIRS1 mice, analysis was performed using the BAT activation mediator (Konermann et al., Nature 2015) and specific gRNAs from ECIRS1/PdgfRα-Cre-ER-tdTomato-Gfp reporter mice and confirmed the to boost endogenous UCP1 mRNA and protein expression in human white precursors of BAT progenitors. Using cultured BAT progenitors, sodium nitro- preadipocytes. After induction of differentiation, the UCP1-overexpressing prusside (SNP), a direct NO donor, induced Ucp1 and Prdm16 mRNA by 7.4 white adipocytes had significant increases of mitochondrial activities, and 4.2 fold respectively, which were inhibited by soluble guanylate cyclase UCP1-dependent respiration, and thermogenic capacity, as well as enhanced inhibitor (ODQ). Interestingly, BMP7, a known BAT differentiation factor, and glucose and fatty acid utilization, when compared with the parental white SNP, synergistically, induced BAT differentiation and their signaling activi- adipocytes. All of these changes in the UCP1-overexpressing white adipo- ties were inhibited by ODQ, indicating the requirement for the activation of cytes were comparable to bona fide human brown adipocytes derived from cGMP-dependent kinase. Thus, insulin’s actions in the endothelium via NO the same individual, suggesting that the CRISPR-engineered human white can regulate the differentiation of perivascular BAT progenitor cells in vivo, fat cells had acquired brown fat-like features. To assess the metabolic out- which can improve insulin sensitivity and reduce weight gains induced by comes of these CRISPR-engineered human brown-like adipocytes in vivo, HFD. Thus, improving endothelial dysfunction could be an important regula- we transplanted the cells into the immune-deficient nude mice and fed them tor of BAT development in obesity and insulin resistant states. with 45% high-fat diet for 14 weeks. In contrast to mice transplanted with Supported By: National Institute of Diabetes and Digestive and Kidney Diseases human white preadipocytes, mice receiving the CRISPR-engineered human (5R01DK053105) brown-like cells displayed enhanced cold tolerance and significant improve- ment in glucose tolerance, especially upon cold activation. 260‑OR In summary, these data demonstrate the utility of using the CRISPR/ Activation of RalA Enhances Glucose Disposal into Brown Adipose Cas9 system to activate the endogenous UCP1 expression in human white Tissue and Protects against Metabolic Disease adipocytes, and provide a potential therapeutic strategy against metabolic YULIYA SKOROBOGATKO, MORGAN DRAGAN, SHANNON M. REILLY, MARTINA disorders. WALLACE, CHRISTIAN M. METALLO, OLIVIA OSBORN, JERROLD OLEFSKY, ALAN R. SALTIEL, La Jolla, CA 258‑OR Our previous studies in 3T3-L1 adipocytes established that prior to exo- Mitochondrial Protein Succinylation and Malonylation Is a Highly cytosis, Glut4 storage vesicles (GSV) are tethered to the exocyst complex, Regulated Process that Affects Mitochondria Respiration and Fuel which is assembled at the plasma membrane in response to insulin. The Preference in Brown Fat tethering is regulated by the GSV-associated small G protein RalA. RalA GUOXIAO WANG, JESSE MEYER, MENGYAO LI, SAMIR SOFTIC, BRADFORD activity is controlled by its cognate GAP, an AKT substrate. Under basal GIBSON, CHRISTOPHER NEWGARD, C. RONALD KAHN, Boston, MA, Novato, CA, conditions RalGAP maintains RalA in the inactive state. Phosphorylation of Durham, NC RalGAP by AKT disrupts its association with RalA, and RalA is thus activated Brown adipose tissue (BAT) has high mitochondria density and plays and able to interact with the subunits of the exocyst complex. important roles in energy expenditure, thermogenesis and glucose homeo- To test the role of RalA and its GAP in glucose homeostasis in vivo, we generated mice with adipose-specific knockout of RalGAPB (KO mice),

ORALS stasis. Modification of proteins by addition of acetyl, malonyl and succinyl groups has been shown to affect their activity and is a regulated process by a scaffolding subunit of the RalGAP complex. RalGAPB knockout led to a a family of deacylases, the sirtuins (Sirts). We find that compared to other dramatic increase in RalA activity. While maintaining the same weight, KO tissues, brown fat has high levels of protein malonylation and succinylation, mice had increased fat depots and improved glucose tolerance. Glucose dis- which increases dramatically with cold acclimation. Genetic knockout of the posal and fatty acid synthesis in brown adipose tissue (BAT) were strongly mitochondrial desuccinylase/demalonylase Sirt5 in BAT (Sirt5-BKO) further upregulated, while glucose disposal into other insulin responsive tissues increased protein malonylation/succinylation in BAT and also resulted in was decreased, at least in part due to lower plasma insulin and decreased intolerance to acute cold exposure. Sirt5-BKO mice switched fuel preference Glut1 levels. This altered glucose homeostasis was preserved on high fat from glucose to fatty acid as demonstrated by a lower respiration exchange diet, contributing to dramatically reduced blood glucose levels and reduced ratio in Sirt5-BKO mice during the feeding period. Consistent with this, mito- steatosis in KO mice. The lipids stored in KO adipose tissue were enriched chondria isolated from BAT of fasted Sirt5-BKO mice had decreased oxygen with palmitoleate, which was previously implicated as an anti-inflammatory consumption rates (OCR) compared to those from control mice. In addition to molecule. In this regard, we observed reduced inflammatory gene expres- that, cultured brown adipocytes with knockout of Sirt5 also had decreased sion in both epididymal adipose tissue and liver of KO mice on high fat diet. OCR in vitro. Metabolomic analysis using BAT from Sirt5-BKO mice found Pharmacological inhibition of RalA in vivo reduced glucose disposal into BAT decreased fumarate levels with no change in succinate levels, indicating twice. Thus we showed that RalA plays a crucial role in glucose transport in decreased succinate dehydrogenase activity. Proteomic and immunoblotting BAT in vivo, and further that enhancing glucose uptake specifically into this further confirmed that succinate dehydrogenase B (SDHB) is succinylated and tissue profoundly influences glucose homeostasis in a beneficial way. is a target of Sirt5, such that when Sirt5 is absent, the succinylation of SDHB Supported By: National Institute of Diabetes and Digestive and Kidney Dis- is significantly increased, possibly leading to decreased SDHB activity. eases; American Heart Association To sum up, our study showed that succinylation and malonylation are important post-translational modifications of mitochondrial proteins that reg- ulate brown fat function through affecting mitochondria enzyme activities. Supported By: National Institutes of Health

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A68 STRESS RELIEF FOR THE ISLET

261‑OR STRESS RELIEF FOR THE ISLET OPA1 Deletion in Adipose Tissue Results in BAT Remodeling and Impaired Glucose Homeostasis 263‑OR RENATA O. PEREIRA, ROSE MCGLAUFLIN, MATTHEW J. POTTHOFF, E. DALE Disrupted Cx36 Gap Junction Coupling Contributes to the Progres- ABEL, Iowa City, IA sion of Type 1 Diabetes in NOD Mice Mitochondrial dynamics is a conserved process by which mitochondria NIKKI L. FARNSWORTH, AUDREY HEINTZ, RICHARD K. BENNINGER, Aurora, CO undergo repeated cycles of fusion and fission. Altered mitochondrial dynam- Loss of islet mass and function in type 1 diabetes is in part mediated by ics may alter brown adipocyte metabolism in vitro and change thermogenic pro-inflammatory cytokines. In vitro cytokines decrease connexin36 (Cx36) gap response in vivo. However, the specific contribution of mitochondrial dynamics junction coupling, leading to altered β-cell Ca2+ signaling and insulin secretion. to adipose tissue physiology and adaptation to stress is incompletely under- Loss of Cx36 coupling exacerbates cytokine-induced apoptosis. The goal of stood. We examined the role of the mitochondrial fusion protein optic atrophy this study was to investigate changes in Cx36 coupling and islet function in 1 (OPA1) in adipose tissue, by crossing OPA1 floxed mice to mice harboring the NOD mice prior to disease onset and determine if modulating Cx36 coupling Cre recombinase under the control of the adiponectin promoter, to generate can protect against islet dysfunction and diabetes progression. Adipo-/- adipocyte-specific deletion of the Opa1 gene (OPA1 ). Under basal condi- Glucose tolerance, insulin secretion, intracellular Ca2+, and Cx36 cou- Adipo-/- tions, young OPA1 mice had similar body weight, but slightly increased fat pling were measured in NOD and NOD-RAG1 KO (RAG) mice at 6, 9, and Adipo-/- mass relative to wild type (WT) mice. Upon euthanasia, OPA1 mice had 12 weeks of age. Insulin secretion and Cx36 coupling were studied in islets significantly larger and pale appearing BAT, compared to WT mice. By histol- over-expressing Cx36 (RIP-Cx36 mice) treated with a cocktail of cytokines Adipo-/- ogy, BAT morphology in OPA1 mice appeared like white adipose tissue (10ng/mL TNF-α, 5ng/mL IL-1β, 100ng/mL IFN-γ); human islets treated with (WAT), with large, unilocular lipid droplets. UCP1 levels were unchanged in BAT, cytokines plus 50µM Modafinil; and RIP-Cx36 mice on NOD background Adipo-/- whereas PGC-1α and VDAC protein levels were increased in OPA1 mice, (NOD-RIP-Cx36). suggesting compensation that could increase mitochondrial biogenesis. None- Islets from 9 and 12 week NOD mice showed altered Ca2+ dynamics and Adipo-/- theless, mitochondrial complexes I and III were reduced in BAT of OPA1 decreased Cx36 coupling (p=0.02, p<0.001); insulin secretion and glucose mice, consistent with impaired mitochondrial oxidative capacity. OPA1 deletion tolerance were similar compared to islets from RAG mice. RIP-Cx36 islets increased FGF-21 protein levels in BAT and gonadal fat, which correlated with showed reduced cytokine-induced cell death (p=0.04) and slightly improved a 4-fold increase in FGF-21 circulating levels. UCP1 and PGC-1α protein lev- insulin secretion compared to WT mice. Modafinil increased Cx36 coupling and els were increased in inguinal fat, indicating induction of browning. Glucose reduced cell death in cytokine-treated human islets compared to untreated. Adipo-/- tolerance was impaired in OPA1 mice, which also failed to maintain core NOD-RIP-Cx36 mice showed improved Cx36 coupling; with delayed onset and body temperature upon cold exposure. Taken together, these data suggest that decreased incidence of diabetes compared to NOD littermates. OPA1 deletion in adipose tissue induces remodeling of BAT, resulting in lipid In conclusion, Cx36 coupling and Ca2+ dynamics are disrupted in NOD accumulation, cold intolerance and impaired glucose homeostasis, despite FGF- mice prior to diabetes onset. Modulating Cx36 coupling reduced cell death 21-mediated induction of browning in subcutaneous adipose tissue. in mouse and human islets, and delayed/reduced diabetes onset in NOD Supported By: American Heart Association mice suggesting altered Cx36 coupling plays a role in diabetes progression. Modulating Cx36 may provide a potential therapeutic pathway to protect 262‑OR islet function early in type 1 diabetes progression. Adrenaline/Myeloid CaMKII Axis Is Required for Cold-Induced Supported By: National Institutes of Health (F32DK102276, R00DK085145, Activation of Beige Adipocytes R01DK102950, R01DK106412); JDRF (5-CDA-2014-198-A-N) YAN LUO, BILIAN LIU, XIN YANG, XIAOXIAO MA, WENDONG HUANG, MEILIAN LIU, Albuquerque, NM, Duarte, CA 264‑OR Alternatively activated macrophages orchestrate cold-induced thermo- The Role of Islet Resident Macrophages in Amyloid-Induced IL-1β genesis through the production of catecholamine in adipose tissue. How- Production and β-Cell Fas Expression in Human Islets ever, the mechanisms underlying cold-induced catecholamine production QUEENIE HUI, TIMOTHY J. KIEFFER, YOO JIN PARK, ZILIANG AO, NOOSHIN in macrophages remains largely unknown. Here, we show that the plasma SAFIKHAN, MARK MELOCHE, GARTH L. WARNOCK, LUCY MARZBAN, Vancouver, level of adrenaline was induced by 10 hour-cold stress (6°C), and treatment BC, Canada of RAW 264.7 murine macrophages with adrenaline stimulated the phos- Islet amyloid is a pathologic characteristic of type 2 diabetes (T2D) that 40 phorylation at Ser of tyrosine hydroxylase (TyrH), a rate-limiting enzyme of also forms in human islets during culture and after transplantation. These catecholamine biosynthesis, as well as phosphorylation of PKA substrates -cell toxic protein aggregates are mainly comprised of a normally produced 286 β and CaMKII at Thr . Moreover, treatment of macrophages with dibutyryl -cell peptide named human islet amyloid polypeptide (hIAPP). The mecha- 2+ β cyclic AMP (dbcAMP), an analog of cyclic AMP, elevated intracellular Ca nisms underlying amyloid-induced β-cell death in human islets are still and stimulated phosphorylation of CaMKII and TyrH as well. Consistent with unclear. We previously showed that biosynthetic hIAPP aggregates promote this, inhibition of PKA suppressed adrenaline or dbcAMP-induced phosphor- islet interleukin (IL)-1β production thereby inducing β-cell upregulation of ylation of CaMKII and TyrH in macrophages. Furthermore, blocking CaMKII the Fas cell death receptor and apoptosis. Here, we investigated the cellular signaling by ablation of CaMKIIγ or treatment with CaMKII-specific inhibi- source(s) of IL-1β in human islets during amyloid formation. Isolated human ORALS tor KN93 diminished dbcAMP-induced phosphorylation of TyrH in primary islets (n = 6-8 donors) transduced with Ad-prohIAPP-siRNA (to suppress peritoneal macrophages. In addition, myeloid-specific disruption of CaMKIIγ amyloid formation) or non-transduced were treated with or without a neu- suppressed adrenaline-induced production of norepinephrine and adipose tralizing IL-1β antibody or clodronate (to deplete macrophages) and cultured UCP1 expression in vivo and in vitro. Lack of CaMKII signaling attenuated in elevated (11.1 mmol/l) glucose (to potentiate amyloid formation) for up catecholamine production mediated by IL-4 and IL-13, the key inducer of to 7 days at 37°C. Freshly isolated islets had low IL-1β levels. Islet culture type 2 immune response in primary macrophages. Taken together, these resulted in progressive amyloid formation (detected by electron microscopy results suggest a feedforward mechanism of adrenaline in adipose-resident and thioflavin S staining), elevated islet IL-1β production (mainly in β-cells), macrophages, and that myeloid CaMKII signaling plays an important role in β-cell Fas upregulation, caspase-8 and -3 activation and apoptosis, all of catecholamine production and subsequent beige fat activation. which were prevented by inhibition of amyloid. Interestingly, islet resident Supported By: American Diabetes Association (1-13-JF-37 to M.L.); American macrophages were detectable after 7 days culture at 37°C. Macrophage Heart Association depletion significantly reduced, but did not completely prevent, amyloid- induced IL-1β immunoreactivity in β-cells. Moreover, neutralizing IL-1β markedly reduced (but did not completely prevent) IL-1β immunoreactivity in β-cells. Taken together, these data suggest that resident macrophages (mainly) and β-cells (to a lesser extent) are two cellular sources of amyloid- induced IL-1β production in human islets. Blocking IL-1β can protect human islets in conditions associated with islet amyloid formation such as T2D and islet grafts. Supported By: Canadian Institutes of Health Research

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A69 STRESS RELIEF FOR THE ISLET

265‑OR 267‑OR SPCA1 Loss Leads to Impaired Insulin Secretion and Autophagy in WITHDRAWN the β-Cell ROBERT N. BONE, SOLAEMA TALEB, XIN TONG, TATSUYOSHI M. KONO, CARMELLA EVANS-MOLINA, Indianapolis, IN Significant levels of Ca2+ are found within the β-cell Golgi, which is an important site of proinsulin maturation. However, whether altered Golgi Ca2+ contributes to diabetes pathophysiology is unknown. The Golgi primar- ily utilizes the Secretory Pathway Ca2+ ATPase (SPCA1) to maintain intra- Golgi Ca2+ stores. SPCA1 expression was measured in islets from Akita and db/db mice and cadaveric human islets from donors with T1D and T2D. In all cases, SPCA1 levels were significantly lower compared to nondiabetic controls. Reverse Phase Protein Array analysis performed in INS-1 β-cells lacking SPCA1 (SPCA1KO) indicated dysregulated cell death, cell growth, and proliferation pathways compared to WT INS-1 cells. Consistent with this finding, SPCA1KO cells exhibited increased susceptibility to apoptosis and higher expression of ARF4, a transcription factor that induces Golgi col- lapse, following tunicamycin or brefeldin A treatment. SPCA1KO cells also had elevated basal cytosolic Ca2+ levels, decreased organelle Ca2+ uptake following organelle Ca2+ store depletion, reduced ER Ca2+ levels, and acceler- ated Golgi collapse. Despite a significant reduction in GSIS, SPCA1KO cells exhibited a 12-fold insulin content increase. Autophagy has been reported as a key regulator in maintaining β-cell insulin homeostasis. Following loss of SPCA1, immunoblot exhibited increased activated p70 S6k and 4EBP-1, which suppress autophagy, and reduced expression of the autophagy marker LC3-II. To investigate SPCA1 in a diabetic model, SPCA1+/- and WT mice were challenged with high fat diet (HFD). After 16 wks of HFD, SPCA1+/- mice had 266‑OR increased weight gain, a trend towards higher incidence of diabetes, while Identification of StAR (Steroidogenic Acute Regulatory Protein) in SPCA1+/- islets exhibited elevated cytosolic Ca2+ levels and Ca2+ oscillation Islets Expressing Amyloidogenic hIAPP amplitude. Taken together, we find thatβ -cell SPCA1 plays an important role 2+ MEGHAN F. HOGAN, MARK ZIEMANN, ANDREW T. TEMPLIN, MAHNAZ MEL- in the maintenance of Golgi Ca levels and the alleviation of Golgi stress, 2+ LATI, THINN THINN KHINE, SAKENEH ZRAIKA, REBECCA L. HULL, ASSAM EL- while loss of SPCA1 under diabetic conditions led to dysregulated β-cell Ca OSTA, STEVEN E. KAHN, Seattle, WA, Melbourne, Australia homeostasis. In type 2 diabetes, islet amyloid polypeptide (IAPP) aggregates as amyloid Supported By: National Institutes of Health (T32-AI060519 to R.N.B.), resulting in β-cell apoptosis. To identify genes differentially regulated by (R01DK093954 to C.E-M.); Veterans Affairs Medical Center (to C.E-M.) amyloid, a mouse model expressing human IAPP and the non-amyloidogenic mouse IAPP control were used. 268‑OR Isolated islets were cultured for 2 days in 11.1 or 16.7 mM glucose, the Reversal of Human Islet Functional Damage Induced by Gluco-lipo- latter to induce amyloid deposition in hIAPP islets. RNA-seq identified toxic Conditions and Its Association with Transcriptomic Changes 10,000 differentially regulated genes, with STAR upregulated only in islets MARA SULEIMAN, LORELLA MARSELLI, YUCHEN BAI, BRIAN RADY, MARCO with amyloid (FDR=7.17 E-128). Classically, StAR moves cholesterol across the BUGLIANI, KIRSTINE BELONGIE, IVONA BAKAJ, SEUNGHUN LEE, LISA NOR- mitochondrial membrane in steroid producing tissues, is involved in “alterna- QUAY, UGO BOGGI, FRANCO FILIPPONI, ALESSANDRO POCAI, PIERO MAR- tive” synthesis of bile acids, and is implicated in tissue protection. CHETTI, Pisa, Italy, Spring House, PA To confirm StAR upregulation with amyloid, we determined gene (Table; Gluco-lipotoxic conditions (GLTc) reduce glucose-stimulated insulin 1a-b) and protein expression (Table; 2) in islets under low and high glucose. secretion (GSIS) and increase beta cell death, contributing to type 2 dia- Both were increased in amyloidogenic islets, with StAR protein enriched in betes (T2D). We comprehensively studied the effects of several GLTc on mitochondria (Table; 3a-b) consistent with its known function. A pathophysi- human islets (HI), including the possible reversal of GSIS damage and the ological role for StAR is suggested by its increase in amyloidogenic islets in associated transcriptomic changes. HI isolated from 26 nondiabetic organ vivo (Table; 4). Cultured with an amyloid inhibitor (200 μM Congo Red [CR]), donors were cultured (3 to 6 preparations per condition) with/without: STAR expression was abrogated (Table; 5), implying regulation downstream 0.5 mM palmitate (P), 11.1 mM glucose (g), 22.2 mM glucose (G), P+g, P+G, of amyloid aggregation. 1.0 mM palmitate+oleate, (1:2, P+O), P+O+g, P+O+G. Islets were studied We identified StAR as a novel islet protein upregulated by amyloid. basally (Bas), after 2 days (2 d) of GLTc incubation and following 4 additional ORALS Studies to determine StAR’s role in amyloid-induced β-cell apoptosis are days in normal medium (wash-out, WO). RNA (RIN ≥ 7.9) of HI from the P ongoing. alone experiments was sequenced by Illumina HiSeq2500; reads (≥198M/ sample) were mapped using the OmicSoft Aligner. Overall, Bas insulin release was 53±3 and 155±12 μU/ml (insulin stimulation index, ISI: 3.1±0.2) respectively at 3.3 and 16.7 mM glucose (p<0.01). No significant change occurred with Ctrl, g, P+O and P+O+g. However, ISI at 2 d declined (p<0.05 or less) with P, G, P+g, P+G and P+O+G. Notably, normalization of GSIS was observed at WO vs. 2 d with P, G and P+g, but not with P+G and P+O+G. By RNA-seq the genes differentially (FDR<0.05) expressed were: 151 with 2 d treated vs. 2 d Ctrl HI; 205 with WO vs. Ctrl HI; and 2,873 with WO vs. 2 d treated HI. In this latter comparison, 45 pathways were identified, includ- ing: MODY, ABC transporters, insulin signaling, calcium signaling (upregu- lated); and Notch signaling, Wnt signaling and apoptosis (downregulated). This study shows that: several GLTc impaired GSIS from HI, depending on stressor type, concentration and combinations; reversal of functional dam- age occurred after removal of some, but not all, of the deleterious GLTc; several genes and pathways were associated with insulin secretion recov- Supported By: National Institutes of Health ery from palmitate toxicity, which may represent potential targets to better prevent and treat T2D. Supported By: Janssen Research & Development, LLC

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A70 DIABETIC RETINOPATHY—MORE THAN MEETS THE EYE

DIABETIC RETINOPATHY—MORE THAN MEETS Conclusion: IF mediated protective effects in db/db mice. DR was pre- THE EYE vented, gut microbiota and gut barrier was restored, liver metabolism was enhanced, and tissue and systemic inflammation reduced. Supported By: National Institutes of Health (R01EY0126001, R01EY007739, 269‑OR R01HL110170, R01DK090730); Research to Prevent Blindness Characterizing Retinol Binding Protein 3 Levels in People with Dia- betes and Its Protective Actions in Transgenic Mice with Specific Overexpression in the Retina 271‑OR HISASHI YOKOMIZO, YASUTAKA MAEDA, KYOUNGMIN PARK, ATSUSHI Oral Delivery of Angiotensin-(1-7) Bioencapsulated in Plant Cells ISHIKADO, ALLEN C. CLERMONT, LIANE J. TINSLEY, DAVID M. POBER, I-HSIEN Protect against Diabetes-Induced Tissue Damage and Retinopathy WU, EDWARD P. FEENER, JENNIFER K. SUN, LLOYD PAUL AIELLO, HILLARY A. QIUHONG LI, KANG XU, TAO DU, PING ZHU, AMRISHA VERMA, MANOJ KEENAN, GEORGE L. KING, Boston, MA KULKARNI, TUHINA PRASAD, HENRY DANIELL, Gainesville, FL, Philadelphia, PA Retinol Binding Protein 3 (RBP3), a protein secreted by photoreceptor Purpose: Previous studies have established that activation of the mem- cells, has been identified as a potential protective factors against the pro- bers of the vasoprotective axis of the renin-angiotensin system [ACE2 or gression of retinopathy (DR) by proteomic analysis of the retina from people Angiotensin-(1-7) (Ang-(1-7)] prevents and arrests progression of diabetic with type 1 diabetes (T1DM) of 50 years or more (Medalist Study). Immu- retinopathy. This study was aimed to test the hypothesis that oral deliv- noblot analysis of vitreous from Medalists, people with T1DM or T2DM and ery Ang-(1-7) bioencapsulated in plant cells would confer protection against controls validated that RBP3 expressions were lower progressively in people diabetes-induced retinopathy in animal models. with no-mild non-proliferative DR (no-mild NPDR) (N=36), moderate NPDR Methods: Ang-(1-7) peptide fused with the non-toxic cholera B toxin sub- (N=13) and quiescent QPDR (-48.0%, P<0.01; N=41) than controls (N=15). In unit B (CTB) was expressed in plant chloroplasts. Diabetic eNOS-/- mice contrast, elevation of vitreous vascular endothelial growth factor (VEGF) induced by STZ and Akita mice were orally gavaged daily with wild type or levels correlated with the severity of DR, and, significantly, inversely to the Ang-(1-7) leaf materials for eight weeks. levels of RBP3, from no-mild NPDR to PDR. Mechanistically, recombinant Results: Increased level of Ang-(1-7) was observed in circulation and retina RBP3 inhibited retinal endothelial cell migration induced by high glucose after oral administration of CTB- Ang-(1-7). Ang (1-7) leaf material treatment and VEGF by binding to VEGF or its receptors (FLK). To test the therapeu- significantly improved the glucose tolerance and insulin sensitivity in diabetic tic effects of RBP3 on diabetes induced retinal dysfunction, we generated eNOS-/- and Akita mice, increased insulin expression of the pancreatic islets RBP3 transgenic mice that specifically overexpressed human RBP3 to the compared to control groups (untreated or treated with wild type leaf material). retina (RhRBP3 Tg) by 2 fold using the rhodopsin promotor. After 2 month Ang (1-7) leaf material treatment also significantly reduced apoptotic cell death of diabetes induced by STZ, retinal expressions of RBP3 were decreased by in kidney, as well as diabetes-induced RGC loss, gliosis and microglial cell acti- 49% (P=0.02) vs. controls, but RBP3 levels were elevated by 2.1-fold (P=0.02) vation, expression of inflammatory cytokines in diabetic retina, improved mito- in diabetic RhRBP3 Tg mice. Analysis of retinal functions by electroretino- chondrial function and prevented retinal endothelial capillary loss. gram and structures by ocular coherence tomography showed that diabetes Conclusions: Our results demonstrate that orally administered Ang-(1-7) induced abnormalities such as decreased amplitudes of a and b waves and bioencapsulated in plant cells can be efficiently delivered into circulation thinning of the photoreceptor layers were not observed in diabetic RhRBP3 and target tissues; orally administered bioencapsulated Ang-(1-7) not only Tg mice. Similarly, elevations of retinal VEGF expression and vascular per- mitigated diabetic retinopathy, but also improved systemic parameters and meability measured by Evan’s blue dye exhibited by diabetic WT mice were other diabetic complications, thus enhancing the protective axis of RAS by prevented in diabetic RhRBP3 Tg mice. These findings strongly support that oral delivery of Ang-(1-7) bioencapsulated in plant cells provide an innova- RBP3 has protective effects against DR, possibly by binding to VEGF and can tive, highly efficient and cost-effective therapeutic strategy for treating dia- be used therapeutically. betes and diabetic complications. Supported By: National Institutes of Health; National Eye Institute; National Supported By: American Diabetes Association (1-15-BS-115 to Q.L.); National Institute of Diabetes and Digestive and Kidney Diseases; JDRF; Thomas J. Beat- Institutes of Health (EY021752, EY024564); Bright Focus Foundation son, Jr. Foundation; Dianne Nunnally Hoppes Scholarship Fund 272‑OR 270‑OR Role of Epigenetics in mtDNA Heteroplasmy in Diabetic Retinopathy Long-Term Intermittent Fasting (IF) Initiated at Night Prevents RENU A. KOWLURU, MANISH MISHRA, Detroit, MI Development of Diabetic Retinopathy (DR) and Corrects Microbial DNA methylation is one of the important epigenetic modifications in the Dysbiosis in db/db Mice regulation of gene expression. In diabetes, mitochondrial DNA (mtDNA) is ELENI BELI, LENI MOLDOVAN, YUANQING YAN, FANG-I CHU, YAQIAN DUAN, hypermethylated and the levels of 5 methyl cytosine (5mC) are significantly DHAMI HARKEERAT, SHAKIR HINDI, TATIANA SALAZAR, EMILY HUTCHINSON, elevated, especially in the D-loop region of the mtDNA, the region with tran- MARIA B. GRANT, Indianapolis, IN, Houston, TX scription/replication elements. D-loop region also experiences increase in Purpose: Diabetes is associated with an altered composition of the gut sequence variants/heteroplasmy. Methylated cytosine can undergo sponta- microbiota. We investigated whether influencing the commensal microbes neous deamination to thymine, and increase in 5mC is considered as one of by the use of intermittent fasting (IF) would reduce inflammation, correct the potential causes of DNA mutation. Our aim is to investigate the role of ORALS metabolic dysfunction and prevent the development of DR in diabetic mice. mtDNA methylation in heteroplasmy. Methods: db/db and db/m mice were maintained either on ad libitum (ad Methods: Mitochondrial DNA methylation patterns were investigated in lib) or IF regimen (every other day with food withdrawal at nighttime) for 7 human retinal endothelial cells incubated in normal or high glucose in the months. Fecal samples were collected every 4 h for 48 h and genomic DNA presence or absence of DNA methylation inhibitor 5-azacytidine by digesting sequencing was used to distinguish bacterial taxa. DR was assessed by enu- mtDNA with methylation specific endonuclease Hpall, and with a sequence meration of acellular capillaries. Liver, colon and retinal tissue was used for variant specific surveyor endonuclease. The fragments were analyzed on an RT-PCR of inflammatory genes. Macrophages isolated from the peritoneal agarose gel. Since mtDNA lacks histones, and is directly exposed to free cavity and spleen were stimulated ex vivo with LPS and their phenotype radicals, the effect of regulation of mitochondrial free radicals on mtDNA assessed by flow cytometry and secretion by ELISA. heteroplasmy was determined in the cells overexpressing mitochondrial Results: db/db mice of eleven months of age showed the expected superoxide dismutase (Sod2). increased numbers of acellular capillaries (20±4mm2 p<0.05) compared to Results: Methylation of mtDNA was increased by high glucose, and age-matched control mice (5±1mm2). db/db mice under the IF regimen did not 5-azacytidine prevented glucose-induced increase in mtDNA methylation, show this increase in acellular capillaries (9± 2/mm2). Fecal genomic DNA and also attenuated heteroplasmy in mtDNA. Similarly, regulation of mito- showed that IF corrected dysbiosis and restored, toward nondiabetic levels, chondrial free radicals by Sod2 ameliorated both, mtDNA methylation and key microbial species known to be upregulated in diabetes. IF restored the increase in heteroplasmy. loss of mucus producing cells, goblet cells in diabetic mice (p<0.001), restor- Conclusions: Thus, hypermethylation of mtDNA has a significant role in ing the gut barrier and reducing leakage. In db/db mice, IF reduced TNF-α increased heteroplasmy seen in hyperglycemic milieu, and both, mtDNA production in macrophages and reduced retinal (p<0.008) and liver (p<0.05) hypermethylation and increase in heteroplasmy are under the control of TNF-α mRNA levels. During the fasting period tissue macrophages were free radicals. Manipulation of aberrant mtDNA heteroplasmy could serve as induced towards an M2 phenotype, which was associated with increased one of the therapeutic targets to maintain mitochondrial homeostasis in the mitochondrial biogenesis and enhanced LXR-β signaling in liver. development of diabetic retinopathy. Supported By: National Eye Institute (R01-EY014370, R01-EY017313, R01-EY022230)

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A71 DIABETIC RETINOPATHY—MORE THAN MEETS THE EYE

273‑OR 275‑OR Hyperglycemia-Mediated Translational Control of Gene Expression Diabetic Retinopathy Grade as a Predictive Marker of Severity of in Retina Cardiovascular Disease and Mortality MICHAEL D. DENNIS, PREMAL SHAH, LEONARD S. JEFFERSON, SCOT R. KIM- KIRAN SHAH, S. NATARAJAN, MILIND PHADKE, NAVNEET WADHWA, Mumbai, BALL, Hershey, PA, Piscataway, NJ India The principal cause of retinal cell death in diabetic retinopathy is diabe- Diabetic Retinopathy (DR) is a risk marker for cardiovascular death. We tes-induced hyperglycemia. Available evidence demonstrates that hyper- explored the association of grade of DR to corroborate with severity of glycemic conditions result in the post-translational modification of proteins cardiovascular disease (CVD) and mortality, to facilitate the development by O-linked addition of N-acetylglucosamine (O-GlcNAcylation) to Ser/Thr of a risk prediction model, through retrospective analysis of electronic residues in a manner that contributes to diabetic complications. In both health records of 4000 T2DM patients with an established CVD screened the retina of diabetic mice and cells in culture exposed to hyperglycemic for DR in year 2010 at a tertiary care cardiac hospital, followed for next conditions, the repressor of mRNA translation 4E-BP1 is O-GlcNAcylated, 5 years. Goodness of fit was examined using Pearson Chi Square test. DR concomitant with enhanced expression and sequestration of the mRNA cap- was observed in 64% of patients (NPDR n=1480, 37%; PDR n=1080, 27%). binding protein. Moreover, O-GlcNAcylation has been detected on a number DR and CVD (p<0.00001) were strongly related with the highest association of eukaryotic translation initiation factors (eIFs) and ribosomal proteins. observed for Congestive Heart Failure (CHF) (n=1325), followed by Myocar- However, the functional consequence of this extensive level of modifica- dial Infarction (MI) (n=795), Unstable Angina (UA) (n=275) and cardiomyopa- tion on gene expression is unknown. Thus, the present study evaluated the thy (n=165). Non-Proliferative DR (NPDR) resulted in a greater risk for CHF, effect of enhanced O-GlcNAcylation on retinal gene expression using ribo- MI, UA and cardiomyopathy than the Proliferative DR (PDR), Hazard Ratio some profiling. C67BL/6 mice were treated with the O-GlcNAcase inhibitor (HR) 1.32, 1.44,1.2, and 1.75 respectively. The five-year all-cause mortality Thiamet G (TMG). Next-generation sequencing identified changes in both and CV mortality was significantly higher in patients with DR as compared to ribosome-associated mRNA (i.e., mRNAs undergoing translation) and total non-DR (All cause: 94.2% n= 766 vs. 5.78% n=47, p < 0.00001), (CV Mortality: mRNA expression. Whereas a number of genes exhibited altered mRNA 93.82% n= 532 vs. 6.17% n=35, p < 0.00001), respectively. NPDR patients expression, the principal effect of TMG on retinal gene expression was who underwent CABG (n=765) had a lower five-year risk of mortality than observed in ribosome-associated mRNAs. Although some mRNAs exhibited who underwent PTCA (n=615) (8.36% vs. 25.85%, p<0.00001). Patients with TMG-induced association with ribosomes, over 600 mRNAs exhibited a dra- PDR who underwent CABG (n=565) also reported three times lower five- matic reduction. Pathway analysis of mRNAs exhibiting altered translation year mortality risk as compared to who underwent PTCA (n=265) (25.3% vs. identified attenuation of a molecular network that drives neuronal viability. 72.2%, p<0.00001). Mortality outcome approach based on severity of DR Specifically, a family of protocadherins that prevent neuronal apoptosis in could assist the choice of cardiovascular intervention. Across the cardiovas- retina exhibited dramatic translational repression in response to enhanced cular continuum, even NPDR is associated with higher cardiovascular risk as O-GlcNAcylation. Overall, these findings provide insight into mechanisms compared with PDR and exhibit a ‘J’ curve effect for the association of the whereby diabetes-induced O-GlcNAcylation of mRNA translation initiation severity of diabetic retinopathy with cardiovascular disease and mortality. factors alters gene expression in retina and thus contributes to diabetic These results through multi-centric corroboration could be incorporated into retinopathy. the multi-variate CV risk model. Supported By: American Diabetes Association (1-14-INI-04 to M.D.D.) 276‑OR 274‑OR Diabetic Retinal Sensory Neuropathy Progression Predicts Cardio- Neuroretinal Layer Thickness in Patients across Eight Decades of vascular Autonomic Neuropathy in Type 1 Diabetes Type 1 Diabetes THOMAS GARDNER, MAMTA JAISWAL, MAXWELL STEM, GRACE DUNBAR, SCOTT R. PETERSON, WARD FICKWEILER, HILLARY A. KEENAN, GEORGE L. CLAY BAVINGER, JOSE DAVILA, VINICIUS DE CASTRO, KATHERINE JOLTIKOV, KING, LLOYD PAUL AIELLO, JENNIFER K. SUN, Boston, MA RODICA POP-BUSUI, Ann Arbor, MI Although diabetic neuroretinal abnormalities have been described, Diabetic retinal sensory neuropathy (DRSN) and cardiovascular autonomic changes in individual retinal layers have not been fully explored across neuropathy (CAN) may result from type 1 diabetes (T1D)-induced dysfunc- multiple decades of type 1 diabetes (T1DM) duration. We performed time tion of unmyelinated sensory neurons. We tested the hypothesis that CAN and spectral domain optical coherence tomography (SDOCT) of 776 patients and DRSN progress in parallel. Forty T1D patients (mean age 38±14 years, (1413 eyes) with T1DM duration from 0-78 years with no macular edema mean diabetes duration 14±7 years, mean HbA1c 7.9±1%, mean visual acu- (SDOCT central subfield thickness [CST]: male <320 µm, female <305 µm). ity 20/20) without known complications at baseline were assessed for CAN Retinal nerve fiber (RNFL), ganglion cell (GCL), inner and outer plexiform (IPL, and DRSN. CAN was evaluated with standardized cardiovascular reflex OPL), inner and outer nuclear (INL, ONL), and photoreceptor (Photo) layers tests [deep breathing test (expiration/inspiration ratio E/I), Valsalva ratio], were segmented on SDOCTs. Age, age at DM diagnosis, gender, DM dura- and heart rate variability [low frequency (LF), high frequency (HF) and their tion, A1c, blood pressure, body mass index (BMI), and lipids were recorded. ratio (LF/HF)] at baseline and during 3 years follow-up. Measures of DRSN Mean±SD age was 61±12 yrs, DM duration 46±14 yrs, A1c 7.5±1.3% and 60% included dilated ophthalmic examination, frequency doubling perimetry were female. Of eyes, 16%, 34%, 14%, and 35% had no DR, mild NPDR, mod- (FDP) using the 24-2 strategy, fundus photographs, and optical coherence ORALS erate-severe NPDR, and PDR, respectively. Bivariate analyses revealed that tomography (OCT) with retinal layer segmentation. Twenty-six T1D subjects increased CST in all patients and those with no-mild NPDR was associated had valid CAN and DRSN data at baseline and follow-up. During follow-up 11 with increased age (all: p=0.0016, no-mild NPDR: p=0.035), male gender T1D subjects developed mild diabetic retinopathy (DR) and 3 moderate non- (all: p<0.0001, no-mild NPDR: p= <0.0001), and greater age at diagnosis (all: proliferative DR. At 3 years FDP threshold sensitivities were unchanged or p=0.0012, no-mild NPDR: p= 0.038), but only gender was related to CST after improved in 81% of T1D participants (nonprogressors); 19% of T1D patients backwards elimination multivariable modeling. CST was not related to BMI, exhibited a > 3 dB sensitivity reduction (progressors). Students t-test was lipids or DM duration. Males had increased RNFL (p=0.01), GCL (p=0.013), used to identify characteristics that were different between progressors IPL (p=0.0005), INL (p=0.0004), OPL (p=0.033) and ONL (p<0.0001) thick- and non-progressors. Older age at baseline and greater diabetes duration ness. Eyes with PDR had increased RNFL (p=0.03), INL (p<0.0001), and OPL were associated with progression whereas gender, baseline HbA1c, body (p=0.0046), but decreased ONL (p=0.0001) and Photo (p<0.0001) thickness. mass index, total cholesterol, LDL-c, HDL-c, and triglycerides were not. In models adjusting for gender and scatter laser as possible confounders, Mean deep breathing HF, LF/HF, and baseline and 3 year E/I ratios were sig- PDR remained related to increases in INL and decreases in ONL. Across a nificantly different between DRSN progressors vs. nonprogressors (p<0.05 wide range of age, DM duration and DR severity, male gender is consistently for all). These are the first data to suggest a longitudinal correlation between associated with thickened retinal layers, whereas PDR has opposing effects progression of DRSN and CAN in persons with T1D. on inner vs. outer retinal layers. These findings provide further insight into Supported By: National Heart, Lung, and Blood Institute; National Institute of neuroretinal abnormalities in advanced diabetic eye disease. Diabetes and Digestive and Kidney Diseases Supported By: National Institute of Diabetes and Digestive and Kidney Diseases (P30DK036836, UL1RR025758-03, R24DK083957-01, DP3DK094333-01); National Eye Institute (1R01EY024702-01, R01EY026080-01); JDRF (2-SRA-2014-264-M-R, 17-2013-310); Thomas J. Beatson, Jr. Foundation; Massachusetts Lions Eye Research Fund

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A72 POTENTIAL IMPLICATIONS OF THE AFFORDABLE CARE ACT ON DIABETES CARE

POTENTIAL IMPLICATIONS OF THE AFFORDABLE 279‑OR CARE ACT ON DIABETES CARE Drug Copay and Medication Adherence in Medicare Patients with Type 2 Diabetes 277‑OR LIOU XU, MANJIRI PAWASKAR, YUEXIN TANG, GARY PUCKREIN, SWAPNIL Access to Diabetes Care in the Era of the ACA: A National Survey RAJPATHAK, BRUCE STUART, Washington, DC, Kenilworth, NJ, Baltimore, MD Prior studies that have shown that higher copay was associated with of Physicians lower medication adherence were mostly conducted in younger commer- MATTHEW PRESENT, LUISA SEPULVEDA, AVIVA G. NATHAN, ROBERT M. SAR- cially insured type 2 diabetes (T2D) patients. This relationship is unclear in GIS, MICHAEL QUINN, ELBERT S. HUANG, CHRISTOPHER MASI, NEDA LAITEER- elderly patients. The current study examined this association in Medicare APONG, Chicago, IL 3.5 million Americans are unaware they have diabetes. Because of the patients with T2D using branded or generic non-insulin anti-hyperglycemic passage of the ACA in 2013, about half of these undiagnosed patients met agents (AHA). income criteria for Medicaid insurance. However, because 19 states opted This retrospective database study using Medicare claims included =>65 out of the Medicaid expansion, many undiagnosed patients still may not years T2D patients on AHA monotherapy during index period (1/1/2013- have health insurance. To assess the reported impact of the ACA Medicaid 2/28/2013) either using branded (n=28,656) or generic (n=131,594) AHAs. expansion on these undiagnosed and undertreated patients, we conducted Drug copay was calculated for a 30-days supply of the index AHA. Medica- a national survey of 1,200 primary care and endocrinology physicians who tion adherence was estimated as proportion of days covered and also as care for patients with type 2 diabetes mellitus. We asked physicians to discontinuation (treatment gap ≥ 60 days) during the 10 months follow-up report if they had seen an increase since 2014 in patients with newly diag- period. nosed diabetes or newly insured receiving care for established diabetes. Mean drug copay was $15 (branded= $40; generic= $5). Higher drug copay We obtained physician lists from the AMA Physician Masterfile; 50% of our was associated with lower drug adherence and higher discontinuation in sampling pool resided in Medicaid expansion states. We performed descrip- patients on branded AHAs (e.g., patients with $60+ copay were 71% less tive analyses and logistic regressions adjusting for physician demographics, likely to be adherent and 1.5 times more likely to discontinue branded AHAs race, ethnicity, practice characteristics, professional activity and specialty. compared to those with <$10 copay) (Table). However, this association was Our overall response rate was 41% (N=426) with 52% of respondents from not observed for generic AHAs. Medicaid expansion states. We found that physicians who lived in expan- This study suggests that the impact of drug copay on adherence and dis- sion states had 87% higher odds of reporting an increase in newly insured continuation varies considerably for branded vs. generic AHAs among Medi- patients with diabetes than those who did not practice in expansion states care patients. Payers should take into consideration these findings while (CI: 1.24-2.83, p=0.003). Additionally, physicians who reported panels of making formulary decisions. fewer than 1,000 patients had 95% higher odds of reporting an increase in newly insured patients (CI: 1.28-2.99, p=0.002). Physicians practicing in Medicaid expansion states were more likely to report treating patients with newly diagnosed type 2 diabetes compared to physicians in non-expansion states. This finding was most notable among physicians with small practices. Given the large number of patients with undiagnosed and undertreated dia- betes, insurance expansion may have important impacts on improving the health of U.S. adults with diabetes. If the ACA is repealed, access to health care for many U.S. adults with diabetes may decline. Supported By: National Institutes of Health

278‑OR Impact of the Affordable Care Act on the Quality of Life of Ameri- cans with Diabetes, Aged 19-64 Years LORINETTE S. WIRTH, LILA BALLA, St. Louis, MO Purpose: Several programs were implemented under the Affordable Care Act (ACA) to improve diabetes management and outcomes, including Medic- aid expansion benefits to individuals below/at 138% of the federal poverty level (FPL). We aimed to evaluate the impact of the ACA on the Health- related Quality of Life (HRQoL) of adults reporting diabetes, by FPL (≤138% vs. >138%). Methods: A nationally representative adult sample of 19-64 year olds 280‑OR reporting diabetes diagnosis was pooled from a pre-ACA (n=1501) and Impact of Switching to a High-Deductible Health Plan on Diabetes Treatment Discontinuation within-ACA (n=1607) cohort of the Medical Expenditure Panel Survey, sur- ORALS vey years 2009 and 2014, respectively. Adjusting for clinical and socioeco- MARK A. FENDRICK, YUEXIN TANG, SWAPNIL RAJPATHAK, LIISA PALMER, nomic variables such as the number of discordant comorbid diseases and ANNA VLAHIOTIS, MICHAEL E. CHERNEW, Ann Arbor, MI, North Wales, PA, education, the relationships between cohort year and SF-12 [physical health Boston, MA component scale (PCS-12) and mental health component scale (MCS-12) Objective: High-Deductible Health Plans (HDHPs) are an increasingly com- scores] were examined utilizing regression methods. Results are reported mon cost-savings option for employers. However, they may lead to under- at the 95% CI. utilization of necessary treatments, as beneficiaries bear the full cost of Results: Diabetes prevalence for adults aged 19-64 years were 6.1% health care, including medications. The aim of this study was to evaluate the and 6.9% in the pre-ACA and within-ACA cohorts, respectively. Compared impact of switching from a non-HDHP to an HDHP on medication discontinu- to nondiabetics, median PCS-12 and MCS-12 scores were 15.8% and 7.4% ation in patients with type 2 diabetes mellitus (T2DM) and, specifically, on lower in the pre-ACA cohort and 12.4% and 6.6% lower in the within-ACA branded medications. Methods: A retrospective, observational cohort study of administra- cohort for diabetics, respectively. The PCS-12 score was 4.17 units higher for ® the within-ACA cohort compared to the pre-ACA cohort, but only for indi- tive claims from MarketScan Commercial Claims and Encounters data- viduals below/at 138% FPL. While insurance coverage was higher for the base was conducted. Adult T2DM patients using ≥1 non-insulin diabetes medication in 2013 were divided into 2 cohorts: those who switched from a within-ACA cohort (χ2=0.01), the PCS-12 score remained significantly higher for the within-ACA cohort independent of insurance coverage. No statisti- non-HDHP in 2013 to a full-replacement HDHP in 2014 (no non-HDHP option cally significant difference was found between the pre-ACA and within-ACA offered, n=1,496) and those who were in a non-HDHP in both 2013 and 2014 cohorts for MCS-12. (n=21,623). Study outcomes included T2DM medication discontinuation Conclusion: Higher HRQoL for the within-ACA cohort suggests that the (treatment gap/without T2DM medications ≥ 60 days). ACA was effective in improving diabetes outcomes for individuals under/at Results: There were slightly more females in the non-HDHP cohort (43.7% the 138% FPL; however, mental health improvements continue to lag. Policy vs. 35.7%), and baseline healthcare expenditures were higher ($13,381 makers should consider these strengths and weaknesses when applying vs. $10,678). A higher proportion of patients in the non-HDHP cohort had macro level changes. microvascular T2DM complications (12.6% vs. 10.6%), but a lower propor-

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A73 POTENTIAL IMPLICATIONS OF THE AFFORDABLE CARE ACT ON DIABETES CARE

tion had macrovascular complications (9.8% vs. 11.3%). In the overall study (by 2.10% to 3.14%, annually) during the study period. Reasons for changes sample, medication discontinuation rates were similar between HDHP and in the cost per admission and its two contributed components need further non-HDHP cohorts (41.3% vs. 39.0%). In those using branded medications, a investigation. significantly greater proportion of HDHP patients discontinued therapy dur- Table. Estimates and Trends of DRPH Cost Per Admission, Mean Length of ing follow-up (45.6% vs. 33.3%; standardized mean difference >10). Stay, and Cost Per Day of Admission, 2002-2013. Conclusions: Diabetes medication discontinuation may be impacted in T2DM patients who switch to an HDHP, compared to those who remain in Outcome/DRPH Type Estimates Annual Trends a non-HDHP, especially for patients using branded medications. Unintended 2002 2013 Percent Trend P-value health consequences may result, and should be considered by employers Cost per admission (2013$)γ: making healthcare benefit decisions. Supported By: Merck & Co., Inc. Short-term complication 7,320 ref 7,282 ref -0.26(0.16) ref Long-term complication 10,894 *** 12,065 *** 0.87(0.12) *** *** 281‑OR Uncontrolled diabetes 4,546 *** 5,128 *** 0.86(0.21) ** *** High-Deductible Insurance and High-Acuity Outcomes in Diabetes JAMES F. WHARAM, FANG ZHANG, EMMA EGGLESTON, CHRISTINE LU, STEVEN Lower extremity amputation 20,492 *** 20,968 *** -0.13 (0.18) SOUMERAI, DENNIS ROSS-DEGNAN, Boston, MA, Morgantown, WV Length of stay per admission Φ: High deductible health plans (HDHP) are the centerpiece of ACA replace- Short-term complication 4.13 ref 3.45 ref -1.75 (0.08) *** ref ment proposals, but effects on high acuity outcomes among chronically ill patients are unknown. Long-term complication 6.49 *** 5.67 *** -1.32(0.08) *** *** We studied Optum data derived from a large U.S. health insurer. We Uncontrolled diabetes 3.62 *** 3.06 *** -1.59(0.11) *** ** used a controlled interrupted time series design to examine employer man- Lower extremity amputation 11.71 *** 9.52 *** -2.21(0.14) *** *** dated HDHP transitions, minimizing selection bias. The intervention group comprised 26,674 HDHP members with diabetes (DM) age 12-64 included Costs per day of admission (2013$)γ: between 2003-2012. HDHP members were enrolled for 1 year in a low Short-term complication 1,860 ref 2,371 ref 2.10(0.15) *** ref deductible ( $500) plan then 1 year in a HDHP ( $1000) and propensity score ≤ ≥ Long-term complication 1,763 *** 2,355 *** 2.67(0.06) *** *** matched 1:1 to DM patients with low deductibles. Low income HDHP mem- bers (n=9641) were a subgroup of interest. Measures included emergency Uncontrolled diabetes 1,363 *** 1,927 *** 3.14(0.14) *** *** department (ED) visits, hospitalizations, and total healthcare expenditures. Lower extremity amputation 1,822 *** 2,376 *** 2.55(0.10) *** *** Measure of adverse outcomes were high severity ED visit expenditures *=p<0.05, **=p<0.01, ***=p<0.001 for t-test; Values in parentheses are and high severity hospitalization days. We estimated pre to post changes standard errors; ref=reference against which other condition were com- in HDHP members vs. controls using adjusted segmented regression on pared; Φ Based on negative binomial regression model. γ Based on general- monthly cumulative measures. ized linear regression model with log link and gamma distribution. Covari- HDHP members had small reductions in ED visits (-3.1% [-3.9,-2.3]), hos- ates included age, sex, race/ethnicity, payers, location and teaching status pitalizations (-4.2% [-5.5,-2.8]), and total healthcare expenditures (-3.6% of hospitals, and severity status; costs were adjusted to 2013$ using the [-4.3,-3.0]). Low income HDHP members had increased high severity ED visit GDP price deflator. expenditures (8.1% [3.0,13.2]) and high severity hospitalization days (26.1% [19.7,32.5]). Low income DM patients switched to HDHPs experienced substantial 283‑OR increases in adverse high-acuity outcomes. Using Public Big Data from GP Practices (GPP) in NHS England to Inform Changes Needed to Improve Patient Outcomes in People Figure. with Type 2 Diabetes NAGARAJ S. MALIPATIL, MARK LIVINGSTON, MIKE STEADMAN, GABRIELA MORENO, ADRIAN H. HEALD, Manchester, United Kingdom, Walsall, United King- dom, Wiltshire, United Kingdom, Mexico City, Mexico There is continuing discussion globally about how to optimize outcomes for type 2 diabetes patients. National (NICE) guidance was updated in 2016 (NG28). Annual data from 4,050 GPP (50% of total) covering 1.6 million T2DM patients in the National Diabetes Audit 2013_15 covering population char- acteristics, services and outcomes, including total glycemic control (TGC) (66.8% HBA1c results ≤ 58mmol/ml) and higher glycemic risk (HGR) (6.6% HBA1c results > 86mmol/ml), was joined to GPP diabetes medication pre- ORALS scribing in primary care data 2013_15 converted by chemical to Defined Daily Doses (DDD). Supported By: National Institutes of Health; Centers for Disease Control and While patient numbers grew 4% annually and medication expenditure 8%, Prevention TGC and HGR did not improve. Outcomes indicators were linked by multi-variant linear regression to 282‑OR sets of epidemiological, service and medication indicators. TGC correlation Trends in the Costs of Diabetes-Related Preventable Hospitaliza- to previous year’s r2 67% considered as predictability potential, selected tions, 2002-2013 indicators r2 @25% = 39% of potential. HGR correlation to previous year’s SUNDAR S. SHRESTHA, PING ZHANG, Atlanta, GA r2=55% and selected indicators r2 @29% = 53% of potential. The rate of diabetes-related preventable hospitalizations (DRPH) has Indicators showed GPP with improved TGC and HGR had: declined over last decade. However, little is known on how the cost for DRPH a) Higher Age % >65. has changed overtime. Using the 2002-2013 U.S. National Inpatient Survey b) Higher levels of local diabetes services (including case identification, data, we examined the cost per hospital admission among adults (age >= 18 care checks completion, patient education, % of patients with BP and cho- years) by type of DRPH, as defined by Agency for Healthcare Research and lesterol under control and more T1DM patients achieving TGC). Quality. We further examined how each of the two factors for the cost per c) Less Medication: Overall DDD and spend; Sulphonylurea and Insulin for admission (mean length of stay (LOS) and cost per inpatient day) has con- T2DMs. tributed to the change. In addition, we performed a trend analysis to detect d) More Medication: Metformin, DPP-4i, blood glucose monitoring. any changes in cost per admission, mean LOS and cost per inpatient day by T2DM ethnicity and social disadvantage, prescribing of GLP-1 agonists DRPH type. From 2002 to 2013, cost per admission remained stable for short- and pioglitazone had low impact on outcomes. SGLT2 inhibitor use was too term complication and lower extremity amputation but increased slightly for small to see any effect. long-term complications and uncontrolled diabetes (0.86 to 0.87%, annually) Conclusion: If GPP raise service and medication to levels of top decile this depending on the DRPH type (Table). Regardless of type of DRPH, mean LOS showed, without more spend on medication, increased TGC to 77%, and declined (by 0.32% to 2.21%, annually) but cost per inpatient day increased reduce HGR to 4.0%; equivalent ≈200k/60k in total T2DM population. This

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A74 FROM PREDICTION TO TRANSITION—TYPE 1 DIABETES MELLITUS ACROSS STAGES would have a large impact on health care costs of managing diabetes com- Figure. plications estimated at over £7billion/year.

284‑OR Connected Glucose Meter plus Coaching Improves Diabetes Clini- cal Outcomes and Decreases Costs JENNIFER BOLLYKY, CHRIS WHALEY, JENNIFER SCHNEIDER, Mountain View, CA, Santa Monica, CA Background: Given the growing prevalence and costs of diabetes, there is a strong interest for self-insured employers, at-risk providers, and payers to empower people with diabetes through novel technologies to optimize real- time patient behavior and improve diabetes self-management. The Livongo Diabetes Program offers patients (1) a cellular-enabled, two-way messaging device that measures blood glucose, (2) free unlimited blood glucose test strips; and (3) access to Certified Diabetes Educators for real-time support and goal setting. Here we investigated the clinical and financial impact of the Livongo program using biometric lab and medical claims data. Methods: We compared medical claims and clinical lab outcomes (hemo- globin A1c, total cholesterol, and triglyceride levels) for Livongo users (n = 646) with non-Livongo users (n = 3014) 12 months before and 12 months after the launch of the Livongo program using difference-in-differences and instrumental variable regression models that included controls for year, patient demographics (e.g., age, gender, geography), and patient risk characteristics (e.g., comorbidity scores, prior-period medical spending and utilization). Results: There was a 37% reduction (64 point total decrease) in total cho- 286‑OR lesterol (p = 0.04), a 16.2% reduction in HbA1c (1.2 point decrease) (p = 0.12), Development of Islet Autoimmunity and Type 1 Diabetes in Twins and a 8.3% reduction (10 point decrease) in triglycerides (p = 0.80) seen in and Siblings Livongo users compared with non-users. Livongo users showed significantly TAYLOR M. TRIOLO, ALEXANDRA R. FOUTS, LAURA PYLE, LIPING YU, SARAH slowed increase in the cost of medical claims relative to non-users (5% vs. MULLER, PETER A. GOTTLIEB, ANDREA STECK, Aurora, CO, Tampa, FL 13%, respectively) resulting in a savings of $136 per member per month. Identical twins (IT) have a high risk of concordance to progression of Conclusion: Our findings suggest that the Livongo program is associ- autoantibodies (Ab) and type 1 diabetes (T1D) after one twin is diagnosed. ated with cost savings for people with diabetes likely driven by metabolic We examined the development of Ab and T1D over time in self-reported IT, improvements in total cholesterol and HbA1c levels. non-identical twins (NT) and full siblings (FS). A total of 13,292 unaffected siblings were screened in the TrialNet Pathway to Prevention Study between 2004-2015. Ab results for GAD65 (GADA), ICA512 (IA2A), and insulin (IAA) FROM PREDICTION TO TRANSITION—TYPE 1 were available over time for 8,387 participants, including 90 IT, 118 NT and DIABETES MELLITUS ACROSS STAGES 8179 FS (median age at screening 9 yrs., median follow-up 2 yrs). Devel- opment of IAA was highest among IT (34%) compared to 21% among NT (p=0.03) and 15% among FS (p=0.06 for NT vs. FS). Development of GADA 285‑OR and IA2A were higher among IT (49% and 29%) compared to both NT (18% Ethnic Differences in Progression to Type 1 Diabetes in Relatives and 14%) and FS (18% and 12%) (p<0.0001). When stratified by Ab status at at Risk screening, survival analysis was significantly different by sibling type. IT had MUSTAFA TOSUR, SUSAN GEYER, HENRY RODRIGUEZ, INGRID LIBMAN DE a risk for developing T1D by 3 years of ~70% for both single and multiple Ab GORDON, DAVID BAIDAL, MARIA J. REDONDO, Houston, TX, Tampa, FL, Pittsburgh, compared to 5% for Ab negative subjects (Figure). The 3 year T1D risk for NT PA, Miami, FL was 73% for multiple Ab, 8% for single Ab and <1% for Ab negative, while FS Studies on racial/ethnic differences in type 1 diabetes (T1D) pathogenesis had a 3 year T1D risk of 47% for multiple Ab, 11% for single Ab and <1% for are lacking. We aimed to compare the progression of islet autoimmunity Ab negative subjects. IT have a higher risk of developing Ab and once posi- (IA) and T1D among races/ethnicities in at-risk individuals. We studied 4227 tive for >1Ab, a faster progression to T1D. NT seem to have an intermediate TrialNet Pathway to Prevention participants (nondiabetic, autoantibody risk with multiple Ab NT having a T1D risk similar to IT, while single Ab NT [Ab]+ relatives of patients with T1D; 12% Hispanics [Hisp], 79.3% non-Hisp have a risk similar to FS. whites [NHWs], 2.9% non-Hisp blacks, 1.4% non-Hisp Asians and 4.3% non-

Hisp others) followed prospectively. At screening, NHWs were more likely Figure. ORALS to have multiple +Ab (59% vs. 48%) and higher T1D risk score (DPTRS) than Hisp (both p<0.00001). Conversion to multiple Ab+ was less common in Hisp than NHW (HR=0.59, 95% CI=0.40-0.88, p=0.01) after adjustment for Ab, age, sex, DPTRS and HLA DR3/DR4. Time to T1D (n=498) among multiple Ab+ participants did not differ by race/ethnicity. However, among children <12 years old (y/o), Hisp had lower T1D risk than NHWs (HR=0.49, 95% CI=0.27-0.91, p=0.02) in multivariable model adjusting for age, sex and HLA DR3/DR4. Further, BMI percentile (BMI %) was a significant effect modifier (p=0.006) in children <12 y/o: Compared to NHW with normal BMI %, Hisp had lower T1D risk if they had normal BMI %, but higher if they were over- weight/obese (HR=2.12, 95% CI: 1.3-3.45, p=0.003). Overall, compared with NHWs, progression of IA was less common in Hisp, while differences on T1D development were limited to children <12 y/o and modified by BMI.

Supported By: American Diabetes Association (1-14-CD-17 to A.S.); The Leona M. and Harry B. Helmsley Charitable Trust (61586)

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A75 FROM PREDICTION TO TRANSITION—TYPE 1 DIABETES MELLITUS ACROSS STAGES

287‑OR (123 vs. 133 mmHg, p=0.02) and free fatty acids (FFA) in response to 16 mU/m2 Glucose Control as Measured by A1c in Diabeter Clinic Patients insulin (218 vs. 399 mmol/L, p<0.05). Youth with BMI < 90%ile on metformin Compared with T1D Exchange Patients had a significant increase in VO2peak (28.9 to 30.4 ml/kg/min, p<0.05; 40.9 HENK J. VEEZE, DICK MUL, MARTINE M.C. DE VRIES, JAVIER CASTANEDA, to 43.6 ml/lean kg/min, p=0.03) and decrease in FFA’s fasting (444 to 325 FRANCINE R. KAUFMAN, HENK-JAN AANSTOOT, Rotterdam, Netherlands, Maas- p=0.04) and in response to 10 mu/m2 of insulin (451 to 328, p=0.01). HbA1c tricht, Netherlands, Northridge, CA did not change significantly in any group. The Diabeter Clinics in the Netherlands deliver standardized, value-based, In summary, metformin can lower insulin dose and improve body composi- comprehensive care to pediatric T1D patients. Central to the Diabeter model tion, blood pressure and adipose IR in T1D youth with high BMI. Of note, is the VCare system that uses meter, pump and CGM uploads to automati- in T1D youth with BMI < 90%ile, metformin did not alter weight or body cally generate personalized treatment assessments and therapy advice composition, but improved adipose IR and exercise capacity, factors also sent via Ther@pymail email to patients, between clinic visits. A1c values associated with CVD. of patients seen at 4 Diabeter clinics for >1 yr were compared to published Supported By: American Diabetes Association (7-11-CD-08 to K.J.N.) data from T1D Exchange patients, from 2015-2016 (https://t1dexchange.org/ pages/resources/our-data/studies-with-data/, 14 Dec 2016). Mean±SD age 289‑OR of Diabeter patients (n=1162) was 16.4±5.0 yrs (51% male); 47% used MDI, Safe Triage of Patients with Acute Diabetes Concerns by General 44% pumps, and 9% sensor-augmented pumps (SAPs). Mean±SD age of T1D Pediatric Advice-Line Nurses Exchange patients, of <25 yrs, was 14.2±4.9 yrs (51% male); 40% used MDI, MEGAN PRUETT, ANDREW B. MUIR, TERRI WEINZIERL, JOSEPH SIMON, DANIEL 43% pumps, and 15% SAPs. As previously reported, T1D and Diabeter clin- A. HIRSH, Atlanta, GA ics used an IFCC/NGSP certified A1c method. The graph shows consistently Background: Diabetes is increasingly managed by a team of providers, lower A1c by age in Diabeter compared to T1D Exchange patients (overall rather than individual physicians. In order to standardize care, experts at a 0.85 lower, p<0.0001). The mean number of Ther@pymail emails sent was large quaternary pediatric healthcare system designed best practice guide- 10.33/patient in 2015, in addition to a mean 15.5 phone and email contacts/ lines to manage hyperglycemia, hypoglycemia, and ketonuria. These guide- patient. The data suggest the Diabeter care model, utilizing frequent com- lines were then transformed into computerized branch chain logic protocols munications between clinic visits via automatically generated individualized and placed into the healthcare system’s advice line software. Thirteen gen- Ther@pymail emails, may facilitate improved pediatric glucose control com- eral pediatric advice line registered nurses (RNs) were trained and monitored pared to usual diabetes care. on an ongoing basis by a diabetes nurse practitioner and an endocrinologist. Figure. RNs use the computerized protocols for every call and handle first-line tri- age 24 hours a day, 7 days a week. The under-referral rate (URR)—those calls managed by RNs without second level triage who get admitted with 24 hours of the call—is a standard quality metric to evaluate safety. Objective: To determine the under-referral rate for general pediatric advice line RNs using diabetes specific protocols. Methods: Dispositions and subsequent ED visitation and hospital admis- sions for all calls seeking acute diabetes care were reviewed between August and December 2016. Results: During the study period, there were 1,112 calls seeking acute dia- betes care. Of these calls, 491 (44%) were managed solely by the RN, 592 (53%) were referred for second level triage and management to the endocri- nology team, 36 (3%) were referred for immediate ED evaluation, and 6 (<1%) were referred to 911. None of the calls that were managed solely by the RN resulted in an admission within 24 hours of the call, yielding a URR of zero. Conclusion: Advice line RNs with general pediatrics experience can safely triage diabetes patients using protocols.

290‑OR Provider Survey of Hypertension (HTN) and High-LDL Treatment in Teens with T1D Supported By: Medtronic MICHELLE L. KATZ, ZIJING GUO, LORI M. LAFFEL, Boston, MA Introduction: Current practice guidelines recommend aggressive treat- ment of CVD risk factors (HTN and high LDL) in teens with T1D but clinical 288‑OR practice may fall short. We compared provider-reported medication (med)

ORALS Metformin’s Impact on Insulin Resistance (IR) and Fitness in Youth management for CVD risk factors vs. ADA Standards of Medical Care 2016. with Type 1 Diabetes (T1D) Methods: A multidisciplinary team led by pediatric endocrinologists KRISTEN J. NADEAU, MELANIE CREE-GREEN, AMY BAUMGARTNER, JAYNE developed and piloted an electronic survey. The survey was fielded to ADA’s WILLIAMS, YESENIA GARCIA-REYES, PAUL WADWA, JUDITH G. REGEN- Youth Interest Group and the Pediatric Endocrine Society. For each question, STEINER, JANE E.B. REUSCH, Aurora, CO respondents chose the option(s) that best fit their current practice. Cardiovascular disease (CVD) is the leading cause of death in T1D and Results: Respondents (N=152, 32% male) were 92% MDs and 75% were relates to IR, BMI and fitness. Metformin improves markers of IR (insulin located at academic medical centers. Most respondents (>80%) recommended dose and body composition) in obese T1D youth. Yet, little is known about its lifestyle changes (healthy eating, physical activity, losing weight) Often/Always impact in normal weight T1D youth, who like their obese counterparts, dis- for initial management of confirmed HTN or LDL≥ 130 mg/dl. A substantial pro- play multi-tissue IR and reduced VO2peak, despite normal BMI. We hypoth- portion of respondents never initiate meds themselves, especially for HTN; 21% esized that metformin would decrease markers of IR in lean subjects with reported never starting meds for HTN while 8% reported never starting meds T1D. Fifty T1D youth ages 12-21 years (40% with BMI ≥ the 90%ile; high for high LDL (p=.0007). Among those who prescribe meds, the majority reported BMI) were randomized 1:1 to 3 months of 2000 mg metformin or placebo following ADA guidelines for med use for high LDL while fewer did so for HTN. daily. All youth underwent VO2peak via supine ergometer and metabolic cart, For LDL, 76% would Often/Always start a med for persistent LDL≥ 160 mg/dl DXA scan, fasting labs following overnight intravenous glycemic control, and and 55% for persistent LDL≥ 130 mg/dl with CVD risk factors per ADA guide- a multi-stage hyperinsulinemic euglycemic clamp (10, 16 and 80 mU/m2/min lines. For HTN, 42% would Often/Always start a med for initial management of insulin). The metformin group had a reduction in daily insulin dose (DID) (60 confirmed HTN and 43% would start a med after a 6 month trial of lifestyle for to 53.8 units, p<0.05) and fat mass (22.9 to 21.6 kg, p<0.03). Between the preHTN per ADA guidelines. Providers were more likely to titrate meds to the metformin and placebo groups, there was also a difference in DID (53.8 vs. ADA target for LDL than for HTN (55% vs. 23%, p=.01). 67.6, p= 0.04). Youth with high BMI in the metformin group had a reduction in Conclusions: Providers may be less aggressive with management of HTN DID (72.0 to 59.8, p<0.02), fat mass (32 to 29.5 kg, p<0.05) and waist circum- than high LDL, as respondents endorsed less med use and less titration to ference (88.5 to 84.3 cm, p=0.003). Those with high BMI in the metformin vs. target for HTN in teens with T1D. Yet, both CVD risk factors appear to be placebo group had lower DID (59.8 vs. 85.0, p=0.04), systolic blood pressure undertreated. As CVD is the leading cause of future morbidity and prema-

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A76 PUMPS AND LOOPS ture mortality for teens with T1D, further provider education may be needed, PUMPS AND LOOPS especially regarding HTN management. Supported By: National Institute of Diabetes and Digestive and Kidney Dis- 293‑OR eases; National Heart, Lung, and Blood Institute Do Patients under Pump Therapy Benefit from Using the Predictive Low Glucose Management System for Prevention of Hypoglycemia 291‑OR and Improved Glycemic Control in Type 1 Diabetes Mellitus? Health-Care Utilization across the Pediatric-to-Adult Transition in a PETROS THOMAKOS, ASIMINA MITRAKOU, OLGA KEPAPTSOGLOU, IBRAHIM National Cohort of Patients with Type 1 Diabetes (T1D) TARAOUNE, CAROL BARETTO, CHRISTOS ZOUPAS, Athens, Greece KATHARINE C. GARVEY, JAMES F. WHARAM, FANG ZHANG, ROBERT LECATES, Insulin pump is considered the most advanced therapy of choice for the LORI M. LAFFEL, JONATHAN A. FINKELSTEIN, Boston, MA optimum management of type 1 diabetes mellitus (T1DM). Our study aims Introduction: Lack of effective transition from pediatric to adult care may to compare the effects of the Predictive Low Glucose Management (PLGM) contribute to adverse outcomes in young adults (YA) with T1D. Patterns of system of the MiniMed 640G Insulin Pump to the Low Glucose Suspend Sys- care utilization and predictors of emergency department (ED) and inpatient tem (LGS) of the MiniMed Veo Insulin Pump, relative to frequency of hypogly- use for transitioning T1D patients are poorly understood in the United States. cemia and glycemic control in people with T1DM. The PLGM system can pre- Methods: We studied claims data from 17,426 patients with T1D, ages vent hypoglycemia by suspending insulin delivery based on predicted sensor 16-24 years, enrolled in a large national health plan for ≥1 year from 2005- glucose values and the LGS system automatically suspends insulin delivery 2012. Annual outpatient and ED visit and non-birth hospitalization rates when the sensor glucose value reaches a preset threshold. A cross-sectional were calculated using a time-series design. Generalized estimating equa- study was conducted in 30 T1DM patients using the MiniMed 640G vs. 30 tions (GEE) assessed the impact of age group (16-18 vs. 19-24 y), outpatient using the MiniMed Veo sensor-augmented Insulin Pump for a minimum of visits, and sociodemographic variables on ED visit and hospitalization rates. 3 months. The patients were matched for Age and duration of Diabetes. Results: In time-series plots, endocrinologist visits declined from 2.3/year [(Mean±SD) age: 33.4±11.5 vs. 34.2±11.4 years, p=NS; gender: 50 vs. 53% in 16 y/o to 1.5/year in 22 y/o. ED rates increased from 45/100 in 16 y/o males, p=NS; diabetes duration: 20.5±11.8 vs. 21.1±11.7 years, p=NS; BMI: to 63/100 in 20 y/o and decreased to 60/100 by age 24. Hospitalizations 23.4±3.6 vs. 24.5±3.4 kg/m2, p=NS; total daily insulin dose: 44.9±29.5 vs. climbed from 14/100 in 16 y/o to 21/100 in 19 y/o and decreased to 17/100 by 46.5±28.5, p=NS)]. The effectiveness of these two sensor-augmented pumps age 24. In GEE models, YA were more likely than teens to have ED visits (IRR was evaluated using CareLink software data. Hypoglycemia was defined as 1.24 [1.18-1.31]) and hospitalizations (IRR 1.25 [95% CI, 1.15-1.36]). Females an episode of interstitial glucose≤54mg/dl for ≥20 minutes and expressed were more likely to use the ED (IRR 1.19 [95% CI, 1.12-1.26]) and be hospital- as episodes per week. Patients used the 640G system exhibited significantly ized (IRR 1.32 [95% CI, 1.19-1.45]), as were black patients, (ED IRR 1.35 [95% lower hypoglycemia episodes/week (1.9±1.3 vs. 3.6±1.9, p=0.0004) as well CI, 1.12-1.63]; hospitalization IRR 1.43 [95% CI, 1.06-1.93]). Patients with ≥2 as better glycemic control (HbA1c: 6.9±0.6 vs. 7.3±0.9%, p=0.03). There was endocrinologist visits/year were less likely to have ED visits (IRR 0.78 [0.73- only one episode of severe hypoglycemia in the Veo group. 640G group had 0.82]) and hospitalizations (IRR 0.76 [0.69-0.84]). Higher income was also better hypoglycemia awareness status (Gold Score: 1.8±0.8 vs. 2.6±1.6, protective (ED IRR 0.82 [0.75-0.89]; hospitalization IRR 0.82 [0.72-0.93]). p=0.01). The mean activation of the “Suspend before low” feature of the Conclusion: Results show concerning increases in acute care utilization 640G pump was 2.2±1.6 times/day. Our results indicate that the use of the for YA with T1D who are less engaged with outpatient diabetes care and MiniMed 640G sensor-augmented pump system can help reduce the fre- highlight socioeconomic risk factors that need further study. Improved tran- quency of hypoglycemia, and lead to improved glycemic control. sition coordination may help decrease acute care utilization and complica- tions in YA with T1D. 294‑OR Supported By: National Institute of Diabetes and Digestive and Kidney Diseases Artificial Pancreas in an Acute General Hospital: A Randomised Controlled Study 292‑OR HOOD THABIT, LIA BALLY, SARA HARTNELL, MALGORZATA E. WILINSKA, A Structured Transition Program in Young Adults with Type 1 Dia- YUE RUAN, ANDREA LAKE, SHANNON FARNHAM, JOANNA GREY, HARRIET betes Is Associated with Improved Satisfaction with Diabetes Care CHURCHILL, MARK L. EVANS, ANTHONY P. COLL, ROMAN HOVORKA, Cambridge, TAMARA SPAIC, ELLEN GOLDBLOOM, PATRICIA GALLEGO, IRENE HRAMIAK, United Kingdom MARGARET LAWSON, JANINE MALCOLM, JEFFREY MAHON, DERIC MOR- Automated fully closed-loop (CL) insulin delivery system without meal- RISON, AMISH PARIKH, ANGELO SIMONE, ROBERT STEIN, CHERIL CLARSON, bolusing was evaluated in a mixed medical and surgical non-critical care London, ON, Canada, Ottawa, ON, Canada, Mississauga, ON, Canada inpatient population of an acute hospital. In a randomised controlled parallel Transition from pediatric to adult diabetes care in young adults (YA) with design study, 30 adults with inpatient hyperglycaemia requiring subcutane- type 1 diabetes (T1D) is associated with poor health outcomes. We initiated ous (s/c) insulin were randomised to receive either CL-directed s/c delivery a multicenter randomized trial to determine if a structured transition pro- of insulin lispro (n=14) or conventional s/c insulin therapy adjusted as per gram in YA (age 17-20 yrs) with T1D improves clinic attendance, complication usual clinical guidelines with masked continuous glucose measurements screening, and glycemic control, after transition from pediatric to adult care. (n=16) for maximum of 15-days. Participants consumed self-selected hos-

The structured program was designed to provide support to the intervention pital meals and were matched for age (64±12 vs. 71±13 yrs; CL vs. control), ORALS arm participants during the transition period with diabetes educators func- HbA1c (7.9±1.3% vs. 8.3±1.8%) and BMI (30.6±6.3 vs. 32.3±10.7kg/m2). Par- tioning as the Transition Coordinators (TC) via text, email, phone and/or clinic ticipant’s usual insulin and sulphonylurea therapy were withheld during CL. visits. During the 18-month intervention, subjects were seen in the pediatric In an intention to treat analysis, the proportion of time when sensor glucose care setting for 6 months and then transferred to adult care where they was in target range [5.6-10.0mmol/l (100-180mg/dl)] was significantly higher continued intervention for 1 year. Client Satisfaction Questionnaire (CSQ), during CL (p=0.003, Table). Time spent above target was significantly lower Diabetes Quality of Life (DQL), and Diabetes Distress Scale (DSS) were during CL (p=0.036). There was a trend towards reduction of mean sensor administered at enrolment and completion of the intervention. glucose during CL (p=0.36). Time spent below target was low and compa- Two hundred and five subjects were randomized (104 structured transi- rable. Total daily insulin was not significantly different (p=0.95). tion; 101 standard care). Seventy one (68.3%) subjects in structured transi- In conclusion, automated artificial pancreas system without meal-bolus- tion and 57 (56.4%) in standard care completed the questionnaires. There ing is safe, and may improve glucose control in a heterogeneous inpatient were a mean of 17.6±7.3 contacts per subject with TC during the 18-month population. intervention. Structured transition subjects attended more clinic visits than those in standard care (4.1±1.1 vs. 3.6±1.2, p=0.002). YA in structured transi- tion were more satisfied with care than those in standard care (28.9±2.7 vs. 27.9±3.4, p=0.04) and reported less emotional burden of diabetes (2.3±1.1 vs. 2.7±1.2%, p=0.03). The DQL and DSS found no differences between the groups for physicians, insulin regimen, or interpersonal domains. A structured transition program in YA with T1D was associated with greater clinic attendance, improved satisfaction and less emotional burden with diabetes care. Outcomes will be further assessed during the one year follow-up after completion of the intervention. Supported By: JDRF/Canadian Clinical Trial Network

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A77 PUMPS AND LOOPS

Table. basal rates were used to induce hypoglycemia (targeted blood glucose <60 mg/dL) overnight (Figure 1). Reference BG samples were collected every Closed-loop Conventional p-values 15-30 minutes during hypoglycemia induction and at each pump suspension insulin delivery insulin therapy and resumption. Median (IQR) reference BG at insulin suspension was 88 (n=14) (n=16) (77-100) mg/dL and at insulin resumption was 83 (74-93) mg/dL. CGM value Time spent at sensor 55.1±22.4 33.2±14.7 0.003 at suspension was 78 (65-89) mg/dL. CGM nadir during suspension was 71 glucose levels (%) (59-78) mg/dL with post-suspension peak of 91 (74-104) mg/dL. There was 5.6 to 10.0 mmol/l 100% agreement between algorithm-recommended pump action and actual > 10.0 mmol/l 34.8±23.5 54.5±25.2 0.036 pump action and there were no reference BG values <60 mg/dL. The Tandem PLGS system was safe and feasible in overnight glucose control in young < 5.6 mmol/l 10.1±4.9 12.3±16.5 0.63 adults during this study. < 3.5 mmol/l 0.3 (0.0, 0.9) 0.1 (0.0, 5.1) 0.76 Mean sensor glucose 9.9±2.6 11.0±2.5 0.36 (mmol/l) Total daily insulin (U) 68.6±40.0 69.8±54.3 0.95 Data are mean±SD or median (IQR). Supported By: Diabetes UK (14/0004878); European Foundation for the Study of Diabetes; JDRF; National Institute for Health Research, UK/Cambridge Bio- medical Research Centre (100574/Z/12/Z); Swiss National Science Foundation (P1BEP3_165297)

295‑OR Closed-Loop Systems Compared with Insulin Pump Therapy for Out- patient Glucose Control in Type 1 Diabetes: A Meta-analysis ALANNA WEISMAN, JOHNNY WEI BAI, MARINA CARDINEZ, CAROLINE K. KRAMER, BRUCE A. PERKINS, Toronto, ON, Canada Inpatient closed-loop systems (CLS) have generally demonstrated 20% improvement in time in target glucose range. A unified estimate of efficacy in outpatient settings is of greater clinical relevance. We aimed to compare CLS and standard continuous subcutaneous insulin infusion (CSII) for % time in target glucose range (70-140mg/dL or 70-180mg/ dL depending on the study), % time in hypoglycemia (<70mg/dL) and insulin dose (units/hour). The OvidSP search platform in the MEDLINE, EMBASE and EBM Reviews Cochrane Central Register of Controlled Trials databases was systematically searched (September 1, 2016) for outpatient or camp studies Supported By: Tandem Diabetes Care that reported paired mean differences. Inclusion criteria, study character- istics, bias assessment, and outcomes were extracted by two reviewers. All outcomes were synthesized as mean differences and standard errors 297‑OR using a random effects meta-analysis with weighting by inverse variance Single and Dual-Hormone Closed-Loop Glucose Control with (Review Manager 5.3). Of 36 studies identified, 19 were conducted in out- Automated Exercise Detection to Prevent Hypoglycemia in Type 1 patient or camp settings and all had crossover designs. Ten studies (N=290) Diabetes were included as they reported paired mean differences. Study duration JESSICA R. CASTLE, JOSEPH EL YOUSSEF, RAVI REDDY, NAVID RESALAT, DEBO- ranged from 8 hours overnight to 12 weeks of continuous use. % time in RAH BRANIGAN, UMA RAJHBEHARRYSINGH, BRIAN SENF, SAMUEL SUGER- target during CSII was 48.8% and increased by 13.04% during CLS (95% CI MAN, NICHOLAS PREISER, PETER G. JACOBS, Portland, OR 10.04-16.05, I2=87%). % time in hypoglycemia during CSII was 2.98% and We developed and tested single-hormone and dual-hormone closed- this was unchanged by CLS (mean difference 0%; 95% CI -0.4-0.4, I2=86%). loop (CL) systems that automatically detect exercise and adjust dosing in Insulin dose was unchanged (mean difference 0.01 u/hr; 95% CI -0.01-0.03, response to exercise using accelerometry and heart rate inputs to help I2=90%). Heterogeneity across studies was high. Sensitivity analysis using reduce exercise-related hypoglycemia in people with type 1 diabetes (T1D). group means rather than paired individual mean differences revealed a bias We compared single hormone (SH) and dual-hormone (DH) algorithms with toward over-estimation of differences in % time in target (14.8%; 95% CI a predictive low glucose suspend (PLGS) system, and the person’s usual current care (CC). In random order, adult subjects with T1D underwent four

ORALS 9.74-19.86). The current body of evidence suggests that outpatient CLS improves time 4-day outpatient visits: DH, SH, PLGS, and CC. Exercise detection in both in target by 13%. In future long-term outpatient CLS studies, it is critical CL systems stopped insulin for 30 m, then 50% reduction for 60 m and in to reduce bias by standardizing reporting of outcomes and reporting paired DH, increased glucagon by 2 fold for 1.5 h. Glucose values from a Dexcom differences. G5 sensor were pushed every 5 m to a Google Nexus phone running the CL Supported By: JDRF/Canadian Clinical Trial Network; Canadian Society of Endo- algorithm. Delivery commands were sent every 5 m to t:slim pumps for SC crinology and Metabolism; Fernand Labrie Fellowship infusion of insulin and/or glucagon. Capillary blood glucose levels were mea- sured four times daily. Subjects exercised for 45 m at 60% VO2max on day 1 and 4 in the human performance lab and completed at least one at home 296‑OR exercise session. Subjects estimated carbohydrate and entered estimates Inpatient Safety and Feasibility of the Tandem Predictive Low Glu- into the controller, which automatically delivered a portion of the estimated cose Suspend (PLGS) Insulin Pump System pre-meal insulin dose. Results from a subset of the 20 adult subjects from GREGORY P. FORLENZA, PAUL WADWA, ROBERT SLOVER, ROBERT O’BRIEN, 17 visits show that overall sensed glucose during DH use was 152±24 mg/ THOMAS J. MOUSE, JOHN LUM, CARI BERGET, TATIANA MARCAL, ROY W. dL (mean±SEM) with 1.1% time in hypoglycemia (CGM<70 mg/dL). During BECK, BRUCE A. BUCKINGHAM, TRANG T. LY, Aurora, CO, Tampa, FL, Palo Alto, CA SH, mean glucose was 134±2 mg/dL, with 4.3% time in hypoglycemia, dur- Hypoglycemia limits aggressive glycemic control in type 1 diabetes (T1D). ing PLGS, mean glucose was 148±12 mg/dL, 1.4% hypoglycemia, and with PLGS allows for prevention of prolonged hypoglycemia by suspending insulin CC glucose was 152±11 mg/dL, 2.9% hypoglycemia. Mean sensed glucose delivery prior to predicted hypoglycemia. Safety and feasibility testing of after exercise was significantly lower for SH compared with DH, 67±6 mg/dL the Tandem PLGS system was conducted as a first step for translating this and 100±9 mg/dL, respectively (p=0.002). Preliminary results show that fully system to clinical use. Ten participants were studied (22±5 years-old, 20% automated insulin and glucagon delivery combined with automated exercise M, 13±4 years of T1D, HbA1c 7.4±0.7%) at two sites in an overnight hospital detection effectively controlled glucose levels and reduced time in hypogly- setting. Participants were admitted in the evening and started on the Tan- cemia and can safely be used in a home environment. dem PLGS system (t:slim insulin pump, Dexcom G4 CGM) which suspends Supported By: National Institutes of Health insulin delivery for 30-min-predicted CGM ≤80 mg/dL. Serial increases in

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A78 THE EPIDEMIOLOGY OF DIABETES COMPLICATIONS

298‑OR with CL vs. TLGS: 67 vs. 41%, 42 vs. 20% and 162 vs. 192mg/dl, respectively Insulin Pump Use in Adults with Type 1 Diabetes (T1D): International (all p<0.001), while % time with CGM<70mg/dl was lower: 0.9 vs. 1.3 albeit Comparison with 18,165 Adults from the T1D Exchange (U.S.) and the not significantly. Over 48 hours, the same indices were also better in CL: 64 DPV Initiative (Germany and Austria) vs. 48%, 39 vs. 28% and 160 vs. 180 mg/dl, respectively (all p<0.001). Our KELLEE M. MILLER, JULIA M. HERMAN, DAVID M. MAAHS, SABINE E. HOFER, data shows a better glucose control can be obtained with CL vs. TLGS ID in MICHAEL R. RICKELS, MICHAEL HUMMEL, JENNIFER L. SHERR, INGRID still poorly investigated prepubertal T1D outpatients. Confirmation on longer SCHÜTZ-FUHRMANN, CLAIRE T. BOYLE, REINHARD W. HOLL, Tampa, FL, Ulm, duration would have a valuable positive impact for T1D children. Germany, Stanford, CA, Innsbruck, Austria, Philadelphia, PA, Rosenheim, Germany, Supported By: French Ministry of Health New Haven, CT, Vienna, Austria While use of insulin pumps has expanded dramatically in the past decade, 300‑OR there remains considerable variability between countries in use of pump Diabeloop Closed-Loop Achieves Better Blood Glucose Control technology. In this analysis we compared pump use and glycemic outcomes than Sensor-Augmented Pump over Three Days Involving Intensive between the U.S. T1DX and Germany/Austria DPV registries. The analysis Physical Exercises, Gastronomic Dinners, or Rest in T1D Patients included 18,176 adult patients (age ≥ 18 years) with diabetes duration ≥ 1 YVES REZNIK, NATHALIE JEANDIDIER, PIERRE YVES BENHAMOU, SOPHIE year and a registry update from April 1, 2015 to July 1, 2016 (9219 individu- BOROT, MAEVA DORON, SYLVIA FRANC, HÉLÈNE HANAIRE, ERIK HUNEKER, als from 72 T1DX sites, and 8957 individuals from 317 DPV sites). Pump use ERIC RENARD, PAULINE SCHAEPELYNCK, ILHAM XHAARD, ALFRED PENFORNIS, was higher in T1DX compared with DPV for all age groups (Figure). HbA1c GUILLAUME CHARPENTIER, BRUNO GUERCI, DIABELOOP STUDY GROUP, Caen, was higher among T1DX injection users vs. DPV injection users (adjusted France, Strasbourg, France, Grenoble, France, Besancon, France, Corbeil-Essonnes, mean 8.4% vs. 8.1%, P<0.001) however, no differences in HbA1c between France, Toulouse, France, Montpellier, France, Marseille, France, Evry, France, Nancy, registries was observed for pump users (adjusted mean 8.0% vs. 7.9%; France P=0.32). Conversely frequency of DKA in the past 12 months was higher Objective: Variability of way of life is an issue for good BG control in among DPV adults compared with T1DX for both pump (adjusted estimate type 1 diabetes (T1D). Diabeloop is a closed-loop (CL) system with an MPC 3% vs. 2%, P=0.001) and injection (adjusted estimate 8% vs. 5%, P<0.001) algorithm reinforced by a decisional matrix, uploaded on an android smart- users. For both registries frequency of DKA was lower in pump users than phone linked to Dexcom CGM and a Cellnovo insulin patch-pump. The pri- non-users (P<0.001). Pump use is less common and DKA more frequent in mary aim of the study was to compare BG control with Diabeloop CL vs. adults with T1D in the German and Austrian DPV registry compared with sensor-augmented insulin pump therapy (SAP) in patients well-educated on the U.S. T1DX registry however this could be due in part to differences in treatment taking repeated intensive physical exercises, having gastronomic registry populations. dinners or resting over 3 days. Figure. Methods: Thirty-eight T1D patients on ITP (49.9±14.5 years, HbA1c: 7.8±0.7%) took part in a randomized 9-center crossover study comprising two 72-hr periods under various exercise conditions for group 1, gastronomic dinners for group 2 and rest for group 3, with either SAP or CL. Results: Percentage time in the 80-140 mg/dL range over the 3 nights was significantly higher for CL vs. SAP (61.1 [56.1;66.7]% vs. 27.4 [19.2;39.0]% P<0.0001), as was percentage time in the 70-180 mg/dL target range over the entire 72 hours: 79.0[75.6;82.5]% vs. 60.8[55.2;67.0]% P<0.0001). Three-day mean BG (mg/dl) was significantly lower for CL vs. SAP (138.7[133.5;144.2] vs. 156.5[148.5;165.0], p<0.0001), as was % time in hypoglycemia. Patient satisfaction with treatment (DTSQ) was higher for CL (31.0±5.5) vs. SAP (26.0±5.5), P=0.0003. The variation in percentage time in the 70-180 mg/dl range between D1 and D2 increased with CL to 3.1[-1.0; 7.1]% but decreased with SAP to -6.4 [-11.8;-1.0], P=0.0128. Between D1 and D3, the difference Supported By: The Leona M. and Harry B. Helmsley Charitable Trust; German in % time at 70-180mg/dL increased in CL to 6.2 [1.6; 10.8]% but decreased BMBF Competence Network Diabetes Mellitus (FKZ01GI1106) with SAP to -1.0 [-7.4; 5.5]%, P= 0.0982. Conclusion: In various situations such as intensive exercises, gastronomic dinners or rest, Diabeloop was able to double the %time spent in 80-140mg/ 299‑OR dl BG range during the night, to reduce the time in hypoglycemia and to Closed-Loop Outperforms Threshold-Low-Glucose Suspend Insulin decrease average BG level, compared to SAP. Delivery on Glucose Control in Prepubertal Outpatients with Type 1 Diabetes ERIC RENARD, NADIA TUBIANA-RUFI, ELISABETH BONNEMAISON-GILBERT, THE EPIDEMIOLOGY OF DIABETES COMPLICATIONS REGIS COUTANT, FABIENNE DALLA-VALE, ANNE FARRET, AMELIE POIDVIN,

NATACHA BOUHOURS-NOUET, CHARLOTTE ABETTAN, JEROME PLACE, MARC ORALS D. BRETON, Montpellier, France, Paris, France, Tours, France, Angers, France, Char- 301‑OR lottesville, VA Glycemic Control, Glucose-Lowering Medication Use, and Utiliza- Glucose excursions result in deleterious brain outcomes and impaired tion among Older Patients with Diabetes quality of life in children with type 1 diabetes (T1D). Our randomized cross- JENNIFER L. KUNTZ, GREGORY A. NICHOLS, Portland, OR over outpatient study compared glucose control with closed-loop (CL) vs. Guidelines suggest the need for individualized glycemic control targets for threshold-low-glucose suspend (TLGS) insulin delivery (ID) in prepubertal older adults. Evidence about healthcare utilization among older adults with T1D children. The ID system included Dexcom G4 Share continuous glucose different levels of glycemic control and treatment may inform personalized monitoring (CGM), Tandem t:slim insulin pump and DiAs control platform glycemic control targets. We studied 10,118 diabetic patients age >65 years (University of Virginia) to which CGM and pump were wirelessly con- from Kaiser Permanente Northwest. We measured glycemic control through nected and which ran alternatively a model predictive control/control to mean A1c, use of glucose-lowering medication (GLM) classes, and health- range (MPC/CTR) or a TLGS algorithm with CGM glucose alarm threshold at care utilization (hospitalization, number of emergency room (ER) and outpa- 70 mg/dl resulting in insulin infusion stop for 2 hours in case of missed alarm. tient visits) from 10/1/2014 to 9/30/2015. Mean A1c was categorized as tight Glucose control was assessed from CGM data. The children (n=24, 14M/10F, (<7%), moderate (7-8.9%) or poor control (≥9%). GLM classes included insu- age (mean, range): 9.4 (7-12), A1c: 7.5±0.5%, pump use since 5.2±3.1 yrs) and lin, secretagogues, metformin, and other GLMs. We categorized patients by their parents were admitted on day 1 at 17:00 in a hotel for two 3-day ses- level of glycemic control and use of <2 or ≥2 GLM classes. We used gener- sions at 3-4-week interval. ID system was installed at admission time and CL alized linear models to examine utilization among patients categorized by or TLGS were initiated at 8:00 on day 2 for 48 hours. Free meals were taken glycemic control and GLM class use, controlling for demographics, diabetes at 9:00, 13:00 and 20:00 and a free snack at 17:00; meal boluses were man- duration and comorbidities. Our population was, on average, 75 years old aged according to individual ins/carb ratios. Free physical exercise occurred with 1.5 comorbidities; 50% were women. The overall mean A1c was 7.2%. after breakfast and lunch. Night sleep was from 22:00 to 8:00. Percent time 50% of patients had a mean A1c <7%; 6% had a mean A1c ≥9%. Among spent with CGM in 70-180mg/dl and 70-140mg/dl ranges and mean CGM those with tight control (n=5,084), 84% received <2 GLM classes. 51% of level during the 2 consecutive nights (22:00-8:00) were significantly better patients with moderate control (2,254 of 4,393) and 70% with poor control

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(448 of 641) received ≥2 GLM classes. After adjustment, patients with A1c Conclusions: The global burden of macrovascular and microvascular com- <7% and ≥2 GLMs had 24% more mean hospitalizations compared with A1c <7% plications is substantial, even among patients initiating second-line treat- and <2 GLMs (0.21 vs. 0.24, p=0.013), and 55% more than 7-8.9% and <2 ment who are presumably still at low risk. Particularly high rates were seen GLMs (0.20, p<0.001). Similarly, mean hospital days were 37% and 63% in Eastern European, Middle Eastern and African countries. higher for these same comparisons (1.3 vs. 0.9 and 0.8, p=0.014 and <0.001), respectively. Groups did not differ on office or ER visits. Tight glycemic control achieved with multiple GLMs is associated with greater hospital utilization compared with tight and moderate control using <2 GLMs, suggesting over-treatment may be hazardous for elderly patients.

302‑OR Interleukin-6 Levels and the Risk of Hospitalization for Heart Failure in Type 2 Diabetes: Insights from Look AHEAD MARIA BELALCAZAR, WEI LANG, STEVEN HAFFNER, RUSSELL TRACY, ALAIN BERTONI, XAVIER PI-SUNYER, JOHN FOREYT, CHRISTIE M. BALLANTYNE, THE LOOK AHEAD RESEARCH GROUP, Galveston, TX, Winston-Salem, NC, San Antonio, TX, Colchester, VT, New York, NY, Houston, TX Individuals with diabetes are at high risk for heart failure (HF). Circulat- ing interleukin-6 (IL-6) levels and genetic variants in the IL-6 receptor have been associated with cardiovascular (CV) event (CVE) risk. However, there is little information on the association of IL-6 levels with incident HF. We hypothesized that plasma IL-6 levels and their changes are related to HF hospitalization (HFH) risk among obese persons with diabetes. Look AHEAD, a trial in overweight/obese adults with diabetes, evalu- ated the effect of intensive lifestyle intervention for weight loss (ILI) on CVE compared to a control of diabetes support and education (DSE); no differ- ence in CVE was noted for ILI vs. DSE. This post-hoc analysis, in a subset of 1,617 participants, combined both treatment arms, measured IL-6 levels at baseline and 1 year after enrollment, and tested the association of baseline IL-6 levels and their 1 year changes with the occurrence of HFH through 9.6 years of median follow-up. We estimated HFH risk across treatment arms using Cox proportional hazard ratio (HR) modeling for 1 standard deviation (SD) of IL-6 levels or their changes, adjusting for demographics, CV disease and smoking. HFH event rate/100 person-yr was 0.4. Baseline IL-6 (median (interquartile range (IQR)) was 2.1(1.4, 3.3) pg/mL. A higher baseline IL-6 level (1 SD or 5.28 pg/mL) was associated with an 8% higher risk of HFH (HR 1.08; 95% confidence interval (CI) 1.03-1.14; p=0.005). IL-6 levels decreased at 1 year by a median of 18.3 (IQR-47.4, 21.0) %; absolute change-0.32 (IQR-1.1, 0.35) pg/mL. A 1-year decline in IL-6 levels was associated with a lower risk of Supported By: AstraZeneca HFH during trial follow-up: a 1 SD (5.31 pg/mL) reduction in IL-6 levels was associated with a 39% lower risk of HFH (HR 0.61(CI 0.38-0.97; p=0.036)). 304‑OR Conclusion: IL-6 plasma levels were associated with HFH risk in obese Pan European (Pan EU) Multi-database Bladder Cancer Risk Char- persons with diabetes and a decline in IL-6 levels with a lower risk of future acterisation Study: Cause-Specific CV Mortality Risk Analysis events. Our data link inflammation with incident HF risk in type 2 diabetes. FABIAN HOTI, PASI KORHONEN, SOLOMON CHRISTOPHER, MAILA MAJAK, Supported By: National Institutes of Health RACHAEL WILLIAMS, HELEN STRONGMAN, MARIE LINDER, SHAHRAM BAH- MANYAR, EDITH M. HEINTJES, DIMITRI BENNETT, Espoo, Finland, London, United 303‑OR Kingdom, Stockholm, Sweden, Utrecht, Netherlands, Cambridge, MA Global Prevalence of Type 2 Diabetes Complications in 14,391 In the Pan EU bladder cancer risk characterization study, using pooled Patients Initiating Second-Line Therapy: The DISCOVER Study data from 6 datasets from 4 countries [Finland (FIN), the Netherlands (NL), MIKHAIL KOSIBOROD, NIKITA ARYA, JAVIER CID-RUZAFA, PETER FENICI, Sweden (SWE), and the United Kingdom (UK)], we observed a statistically significant 33% reduction in all-cause mortality for type 2 diabetes melli-

ORALS MARILIA B. GOMES, NIKLAS HAMMAR, SAMER KAMAL, ANTONIO NICOLUCCI, STUART POCOCK, WOLFGANG RATHMANN, MARINA V. SHESTAKOVA, IICHIRO tus (T2DM) patients ever exposed to pioglitazone (PIO) compared to never SHIMOMURA, FENGMING TANG, HIROTAKA WATADA, KAMLESH KHUNTI, Kan- exposed to pioglitazone (non PIO). As a further step, we investigated and sas City, MO, Gaithersburg, MD, Barcelona, Spain, Cambridge, United Kingdom, Rio characterized cardiovascular disease (CV) related cause-specific mortality de Janeiro, Brazil, Mölndal, Sweden, Luton, United Kingdom, Pescara, Italy, London, risk in relation to PIO use by using selected datasets from the Pan EU study. United Kingdom, Düsseldorf, Germany, Moscow, Russian Federation, Osaka, Japan, Cause specific death records were obtained from national death registries Tokyo, Japan, Leicester, United Kingdom of FIN, SWE and UK, but were not available for the NL. Background: The global prevalence of diabetes-related complications is Results: There were 15,315, 3,712, and 12,106 PIO patients and propen- currently not well described. DISCOVER (NCT02322762) is a global, prospec- sity score matched non PIO patients in FIN, SWE and the UK databases, tive, observational study involving 14,391 patients from 37 countries with respectively. The mean age was 63.2 years for PIO and 65.9 years for non T2DM initiating second-line glucose-lowering therapy. PIO patients. The mean follow-up was 2.6 years for PIO and 2.7 years for non Methods: Patients were recruited from primary and specialist healthcare PIO patients. Prior to follow-up, the PIO patients had less myocardial infrac- settings. Data were collected using a standardized case report form. Mac- tions (MI) or strokes (8.6% vs. 12.4%) and less congestive heart failures (HF) rovascular complications were defined as a composite of coronary artery (3.4% vs. 7.1%) compared to non PIO patients. The main CV related causes of disease, heart failure, stroke and peripheral artery disease. Microvascular death were MI, stroke, and HF, with 1,847 (3.0%), 432 (0.7%) and 179 (0.3%) complications were defined as a composite of retinopathy, nephropathy and deaths, respectively. We observed a statistically significant decrease in the neuropathy. Prevalence estimates were standardized for age and sex using risk for MI, stroke and HF mortality, with the adjusted hazard ratio (HR) for a hierarchical logistic model. PIO vs. non PIO of 0.61 (95% CI: 0.55, 0.69), 0.48 (0.38, 0.62), 0.60 (0.42, 0.86), Results: Median time since diagnosis was 4.1 years (interquartile range: respectively. 2.0-7.9 years). The overall adjusted prevalence of macrovascular complica- Conclusions: In this large, observational cohort study, we observed a sta- tions was 13.0%, ranging from 4.1% to 46.6% across countries (Figure A). tistically significant and clinically relevant reduction in the risk for MI, stroke The overall adjusted prevalence of microvascular complications was 17.7%, and HF cause related deaths in patients with T2DM for ever exposed to pio- ranging from 5.5% to 41.1% across countries (Figure B). glitazone users compared to never exposed to pioglitazone users.

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305‑OR 306‑OR The Cumulative Incidence of Advanced Renal Disease Affects over Patterns of Longitudinal Glycemic Control and Outcomes among 70% of Those with Type 1 Diabetes with Long-Term Follow-Up Patients with Type 2 Diabetes TREVOR J. ORCHARD, TINA COSTACOU, Pittsburgh, PA MIYANG LUO, WEI YEN LIM, CHUEN SENG TAN, KEE SENG CHIA, ROB M. VAN It is commonly thought that only a minority (approximately 40%) of those DAM, WERN EE TANG, NGIAP CHUAN TAN, RICHARD CHEN, E. SHYONG TAI, with type 1 diabetes (T1D) will develop Advanced Renal Disease (ARD) KAVITA VENKATARAMAN, Singapore, Singapore defined as Overt Nephropathy (Albumin excretion rate (AER) >200 μg/min) or Objective: To analyze the effect of patterns of glycemic control over time renal failure (RF). However, as few of those with T1D survived to older ages with microvascular and macrovascular events and mortality among multi- until recently, long term risks are unclear. We thus examined the 50 years ethnic patients with type 2 diabetes in Asia. cumulative risk of ARD in the Pittsburgh Epidemiology of Diabetes Complica- Methods: 6079 participants recruited from polyclinics and hospital out- tions study cohort. Participants (n=934, diagnosed in 1950-80) included 146 patient clinics in Singapore were included. HbA1c measurements for the who died prior to the baseline exam (1986-88) and 788 who were followed five years previous to recruitment were obtained from medical records and with periodic surveys (n=130) or biennial surveys and a maximum of 9 exams used to identify patterns of HbA1c trajectories. Outcome data with average (n=658) for 25 years. Mean baseline age was 29 and duration 19 years. ON 7-year prospective follow-up from recruitment were obtained through link- and microalbuminuria (AER 20-199 μg/min) were determined based on two of age with the National Disease Registry. HbA1c trajectories were identified three timed urines at and prior to each exam. Participants were divided into using latent class growth modeling. The association of trajectories and out- calendar years of diabetes onset and cumulative incidences were estimated comes were analyzed using Cox proportional hazards models. at 5 yr intervals between 20 and 50 yrs duration (Figure 1). By 50 yrs’ dura- Results: Four distinct patterns of longitudinal glycemic control were tion RF (determined among all participants) affected 60% and ON and MA observed, and hazard ratios (HR) for end-stage renal failure, acute myocar- (determined in the examined cohort only) occurred in almost 80% and 90%, dial infarction (AMI), stroke, and death were compared (Table 1). respectively. Little evidence for major declines in cumulative incidence in Conclusions: Poor glycemic control trajectories are associated with recent cohorts was seen. ARD in T1D is almost universal (and not declining) increased risk of long-term complications and death, suggesting that efforts which has major implications for formulating research strategies. to alter the trajectory may be helpful in reducing the risk. Deteriorating gly- cemic control and extremely high initial HbA1c are associated with increased Figure 1. Cumulative Incidence of Microabluminuria, Overt Nephrophathy, risk of outcomes after controlling for recent HbA1c. and Renal Failure by Diabetes Duration and Diagnosis Cohort. Table 1. Comparison of HbA1c Levels and Outcomes Hazard Ratios among Four HbA1c Trajectory Patterns. Group 1 Group 2 Group 3 Group 4 “low-stable” “moderate- “moderate- “high-decrease” stable” increase” Number of participants 4389 (72.2) 1339 (22.0) 179 (2.9) 172 (2.8) Mean HbA1c (%) 7.1 (0.6) 8.5 (0.6) 10.6 (1.1) 9.2 (1.2) Initial HbA1c (%) 7.4 (1.2) 9.2 (1.4) 10.4 (1.8) 12.7 (1.8) Recent HbA1c (%) 7.1 (0.8) 8.5 (1.3) 11.1 (1.8) 8.6 (1.6) End-stage renal failure HR 1.00 1.19 2.81 3.53 (0.71-2.01) (1.23-6.40) (1.81-6.89) AMI HR 1.00 1.33 1.86 2.63 (0.99-1.77) (1.00-3.44) (1.63-4.23) Stroke HR 1.00 1.42 2.58 1.85 (0.97-2.97) (1.10-6.08) (0.87-3.96) Death HR 1.00 1.14 2.18 2.53 (0.94-1.39) (1.39-3.43) (1.78-3.58) Data are number (%), mean (SD), or HR (95% CI). Cox proportional hazard models were adjusted for age, gender, ethnicity, smoking, BMI, WHR, diabetes duration, insulin treatment, place receiving medical care, hyper- tension, retinopathy, blood pressure, total cholesterol, triglycerides, and recent HbA1c. Supported By: A*STAR Biomedical Research Council

307‑OR Prediabetes and the Incidence of Major Adverse Cardiovascular ORALS Events GILLIAN L. BOOTH, MOHAMMAD R. REZAI, CLARE ATZEMA, PETER C. AUSTIN, SACHA BHATIA, ARLENE S. BIERMAN, KRISTIN K. CLEMENS, SHARON JOHN- STON, DENNIS T. KO, DOUGLAS S. LEE, KAREN TU, JACK V. TU, Toronto, ON, Canada, London, ON, Canada, Ottawa, ON, Canada Prediabetes is thought to be a risk factor for the development of car- diovascular disease (CVD). However, it is unclear whether the subsequent development of diabetes accounts for this association. We tested this hypothesis among 1,415,241 members of the CANHEART cohort, created using administrative health databases from Ontario, Canada. Adults aged ≥40 years who were free of CVD on Jan 1 2008 were followed until Dec 31, 2012 for major adverse cardiovascular events (MACE), consisting of nonfatal myocardial infarction, nonfatal stroke or CVD death. Cox Proportional Haz- Supported By: National Institutes of Health (DK34818); Rossi Memorial Fund ards models were conducted to compare the incidence of MACE in those with prediabetes (impaired fasting glucose or impaired glucose tolerance) at baseline relative to those with normoglycemia, with and without adjusting for diabetes development as a time-varying covariate. Based on glucose test results and medication claims, there were 111,826 individuals with predia- betes at baseline, 261,193 with diabetes and the remainder with normal glu- cose status. On follow-up, prediabetes was associated with a significantly increased incidence of MACE in groups under age 65 (HR for prediabetes

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vs. normoglycemia 1.10, 95% CI 1.04-1.17) but not among adults ≥65 years (p=0.049). Reassuringly, there were no incidents of severe hypoglycemia. (HR 1.05, 95% CI 1.00-1.10) after adjusting for age, sex and CVD risk factors. Insulin suppression in response to AE after ITx may be impaired. Further Results were similar after accounting for the development of diabetes during studies may clarify the regulation of insulin release from intrahepatic islets follow-up (age <65, HR: 1.16, 95% CI 1.07-1.25; ≥65 HR: 1.06 95% CI 0.99- during AE. 1.12). In younger groups, prediabetes performed similarly to other elements Figure. of the metabolic syndrome as a predictor of MACE, but was a weaker risk factor than diabetes of recent onset (diabetes <2 years vs. normoglycemia: HR 1.41, 95% CI 1.29-1.53) or diabetes of longer duration (diabetes >15 years vs. normoglycemia: HR 4.02, 95% CI 3.74-4.33). In summary, prediabetes was associated with a modestly increased risk of MACE in our population that was independent of the subsequent develop- ment of diabetes. Supported By: Canadian Institutes of Health Research

308‑OR Recurrent Hospitalizations for Severe Hypoglycemia and Hypergly- cemia ROZALINA G. MCCOY, JEPH HERRIN, KASIA J. LIPSKA, MOLLY M. JEFFERY, NILAY D. SHAH, Rochester, MN, New Haven, CT Many patients with diabetes experience recurrent severe hypoglycemia and hyperglycemia, causing morbidity and impairing quality of life. Highest severity episodes require hospitalization, and preventing them is challeng- ing as key risk factors are poorly understood. Using data from OptumLabs, a national administrative dataset of 100 million racially and socioeco- nomically-diverse commercial and Medicare Advantage beneficiaries, we examined 30-day readmissions for severe hypoglycemia and hyperglyce- mia (ketoacidosis and hyperosmolar state) after hospitalization for a prior severe hypoglycemic or hyperglycemic event. Between 1/1/09 and 12/31/15, there were 7674 admissions for hypoglycemia among 5860 adults and 7264 admissions for hyperglycemia among 6683 adults. Patients admitted for hypoglycemia were younger (48.7 vs. 68.3 years), female (52.4% vs. 48.2%), insulin-treated (65.5% vs. 48.3%), and with fewer comorbidities than those admitted for hyperglycemia. After hypoglycemia admissions, 29 (0.4%) were readmitted for recurrent hypoglycemia, 327 (4.3%) for new hyperglycemia, and 441 (5.7%) for other cause. The strongest independent risk factor for recurrent hypoglycemia was older age. Risk factors for new hyperglycemia were younger age, more comorbidities, and history of prior hospitalization. After hyperglycemia admissions, 16 (0.2%) were readmitted for recurrent Supported By: Alberta Diabetes Institute hyperglycemia, 97 (1.3%) for new hypoglycemia, and 712 (9.8%) for other cause. Prior hospitalization was the main risk factor for these readmis- 310‑OR sions. Thus, patients hospitalized for hypoglycemia are at high for early Mechanisms of Hypoglycemia after a High-Carbohydrate Meal in readmission for severe hyperglycemia, particularly if they are younger and Pancreatic Autoislet Recipients with comorbidities. In contrast, patients hospitalized for hyperglycemia are LINDSEY D. BOGACHUS, MELENA D. BELLIN, ADRIAN VELLA, R. PAUL ROBERT- readmitted for hypoglycemia or, more often, unrelated causes. These find- SON, Bellevue, WA, Minneapolis, MN, Rochester, MN, Seattle, WA ings support individualized discharge planning, including attention to dia- Successful recipients of intrahepatic autoislet transplantation after total betes medication changes, education, and early follow-up to ensure post- pancreatectomy for chronic, painful pancreatitis (TPIAT) often complain of discharge glycemic control. severe hypoglycemia after meals. To examine mechanisms of this glycemic Supported By: National Institutes of Health; National Center for Advancing dysregulation, we conducted triple isotope-labeled glucose studies during Translational Sciences (UL1TR000135) a high carbohydrate meal in 10 TPIAT recipients. All recipients had normal fasting glucose and HbA1c levels. Prior to ingesting the meal, mean ± SE TRANSPLANTATION—BASIC SCIENCE AND levels of fasting glucose, insulin, and glucagon were 5.6 ± 0.2 mmol/L, 5.1 ORALS ± 0.6 µU/ml, and 90 ± 17 pg/ml, respectively. Compared to normal control PHYSIOLOGY subjects, peak glucose levels were significantly higher in the TPIAT group (14.2 ± 1.2 vs. 9.66 ± 0.3 mmol/L; p<0.001). However, at 150 to 330 min- 309‑OR utes, glucose levels for the recipient group were 3.8 ± 1.2 mmol/L, and 5 Aerobic Exercise Reveals Impaired Insulin Suppression in ITx subjects were in the hypoglycemic range. Despite the glucose levels, Recipients Compared with Nondiabetic Individuals glucagon levels increased only slightly during the study (delta glucagon = JANE E. YARDLEY, DEANNA FUNK, SAEED REZA TOGHI-ESHGHI, JORDAN REES, 22 ± 7 pg/ml). Triple-labeled glucose isotopes measurements during these NORMAND G. BOULÉ, PETER A. SENIOR, Camrose, AB, Canada, Edmonton, AB, studies revealed similar rates of glucose appearance and disappearance in Canada the TPIAT recipients compared to controls. However, endogenous glucose Islet transplantation (ITx) prevents severe hypoglycemia in type 1 diabetes production tended to be lower in those recipients who became overtly hypo- but in animal models aerobic exercise (AE) can induce hypoglycemia after glycemic. These studies demonstrate that during a high carbohydrate meal intrahepatic ITx. We hypothesized that glucose would decrease more in ITx TPIAT recipients develop excessively high glucose levels initially followed by patients after AE compared to nondiabetic individuals (CON) due to higher a brisk fall in glucose levels by some into the hypoglycemic range and these post-AE plasma insulin. Eleven insulin-independent ITx individuals (5:6 m/f) recipients did not have a quantitatively appropriate glucagon response. and 10 CON (5:5 m/f) participants of similar age (p=0.21) and BMI (p=0.86) Initially high glucose levels followed by hypoglycemia and inadequate glu- performed 45 min of late afternoon cycling (60% VO2peak). A resting control cagon response is a likely mechanistic series of events that contributes to condition (R) took place on a separate day. Participants replicated the timing post-prandial hypoglycemia in TPIAT recipients. and composition of their diet. Glucose and log transformed insulin values Supported By: National Institutes of Health were analyzed by 2x2x2 ANOVA. The analysis of insulin levels revealed a group (ITx vs. CON) by condition (AE vs. R) by time (pre- (T1) to post-AE (T2)) interaction with a smaller decrease in insulin from T1 to T2 in the ITx group on the AE day (p=0.025). A 3-way interaction was also found for capillary glucose with a greater decrease during AE compared to R, in ITx vs. CON

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311‑OR 313‑OR Rapamycin Impairs Human β-Cell Function and Inhibits Juvenile Leukocyte-Derived Microparticles Favor Endothelial Senescence: Human β-Cell Proliferation A New Mechanism Possibly Contributing to IBMIR in Islet Trans- CHUNHUA DAI, ALENA SHOSTAK, ANA PADGETT, SCOTT WISNIEWSKI, plantation NRIPESH PRASAD, GREG POFFENBERGER, NEIL PHILLIPS, DANIELLE DEAN, ALI EL HABHAB, MOHAMAD KASSEM, GUILLAUME KREUTTER, MALAK ABBAS, ASMA K. ALJABERI, ARAMANDLA RADHIKA, YAN HANG, SHAWN E. LEVY, BLANDINE YVER, FATIHA ZOBAIRI, VALERIE SCHINI-KERTH, FLORENCE TOTI, DALE L. GREINER, LEONARD D. SHULTZ, RITA BOTTINO, SEUNG KIM, ALVIN C. LAURENCE KESSLER, Strasbourg, France POWERS, Nashville, TN, Huntsville, AL, Stanford, CA, Worcester, MA, Bar Harbor, Microparticles (MPs) have emerged as a surrogate marker of vascular ME, Pittsburgh, PA endothelial cell injury during transplantation and act as noxious mediators Post-transplant diabetes likely develops as a result of required immu- in immune response. Tissue factor (TF), the cellular initiator of coagulation, nosuppressive drugs, such as rapamycin (sirolimus). However, our under- is expressed by inflamed endothelium and activated leukocytes. During standing of the effects of these drugs on human islets in vivo at clinically “instant blood mediated inflammatory reaction,” IBMIR, activated leu- relevant drug levels is limited. To investigate the effects of rapamycin on kocytes are recruited at the vicinity of transplanted islets. We aimed the human islets in vivo, we developed a dosing approach in mice that achieved impact of MPs from stimulated leukocytes on endothelial senescence and clinically relevant rapamycin levels and found that the rapamycin levels inflammatory response. Pig endothelial coronary cells (ECs) were incubated were dependent on the mouse strain. Next we transplanted adult or juve- with MPs 1-30 nM isolated from rat splenocytes treated by 5 μg/ml LPS or nile (<10 years of age) human islets into immunodeficient mice and treated 25 ng/ml PMA-1 μM A23187 ionophore. The interaction of MPs with tar- with rapamycin to obtain clinically relevant serum levels. Rapamycin treat- get ECs was assessed using the fluorescent lipid probe PKH26, apoptosis ment for 4 weeks impaired glucose/arginine-stimulated insulin secretion by flow cytometry. The level of endothelial senescence was assessed as (GSIS) by transplanted adult human islets (NaCl vs. rapamycin: 1.15±0.16 vs. senescence-associated β-galactosidase (SA-β-GAL) activity by C12FDG 0.61±0.09ng/ml; p=0.0051, n=5 donors, age 16-55 years). Rapamycin also probe, oxidative stress using the redox-sensitive probe dihydroethidium, the impaired insulin secretion by transplanted juvenile islets from a 6 year old level of target protein expression by Western blot. The capture of fluores- donor (1.37±0.06 vs. 0.60±0.06ng/ml; p=0.0008) but not by juvenile islets cent MPs was observed in about 82% of ECs by flow cytometry and fluores- from a 3 month old and a 10 month old donor. Rapamycin did not induce cent microscopy at 24 h. MPs induced a significant raise in SA-β-GAL activity apoptosis in adult or juvenile human grafts and insulin content was simi- in young P1 ECs (18±5 vs. 58±6 MFI) after 48 h associated with p53, p21, lar in NaCl and rapamycin-treated adult islet grafts (887 ± 232 vs. 1042 ± p16 up-expression level. The 2-fold up-expression of NADPH oxidase sub- 308ng/graft; n=3 donors, p=0.6864). Ki67 staining showed that rapamycin units and 3-fold down-expression of eNOS indicated MP-mediated oxida- did not affect β cell proliferation in adult grafts (Ki67+ β cells: 0.10±0.02% vs. tive stress. MPs prompted procoagulant TF up-expression and a secondary 0.09±0.02%; p=0.9188; n= 4 donors). In contrast, transplanted juvenile islets generation of MPs. MPs up-regulated VCAM1 and ICAM1 and COX-2 but had greater β cell proliferation than adult islets and this was inhibited by not COX-1. These MPs induced phosphorylation of MAPKs and up-regulated rapamycin (3.78±0.84% vs. 1.34±0.43%; p=0.013; n=3 donors, age 3 month, AT1 receptors and ACE in P1 ECs. No significant variation in ECs apoptosis. 10 month, and 6 year). Importantly, adult human β cell function returned MPs from splenocytes induce premature senescence and thrombogenicity to normal 4 weeks after rapamycin withdrawal. These data indicate that in young primary ECs. Our in vitro data suggest a new paracrine MP-driven rapamycin in clinically relevant doses primarily impairs insulin secretion and pathway possibly contributing to poor islets survival during IBMIR through this is reversible. endothelial damage. Supported By: National Institutes of Health; JDRF; U.S. Department of Veterans Affairs 314‑OR Islet Encapsulation with Polyphenol Coatings Decreases Proin- 312‑OR flammatory Immune Responses and Restores Euglycemia in Dia- Ex Vivo Expanded Murine Mesenchymal Stem Cells as Targets for betic Mice after Islet Transplantation the Generation of a Cell Replacement Therapy for Type 1 Diabetes JESSIE M. BARRA, DANA PHAM-HUA, LINDSEY E. PADGETT, BING XUE, BRIAN DARIO GERACE, ROSETTA MARTINIELLO-WILKS, NAJAH T. NASSIF, BINHAI ANDERSON, MICHAEL ZEIGER, VERONIKA KOZLOVSKAYA, EUGENIA KHAR- REN, ANN M. SIMPSON, Sydney, Australia LAMPIEVA, HUBERT M. TSE, Birmingham, AL Gene therapy as a means of generating “artificial” insulin-producing cells Type 1 diabetes (T1D) is a chronic pro-inflammatory autoimmune disease is being explored as a potential cure for type 1 diabetes (T1D). The aim of this consisting of pancreatic β-cell death caused by islet-infiltrating leukocytes. study was to evaluate the utility of ex vivo expanded murine mesenchymal One promising treatment for T1D is islet transplantation; however, its clinical stem cells (MSCs) as targets for gene therapy and the development of a application is constrained due to islet availability, adverse effects of immu- T1D cell replacement therapy. A sub-population of stromal cells was FACS nosuppressants, and poor graft survival. Islet encapsulation may provide sorted from the bone marrow of nonobese diabetic (NOD) mice, expanded an immunoprotective barrier to prevent immune-mediated rejection and and nucleofected to express the bioluminescence reporter protein Firefly maintain pancreatic β-cell function following transplantation. Using a novel luciferase (Luc2). Ex vivo culture-expanded MSCs were subsequently trans- nanothin multilayer coating consisting of tannic acid (TA), an immunomodu- duced with the HMD lentiviral vector (MOI=10) to express furin-cleavable latory antioxidant, and poly(N-vinylpyrrolidone) (PVPON), we hypothesized human insulin (INS-FUR), murine NeuroD1 and Pdx1; followed by in vitro that (PVPON/TA)-encapsulated islets can restore euglycemia, provide immu- ORALS characterisation of pancreatic transdifferentiation using reverse transcrip- noprotection, and prolong graft function post-transplant in diabetic mice. tase polymerase chain reaction (RT-PCR), and acute and chronic insulin We demonstrate that CD80 expression on p(I:C)-stimulated macrophages secretion assays. The persistence of a subcutaneous (s.c) transplant of Luc2- was decreased 2.9-fold (p < 0.01) in the presence of (PVPON/TA) capsules, expressing MSCs was assessed using bioluminescence imaging in immune- suggesting that redox modulation can influence pro-inflammatory M1 mac- competent NOD (n=4) and immune-deficient NOD/Scid (n=4) animal models rophage differentiation. Our results also demonstrate that (PVPON/TA)- of diabetes. A s.c transplant of 1x107 and 5x107 INS-FUR-expressing MSCs in encapsulated islets can significantly attenuate Ifng, Cxcl10, and Ccl5 mRNA NOD/Scid mice (n=5) was assessed for their ability to reverse diabetes. INS- accumulation (p < 0.05) and protein expression (p < 0.05) in a T cell co-culture FUR-expressing MSCs lacked glucose-responsiveness and secreted human assay with dendritic cells. In vivo, (PVPON/TA)-encapsulated islets trans- insulin chronically, whereas NeuroD1 and Pdx1-expressing MSCs lacked planted under the kidney capsule restored euglycemia after transplanta- glucose-responsiveness and insulin secretion capabilities. Luc2-expressing tion into streptozotocin (STZ)-treated diabetic mice. Our results support the MSCs persisted for 2 weeks and 12 weeks respectively in NOD and NOD/ hypothesis that (PVPON/TA)-encapsulated islets may suppress allo-specific Scid mice. Transduced MSCs did not undergo pancreatic transdifferentiation immune responses and maintain islet function following transplantation. as determined by RT-PCR analysis and upon transplantation failed to reverse Future studies will determine the efficacy of (PVPON/TA)-encapsulated diabetes. These data suggest ex vivo expanded MSCs may be more useful islets to decrease allo- and autoreactive immune responses in mouse mod- as gene therapy targets prior to expansion. This correlates with published els T1D, as well as investigate the potential of combinatorial immunothera- studies from other groups showing ex vivo expansion of MSCs is associated pies to delay islet graft rejection. with negative T1D clinical outcomes. Supported By: American Diabetes Association (7-12-CD-11 to H.M.T.); National Supported By: Australian National Health and Medical Research Council; Institutes of Health/National Institute of Diabetes and Digestive and Kidney Rebecca L. Cooper Foundation; Arrow Bone Marrow Transplant Foundation Diseases (DK099550); JDRF (1-SRA-2015-42-A-N); National Institutes of Health/ National Institute of Allergy and Infectious Diseases (5T32AI007051-35); National Science Foundation (1306110)

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A83 OBESITY PATHOGENESIS AND TREATMENT—INSIGHTS FROM HUMAN STUDIES

315‑OR from RGS14 KO or from C57 WT to their WT littermates. Measurements were Adipose Tissue: A Potential Ideal Site for Islet Transplantation made 3 days following BAT transplant surgery. BAT donors (n =6) and recipi- TAO DU, KANG XU, RAOYING XIE, XIAOLIN LIN, LI CHEN, JUNSHUANG JIA, ents (n = 6) were challenged by a glucose tolerance test (GTT) or insulin toler- DONG XIAO, Guangzhou, China ance test (ITT) on non-consecutive days following a 6 hour fast. RGS14 KO BAT The liver is widely used as the site for clinical islet transplantation. How- recipients had improved glucose tolerance with lower areas under the curves ever, the liver is far from being an ideal site because of low efficiency and (AUCs) (6,881 ± 1,193) than their BAT donors (11,126 ± 653; p <0.05). Insulin serious complications. Alternative injection sites that could extend islet tolerance was improved, as evidenced by a 39% improvement (p<0.05) in AUC graft survival and reduce the required number of engrafted islets would during an ITT. Conversely, RGS14 KO BAT donors lost their protection against consider islet transplantation a routine procedure. Here, our results strongly glucose and insulin intolerance and exhibited glucose and insulin curves simi- suggested adipose tissue appear to be the excellent site for islet trans- lar to WT. A second goal was to determine if BAT transplanted from WT to WT plantation. A small number grafted islets (80-100 islets) in the both white mice elicited the same protection. Interestingly, WT mice receiving BAT from adipose and brown adipose tissue could completely restore mice blood glu- a C57 donor showed no improvement when challenged with a GTT or ITT 3 cose to normal. Most importantly, morphological characteristics and insulin days post-transplant, but did exhibit improved glucose and insulin tolerance 8 staining showed the transplanted islets appeared well vascularized with weeks after transplantation. Thus, these findings suggest that BAT is a novel extra- and intra-islet vasculature and high insulin expression without sur- mediator of glucose and insulin tolerance and that BAT from the RGS14 KO rounding immunocytes in the tissue of each transplantation site for one year. mouse is even more potent, suggesting a better target for this new therapeutic Additional, intact and well-preserved ectopic islets were glucose-stimulated modality for diabetes. insulin secretion and its function in the adipose tissue was most similar to Supported By: National Institutes of Health (2R01HL106511-05A1) control mice in terms of the IPGTT and AUC (p>0.05, n=6-9/group), reflecting a physiologically normal delivery of insulin. Thus, choosing human subcuta- neous white adipose tissue as clinical islet transplantation site would make OBESITY PATHOGENESIS AND TREATMENT— it as simple as insulin injection without the serious complications such as INSIGHTS FROM HUMAN STUDIES bleeding and thrombosis, and easy to reduplicate and monitor. Figure. Long-Term Grafted Islet Function in Mice Maintaining Normoglyce- 317‑OR mia for One Year. Body Weight and Energy Intake Changes in Overweight Individuals Treated with Canagliflozin, Phentermine, or Canagliflozin + Phen- termine DAVID POLIDORI, NATHAN P. GILL, FRANK VERCRUYSSE, NGOZI ERONDU, KEVIN D. HALL, San Diego, CA, Bethesda, MD, Beerse, Belgium, Raritan, NJ SGLT2 inhibitors (SGLT2i) induce a caloric loss by increasing urinary glu- cose excretion (UGE) leading to a modest yet sustained weight loss (WL) of ~2-4% in patients with type 2 diabetes. This WL is much less than predicted based on the UGE caloric deficit alone due to compensatory increases in energy intake (EI) that occur in response to WL. A 26-week study in over- weight, otherwise healthy individuals (N = 334, 82% female, mean (SD) age = 46 (11) y, body weight (BW) = 103 (18) kg, BMI = 37 (5) kg/m2) tested the hypothesis that combining the appetite suppressant phentermine (PHEN 15 mg) with the SGLT2i canagliflozin (CANA 300 mg) results in greater WL than either monotherapy. Changes in EI were estimated using a previously validated mathematical model of energy balance using measured BW profiles and an estimated UGE of 55 g/day with CANA. As expected, WL was greatest with CANA+PHEN, and estimated EI was increased with CANA and decreased with PHEN (Figure). Surprisingly, despite the greater WL with CANA+PHEN, EI with CANA+PHEN was virtually identical to EI with PHEN alone, suggesting that co- administration of PHEN was able to fully block the compensatory EI increase that occurs with CANA alone. This effect led to greater-than-additive WL with CANA+PHEN, and individuals were still in negative energy balance and los- ing weight at week 26. Longer-term studies with CANA+PHEN are warranted. Figure. ORALS

Supported By: Natural Science Foundation of Guangdong Province of China (S2012010009212, 2014A030313488); Science and Technology Planning Project of Guangdong Province of China (2015A030302014, 2016A030303066)

316‑OR Brown Adipose Tissue, a Novel Therapeutic Target for Glucose and Supported By: Janssen Research & Development, LLC Insulin Intolerance JOHN J. GUERS, DOROTHY E. VATNER, JIE ZHANG, ELENA KATSYUBA, SEON- 318‑OR GHUN YOON, JOHAN AUWERX, STEPHEN F. VATNER, Newark, NJ, Lausanne, Epigenetic Changes of DNA Methylation with Remission of Switzerland Prediabetes The mouse model of Receptor for G Protein Signaling 14 (RGS14) knockout FRANKIE B. STENTZ, DIVYEN PATEL, Memphis, TN (KO) is unique as it not only extends longevity, but also improves exercise toler- Obesity is a disease that has reached epidemic levels over the past two ance and glucose and insulin tolerance. This model is also unique since it has decades. Prediabetes or impaired glucose tolerance (IGT) is often seen in 47% more brown adipose tissue (BAT) mass compared to their wild type (WT) conjunction with obesity and both are associated with increased incidence littermates, a mechanism that could mediate the protection against glucose of various diseases. The purpose of this study was to determine if epigenetic and insulin intolerance in the RGS14 KO. The first goal of this investigation changes occur in patients that convert from prediabetic to normal glucose was to determine if removing BAT from the RGS14 KO affected glucose and tolerance (NGT) by determining DNA methylation at baseline and at remis- insulin tolerance and then by transplanting the BAT to WT mice, affected their sion of prediabetes at 6 months (mo). glucose and insulin tolerance. Accordingly, we transplanted 0.2 grams of BAT

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A84 OBESITY PATHOGENESIS AND TREATMENT—INSIGHTS FROM HUMAN STUDIES

24 obese, prediabetic adults were randomized to a HP or HC diet for 6 mo sleep restriction, and no sleep. Abdominal subcutaneous WAT biopsies were with all food provided. The HP diet consisted of 30% protein (P), 30% fat(F), taken in the evening and morning to analyze diurnal transcriptome regula- 40% carbohydrates(C) and HC diet consisted of 15%P, 30%F, 55%C distrib- tion. Blood samples were taken repeatedly to assess glucose homeostasis, uted by percent of daily kcals derived for each subject. Oral Glucose Toler- lipid profiles, adipokines, and inflammation markers. ance Test (OGTT) was performed at Baseline (BL) and 6 mo to determine IGT/ Results: Diurnal transcriptional variations were dramatically blunted after NGT status. The HP diet group had 100% (12/12) conversion to NGT while sleep restriction with further dampening in the absence of sleep. While most the HC diet had 33%(4/12) conversion. Both diet groups had weight loss and core clock genes remained stably rhythmic, diurnally regulated genes associ- improvement in insulin sensitivity determined by Matsuda Index [HP(BL 2.3 ated with metabolic pathways were highly sensitive to sleep loss, suggest- ± 0.3; 6 mo 6.5 ±1.1)], [HC (2.3±0.3; 6 mo 3.2±0.4)]. DNA was extracted from ing a sleep loss-induced uncoupling of circadian and metabolic processes. OGTT 0-minute blood samples from BL and 6-mo visits. BL total genome Genes associated with carbohydrate breakdown lost their diurnal regulation methylation (TGM) was 5.8 ±0.5% for HP and 5.7±0.4% for the HC groups, with an overall up-regulation in the morning after reduced/no sleep. Genes respectively. HP group had a 6 mo TGM of 3.9±0.4% while the HC group of lipid metabolism mostly remained unaffected. Secretory β-cell capacity was 4.6±0.4% and 5.3±0.5% in the remission and non-remission patients, as indicated by reduced circulating insulin c-peptide was diminished, while respectively. Specific site DNA methylation was determined using Illumina RBP4 was increased after sleep restriction and in particular in the absence chips for Whole Genome Bisulfite Sequencing. Changes in DNA methylation of sleep. Lipid profiles and inflammation markers were mainly unaffected. of numerous genes were observed from BL to 6 mo with remission of pre- Discussion: Acute sleep loss disturbs diurnal transcriptome regulation diabetes and weight loss. Some of these genes with altered DNA methyla- in human adipocytes thereby facilitating an unfavorable metabolic profile. tion include: 32 genes involved in metabolic pathways, 17 cytokine genes, Identifying sleep sensitive genes overrepresented in metabolic pathways, 15 MAPK signaling genes, 31 cancer associated genes, 9 diabetes genes, 3 our findings concur with increased glucose breakdown and lipogenesis in the cardiovascular genes. The decreased total DNA methylation from 0 to 6 mo morning after short term sleep loss. correlates with the reduced blood glucose. The DNA methylation changes Supported By: Deutsche Forschungsgemeinschaft of specific genes may be important for reduction of certain disease states. Supported By: A.D. Baskin Memorial Cancer Research (R073316012) 321‑OR Changes in Weight and Glycemic Control in Obese T2DM and Pre- 319‑OR diabetes 18 Months after Creation of a Dual-Path Enteral Diversion Epigenetics Links Hyperinsulinemia with Liver Overproduction of by an Incisionless Magnet Anastomosis System (IMAS) Fibrosis Marker PDGFA and to Hepatic Insulin Resistance DONALD C. SIMONSON, EVŽEN MACHYTKA, MAREK BUŽGA, DAVID B. LAUTZ, AMAR ABDERRAHMANI, LOÏC YENGO, MICKAËL CANOUIL, AMÉLIE BON- MARVIN RYOU, CHRISTOPHER C. THOMPSON, Boston, MA, Ostrava, Czech Repub- NEFOND, STÉPHANE CAUCHI, ROBERT CAÏAZZO, FRANÇOIS PATTOU, PHILIPPE lic, Concord, MA, Bridgewater, MA FROGUEL, Lille, France Obesity can effectively be treated by intestinal bypass surgery, but a less DNA methylation is a major mechanism that links the environment to sys- invasive approach would be desirable. This is the first clinical series evalu- temic insulin resistance in diabetes. We have investigated the liver methylome ating endoscopic creation of a dual-path enteral diversion using an IMAS and transcriptome in European women undergoing bariatric surgery (96 T2D that relies on magnetic compression to create an anastomosis allowing a cases and 96 normoglycemic controls matched for age and BMI), using Infin- portion of the ingested nutrients to bypass much of the small bowel. The ium HumanMethylation450 BeadChip arrays and HumanHT Whole-Genome IMAS was preloaded into the biopsy channels of two endoscopes, and simul- HT Assays. We identified one genome-wide significant differentially methyl- taneous colonoscopy and enteroscopy was performed. When endoscopi- ated CpG site in fibrosis and cancer marker Platelet Derived Growth Factor cally deployed, the devices self-assemble to form magnetic octagons in the alpha (PDGFA) locus. The methylation level of PDGFA was decreased in T2D jejunum and ileum, and then couple to create a compression anastomosis. cases and was associated with elevated PDGFA mRNA level, hyperinsulinemia Mated magnets were passed in the stool after the compression anasto- and systemic insulin resistance. The association was replicated in other Euro- mosis was formed, typically in 1-2 wks. Ten obese patients were studied pean liver samples. Moreover, in line with the role of PDGFA in liver fibrosis, (4 T2DM, 3 pre-DM, 3 non-DM; 6M/4F; age = 48 ± 11 yrs; weight = 121 ± 18 the increased PDGFA expression and hypomethylation were associated with kg; BMI = 41.3 ± 4.4 kg/m²). In all patients, weight change at 6, 12, and 18 mos liver fibrosis and nonalcoholic steatohepatitis (NASH) in T2D cases. Mende- was -12.9 ± 2.4 kg, -17.3 ± 3.8 kg, and -16.6 ± 4.8 kg (all p < 0.01 vs. baseline). lian randomization supported a direct effect of insulin levels GWAS associ- During 2-hr mixed meal tolerance tests, fasting insulin (40 ± 6 vs. 22 ± 7 μU/ml; ated SNPs on the PDGFA hypomethylation. This hypothesis was confirmed p < 0.05) and insulin AUC were lower, and GLP-1 and PYY were higher, in Immortalized Human Hepatocytes (IHH) cells. Insulin hypomethylated and post-procedure. In the 4 T2DM, baseline HbA1c (7.8 ± 1.2%) decreased to stimulated the expression and secretion of PDGF-AA in a mechanism involving 6.0 ± 0.2%, 5.9 ± 0.2%, and 6.0 ± 0.1% at 6, 12, and 18 mos (p < 0.05), despite AKT. However, when IHH cells were chronically exposed to insulin, accumula- reduction or cessation of antidiabetic medications. All 3 pre-DM (baseline tion of PDGF-AA hampered insulin signaling, leading to altered glycogen pro- HbA1c = 6.1 ± 0.2%; FPG = 119 ± 2 mg/dl) converted to non-DM status at duction. The mechanism through which PDGF-AA altered the insulin signaling 6 mos (HbA1c = 5.2 ± 0.1%; FPG = 105 ± 3 mg/dl; p < 0.05), which was main- under chronic hyperinsulinemia involved PKCtheta and PKCEpsilon activities. tained at 18 mos (HbA1c = 5.2 ± 0.1%; FPG = 98 ± 4 mg/dl; p < 0.05). In conclusion, the epigenome analysis of liver of obese and diabetics indi- Conclusions: This endoscopic approach to creating a dual-path enteral viduals unveiled a deregulation in the PDGFA expression by insulin, which diversion resulted in 1) sustained weight loss over 18 mos in obese T2DM, ORALS may contribute to the development of fibrosis/NASH, and hepatocyte insu- pre-DM, and non-DM patients, 2) improvements in hormonal responses to a lin resistance in an autocrine viscious cycle fashion. These findings provide mixed-meal, 3) significant improvement in HbA1c and FPG in T2DM, and 4) novel biological mechanism that may open avenues to treat NAFLD associ- conversion of pre-DM to non-DM status. ated complications in T2D. Supported By: GI Windows, Inc. Supported By: Agence Nationale de la Recherche (ANR-10-LABX-46); ANR EQUIPEX Ligan MP (ANR-10-EQPX-07-01); European Research Council (GEPI- 322‑OR DIAB-294785) Superficial Subcutaneous Adipose Tissue Thickness, Mitochon- drial Efficiency, and Stearic-to-Palmitic Acid Ratio Are Decreased 320‑OR in Humans with Type 2 Diabetes Disruption of Circadian White Adipose Tissue Transcriptome and KÁLMÁN BÓDIS, JESPER LUNDBOM, TOMAS JELENIK, DANIEL MARKGRAF, Metabolic Consequences after Experimental Sleep Restriction in VOLKER BURKART, KARSTEN MÜSSIG, MICHAEL RODEN, JULIA SZENDROEDI, Humans Düsseldorf, Germany ELENA M. LEINEWEBER, BRITTA WILMS, HENDRIK LEHNERT, HENRIK OSTER, Whole abdominal subcutaneous adipose tissue (WSAT) is divided into SEBASTIAN SCHMID, Lübeck, Germany deep (DSAT) and superficial (SSAT) layers that may have different metabolic Background: Endogenous circadian clocks align physiology and behavior properties. In glucose-tolerant humans (CON), insulin sensitivity (IS) cor- with the 24 h day-night cycle. Chronodisruption promotes metabolic disor- relates positively with markers of lipogenesis such as stearic-to-palmitic ders and sleep loss has been proposed a key mediator. Here we report on the acid ratio (18:0/16:0) in SAT and negatively with abdominal DSAT/WSAT effects of acute sleep loss on circadian transcriptome regulation in white thickness. IS further correlates with muscle mitochondrial function. How- adipose tissue (WAT), glucose and lipid homeostasis. ever, SSAT/WSAT thickness, 18:0/16:0 and mitochondrial efficiency remain Methods: 15 healthy, normal weight men completed three 24 h condi- unknown in SSAT of patients with type 2 diabetes (T2D). We hypoth- tions in randomized balanced order with regular nocturnal 8 h sleep, 4 h esized that SSAT/WSAT, 18:0/16:0 and mitochondrial efficiency in SSAT

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A85 CONCEPTUAL ADVANCES IN INNATE IMMUNITY AND DIABETES

are decreased in male patients with T2D compared to CON. In 14 T2D compared to variation reported in 1000 Genomes database. We identified sev- and 14 CON matched for body mass index (BMI), age and WSAT thickness eral variants with a high population differentiation (FST) between Pima, Euro- (32±1 kg/m2, 53±2 yrs, 29±2 mm vs. 31±1 kg/m2, 53±2 yrs, 27±3 mm), we pean (CEU), Asian (CHB) and African (YRI). A cross-population composite likeli- assessed M-values by euglycemic-hyperinsulinemic clamps, SSAT and DSAT hood score (XPCLR) analysis showed higher XPCLR score in Pimas compared thickness by ultrasound imaging. In biopsies of SSAT and DSAT 18:0/16:0 to CEU and CHB, indicating positive selection. This observation was further was assessed by gas chromatography-mass spectrometry and maximal supported by longer linkage disequilibrium (250 kb) near MC4R in Pimas com- mitochondrial oxidative capacity and efficiency, i.e., respiratory control ratio pared to others. We estimated the extended haplotype homozygosity (EHH) (RCR=state 3/state 4), by high-resolution respirometry. T2D had 41% lower and integrated haplotype score (iHS), and observed that the derived C allele M-value and 33% lower SSAT/WSAT than CON (both p<0.001). In SSAT T2D at rs8092350 in Pimas uniquely captured a long-range haplotype and negative had lower 18:0/16:0 than CON (0.15±0.01 vs. 0.18±0.01, p<0.05). Compar- iHS score (-1.012), suggestive of recent positive selection. Association analysis ing both compartments 18:0/16:0 was lower in SSAT than in DSAT of T2D of rs8092350 in 5,840 longitudinally studied Pima Indians identified a mod- (0.15±0.01 vs. 0.17±0.01, p<0.01). While maximal oxidative capacity was est association with maximum BMI in a nondiabetic exam (B= 0.01; P=0.001 comparable in both layers, maximal oxidative capacity of SSAT correlated adjusted for age, birth year, sex, relatedness, first five principal components positively with M-value (r=0.80, p<0.001) in CON upon adjustment for age and genomic control), where the derived C allele predicted higher BMI. and BMI. RCR was 33% lower in SSAT of T2D compared to SSAT of CON In summary, our study supports the hypothesis that key genes for meta- (p<0.001). SSAT/WSAT and 18:0/16:0 did not relate to M-value. bolic disease, which in modern society are detrimental, may have provided In conclusion, SSAT represents a distinct abdominal SAT compartment a historical survival benefit. with reduced thickness, mitochondrial efficiency and stearic-to-palmitic acid ratio in T2D. Supported By: German Center for Diabetes Research CONCEPTUAL ADVANCES IN INNATE IMMUNITY AND DIABETES 323‑OR Race Affects the Association of Obesity Measures with Insulin 325‑OR Sensitivity Type 1 Interferons Create a Virulent Islet Microenvironment JEANNIE TAY, AMY M. GOSS, W. TIMOTHY GARVEY, BARBARA A. GOWER, BRITTNEY N. NEWBY, MANI ANNAMALAI, TODD M. BRUSKO, IVAN C. GERLING, Birmingham, AL CLAYTON E. MATHEWS, Gainesville, FL, Memphis, TN Background: Compared to Caucasian Americans (CA), African Americans During the progression to type 1 diabetes (T1D), signals within the pancre- (AA) have a disproportionate burden of insulin resistance and risk factors atic microenvironment determine the evolution of insulitis. We propose that that result in higher prevalence of T2D and CVD. Ethnic differences in body innate inflammatory mediators, such as type 1 interferons (T1-IFN: a signal composition and fat distribution may explain the differences in insulin sen- enriched in the pancreas of patients with T1D), promote pathogenesis. How- sitivity (SI). ever, the role for T1-IFN in regulating β cell death and dysfunction remains Objective: To determine if differences in conventional markers of obesity largely unexplored. Therefore, we examined the regulation of β cell function such as BMI, body composition and fat distribution explain the differences in by T1-IFN to define the mechanisms at play during the interplay ofβ cells, clamp-derived SI between AA and CA adults without diabetes. innate immune cells, and the adaptive T cell response. Methods: Peripheral SI was measured by hyperinsulinemic-euglycemic Exposure of primary islets (n=10 donors) and β cell lines to T1-IFN resulted clamps (insulin dose 120 mU/m2/min) in 61 adults (56% African Americans, in 2-fold upregulation of Class I HLA transcript and surface protein. Further 36% males, age 29 ± 8 yrs, BMI 27.6 ± 5.9) without T2D. Subcutaneous characterization revealed increased expression of immunoproteasome sub- abdominal adipose tissue (SAAT), intra- abdominal adipose tissue (IAAT) and units and antigen processing machinery, including TAP1, TAP2, TAPBP, and intrahepatic fat (HF) were determined by MRI. Total lean mass (LM), fat mass ERAP. Moreover, IFNα and IFNβ priming of β cells resulted in a 54% and (FM) and leg fat (LF) were quantified by DXA. 80% increase β cell lysis by IGRP-specific CD8+ T cells, respectively. Ergo, Results: AA had 33% lower SI after adjustment for various obesity mea- T1-IFN enhance autoimmune surveillance by CTL through global regulation sures, and higher SAAT and LF than CA (P<0.05). In multiple regression analy- of antigen processing and presentation. 2 ses that included gender, age and LM as covariates, race x BMI (R 44%), Human islet preparations (n=25) cultured in the presence of IFNα (1000U/ 2 2 2 race x FM (R 56%), race x SAAT (R 51%), race x LF (R 36%) and race x HF mL) or IFNβ (50U/mL) for 72 hr displayed a 2-fold decline in glucose-stim- (R2 41%, P<0.02 for all) were significant. Race x IAAT was not significant ulated insulin secretion (GSIS). Next, we examined metabolic pathways (P=0.50). Higher BMI, FM, SAAT, LF and HF were significantly associated responsible for coordinating insulin secretion in β cells by transcriptome with lower SI in CA. In contrast, associations between SI and these adipose analysis. Here, we detected decreased expression in the adenine nucleotide measures in AA were weaker and did not reach statistical significance. In translocases (ANT), responsible for regulating mitochondrial ATP export dur- race-specific models, LM was identified as an independent positive predic- ing GSIS. Decreased ANT2 and ANT3 were confirmed in islets from recent 2 tor, and SAAT and HF as negative predictors, of SI in CA (R 73%, P≤0.03). onset T1D cases (n=6) compared to age matched controls (n=18). A strong In contrast, low SI was associated with low LF (p=0.08), and high SAAT IFNα signature was present in T1D islets (significantly elevated expression (p=0.04) and LBM (p=0.06) in AA (R2 41%). of STAT1, IRF9, ISG15, OAS1, and IFIH1). ORALS Conclusions: Conventional measures of obesity and regional adiposity are In sum, T1-IFN enhances the pathogenic nature of islets by enhancing strong determinants of clamp-derived SI in CA but not AA. These findings autoantigen presentation causing β cell destruction and promoting β cell suggest that the etiology of T2D may differ between races and underscore dysfunction prior to onset of human T1D. the importance of considering ethnicity when evaluating risk for T2D. Supported By: National Institutes of Health (UC4DK104155-01, F30DK105788- Supported By: National Institutes of Health/National Institute of Diabetes and 01A1, P01A1042288, R01DK074656) Digestive and Kidney Diseases (R01DK096388); Nutrition Obesity Research Center (P30DK56336); Diabetes Research Center (P60DK079626) 326‑OR NOX-Derived Superoxide Drives Macrophage Antiviral Responses 324‑OR during CB3 Infection to Trigger Type 1 Diabetes Evidence of Positive Selection for a Variant Near the Melanocortin 4 ASHLEY R. BURG, RUTH E. MCDOWELL, SHAONLI DAS, LINDSEY E. PADGETT, Receptor Gene in Pima Indians from Southwestern Arizona HUBERT M. TSE, Birmingham, AL PANKAJ KUMAR, YUNHUA L. MULLER, LESLIE J. BAIER, Phoenix, AZ Coxsackie B3 virus (CB3) infections are pancreas-tropic and highly sus- The prevalence of obesity varies by ethnicity, and susceptibility alleles have pected to trigger type 1 diabetes (T1D). However, it is currently unknown been enriched in some populations due to positive selection during periods whether this triggering event occurs due to direct β-cell damage and/or of famine. One of the best characterized genes for obesity is Melanocortin induction of inflammatory anti-viral immune responses. We recently dem- 4 Receptor (MC4R), where rare missense variants cause monogenic obesity. onstrated that Nonobese diabetic (NOD) mice lacking NADPH-oxidase Recently, genome-wide association studies identified non-coding variations (NOX)-derived superoxide (NOD.Ncf1m1J) were significantly protected near MC4R with modest effects on BMI. Previously, we reported that Pima against spontaneous T1D onset, partly due to dampened inflammatory M1 Indians, who suffer from a high prevalence of obesity, have both missense macrophage responses. We hypothesize that the absence of NOX-derived and common non-coding variants that contribute to obesity. Here, we analyze superoxide will decrease NOD.Ncf1m1J macrophage anti-viral responses MC4R for evidence of positive selection. Variation detected from Pima Indian and delay viral-induced T1D. CB3-infected NOD mice displayed accelerated whole genome sequence data across a 2Mb region encompassing MC4R was onset of T1D, while NOD.Ncf1m1J mice remained protected. Surprisingly, viral

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A86 CONCEPTUAL ADVANCES IN INNATE IMMUNITY AND DIABETES clearance was not compromised, despite significant decreases in circulating attack. Similar to the clinical studies, ATG treatment of AI4 mice did not inflammatory chemokines, CXCL10 and CCL5 (p<0.05). Pancreatic anti-viral deplete CD8+ T cells. Analysis of AI4 peripheral blood cells failed to provide mRNA accumulation of Stat1 (p=0.0012), Tnf (p=0.0472), Ifnb1 (p=0.0104), evidence for ATG-induced changes in frequency of naïve (CD44midCD62L+), and Isg15 (p=0.0041) was dampened, which corresponded to significantly effector (CD62L-CD44mid), or regulatory (CD25+FoxP3+) CD8+ T cells. Adop- reduced TNF-α production (p<0.05) by pancreas-infiltrating NOD.Ncf1m1J tive transfer of splenocytes from ATG or IgG treated AI4 mice resulted in T1D macrophages. In vitro, CB3-infected macrophages displayed decreased pro- onset in NOD recipients, demonstrating that therapeutic effects of ATG on duction of TNF-α, IFN-β, CXCL10 and CCL5 (all p<0.0001). Mechanistic stud- autoreactive CD8+ T cells do not persist in an environment that has not been ies revealed significantly reduced STAT1 phosphorylation by immunofluores- conditioned by ATG. These data suggest that ATG mediated T1D protection cence (p<0.0001), indicating decreased IFN signaling and inflammatory M1 can be independent of adaptive regulatory cells and require shifts in innate macrophage differentiation, which was rescued with the addition of exog- cell populations to restrain autoreactive T cells. enous free radical donors, in CB3-infected NOD. Ncf1m1J macrophages. We Supported By: American Diabetes Association (1-15-TS-22 to C.E.M.) conclude that NOX-derived superoxide exacerbates inflammatory anti-viral responses by NOD macrophages upon CB3 infection to trigger T1D. Future 329‑OR studies will define how NOX-derived superoxide promotes CB3-induced PAHSAs Reduce Type 1 Diabetes Incidence in Nonobese Diabetic bystander activation of autoreactive T cells and determine if human mono- (NOD) Mice through Anti-inflammatory Effects and Direct Protec- cyte anti-viral responses are influenced by redox status. tion against Cytokine-Induced Islet Beta-Cell Death Supported By: American Diabetes Association (7-12-CD-11 to H.M.T.); National ISMAIL SYED, JAMES F. MOHAN, PEDRO M. MORAES-VIERIA, ARCHANA Institutes of Health/National Institute of Diabetes and Digestive and Kidney Dis- VIJAYAKUMAR, MARIA F. RUBIN DE CELIS, ANDREW T. NELSON, DIONICIO SIE- eases (R01DK099550) GEL, ALAN SAGHATELIAN, DIANE J. MATHIS, BARBARA B. KAHN, Boston, MA, La Jolla, CA 327‑OR We recently discovered a novel class of endogenous lipids with anti- Prevention of Type 1 Diabetes Onset through Modulation of Macro- diabetic and anti-inflammatory effects, branchedP almitic Acid esters of phage Polarization Hydroxy Stearic Acids (PAHSAs). We aimed to determine whether PAHSAs XIANGWEI XIAO, GEORGE K. GITTES, Pittsburgh, PA protect against development of type 1 diabetes (T1D) by reducing inflam- Type 1 diabetes (T1D) affects many children worldwide. T1D is charac- mation and/or promoting β-cell survival. Daily oral administration of 5- and terized by a pathogenic, significantly reducedβ -cell mass, resulting from 9-PAHSA in NOD mice raised serum 5- and 9-PAHSA levels 4-5 fold. PAHSA T-cell mediated autoimmune destruction of the pancreatic β-cells. Previous treatment starting at 4 wks of age delayed T1D onset and reduced cumu- studies suggest that macrophages and their polarization may play a critical lative T1D incidence from 82% in vehicle-treated mice to 35% in PAHSA- role in diabetes onset, likely through both immunomodulation and regulation treated mice. Starting PAHSAs at 13 wks of age also reduced cumulative of β-cell proliferation. However, a clinically translatable approach to con- diabetes incidence to 40% vs. 90% in vehicle-treated mice. PAHSA treat- trol macrophage polarization in vivo is lacking. Recent reports showed that ment increased serum insulin levels (vehicle 0.9±0.06 vs. PAHSA 1.2±0.03 TNF-alpha-induced protein 8-like 2 (TIPE2) had the potential to trigger M2 ng/mL). PAHSAs had a subtle effect on the frequency (no infiltration: Vehicle macrophage polarization to affect the pathogenesis of several autoimmune 50±6 vs. PAHSA 65±5% of islets) and overall severity of insulitis (destructive diseases, but any effect in T1D remains unknown. Here we report a strong insulitis: Vehicle 23±5 vs. PAHSA 13±2%). Flow cytometric analysis revealed relationship between macrophage polarization and diabetes onset in NOD that leukocytic infiltration was reduced by 50%, with a concomitant reduc- mice (a mouse model for T1D). Moreover, expression of TIPE2 induced mac- tion in acute T cell activation, measured by CD69 expression, in pancreata of rophage polarization towards the M2 subtype in vitro. Using an intrapan- PAHSA-treated mice. PAHSA treatment did not alter the % of Foxp3+ CD4+ creatic duct infusion model, we delivered an adeno-associated virus (AAV) T cells (Tregs) but increased Foxp3 protein levels in pancreatic Tregs. In MIN6 serotype 6 carrying TIPE2 under a macrophage-specific CD68 promoter into β-cells, both 5- and 9-PAHSA attenuated Cytomix (IL1β, TNFβ and IFNγ)- the NOD mouse pancreas, which significantly delayed the diabetes onset induced apoptotic and necrotic β-cell death and increased β-cell viability. in these mice. Further analyses showed that expression of TIPE2 in mac- Both 5- and 9-PAHSA enhanced BrdU incorporation in MIN6 cells and aug- rophages induced M2 polarization in the NOD mouse pancreas, which pre- mented glucose-stimulated insulin secretion during Cytomix insult. These vented the onset of diabetes, seemingly through augmentation of β-cell pro- data indicate that PAHSAs enhance β-cell proliferation and increase β-cell liferation and increases in Foxp3+ regulatory T lymphocytes. Together, our viability during inflammatory cytokine stress. data suggest that diabetes onset in NOD mice might be significantly delayed Sum/Conclusion: Chronic PAHSA treatment delays T1D onset and reduces through induced macrophage polarization, which could lead to development its incidence in NOD mice by attenuating islet inflammation and exerting of a clinically translatable method to delay or prevent T1D onset in humans. direct protective effects on β-cell survival and function. Supported By: National Institute of Diabetes and Digestive and Kidney Diseases Supported By: Jeffry M. and Barbara Picower Foundation; National Institutes (DK098196) of Health

328‑OR 330‑OR

Mechanisms of Type 1 Diabetes Prevention by Antithymocyte Myeloid Sirtuin 6 Deficiency Causes Insulin Resistance in High-Fat ORALS Globulin Diet-Fed Mice by Eliciting Macrophage Polarization toward an M1 ANDREA LIN, AMANDA POSGAI, ANNA V. CHERNATYNSKAYA, MADISON Phenotype HULL, TODD M. BRUSKO, MARK A. ATKINSON, MICHAEL J. HALLER, CLAYTON YOUNGYI LEE, SO YOUNG PARK, EUN JU BAE, BYUNG HYUN PARK, Jeonju, E. MATHEWS, Gainesville, FL Republic of Korea, Daegu, Republic of Korea, Wanju, Republic of Korea The clinical trial using low dose ATG + granulocyte colony stimulating Obesity-related insulin resistance is closely associated with macro- factor (GCSF) to reverse T1D has shown efficacy in stabilizing and even phage accumulation and subsequent cytokine release in local tissues. Sir- increasing β cell function in patients with long-standing disease. Changes tuin (Sirt) 6 is known to exert an anti-inflammatory function but its role in in CD4+ T cells, natural killer cells (NK cells), and neutrophils imply that macrophages in the context of obesity has not been investigated. Here, we immunomodulation of both innate and adaptive cellular subsets are asso- generated myeloid-specific Sirt6 knockout mice (mS6KO) and investigated ciated with C-peptide preservation. Notably, CD8+ T cells persist despite the metabolic characteristics after high-fat diet (HFD) feeding for 16 weeks. their putative pathogenic role in β cell destruction. Recent clinical efforts Compared with their wild type littermates, HFD-fed mS6KO mice exhibited identified ATG+GCSF super-responders, a subset of patients who maintained greater increases in body weight, fasting blood glucose- and insulin-levels, C-peptide production above baseline levels up to 24 months and had the hepatic steatosis, glucose intolerance, and insulin resistance. Gene expres- highest percentage of CD8+ T cells, even after 2 years. In preclinical models, sion, histology, and flow cytometric analyses demonstrated that liver- and ATG both prevents and reverses T1D. To understand how ATG affects CD8+ adipose tissue-inflammation were elevated in HFD-fed mS6KO mice relative T cells, we utilized an accelerated T1D model, the NOD AI4 T cell receptor to wild type with a greater accumulation of F4/80+CD11b +CD11C + adipose transgenic mouse (AI4) with a monoclonal T cell repertoire of MHC class I tissue macrophages. Myeloid Sirt6 deletion facilitated proinflammatory restricted insulin-autoreactive CD8+ T cells. ATG treatment of 3 wk old AI4 M1 polarization of bone marrow macrophages and augmented the migra- mice resulted in complete protection from T1D onset (n=16). Conversely, 97% tion potential of macrophages toward adipose-derived chemoattractants. of control IgG treated (n=20) and 100% of untreated (n=20) AI4 mice develop Mechanistically, Sirt6 deletion in macrophages promoted the activation of T1D by 6 wks of age (p<0.001). ATG treatment reduced insulitis compared NF-κB and endogenous production of IL-6, which led to STAT3 activation and to IgG treatment reflecting the effectiveness of ATG at the site of immune the positive feedback circuits for NF-κB stimulation; this crosstalk expedited

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A87 INFLAMMATION, IMMUNITY, AND METABOLISM

an M1 polarization. We conclude that Sirt6 in macrophages is required for INFLAMMATION, IMMUNITY, AND METABOLISM the prevention of the development of obesity-associated tissue inflamma- tion and insulin resistance. 333‑OR Partial Depletion of CD206+ Cells Enhances Adipocyte Differentia- 331‑OR tion and Improves Glucose Metabolism through TGFβ Signaling Suppression of Ghrelin Receptor in Myeloid Cells Inhibits Inflam- ALLAH NAWAZ, TOMONOBU KADO, SHIHO FUJISAKA, AKIKO TAKIKAWA, mation, Attenuates Obesity, and Enhances Insulin Sensitivity TAKASHI NAKAGAWA, SAEKI KUMIKO, ISAO USUI, KAZUYUKI TOBE, Toyama, CHIA SHAN WU, JONG HAN LEE, GEETALI PRADHAN, QUN ZANG, YUXIANG Japan, Tokyo, Japan SUN, College Station, TX, Houston, TX, Dallas, TX Adipose tissue-resident macrophages (ATMs) comprise 10-15% of stromal Chronic low-grade inflammation is a hallmark of obesity, which is asso- cells. They express the canonical markers of alternatively activated macro- ciated with metabolic dysfunction and insulin resistance. Gut hormone phages such as CD206, and thus are referred to M2 or M2-like macrophages. ghrelin promotes food intake, adiposity and insulin resistance. To date the Several lines of evidence suggested that they were involved in maintaining only identified ghrelin receptor is Growth Hormone Secretagogue Recep- insulin sensitivity in adipocytes. Although much has been known about the tor (GHS-R). Although ghrelin has been suggested to have anti-inflammatory role of M1 macrophages in inflammatory process during obesity, which con- property, the role of ghrelin signaling in inflammation in vivo remains unclear. tributes to the development of insulin resistance, it is largely unknown how Our recent study showed that GHS-R antagonist decreases expression of M2-like ATM contributes to normal adipocyte functions. We established pro-inflammatory cytokines in macrophages in vitro. To determine the direct conditional cell-ablation system based on the transgenic expression of diph- effect of GHS-R in macrophages, we generated myeloid-specific GHS-R theria toxin receptor (DTR) under the control of the CD206 (+) promoter to knockout mice and studied them under chronic and acute inflammatory con- specifically ablate CD206+ cells. Partial depletion of CD206+ cells did not ditions of diet-induced obesity (DIO) and endotoxin lipopolysaccharides (LPS) affect body weight and food intake. Glucose tolerance and insulin sensitivity treatment, respectively. Suppression of GHS-R in myeloid cells attenuated were improved in CD206+ cells ablated mice, which was associated with DIO and DIO-induced insulin resistance, as well as mitigated LPS-induced increased number of smaller adipocytes and upregulation of favorable meta- inflammation. Under DIO, we found lipid utilization in white adipose tissue bolic genes. Additionally, we show that adipogenesis related marker genes was increased and hepatic de novo lipogenesis in the liver was decreased and mesenchymyl stem cell marker genes were upregualted in CD206+ cells in myeloid-specific GHS-R knockout mice. Under LPS treatment, we found ablated mice. Flow cytometry, IHC and gene expression analysis revealed significant reduction of pro-inflammatory cytokines in the blood circula- that adipocyte progenitors (APs) were increased in CD206+ cells ablated tion, and substantial decrease of pro-inflammatory gene expression in liver, mice. In vivo and in vitro study revealed that TGFβ abundantly expressed in fat and skeletal muscle of the knockout mice. Thus, suppression of GHS-R CD206+ cells, thus regulating APs differentiation and proliferation. in myeloid-cells decreases inflammatory responses in both diet-induced In conclusion, CD206+ cells in adipose tissues are involved in regulating chronic inflammation and LPS-induced acute inflammation, prompting a the proliferation and differentiation of APs through TGFβ signaling to adjust healthier lean and insulin sensitive state. Our findings indicate that mac- adiposity and insulin sensitivity throughout the whole body. rophage GHS-R has profound effects on both lipid metabolism and inflam- Supported By: MSD Japan Inc.; Boehringer Ingelheim; Takeda Pharmaceutical mation, and serves as a critical molecular link that mediates the cross-talks Company Limited; Sanofi; Fuji Chemical Industries Co., Ltd.; Kyowa Hakko Kirin Co., between immunity, lipid metabolism, and insulin sensitivity. Ltd.; Pfizer Japan Inc.; Astellas Pharma Inc.; Mitsubishi Tanabe Pharma Corporation; Supported By: American Diabetes Association (1-15-BS-177 to Y.S.); American AstraZeneca Heart Association (12IRG9230004, 14GRNT18990019); U.S. Department of Agricul- ture (3092-5-001-059); U.S. Department of Agriculture/National Institute of Food 334‑OR and Agriculture (1010840) Adipocyte Specific Deletion of Integrin-Linked Kinase Regulates Lipid and Glucose Homeostasis in High-Fat Diet-Fed C57BL/6 Mice 332‑OR AIMÉE-ROSE BUGLER-LAMB, CHANDANI HENNAYAKE, ASHLEY GAMMACK, Macrophage-Mediated Lysine Methyltransferase, Setdb2, Regu- CLAIRE SNEDDON, LI KANG, Dundee, United Kingdom lates Inflammation in Diabetic Wound Healing ILK (integrin-linked kinase) as an adaptor protein, is a key component of ANDREW S. KIMBALL, AMRITA JOSHI, RON ALLEN, MATTHEW SCHALLER, the IPP (ILK-Parvin-PINCH) complex which associates with the β-subunit of WILLIAM F. CARSON, IV, JENNIFER BERMICK, ANNA BONIAKOWSKI, PETER K. integrin, linking the extracellular matrix (ECM) with intracellular signalling. HENKE, STEVEN KUNKEL, KATHERINE GALLAGHER, Ann Arbor, MI Deletion of ILK in muscle or liver, respectively decreases insulin resistance Dysregulated inflammation results in non-healing wounds in type 2 dia- in high fat diet (HFD)-fed mice. HFD-induced insulin resistance and obesity betes (T2D) and is the leading cause of amputation in the United States. is tightly associated with adipose tissue (AT) remodelling and inflammation. Our recent work has demonstrated that an increased inflammatory phe- We hypothesize that adipocyte-specific deletion of ILK diminishes insulin notype from infiltrating wound monocyte/macrophages contributes to the resistance in HFD-fed mice via regulating lipid and glucose homeostasis and pathology of delayed wound healing in T2D. Since epigenetic alterations inflammation. ILK was knocked out (KO) in AT using Cre transgenic mice under in monocyte/macrophages can alter inflammatory gene expression, and an adiponectin promoter. Both wild type (WT) and KO mice were fed with

ORALS hence, immune cell phenotype; we sought to assess the role of the his- 60% HFD for 16 weeks. Body weight, water and food intake, energy expendi- tone methyltransferase, Setdb2, in the regulation of macrophage-mediated ture, respiratory exchange ratio and physical activity did not differ between inflammation in both normal and diabetic wound healing. Here we show WT and KO mice. The KO mice had decreased percent fat mass (21.6±1.6% that Setdb2 is induced in monocyte/macrophages during the inflammatory vs. 27.3±1.4%; p=0.01) and increased percent lean mass (73.4±1.7% vs. phase of normal wound healing. Increased expression of Setdb2 results in 67.8±1.6%; p=0.02) than WT mice. Glucose tolerance was improved in the repressed expression of the NF-κB-induced inflammatory mediators, includ- KO mice (2412±142 Area under the curve (AUC)) than WT mice (2921±70 AUC; ing IL-1β and TNFα, via Histone 3 Lysine 9 trimethylation (H3K9me3) at the p=0.003). In AT, the KO mice displayed a trend of decrease in expression of inflammatory gene promoters. Mice with the inability to upregulate Setdb2 both anti- and pro-inflammatory genes including Arg-1, TNFα, IL-1β, IL-6, and in their macrophages (Setdb2f/fLyz2cre+) demonstrated impaired wound heal- collagen 24α with a significant decrease in IL-10 (p=0.02), whilst a trend of ing that corresponds with decreased H3K9me3 and increased inflammatory increase in adipogenic genes including PPARγ and CEBPα with a significant gene expression. Interestingly, in our murine model of T2D (Diet induced increase in fatty acid synthase (p=0.006) than WT mice. obese (DIO)), mice demonstrate decreased levels of Setdb2 in macrophages, In summary, we show that AT-specific ILK deletion in HFD-fed mice resulting in decreased repressive H3K9me3 at the promoters of the NF-κB- increases lean mass, decreases fat mass and improves glucose tolerance induced inflammatory genes, and hence, increased inflammatory mediator possibly via regulating inflammation-associated and adipogenic genes. expression. Next we demonstrate that wound macrophage Setdb2 expres- These results further suggest a pivotal role of the ECM-integrin-ILK pathway sion is regulated by the IFNβ-JAK/STAT pathway and levels of IFNβ are sig- in AT in adipogenesis and inflammation, which could contribute to obesity- nificantly decreased in the wounds of DIO mice. Finally, decreased Setdb2 associated insulin resistance and may represent as a therapeutic target. was also found in human T2D wounds compared to non-T2D control wounds. Supported By: European Commission; Tenovus Scotland; Diabetes UK; Diabetes In conclusion, Setdb2 represents an important inflammatory regulator in Research and Wellness Foundation; University of Dundee the late inflammatory phase of wound healing and novel therapies designed to target this pathway may promote resolution of chronic inflammation in diabetic wounds. Supported By: National Institutes of Health (DK102357, T32HL076123)

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A88 INFLAMMATION, IMMUNITY, AND METABOLISM

335‑OR with high fat diet (HFD) and during aging. HFD feeding increases CRTC1 pro- A Novel AMPK-mTOR-KLF2-NFkB Axis Accounts for AMPK Sup- tein and mRNA in WAT. Compared to wild type, CRTC1 KO mice subject to pression of Inflammation HFD or aging stresses exhibited decreased epididymal WAT (HFD: 8.01±0.41 JU HO YOUN, GIULIO ROMEO, JIA YOU, JONGSOON LEE, STEVEN E. SHOELSON, vs. 4.15±0.24% total body weight, P<0.001; aging: 5.90±0.18 vs. 3.50±0.37% Boston, MA body weight, P<0.01), hyperglycemia (HFD: 220±11 vs. 313±18 mg/dL, In addition to well-known metabolic effects, in vivo AMPK activation is P<0.001; aging: 158±7 vs. 202±5 mg/dL, P<0.01), increased hepatic triglycer- intrinsically anti-inflammatory. This has been shown for AMPK agonists ides (aging: 3.40±0.45 vs. 10.8±1.5 mg/g liver, P<0.05), and glucose intoler- including AICAR, metformin and A769662, and is underscored by salicylate, ance (aging: 36±5% increase in AUC IPGTT, P<0.01). CRTC1 KO increased an anti-inflammatory drug that also binds and activates AMPK. We found the macrophage infiltration into the WAT of HFD fed mice and elevated plasma anti-inflammatory actions of AMPK activation to be most prominent in cells TNFα levels of aging mice (9.3±1.9 vs. 41.8±5.3 pg/mL, P<0.01). Expression of the immune system. In macrophages, AMPK agonists function through of adipogenesis regulator PPARγ was inhibited in WAT of HFD-fed CRTC1 KO Tsc1/2 and Rheb signaling to inhibit mTOR and NFkB. Both gain and loss of mice by 66±5% (P<0.001), denoting a possible defect in adipocyte differen- function studies show signaling through this canonical path to be required tiation. Adenoviral shRNA against CRTC1 in 3T3-L1 adipocytes decreased for NFkB inhibition. These include use of cells lacking AMPK or Tsc1/2 activ- mRNA of differentiation markers PPARγ, GLUT4 and PGC-1 α by 96±3% ity, which potently activates mTOR and NFkB, and knockdown of Rheb or (P=0.056), 78±16% (P<0.05), and 99±1% (P<0.05) respectively; increased raptor or inhibitors of mTOR (Torin, INK128), which inhibit mTOR and NFkB lipolysis by 101±18% (P<0.01), and decreased glucose uptake by 23±3% in parallel. However, mTOR does not phosphorylate or otherwise regulate (P<0.01). These data suggest that in WAT, CRTC1 is crucial for sustaining NFkB directly. Instead we found that the transcription factor KLF2 links triglyceride storage and glucose uptake, and protects against hepatic ste- AMPK mediated inhibition of mTOR to NFkB. KLF2 activity increases with atosis and inflammation. Further study of CRTC1 action in WAT will expand AMPK activation and mTOR inhibition (both required for NFkB inhibition), and our understanding of adipocyte function and provide insight into metabolic KLF2 activity is suppressed when AMPK activity is low or absent, which diseases such as T2D. activates NFkB. ChIP-seq results showed that KLF2 binding adjacent to kB Supported By: 5R37DK083834-29 (to M.R.M.) binding sites in proinflammatory cytokine genes (Tnfa, Il1b, Il6) parallels AMPK activation. Conversely, ChIP studies with NFkB p65 show its occu- 338‑OR pancy of these promoters decreases with AMPK activation. KLF2 and p65 Mammary Tumors Cause Insulin Resistance by Expressing IL-6 in thus compete for binding to adjacent sites of the same cytokine gene pro- Female MMTV-PyMT Mice moters. NFkB promoter binding drives cytokine production, whereas KLF2 HYE LIM NOH, HEE JOON KANG, SUCHAORN SAENGNIPANTHKUL, JOSE MER- binding suppresses expression. These results identify a major site for cross- CADO-MATOS, RANDALL H. FRIEDLINE, KUNIKAZU INASHIMA, NICHOLAS K. talk between metabolism and inflammation. AMPK activation is intrinsically ACOSTA, STEPHANIE CHOI, ALYSSA H. KIM, XIAODI HU, KAREN KELLY, LESLIE anti-inflammatory through its activation of KLF2, which competes with NFkB M. SHAW, JASON K. KIM, Worcester, MA p65 at relevant promoter sites to suppress the production of inflammatory Increasing evidence suggests a potential link between cancer and diabe- mediators. These findings have direct clinical relevance given the potential tes. Female MMTV-PyMT mice, a breast cancer model expressing the poly- use of AMPK agonists in treating T2D. oma middle T antigen driven by the Mouse Mammary Tumor Virus promoter, Supported By: American Diabetes Association (1-12-CT-71 to S.E.S.); National develop insulin resistance with significantly reduced whole body glucose Institutes of Health (R01HL133329) turnover compared to WT mice (n=6/group) (Figure 1; *P<0.05). RT-qPCR analysis showed that quadriceps (QD) muscle mRNA levels of CD68, MCP-1, 336‑OR and IL-6 were significantly increased by 2~4 fold in PyMT mice as compared SREBP-1a Deficiency Reduces Phagocytosis via mTOR Signaling in to WT mice (n=5/group), suggesting enhanced muscle inflammation (Figure Macrophages 2; *P<0.05). Strikingly, mammary tumor mRNA expression of CD68, MCP- SEUNG SOON IM, TIMOTHY F. OSBORNE, Daegu, Republic of Korea, Orlando, FL 1, and IL-6 was 6~9 fold higher than in WT-QD, indicating highly inflamma- Sterol response element binding protein (SREBP)-1a is a key transcrip- tory state of tumors. Since IL-6 is an inflammatory cytokine that modulates tional regulator of lipogenesis and cell growth and its’ properly regulated glucose metabolism, we treated female PyMT mice with anti-IL-6 antibody activity is key to cellular lipid homeostasis. Macrophages are highly special- (or IgG) for 24 hrs and conducted a 2-hr hyperinsulinemic-euglycemic clamp ized cells with major functions in the innate immune system. They are critical (n=5~6/group). After anti-IL-6 Ab treatment, whole body glucose turnover accessory cells that are important in the defense against invading patho- and glycolysis tended to increase in PyMT mice as compared to IgG Ab con- gens and are also strongly implicated in the development of atherosclerotic trols (Figures 3 and 4). lesions. In a recent report, it was hypothesized that phagocytes replenish In conclusion, these results indicate that IL-6 secreted by mammary membranes expended during particle engulfment in a rapid phase of lipid tumors causes insulin resistance in PyMT mice by inducing muscle inflam- synthesis. Phagocytosis triggered the proteolytic activation of two lipogenic mation, and this is partially reversed by anti-IL-6 Ab treatment. Thus, our transcription factors, SREBP-1a and SREBP-2. However, a functional role for findings identify a novel paradigm by which oncogene-derived tumors may SREBP-1a in macrophages has not been addressed. In this study, we estab- cause insulin resistance and type 2 diabetes. lished a line of mouse that resulted in a greater than 95% knockdown in Figures. ORALS SREBP-1a mRNA in every tissue examined using a β-geo “gene trap” system. And phagocytosis assay was performed using opsonized targets of sheep red blood cells. We show that macrophages from these SREBP-1a deficient (1aDF) mice exhibit a significant decrease in phagocytosis of sheep red blood cells as compared to macrophages isolated from wild type control mice. Rapamycin, an mTOR inhibitor, reduced phagocytosis through decrease of SREBP-1 in macrophages. These observations indicate that SREBP-1a may play a key role in phagocytosis as an innate immune defense mechanism of macrophages through mTOR signaling.

337‑OR CRTC1 Maintains Metabolic Homeostasis by Regulating Triglyceride Storage, Lipolysis, and Inflammatory Signaling in Adipose Tissue ANILA K. MADIRAJU, SHIGENOBU MATSUMURA, MELISSA TRAN, MARC R. MONTMINY, La Jolla, CA, Kyoto, Japan Ectopic fat in liver and muscle, and impaired adipose expansion, have been shown to cause insulin resistance leading to type 2 diabetes (T2D). Recently, SNPs in the human gene locus for CREB Regulated Transcription Coactivator 1 (CRTC1) were associated with decreased adiposity. CRTC1 is thought to be expressed primarily in hypothalamic neurons where it regu- lates satiety in response to cAMP and Ca2+ signals. Here, we demonstrate Supported By: National Institutes of Health (2U2CDK093000-06) a previously unidentified role for CRTC1 in the normal expansion of adipose

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A89 HEPATIC LIPID AND GLUCOSE METABOLISM

339‑OR possibly antigenic, in SAT as a result of weight gain. Characterization of SAT Mice with Selective Deletion of IFNgamma Receptor in Myeloid antigens may ultimately lead to targeted immunotherapy for diabetes. Cells Are Protected from Diet-Induced Insulin Resistance and Figure. Inflammation in Liver RANDALL H. FRIEDLINE, HYE LIM NOH, KUNIKAZU INASHIMA, STEPHANIE CHOI, ROSEMARY CARTER, ANDY YEE, XIAODI HU, KAREN KELLY, DUY A. TRAN, PEREN COSKUN, WERNER MULLER, JASON K. KIM, Worcester, MA, Manchester, United Kingdom Inflammation plays a major role in insulin resistance, and IFNγ levels are elevated in obese subjects. We have generated mice with myeloid cell-spe- cific ablation of IFNγ receptor by crossing LysM-Cre mice with IFNγR2-floxed mice (Lyz-IFNγR KO). Here we conducted a 2-hr hyperinsulinemic-euglycemic clamp in awake male KO and Lyz-IFNγR heterozygous mice (as controls) after 12 wks of high-fat diet (HFD) (n=8/group). Both groups of HFD-fed mice became obese with fat mass accounting for ~30% of their body weights (~36g). During the clamp, glucose infusion rates tended to be higher in KO mice compared to controls (Figure 1). Basal hepatic glucose production (HGP) did not differ, but insulin-suppressed HGP during clamp was significantly reduced in KO mice (Figure 2; *P<0.05). As a result, hepatic insulin action was increased by 2-fold in KO mice (72±9% vs. 37±8% suppression of HGP in controls; P=0.012). We measured liver cytokine levels and found significant decreases in IL-1β, IL-7, IL-15, and M-CSF in KO mice (Figure 3). Hepatic levels of IL-3, IL-5, IL-17, and TNF-α were also reduced in KO mice. In conclusion, these results indicate that selective loss of IFNγ signaling Supported By: American Diabetes Association (1-14-TS-28 to T.M.) in myeloid cells prevents diet-induced insulin resistance and inflammation in liver, suggesting a role of IFNγ in nonalcoholic steatohepatitis and type 2 diabetes. HEPATIC LIPID AND GLUCOSE METABOLISM Figures. 341‑OR Loss of Adaptation of Hepatic Oxidative Capacity in Patients with Type 2 Diabetes and Nonalcoholic Steatohepatitis (NASH) SOFIYA GANCHEVA, CHRYSI KOLIAKI, TOMAS JELENIK, JULIA SZENDROEDI, DANIEL MARKGRAF, HENRY MAYRINGER, IRENE ESPOSITO, MATTHIAS SCHLENSAK, MICHAEL RODEN, Düsseldorf, Germany, Athens, Greece In patients with type 2 diabetes, steatohepatitis (NASH) increases the risk of further complications such as cirrhosis and hepatocellular carcinoma. Obese humans without NASH exhibit markedly upregulated hepatic mito- chondrial capacity, which may be lost with the progression of liver disease. However, the role of type 2 diabetes for hepatic mitochondrial function in NASH remains unclear. To this end, we studied patients with histologically proven NASH and with (T2D; n=8, age 48±6 years, body mass index 54.0±6.8 kg/m2) or without type 2 diabetes (NDM; n=8, 42±12 years, 52.6±8.3 kg/m2) as well as in nondiabetic humans without liver disease (CON; n=12, 41±3 years, 25.5±0.7 kg/m2). Insulin sensitivity was measured by euglycemic- 2 hyperinsulinemic clamps with [6,6- H2]glucose. High-resolution respirometry served to quantify maximal coupled and uncoupled mitochondrial respiration in liver biopsies obtained during surgery, Amplex Red to assess hepatic H2O2 emission. T2D exhibited good glycemic control but higher HbA1c than the nondiabetic groups (T2D 7.1±1.1%, NDM 5.3±0.2%, CON 5.1±0.3%). They had Supported By: National Institutes of Health (2U2CDK093000-06) similar liver fat content and NAFLD score compared with NDM. T2D had lower hepatic insulin sensitivity than NDM and CON. Hepatic mitochondrial

ORALS 340‑OR oxidative capacity was 31% higher in NDM than CON, while T2D presented T-Cells in Human Subcutaneous Adipose Tissue with 44% lower respiration rates than NDM. Hepatic H2O2 production was TRACEY MCLAUGHLIN, LI FEN LIU, COLLEEN CRAIG, DALIA PERELMAN, OKMI comparable between T2D and NDM. Among NASH patients, maximum respi- CHOI, LORNA TOLENTINO, EDGAR ENGLEMAN, Stanford, CA ration rates related negatively with fasting glucose levels (r=-0.58, p=0.04). Obesity is a heterogeneous disorder, with cardiometabolic risk factors In conclusion, hyperglycemia of type 2 diabetes determines the loss of concentrated in the insulin-resistant (IR) subset. Compelling studies in mice adaptation of hepatic mitochondria in humans with NASH. This likely con- implicate proinflammatory macrophages and T-cells in adipose tissue (AT) as tributes to the accelerated progression of liver diseases in patients with mediators of obesity-induced IR: little work has been done to corroborate type 2 diabetes. this in humans, however. We previously demonstrated that Th2 in SAT and VAT is protective for IR in humans. The current study was designed to further 342‑OR examine the potential role of T-cells in obesity-induced IR. 25 healthy humans Hepatic Sphingolipid Species Relate to Insulin Resistance and Pre- with BMI 25-35 kg/m2 underwent experimental weight gain over 5 weeks dict Both Oxidative Stress and Inflammation in Nonalcoholic Fatty to induce IR, quantified by steady-state plasma glucose (SSPG) test (higher Liver Disease SSPG indicates relative IR). Peripheral blood mononuclear cells (PBMC) and MARIA APOSTOLOPOULOU, RUTH GORDILLO, CHRYSI KOLIAKI, SOFIYA stromal-vascular cells, isolated via collagenase digestion from periumbilical GANCHEVA, TOMAS JELENIK, CHRISTIAN HERDER, DANIEL MARKGRAF, PHILIPP SAT biopsy, were analyzed for T-cell subsets via multicolor flow cytometry E. SCHERER, MICHAEL RODEN, Düsseldorf, Germany, Dallas, TX utilizing fluorescently labeled monoclonal antibodies. Th1 and Th2 were Nonalcoholic Fatty Liver Disease (NAFLD) is tightly associated with defined as CD45+CD3+CD4+CCR5+CXCR3+ and CD45+CD3+CD4+CRTH2+, obesity and T2D. Ceramides have been linked to insulin resistance in ani- respectively. Baseline tests were repeated at peak weight. Results dem- mal models but their role for human insulin resistance and NAFLD remains onstrated significant increases in PBMC Th1 (p=0.029), SAT CD4 T-cells unclear. To examine these relationships, 14 obese patients, with (NAFLD+) (p=0.04), and SAT Th1 (p=0.049). Relative increases in Th1 and Th2 corre- or without hepatic steatosis (NAFLD-) and 7 healthy lean individuals (CON) lated with worsening IR. These dynamic shifts in T-cells point to activation, underwent liver biopsies during bariatric surgery or elective abdominal surgery. Prior to surgery, hyperinsulinemic-euglycemic clamp tests with

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A90 HEPATIC LIPID AND GLUCOSE METABOLISM

2 D-[6,6- H2] glucose were performed to quantify tissue-specific insulin sen- levels in AT and serum, while serum concentrations of free IGF1 are higher. sitivity. Hepatic oxidative capacity and H2O2, lipid peroxidation and c-jun Accordingly, treatment of hepatocytes with recombinant IGFBP3 resulted N-terminal kinase phosphorylation (pJNK) were measured to assess oxida- in impaired insulin signaling and insulin-induced suppression of glucose tive stress and inflammatory activity. Total liver, but not serum, ceramides production. In analogy to AT-DPP-4-KO animals, type 2 diabetes patients were 8% and 19% higher (p<0.05) in NAFLD+ compared to NAFLD- and CON. treated with the DPP-4 inhibitor, sitagliptin, feature increases in serum free Dihydroceramides (16:0, 24:0), sphingosine and sphinganine were exclusively IGF1 and free IGF1/total IGF1 ratio. increased in NAFLD+. Total serum dihydroceramides, liver dihydroceramide In conclusion, these data provide evidence for a key role of adipose DPP-4 22:0 and ceramide 16:0 correlated negatively with peripheral insulin sen- in obesity-related metabolic disorders. Specifically, absence of of adipose sitivity (all r>0.55, p<0.05). Hepatic maximal respiration related positively DPP-4 triggers beneficial AT remodeling with decreased production of to total and certain serum dihydroceramides, liver lactosylceramide 16:0 IGFBP3 during HFD, which gives rise to increased free IGF1 and thereby likely and sphingomyeline 18:0 (all r>0.50, p<0.05). Liver hepatic H2O2 (ceramide improves hepatic insulin sensitivity. 16:0, certain hexosyl- and lactosylceramides), lipid peroxide concentrations (dihydroceramide 24:1, total ceramides, ceramide 24:1) as well as pJNK (total 345‑OR dihydroceramides, ceramide 22:0, lactosyl- and hexosylceramides) corre- Effect of Type 2 Diabetes (T2D) on the Nocturnal Pattern of Change lated all positively with the respective hepatic sphingolipids (r>0.47, p<0.05). of Endogenous Glucose Production, Glycogenolysis (GGL), and Glu- In conclusion, specific sphingolipids are increased in insulin resistant coneogenesis (GNG) people with NAFLD and correlate with higher oxidative capacity, oxida- RITA BASU, RICKEY CARTER, BRENT MCCONAHEY, PRESTIN SCHWICHTEN- tive stress and inflammation in liver. Thus, sphingolipids likely contribute to BERG, ROBERT A. RIZZA, ANANDA BASU, Rochester, MN abnormal mitochondrial function and progression of NAFLD. Fasting hyperglycemia in T2D is due to increased rates of EGP. The cause and temporal pattern of change of EGP during the night is not known. 23 343‑OR subjects with T2D (age 53±11yr, BMI 33±4 kg-m2, HbA1c 63±11mM and 20 Early Type 2 Diabetes Is Characterised by Severe Hepatic Steatosis ND (age 56±11 yr, BMI 31±3 kg-m2) were studied. Sequential primed continu- 3 2 13 and Lipoprotein Triglyceride Export ous infusions of [3- H] glucose, [6,6- H2] glucose and [1- C] glucose were SVIATLANA V. ZHYZHNEUSKAYA, AHMAD AL-MRABEH, CARL PETERS, ALISON started at 2200, 0100 and 0400 respectively and continued until 0700. Blood BARNES, KIEREN G. HOLLINGSWORTH, HELEN PILKINGTON, MIKE LEAN, ROY was sampled for glucose, tracers and hormones. Sequential tracer infusion TAYLOR, Newcastle upon Tyne, United Kingdom, Glasgow, United Kingdom was to account for tracer recycling through glycogen on measurement of Hepatic insulin sensitivity determines fasting plasma glucose concentra- EGP. Primary assessment of hormones and glucose turnover analyses were tion and is strongly modulated by liver fat content. We have evaluated the focused at 0100, 0400 and 0700. Plasma glucose concentrations were higher degree of hepatic steatosis in relation to triglyceride export (very low den- throughout the night (p<0.0001) in T2D vs. ND subjects. Insulin concentra- sity lipoprotein; VLDL1), plasma glucose and insulin in 93 people with early tions were higher in T2D vs. ND at 0100 and 0400 (p<0.0001) but were not type 2 diabetes at baseline as a sub-study of the prospective, randomised different at 0700 (p=0.45). C-peptide and glucagon concentrations remained Diabetes Remission Controlled Trial (DiRECT). The group were typical of constant and higher in T2D vs. ND throughout the night (p<0.05). Despite early type 2 diabetes: diabetes duration 2.9±1.6 years; 52.8±7.9 years; 58% different durations of tracer infusions, rates of EGP with all three glucose male; weight 99.7±16.3kg; BMI 34.5±4.3kg/m2. Fasting liver fat content was isotopes were concordant in both groups indicating no recycling of tracer measured by 3 point Dixon magnetic resonance imaging. On a separate day through glycogen. Regardless of the tracer used, EGP was higher in the the fasting production rate and pool size of VLDL1-triglyceride was mea- T2DM than the nondiabetic subjects at 0100 (18.5 ± 3.9 vs. 13.6 ± 2.0 µmol/ sured by a non-isotopic competitive blocking method. Fasting plasma glu- kg/min), 0400 (16.9 ± 3.8 vs. 12.0 ± 1.7 µmol/kg/min, and 0700 (15.8 ± 3.1 vs. cose was 153±47mg/dl with fasting plasma insulin 93±57pmol/l. Mean liver 12.0 ± 1.8 µmol/kg/min). The percent contribution of GNG and GGL to EGP fat content was grossly elevated at 14.8±9.6% (upper level of normal 5.5%). averaged ~ 50% in ND throughout the night. In contrast in T2D both GGL The production rate and pool size of VLDL1-triglyceride were 547±178mg/kg/ (11 vs. 6 µmol/kg/min) and percent contribution to EGP (62% vs. 43%) fell day and 2372±1751mg respectively. Liver fat positively correlated with both and both GNG (7 vs. 9 µmol/kg/min) and percent contribution of GNG to EGP VLDL1-triglyceride production rate (R=0.43, p<0.0001) and pool size (R=0.31, rose (38% vs. 57%) from 0100 to 0700 indicating circadian alterations of the p=0.003). It also correlated positively with fasting plasma glucose (R=0.35, regulation of GGL and GNG in T2D. These data imply that optimal therapies p=0.001) and fasting plasma insulin (R=0.52, p<0.0001). Mean liver fat in for T2D will need to target not only the absolute rates of overnight EGP but this large primary care cohort was approximately 3 times greater than the also the factors regulating the temporal pattern of change of GNG and GGL upper limit of the population normal range. This was associated with excess through the night. fat supply to all tissues as VLDL-triglyceride export, with implications for Supported By: National Institutes of Health (R01DK29953) both ectopic fat accumulation and cardiovascular disease. The extent of this abnormality is far greater than that of plasma markers of type 2 diabetes, 346‑OR including fasting plasma glucose or insulin. Liver fat content requires to be Regulation of Hepatic Glucose Production by Both Intra- and Extra- recognised as the major metabolic disturbance of early type 2 diabetes. hepatic Lipolysis in Liver-Specific Insulin Receptor Knockout Supported By: Diabetes UK

(LIRKO) Mice ORALS INSUG O-SULLIVAN, RACHEL J. PERRY, JOAO PAUL CAMPOREZ, GARY W. CLINE, 344‑OR GERALD I. SHULMAN, TERRY UNTERMAN, Chicago, IL, New Haven, CT IGF1 Links DPP-4 to Hepatic Insulin Sensitivity Regulation of hepatic glucose production (HGP) by insulin is critical for HENRIKE SELL, TANIA ROMACHO, IRA INDRAKUSUMA, DIANA RÖHRBORN, the maintenance of glucose homeostasis. Fatty acid oxidation (FAO) pro- TOMAS JELENIK, TAMARA R. CASTANEDA, SONJA HARTWIG, JÜRGEN WEIß, motes HGP and regulation of adipose tissue lipolysis plays an important role HADI AL-HASANI, MICHAEL RODEN, JÜRGEN ECKEL, Düsseldorf, Germany in mediating effects of insulin on HGP (Cell 160:745, 2015). Recent studies Dipeptidyl peptidase-4 (DPP-4) is not only a therapeutic target but is also suggest that the ability of insulin to suppress lipolysis in adipose tissue is secreted by adipose tissue (AT) and elevated in AT and in serum in obe- impaired when insulin signaling is disrupted in the liver, and hepatic FoxO1- sity. Adipose DPP-4 may be a missing link between increased AT mass in dependent mechanisms may contribute to this effect (Cell Metab 23:1154, obesity and obesity-associated metabolic diseases. To explore the role 2016). We found that FoxO1 promotes intrahepatic lipolysis and FAO due to of AT-derived DPP-4 in diet-induced obesity, we generated an AT-specific altered expression of adipose triacylglycerol lipase (ATGL) and its inhibitor, DPP-4 knockout (AT-DPP-4-KO) mouse. Under high fat diet (HFD), these mice the G0/S1 switch gene 2 (G0S2) (Cell Rep 15:349, 2016). To better character- have lower circulating DPP-4 levels (340 ± 32 ng/ml vs. 487 ± 30 ng/ml; ize the role of intra- and extrahepatic lipolysis in regulating HGP in hepatic p < 0.01), indicating that AT is a relevant source of soluble DPP-4. Neverthe- insulin resistance, we performed euglycemic-hyperinsulinemic clamps and less, AT-DPP-4-KO animals display similar fasting and glucose stimulated infused 2H-glycerol to measure glycerol turnover as a marker of lipolysis in serum concentrations of glucagon-like peptide-1 and gastric inhibitory pep- liver-specific insulin receptor knockout (LIRKO) mice w/wo adenoviral ATGL tide as wild type animals on HFD. On HFD, KO animals show improvements knockdown (KD). ATGL expression was increased, and its inhibitor, G0S2, in oral glucose tolerance and suppression of endogenous glucose produc- was decreased in LIRKO mice. ATGL KD improved glucose tolerance by 80% tion during hyperinsulinemic euglycemic clamp tests. Despite increased in LIRKO and clamp studies showed that ATGL KD improved insulin sensi- body weight and fat mass, AT-DPP-4-KO have smaller adipocytes as well tivity in LIRKO mice largely due to effects on HGP. Insulin suppression of as increased M2 macrophage markers and decreased fibrosis markers in AT. HGP was abolished in LIRKO mice, and significantly improved by ATGL KD Upon HFD, knockout mice also have lower IGF binding protein 3 (IGFBP3) (50% suppression, vs. 80% suppression in IR floxed mice and 0% in LIRKO

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A91 MILESTONES OF BETA-CELL LIFE

mice). In contrast, the ability of insulin to suppress lipolysis was only par- glyceride (P=0.0003) and a 30% reduction in DAG (P<0.05) content, which tially impaired in LIRKO vs. IR floxed mice (45% vs. 70%) and only modestly was associated with a 40% reduction in hepatic PKCε translocation (P<0.05). improved when ATGL was knocked down. These results indicate that effects Taken together these data show that the mechanism by which CR reverses of hepatic insulin resistance on the ability of insulin to regulate HGP are not hyperglycemia in a rodent model of T2D can be attributed at least in part to due solely to differences in the regulation of lipolysis in adipose tissue, and reduced energy supply to the liver resulting in reduced hepatic steatosis, that intrahepatic ATGL-dependent lipolysis also contributes to the regulation reduced DAG-PKCε-induced hepatic insulin resistance and reduced hepatic of HGP. acetyl-CoA content resulting in decreased pyruvate carboxylase activity and Supported By: U.S. Department of Veterans Affairs; National Institutes of Health hepatic gluconeogenesis. Supported By: National Institutes of Health (R01DK40936, P30DK059635, 347‑OR R01AG23686, T32DK101019) Erythropoietin Alleviates Hepatic Steatosis by Activating SIRT1- Mediated Autophagy TING HONG, ZHIJUAN GE, TIANWEI GU, DALONG ZHU, YAN BI, Nanjing, China MILESTONES OF BETA-CELL LIFE Erythropoietin (EPO) has beneficial effects on insulin resistance and obesity beyond erythropoiesis. However, the role of EPO in hepatic steato- 349‑OR sis remains unknown. Activating autophagy in the liver can be a promis- TrxG-Mediated H3K4 Methylation Is Essential for Reliable Gene ing mechanism for improving fatty liver. This study aimed to investigate Induction in Pancreas Development this effect and seek to determine whether it worked through activation STEPHANIE A. CAMPBELL, CASSANDRA L. MCDONALD, BRAD G. HOFFMAN, of autophagy. Here, we show that EPO decreased hepatic lipid content Vancouver, BC, Canada significantly in vivo and in vitro. Furthermore, EPO induced activation of Background and Aims: All cells of the pancreas arise from multipotent autophagy in hepatocytes with Western blot assay, transmission electron progenitors that differentiate into endocrine, exocrine and duct cell lin- microscopy and confocal microscopy. Meanwhile, EPO increased colocaliza- eages. Following expression of Pdx1 in pancreas progenitors, activation of tion of autophagosomes with cellular lipids as shown by double labeling of various transcription factors is critical for cell specification, but their exact autophagy marker and lipid dye. Suppression of autophagy with inhibitor regulation is largely unknown. Gene activation is associated with histone or small interfering RNA (siRNA) abolished EPO-mediated improvement of H3 lysine K4 methylation; however, recent reports have challenged whether hepatic steatosis in vitro. Importantly, we found that EPO upregulated sir- these modifications are necessary for transcription. We hypothesized that tuin1 (SIRT1) expression in HepG2 cells. SiRNA targeting SIRT1 abrogated H3K4 methylation is not required for gene induction during pancreas cell the EPO-induced increase in protein and deacetylation levels of autophagy specification and differentiation. marker LC3, and the improvement of hepatic steatosis. Taken together, we Materials and Methods: We disrupted H3K4 methylation in pancreas pro- report a new mechanism that EPO alleviates hepatic steatosis through genitors by targeting Dpy30, a core protein of the Trithorax group (TrxG) com- SIRT1-mediated effects on the activation of autophagy by deacetylation of plexes that deposit histone methylation, and generated a Pdx1-Cre-driven LC3, which may have therapeutic implications for hepatic steatosis. Dpy30 knockout mouse (Dpy30ΔP). Figure. Results: At E14.5, pancreas progenitors are segregated into Cpa1+ exo- crine progenitors, Sox9+ duct progenitors, and Ngn3+ endocrine progeni- tors. In Dpy30ΔP mice from E14.5 onward, we observed a significant reduc- tion in Cpa1+ acinar cells. At E18.5, acinar cells lacking H3K4 methylation did not fully induce amylase and the size of the Dpy30ΔP dorsal pancreas was reduced. Additionally, Dpy30ΔP acini were developmentally immature and displayed an increase in centroacinar spaces. Ngn3 was expressed in the absence of H3K4 methylation in E14.5 Dpy30ΔP mice, but only 50% of Ngn3+ endocrine progenitors were induced compared to controls. Downstream of Ngn3, β-cells failed to completely induce the transcription factor Mafa, and there was a 50% reduction in the number of α- and β-cells in E18.5 Dpy30ΔP pancreas. Overall, our results suggest that H3K4 methylation is not essential for gene induction, but that it does promote reliable expression of critical exo- crine- and endocrine-specific genes. Supported By: Canadian Diabetes Association; Natural Sciences and Engineer- Supported By: National Natural Science Foundation of China ing Research Council of Canada

348‑OR 350‑OR ORALS Caloric Restriction Reverses Diabetes in a Rat Model of Type 2 Dia- The Ldb1 Coregulator Acts in Endocrine Progenitors and Beyond to betes by Reducing Hepatic Acetyl-CoA and Diacylglycerol Content Impact the Appearance and Function of Islet Cells RACHEL J. PERRY, LIANG PENG, KITT F. PETERSEN, GERALD I. SHULMAN, MAIGEN BETHEA, YANPING LIU, ELIANA TOREN, JESSICA KEPPLE, ALEXA New Haven, CT WADE, CHAD S. HUNTER, Birmingham, AL Bariatric surgery and matching caloric restriction (CR) rapidly reverse type 2 All forms of diabetes are underpinned by a loss of functional pancreatic diabetes (T2D) but the molecular mechanisms responsible for this reversal beta cells. Future therapies, including beta cell replacement, will be bol- are poorly understood. Given the key roles of hepatic acetyl-CoA and dia- stered by improving our understanding of transcriptional complexes govern- cylglycerol (DAG) in the regulation of hepatic gluconeogenesis and insulin ing beta cell development and function. Past studies revealed that the Islet-1 resistance respectively we hypothesized that short-term CR would rapidly transcription factor (Isl1) and Ldb1 coregulator interact to regulate islet reduce these metabolites and reverse diabetes in a rat model of T2D. Three maturation and function, beginning in late pancreas development. However, days of CR (1/4 their typical ad lib intake) lowered fasting plasma glucose target gene and expression analyses were supportive of Isl1-independent roles for Ldb1. Specifically, we found Ldb1 expression in pancreatic multipo- (144±17 vs. 215±19 mg/dL, P=0.02) and insulin concentrations (34±8 vs. 75±10 + μU/mL, P=0.007) without altering body weight. The lower plasma glucose tent progenitor cells (MPCs) and in neurogenin-3 (Ngn3 ) endocrine progeni- concentrations were associated with a 30% reduction in rates of hepatic tors, where Isl1 is not expressed. This led us to hypothesize that Ldb1 has glucose production (43±4 vs. 66±6 μmol/[kg-min], P=0.007) resulting from an roles in progenitors to impact postnatal glucose homeostasis. To test this, ∆panc equivalent suppression of hepatic gluconeogenesis (P=0.02) measured by a we generated a model of Ldb1 loss in pancreatic MPCs, termed Ldb1 . novel positional isotopomer NMR analysis method following an infusion of Mutant mice were born as expected but had significantly reduced plasma [3-13C]lactate. The lower gluconeogenic rates in CR rats could be explained insulin and severe hyperglycemia on postnatal day (P)1, due to a striking ∆panc by a reduction in hepatic acetyl-CoA concentrations (114±7 vs. 141±6 nmol/g, loss of islet cells. No Ldb1 neonates survived past P7. On embryonic day (E)13.5, we observed cells with an unusual coexpression of the Ngn3 mark P=0.01), which was reflected in a reduction in whole-bodyβ -hydroxybutyrate turnover [62±4 vs. 76±3 μmol/(kg-min), P=0.02] and not associated with any (i.e., “trunk”) with Cpa1, a mark of “tip” MPCs. This suggests that Ldb1 may 13 2 be required for establishing the endocrine progenitor domain. Accordingly, alterations in whole-body lipolysis assessed by [U- C]palmitate and [ H5] + glycerol turnover. In addition, CR resulted in a 65% reduction in hepatic tri- there was a significant loss of Ngn3 cells at E15.5. This indicated that Ldb1

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A92 MILESTONES OF BETA-CELL LIFE acts specifically in the endocrine compartment, as there was no change in ance test. Mutant mice treated with agonist displayed a dampened ability total pancreas mass at P1. Furthermore, we found a significant reduction to clear glucose when compared to agonist treated controls. Taken together, of Pdx1HI, a mark of presumptive beta cells. This appears to be via direct our data reveal for the first time that Lhx1 is required for beta cell incretin regulation by Ldb1, as ChIP revealed occupancy of the Pdx1 promoter. Collec- responses via regulation of GLP-1 R. tively, our observations support that Ldb1 is required for multiple phases of Supported By: American Diabetes Association (1-16-JDF-044 to C.S.H.) beta cell development through Isl1-independent effects on Ngn3+ endocrine progenitors and developing Pdx1HI beta cells, ultimately impacting neonatal 353‑OR glucose homeostasis. Notch Regulates Pancreatic β-Cell Proliferation and Maturity Supported By: American Diabetes Association (1-16-JDF-044 to C.S.H.); National ALBERTO BARTOLOME, UTPAL B. PAJVANI, New York, NY Institutes of Health Many of the molecular mechanisms that govern the dynamic changes of β cell mass and function, a major regulator of T2D pathophysiology, are still 351‑OR unknown. Notch signaling plays an important role in the differentiation of the Novel Spatiotemporal Imaging Reveals Two Distinct Pathways of pancreatic endocrine lineage during embryonic development, but the role of β-Cell Neogenesis this pathway in developed β cells is mostly unexplored. We found high Notch SHUGO SASAKI, TAKESHI MIYATSUKA, TAKA AKI MATSUOKA, YOSHIO FUJI- receptor and ligand expression in adult murine pancreatic islets. Using trans- TANI, HIROTAKA WATADA, IICHIRO SHIMOMURA, Osaka, Japan, Tokyo, Japan, genic Notch reporter mice that express GFP as an indicator of active Notch Gunma, Japan signaling, we found that islet Notch activity localized near-exclusively to A promising therapeutic strategy to cure diabetes is to generate surrogate β cells. β cell Notch activity was altered in parallel with the dynamic changes β cells. Uncovering developmental dynamics of islet formation will contrib- in β cell mass necessitated by pregnancy, and in mice rendered hyperglyce- ute to the ultimate goal of developing efficient protocols for the derivation mic by the β cell toxin, streptozotocin. Similarly, acute exposure of isolated of safe β-cell replacements. Although numerous studies have been designed islets to hyperglycemia was sufficient to increase Notch activity. To test to reach that goal, it remains unclear when and where β cells arise from pro- whether inappropriate Notch activity is sufficient to induce metabolic harm, genitors during development. We have previously generated “Insulin-Timer” we generated a β cell-specific Notch gain-of-function (β-NICD) mice. β-NICD reporter mouse in which β cells change their fluorescent color from green mice show increased β cell proliferation, but a progressive loss of β cell to red over time and revealed characteristics of newly-specifiedβ cells by maturity, associated with proteasomal degradation of the key maturity and flow cytometry (Miyatsuka T et al. Diabetes 63: 3388-93, 2014). However, functional factor MafA. Thus, chow-fed β-NICD mice have impaired insulin the intensity of green fluorescence is below the microscopic detection secretion and glucose intolerance, a phenotype exacerbated by high-fat diet threshold, which makes it hard to clarify where β cells arise from progeni- (HFD)-feeding or aging. Next, we hypothesized that reduced Notch signaling tors. To overcome this limitation, we generated a new Insulin-Timer (nIT) may protect from dietary/aging-induced glucose tolerance, and generated mouse which enabled us to clearly detect newly-specifiedβ cells on micro- cell-specific Notch loss-of-function β( -dnMAML) mice. We found an intrigu- scope. In the pancreas of nIT embryos, green-fluorescent “newborn”β cells ing divergence of phenotype - loss of Notch function from birth results in were observed near the pancreatic ducts (“βduct cells”), whereas green/red decreased postnatal expansion of β cell mass, whereas induced expression double-fluorescent “more differentiated”β cells formed islet-like clusters. of dnMAML in adult β cells stabilizes MafA and improves HFD-induced glu- Unexpectedly, some of green-fluorescent cells were observed away from cose intolerance. In sum, our data suggest that Notch signaling plays an the ducts and attached to both blood vessels and pre-existing β cells (“βvessel important role in the dynamic changes of β cell mass, with parallel effects cells”). Immunostaining with nIT embryos showed larger a number of Mafa- on cell maturity and function. expressing cells in βvessel cells compared with βduct cells, suggesting Supported By: American Diabetes Association (1-17-PMF-025 to A.B.); National different characteristics between them. These findings reveal two distinct Institutes of Health; Russell Berrie Foundation origins of newborn β cells: 1) newborn “βduct cells” arise directly from the endocrine progenitors adjacent to the ducts, and 2) newborn “βvessel cells” 354‑OR arise from the endocrine progenitors adjacent to both blood vessels and NTPDase3 Is a Marker of Mature Human Pancreatic Beta Cells pre-existing islet cells after migration of endocrine progenitors. This novel DIANE SAUNDERS, NEIL PHILLIPS, DAVID FLAHERTY, KEVIN WELLER, SHRISTI approach will lead to a better understanding of the cellular mechanisms SHRESTHA, NRIPESH PRASAD, CHUNHUA DAI, ALENA SHOSTAK, DANIELLE underlying β-cell neogenesis and maturation. DEAN, JULIE PELLETIER, SHAWN E. LEVY, JEAN SÉVIGNY, MARCELA BRISSOVA, ALVIN C. POWERS, Nashville, TN, Huntsville, AL, Quebec City, QC, Canada 352‑OR In spite of significant efforts to identifyβ -cell-specific markers forβ -cell Lhx1 Is Required for Beta-Cell Function via Regulation of GLP-1 imaging and purification, progress has been limited. Here we report a novel Receptor Expression biomarker of human pancreatic β-cells, ectonucleoside triphosphate diphos- MAIGEN BETHEA, YANPING LIU, ALEXA WADE, RACHEL MULLEN, RICHARD phohydrolase-3 (NTPDase3). Using immunocytochemistry and human pan- BEHRINGER, RICHARD DIMARCHI, KIRK M. HABEGGER, CHAD S. HUNTER, creatic tissues (N=18, age range of 0 – 49 years), we show that NTPDase3 is Birmingham, AL, Houston, TX, Bloomington, IN expressed in essentially all adult β-cells and that this expression pattern is

The gradual loss of functional insulin producing beta cells is common to also preserved in islets from individuals with type 1 (N=2) or type 2 diabetes ORALS all forms of diabetes. Examining the transcription factor and co-regulator (N=3). Furthermore, NTPDase3 is dynamically expressed during postnatal complexes governing pancreatic islet cell function is critical for generating human pancreas development, appearing first in acinar cells at birth, but novel diabetes therapies. Our lab previously showed that the LIM-home- several months after birth its expression starts declining in acinar cells and odomain (LIM-HD) transcription factor Islet-1 (Isl1) interacts with the LIM becomes gradually expressed in a subset of islet β-cells. By 1 year of age, domain binding protein 1 co-regulator (Ldb1) to regulate key beta cell genes NTPDase3 expression ceases in acinar cells and becomes broadly expressed (e.g., GLP-1 R and MafA). Recent mRNA analysis and immunofluorescence throughout the β-cell population. Because of its β-cell specificity and studies revealed the presence of another pancreatic LIM-HD transcription membrane localization, we tested the utility of NTPDase3 antibody in two factor, LIM homeobox 1 (Lhx1). Through beta cell co-immunoprecipitation experimental settings. The purification of liveβ -cells by FACS using NTP- experiments, we found that Lhx1 also interacts with Ldb1 and Isl1. Thus, Dase3 antibody yielded a highly pure β-cell population (96%) as confirmed we hypothesized that Lhx1 regulates similar target genes as Ldb1 and Isl1. by immunocytochemical labeling for insulin. Subsequent RNA-Seq analysis To test this, we employed siRNA-mediated Lhx1 knockdown and chromatin of FACS-purified NTDPase3+ β-cells further corroborated this finding show- immunoprecipitation experiments. We discovered that reduced beta cell ing a minimal expression of markers expressed in islet α-cells, other endo- line Lhx1 imparted a significant loss of GLP-1 R mRNA. Glucose stimulated crine cells, and acinar cells. In addition, an injection of NTPDase3 antibody insulin secretion (GSIS) assays conducted in Lhx1-deficient Min6 beta cells detected human β-cells transplanted under the renal capsule of immunode- displayed a significant reduction of insulin secretion under high glucose con- ficient mice, suggesting that this reagent could be useful forβ -cell imaging ditions. Additionally, we revealed that Lhx1 occupied a 5’ domain of GLP-1 and targeting in vivo. Collectively, these data indicate that NTPDase3 is a R associated with both Ldb1 and Isl1. These data strongly support that Lhx1 cell surface biomarker of mature human β-cells. directly regulates GLP-1 R. To uncover pancreatic Lhx1 roles in vivo, we gen- Supported By: National Institutes of Health; JDRF; U.S. Department of Veterans erated a pancreas-specific Lhx1 deficient mouse. Lhx1 loss led to hypergly- Affairs cemia in 4-month old mice, plus significantly reduced GLP-1 R transcripts in isolated islets. We then assessed beta cell responses to GLP-1 in mutant mice by employing GLP-1 R agonism during an intraperitoneal glucose toler-

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A93 NEW INSIGHTS INTO PREVENTION AND TREATMENT OF HYPOGLYCEMIA

355‑OR NEW INSIGHTS INTO PREVENTION AND TREATMENT Pseudotemporal Ordering of Single Cells Reveals Metabolic Con- OF HYPOGLYCEMIA trol of Postnatal Beta-Cell Proliferation CHUN ZENG, FRANCESCA MULAS, YINGHUI SUI, TIFFANY GUAN, YULIANG TAN, 357‑OR FENFEN LIU, ANDREA C. CARRANO, MARK O. HUISING, GENE W. YEO, MAIKE Nasal Glucagon for the Treatment of Moderate-to-Severe Hypo- SANDER, La Jolla, CA, Davis, CA glycemic Episodes in Real-World Settings in Adults with Type 1 Appropriate pancreatic beta-cell mass for maintaining blood glucose Diabetes homeostasis is established during early postnatal life. Beta-cell proliferative ELIZABETH R. SEAQUIST, HELENE DULUDE, MICHELLE X. ZHANG, EMMANOUIL capacity declines postnatally but the extrinsic cues and intracellular signals RAMPAKAKIS, REMI RABASA-LHORET, GEORGE M. TSOUKAS, J. ROBIN CON- that cause this decline remain unknown. Insight gained by population-based WAY, S. JOHN WEISNAGEL, GREGG GERETY, VINCENT WOO, SHUYU ZHANG, transcriptome analysis has been limited because cell heterogeneity masks DOLORES CARBALLO, MYRIAM TRIEST, CLAUDE A. PICHE, CRISTINA B. GUZ- trends occurring across individual cells. To obtain a high-resolution map of MAN, Minneapolis, MN, Montreal, QC, Canada, Scarborough, ON, Canada, Smith beta-cell transcriptome dynamics after birth, we generated single-cell RNA- Falls, ON, Canada, Quebec City, QC, Canada, Albany, NY, Winnipeg, MB, Canada, seq data of beta-cells from multiple postnatal time points and ordered cells Indianapolis, IN based on transcriptional similarity, using a new analytical tool that estab- Objective: This study evaluated nasal glucagon (NG) for efficacy and ease- lishes a linear, pseudotemporal time course of beta-cell maturation. This of-use in moderate or severe hypoglycemic episodes (HEs) in real-world set- analysis captured the expression signature of immature, proliferative beta- tings in adult patients (pts) with type 1 diabetes (T1D). cells. We found that immature, proliferative beta-cells exhibit high expres- Methods: Pts and caregivers (CGs) were taught to administer NG 3 mg sion of mitochondrial genes, genes involved in amino acid metabolism, and for symptomatic HE and to assess for return to normal status over time. In genes encoding transcription factors of the Atf/Jun/Fos family. Experimen- addition, Pt/CG-reported HE symptoms, blood glucose (BG), adverse events tal validation revealed high metabolic activity in immature beta-cells and (AEs), and ease-of-use were evaluated through questionnaire. a role for reactive oxygen species and Atf/Jun/Fos transcription factors in Results: In the efficacy population (EP) 69 pts experienced a total of 157 driving postnatal beta-cell proliferation and mass expansion. Our work pro- HEs (mean [SD], 2.3 [1.77] events/pt). In 96.2% of HEs, pts met the primary vides the first high-resolution molecular characterization of state changes in objective, return to normal status within 30 minutes. There were 6 HEs in postnatal beta-cells and paves the way for the identification of novel thera- which the recovery did not occur within 30 minutes. In 5 of these 6 events, peutic targets to stimulate beta-cell regeneration. pts recovered within 30 to 45 minutes and in 4 events, BG was ≥70 mg/dL Supported By: National Institutes of Health at 30 minutes. Mean BG at HE onset was 47.9 (range 21.6 to 73.9) mg/dL and rose to 112.8 (range: 43.0 to 266.7) mg/dL by 30 minutes and continued to 356‑OR rise with progressive time. No emergency service calls were made. Twelve Cdk4 R24C Rescues the Diabetic Phenotype of Irs2-Deficient Mice, severe HEs in 7 pts were observed in the EP. All severe HEs resolved; and pts with Restoration of Beta-Cell Mass and Pdx1 Expression awoke or returned to normal status within 15 minutes. NG administration RACHEL E. STAMATERIS, ROHIT B. SHARMA, BRIAN GABLASKI, YAHUI KONG, time was <30 seconds for most HEs (70.4%) and was <2 minutes in nearly PANTEA EBRAHIMPOUR, DEEPIKA PANDAY, PAVANA RANGANATH, SUSHIL G. all (97.7%) HEs. The safety population included 74 pts who had a total of 179 RANE, LAURA C. ALONSO, Worcester, MA, Bethesda, MD HEs. At least 1 AE was experienced by 87.8% of pts, with the most common Strategies aimed at expanding functional beta cell mass remain a prime being nasal irritation (82.4%) and headache (54.1%). Most AEs during HEs goal of diabetes research. We recently demonstrated that Irs2 deficient mice lasted ≤1 hour (59.5%) and were of mild or moderate severity. There were no have reduced islet expression of cyclin D2, and that overexpressing cyclin serious drug-related AEs, and CGs were satisfied or very satisfied with NG D2 rescues the beta cell proliferation defect in these mice. Since cyclin D2 after most HEs (82.7%). partners with cdk4 to allow cell cycle progression, we hypothesized that Conclusion: NG showed real-world effectiveness when administered an activating mutation of cdk4 (cdk4 R24C, which is resistant to inhibition to treat moderate or severe HE in pts with T1D. For most HEs (96.2%), pts by Ink4A cell cycle inhibitors) might also rescue the proliferation defect in recovered within 30 minutes and there were no emergency calls. The major- Irs2 deficient mice. Mice heterozygous for both Irs2 deletion and cdk4-R24C ity of CGs were satisfied with NG. NG is a potential alternative to currently (R+HT) were mated, yielding 4 genotypes of interest: ++WT, RRWT, ++KO available injectable recombinant glucagon. and RRKO, where ++ refers to wild type cdk4, RR refers to two copies of the R24C allele, WT refers to wild type Irs2 and KO refers to Irs2 knock out. 358‑OR Intriguingly, having two copies of cdk4 R24C completely rescued not only Restoration of Hypoglycemia Awareness with Closed-Loop Therapy fasting and non-fasting blood glucose (++KO 339 ± 77 mg/dl; RRKO 164 ± 11 RYAN S. KINGMAN, JESSICA L. ROBIC, BRUCE A. BUCKINGHAM, PAULA CLIN- mg/dl, ++WT 179 ± 12 mg/dl, p=0.07) and glucose intolerance (p<0.0001), but TON, BORIS P. KOVATCHEV, STACEY M. ANDERSON, Stanford, CA, Charlottesville, also insulin resistance (p<0.05) in Irs2 KO mice. Beta cell mass was rescued VA in RRKO mice (++KO 41 ± 23mg, RRKO 202 ± 35mg, ++WT 127 ± 30mg, RRWT Introduction: Individuals treated with insulin are at risk for recurrent hypo- 198 ± 59mg) and was comparable to RRWT mice, in which it is established glycemia resulting in hypoglycemia unawareness. We hypothesized that a that beta cell mass is expanded. However, beta cell proliferation was only ORALS novel closed-loop control system would reverse hypoglycemia unawareness. moderately increased, as measured by BrdU incorporation (++KO = 0.12 ± Materials and Methods: During a 5-week intervention subjects were ran- 0.03%, RRKO = 0.51 ± 0.25%, p<0.05). Cdk4 RR restored islet morphology domized to either sensor-augmented insulin pump (SAP) therapy or to the to normal, suggesting the rescue might also involve improved beta cell dif- U of Virginia USS closed-loop system using the Diabetes Assistant (DiAs) ferentiation status. Interestingly, pdx1 expression, which is known to be platform. Clarke hypoglycemia awareness scores and sensor determined decreased in Irs2 KO islets, was restored in RRKO beta cells. low blood glucose index (LBGI) scores were obtained at baseline and at end We conclude that activated cdk4 rescues Irs2 deficiency through multiple of the study. LBGI was used as a metric of the frequency and extent of hypo- mechanisms, related to both cell cycle regulation and beta cell differentia- glycemia. Randomization was stratified based on their prior use of sensors. tion. Results: A total of 37 participants completed the trial (age 37.3±15.8 yrs, Supported By: National Institutes of Health (R01DK095140) range 13-62 yrs; diabetes duration 20.5±10.9 yrs; initial A1c 7.2±1.0%). 18 were stratified to the control SAP group and 19 to the experimental DiAs group based on prior sensor use and LBGI scores. A significant improvement in LBGI (p<0.001) and Clarke scores (p=0.035) was observed in the experi- mental closed-loop group, and these improvements were not seen in the SAP group. Conclusions: We conclude that the use of this closed-loop system over 5-weeks was responsible for restoring hypoglycemia awareness by signifi- cantly decreasing the frequency and duration of hypoglycemia.

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A94 NEW INSIGHTS INTO PREVENTION AND TREATMENT OF HYPOGLYCEMIA

Table. mortality was 47, 46, and 46%, in SAL, β1B, and Keppra, respectively; how- ever, mortality was entirely prevented with β1B+Keppra (p<0.01). Heart Sensor-Augmented Pump USS-Virginia/DiAs Closed-Loop block was decreased by 89 and 99% in β1B and β1B+Keppra, respectively. Baseline End of Study p Baseline End of Study p However, β1B had seizures just prior to death that were reduced by 93% Clarke 3.2 3.0 0.51 3.9 3.0 0.035 with Keppra (p<0.05). LBGI 3.2 2.9 0.45 4.0 1.5 <0.001 In summary, during severe hypoglycemia 1) β1B reduced arrhythmias, but death was associated with seizures, 2) Keppra reduced seizures, but death Supported By: National Institute of Diabetes and Digestive and Kidney Diseases was associated with arrhythmias, and 3) β1B+Keppra reduced arrhythmias (1DP3DK101055-01) and seizures and prevented sudden death. In conclusion, a new role for fatal seizures during severe hypoglycemia 359‑OR was revealed, suggesting strategies to reduce both arrhythmias and sei- zures are essential to prevent hypoglycemia-induced sudden death. Severe Hypoglycemia, Cardiovascular Outcomes, and Death: The LEADER Experience Figure. BERNARD ZINMAN, STEVEN P. MARSO, ERIK CHRISTIANSEN, SALVATORE CALANNA, SØREN RASMUSSEN, JOHN B. BUSE, Toronto, ON, Canada, Kansas City, KS, Søborg, Denmark, Chapel Hill, NC In the LEADER cardiovascular (CV) outcomes trial (N=9340; NCT01179048), the risk of CV and hypoglycemia events was reduced with liraglutide treat- ment vs. placebo, when added to standard of care, in patients with type 2 diabetes and high risk for CV events. This post-hoc analysis examines the potential associations between severe hypoglycemia and time to first MACE (CV death, non-fatal myocar- dial infarction or non-fatal stroke), CV death and all-cause death; comparing patients with/without severe hypoglycemia, and adjusted for different peri- ods of follow-up and randomized treatment. During the trial, 267 patients experienced severe hypoglycemia (liraglutide n=114, placebo n=153; rate ratio, 0.69; 95% CI: 0.51; 0.93). These patients were more likely than those without severe hypoglycemia to experience MACE, CV death and all-cause death, with a considerably higher risk up to 60 days after the hypoglycemic episode (Table), irrespective of treatment group. The protec- tive effect of liraglutide on risk of MACE was unchanged when patients with Supported By: National Institutes of Health severe hypoglycemia were excluded from the analysis (patients with severe hypoglycemia accounted for 5% of all MACE in the trial). 361‑OR In conclusion, patients experiencing severe hypoglycemia were at greater Pharmacological Autonomic Blockade Exacerbates Cardiac Repo- risk of CV events and death, particularly early after the hypoglycemic epi- larization Abnormalities during Experimental Hypoglycemia sode. Reducing severe hypoglycemia remains a cornerstone of diabetes ALAN BERNJAK, ELAINE CHOW, JUSTIN LEE, AHMED IQBAL, ALEXANDRA management. LUBINA-SOLOMON, EMMA WALKINSHAW, SIMON R. HELLER, RICHARD H. Table. CLAYTON, PAUL J. SHERIDAN, Sheffield, United Kingdom Hypoglycemia may contribute to sudden death in patients with diabe- Risk of outcome in patients with vs. without severe hypoglycemia, hazard ratio [95% CI], p-value tes by provoking cardiac arrhythmias. Potential mechanisms include per- turbation of electrophysiological properties and dysfunctional autonomic Outcome Severe Time-dependent: Time-dependent: Time-dependent: Time-dependent: responses. We hypothesized that cardiac autonomic dysfunction may inter- hypoglycemia at event after severe within 15 days† within 30 days† within 60 days† act with direct effects of hypoglycemia to increase arrhythmic risk. any time* hypoglycemia† Six healthy subjects underwent sequential hyperinsulinemic euglycemic MACE 1.9 [1.5; 2.5], 2.2 [1.6; 3.0], 5.4 [1.7; 16.8], 5.8 [2.6; 13.0], 3.1 [1.4; 7.0], (5mmol/L) and hypoglycemic (2.5mmol/L) clamp studies with parasympa- p<0.0001 p<0.0001 p<0.01 p<0.0001 p<0.01 thetic (atropine) and sympathetic (propranolol) blockade given sequentially during hypoglycemia. Twelve lead EKGs and intracardiac electrograms were CV death 2.2 [1.5; 3.2], 3.7 [2.6; 5.4], 9.5 [2.4; 38.1], 12.6 [5.2; 30.5], 6.7 [2.8; 16.1], recorded. Corrected QT (QTc), T wave morphology (T symmetry), complexity p<0.0001 p<0.0001 p<0.01 p<0.0001 p<0.0001 of repolarization (PCA ratio) and intracardiac activation-recovery intervals All-cause death 2.2 [1.7; 3.0], 3.6 [2.7; 4.9], 8.6 [2.8; 26.8], 12.2 [6.1; 24.5], 8.9 [4.9; 16.2], (ARI) were calculated in all four conditions. p<0.0001 p<0.0001 p<0.001 p<0.0001 p<0.0001 During hypoglycemia, mean epinephrine increased to 1.49±1.70nmol/L,

norepinephrine to 2.31±0.84nmol/L and potassium fell to 3.38±0.22mmol/L ORALS *Time to first MACE, CV death or all-cause death, using Cox regression with severe hypoglycemia (yes/no) at any time as a factor. †Severe hypo- (all p<0.05). Heart rate increased (Δ7±16bpm) and QTc prolonged (Δ29±35ms) glycemic episodes leading to MACE, CV death or all-cause death, using a during hypoglycemia vs. euglycemia. Parasympathetic blockade under hypo- time-dependent covariate Cox regression: all events (follow-up until last glycemia caused further increases in heart rate (Δ48±12bpm, p<0.001 vs. contact date), follow-up within 15, 30 and 60 days. CI, confidence interval; euglycemia) and QTc prolongation (Δ78±38ms, p=0.004). T wave symmetry CV, cardiovascular; MACE, major adverse cardiovascular event. significantly decreased Δ( -0.62±0.57, p=0.04) and complexity of repolariza- Supported By: Novo Nordisk A/S tion increased (Δ11.6±10, p=0.04). ARIs shortened with atropine but non- uniformly across the left ventricle (Δ-33ms at apex, p=0.004 vs. Δ-49ms, p=0.001 at free wall). After sympathetic blockade with propranolol all 360‑OR parameters were reversed to hypoglycemia levels. Sudden Death Due to Severe Hypoglycemia Is Mediated by both Blocking parasympathetic activity exacerbates abnormal cardiac repolari- Arrhythmias and Seizures sation during experimental hypoglycemia. This might precipitate arrhythmias CANDACE M. RENO, ALLIE SKINNER, JUSTIN BAYLES, SIMON J. FISHER, Salt that have been reported in clinical hypoglycemic episodes and is relevant to Lake City, UT autonomic dysfunction in diabetes where diminished parasympathetic activ- We previously reported that in rats, β1 blockers reduced severe hypogly- ity is an early manifestation. cemia-induced cardiac arrhythmias but we noted that excess mortality was Supported By: National Institute for Health Research, UK associated with seizures. To test the hypothesis that hypoglycemia induced mortality is determined by both arrhythmias and seizures, male Sprague Dawley rats were randomized into 4 treatment groups: 1) saline (SAL, n=15), 2) β1 Blocker (β1B, atenolol, 2 mg/kg; n=13), 3) anti-seizure (Keppra, 800 mg/ kg/hr; n=13), and 4) combined β1B+Keppra (n=13). Rats underwent hyper- insulinemic (0.2 U/kg/min) severe hypoglycemic (10-15 mg/dl) clamps with electrocardiogram recordings for 3½ hours. Severe hypoglycemia-induced

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A95 VENTURING BEYOND THE BRICKS, MORTAR, AND BOOKS

362‑OR Figure. Prevention of Hypoglycemia Unawareness with Tricyclics ADRIANA VIEIRA DE ABREU, RAHUL AGRAWAL, SIMON J. FISHER, Salt Lake City, UT The awareness of hypoglycemia was measured in laboratory rats by not- ing an increase in food seeking behavior during insulin induced hypoglycemia. Specifically, insulin induced hypoglycemia triggered a 3-fold increase in food intake above saline injected euglycemic control rats. A model of hypoglyce- mia unawareness (HU) was induced with 3 consecutive days of glucoprivation with recurrent 2-deoxyglucose (R2DG, 200mg/kg/d; s.c.) conditioning which resulted in a complete blunting of the food intake response to a subsequent episode of insulin induced (NPH 15 U/kg; s.c.) hypoglycemia (35-40 mg/dl) on day#4. In screening for drugs that might prevent the development of HU, we tested the hypothesis that treatment with serotonergic-norepinephrine reup- take inhibitors would prevent the development of HU. As compared to placebo treatment, both imipramine (5mg/Kg) and amytriptiline (10 mg/kg) tricyclic antidepressents given during the recurrent glucoprivation conditioning period, prevented the development of HU as noted by the normalization of the food Supported By: The Leona M. and Harry B. Helmsley Charitable Trust (226343) intake response to insulin induced hypoglycemia on day #4 (Figure). In conclusion, 1) central serotonin and norepinephrine pathways may medi- 364‑OR ate the development of HU, and 2) tricylclic serotonergic-norepinephrine reup- Impact of Genetic Polymorphism in the Beta-2-Receptor Gene on take inhibitors are promising potential pharmacological agents for the treat- the Risk of Severe Hypoglycemia in Patients with T1 Diabetes ment of hypoglycemia unawareness. KIM Z. ROKAMP, NIELS V. OLSEN, LOUISE FÆRCH, PETER L. KRISTENSEN, Figure. BIRGER THORSTEINSSON, ULRIK PEDERSEN-BJERGAARD, Copenhagen, Denmark, Hillerød, Denmark The frequency of severe hypoglycemia in T1 diabetes is not equally dis- tributed and a fraction of the patients tends to have recurrent severe hypo- glycemia which makes a genetic influence probable. A potential candidate is the beta-2 receptor gene (ADRB2) that has several common polymorphisms and of which the Arg16 allele is associated with agonist-mediated down-reg- ulation. This could be of importance for attenuation of symptoms, counter regulation and promotion of severe hypoglycemia after repeated hypoglyce- mia in patients with T1 diabetes. A cohort of 314 patients with T1 diabetes was recruited in the outpa- tient clinic at Nordsjællands Hospital Hillerød, Denmark. Severe hypoglyce- mic events were reported retrospectively in a validated questionnaire. The patients were further characterized by diabetes history, degree of hypogly- cemia awareness (Clarke, Gold, and Hillerød methods), C-peptide status, hemoglobin A1c (HbA1c), and determination of ADRB2 genotype. The ADRB2 Gly16Arg genotype distribution was in Hardy-Weinberg equi- librium and was similar to the distribution in the general population. There was no association between genotype and degree of awareness. There was a significant difference in rate of severe hypoglycemia between all geno- types (p=0.011) and patients homozygous for the Arg16 genotype (AA, n=60) had a relative rate of severe hypoglycemia of 2.19 (95% CI 1.31-3.64) com- pared to patients homozygotes for the Gly16 genotype (GG, n=117) (p=0.003). In patients with impaired awareness the difference was even more pro- Supported By: JDRF nounced with a relative rate of severe hypoglycemia of 3.18 (95% CI 1.67- 6.04) in patients with the AA genotype (p<0.0001). The difference was not explained by other risk factors (HbA1c, diabetes duration, C-peptide). 363‑OR Genetic polymorphism in the beta-2-receptor gene is associated with risk Effect of Ethanol Intoxication on the Antihypoglycemic Action of of severe hypoglycemia in patients with T1 diabetes, especially in those Glucagon with impaired hypoglycemia awareness. ORALS LAYA EKHLASPOUR, DEBBIE MONDESIR, ARYAN ESMAEILI, MALLORY HILLARD, RABAB Z. JAFRI, MANASI SINHA, RANJAN AJENTHEN, COURTNEY BALLIRO, MICHELLE MAHENO, GINA MASSE, LLAZAR CUKO, STEVEN J. RUSSELL, Boston, VENTURING BEYOND THE BRICKS, MORTAR, MA, Cambridge, MA There is no data on whether the anti-hypoglycemic action of glucagon in AND BOOKS impaired by ethanol intoxication. We tested the effectiveness of a subcuta- neous 50 μg dose of glucagon in the presence and absence of ethanol intoxi- 365‑OR cation using simultaneous hyperinsulinemic-normoglycemic and ethanol Community Health Workers, Mobile Health, or Both for Manage- clamps in subjects with T1D in a random-order crossover trial. Ethanol was ment of Medicaid Patients with Diabetes delivered intravenously by a computer-controlled pump using an automated RICHARD J. KATZ, GAIL NUNLEE-BLAND, MICHELLE F. MAGEE, HEATHER algorithm and frequent Breathalyzer measurements. The primary outcome YOUNG, LINDA WITKIN, CARINE NASSAR, JOSHUA L. COHEN, Washington, DC was area over the curve for the glucose infusion rate (AOCGIR) in the 90 min- Minorities with diabetes (DM), especially African-Americans, have an utes following the glucagon dose with a blood alcohol content (BAC) of 0 vs. excessive burden of illness as well as low self-management skills. Commu- 0.1%. Secondary outcomes were change in GIR from baseline (ΔGIRmax) and nity health workers (CHW) and mobile health (mHealth) have complimentary the mean time required to reach the ΔGIRmax after glucagon injection (Tmax). potential to improve DM care. Fifteen subjects (age 39.3±17.4 years, body mass 78.5±17.5 kg) completed Objectives: We compared 3 strategies to improve DM care for Medicaid the study. During the ethanol experiment the mean BAC was 0.10±0.02%. recipients, addition of: mHealth alone, CHW alone, or mHealth + CHW. There was no statistically significant difference in the AOCGIR (1996±1259 Methods: 166 Medicaid patients with T2 DM, HbA1c >8.0%, failing ≥3 of vs. 1981±938 mg*min/dl, p=0.971), in the ΔGIRmax (83.0±35.2 vs. 101.7±38.8, 13 wellness/clinical goals were randomized and followed for 1 year. Group 1 p=0.158), or the Tmax (28.5±5.5 vs. 24.0±6.7 min, p=0.053) in the presence vs. (n=56) used the Voxiva Care4Life (C4L) mHealth system only; Group 2 (n=56) absence of ethanol. Microdose glucagon is expected to be similarly effec- had a CHW only; and Group 3 (n=54) had both C4L and a CHW. Study end- tive in preventing and treating hypoglycemia in the presence of acute etha- points included wellness/clinical goals, HbA1c, medication adherence, self- nol intoxication as in its absence. care behavior and DM distress.

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A96 VENTURING BEYOND THE BRICKS, MORTAR, AND BOOKS

Results: Achievement of wellness/clinical goals improved in all 3 groups (mean to 42 people with T2DM. The comprehensive approach was based on the +1.3; p=0.0001); HbA1c dropped 1.3% (p<0.0001; NS between groups); only 11 American Association of Diabetes Educator’s AADE7™ self-care behaviors that (6.6%) subjects dropped out. HbA1c <8% was achieved in 30% of all subjects, encouraged participants to acquire skills for better diabetes self-management 17% of C4L only subjects, 29% CHW only subjects, and 43% of the C4L+CHW through patient-centric design. The program covered healthy eating, physical group (p=0.02 vs. C4L alone). Improvements also were observed in medication activity, self-monitoring, medication adherence, problem-solving, reducing risk adherence (p=0.02). Hospitalizations (p=0.02), urgent care visits (p=0.03), and and healthy coping. It was an incremental and supportive program to the exist- DM distress decreased in all groups (p<0.0001; NS between groups). mHealth ing standard of care recommended by the treating physicians. The platform utilization was high, subjects received a mean 3.75 messages from C4L/day and used a rule-based logic model to deliver pre-scripted content to participants. sent a median 3.9 messages to C4L/week with a trend for higher subject-to-C4L The baseline HbA1c was 9.06% (95% CI 8.69- 9.44), mean age and duration messaging in C4L+CHW vs. C4L alone (4.1 vs. 3.1/week). CHWs acted as “digital of diabetes was 48 and 7.7 yrs respectively. Mean daily interactive usage navigators” for C4L which may have led to increased utilization in the combina- was 78%; 76% (n=32) of the participants completed the program with mean tion group. Responses to C4L weekly exercise, weight and medication adherence HbA1c reduction of 0.59% (CI 0.23-0.95, p=0.002) with nearly two-thirds (n=21) queries was low (median 10 responses for each measure, NS between groups). of subjects reporting a reduction in HbA1c with a mean reduction of 1.04% Summary: mHealth and CHW, separately and together, improved self- (CI: 0.63-1.44, p<0.01). This is the first proof of concept of a digital lifestyle management and DM care measures in a Medicaid population, with some intervention for subjects with type 2 diabetes in India which allows for com- advantages to the combination strategy. This study may provide insight into plete replication using AI algorithms and personalization. Once deployed, this future use of CHWs and mHealth for DM care. scalable AI platform will provide physicians with the ability to deliver ongoing Supported By: Patient-Centered Outcomes Research Institute diabetes care at an affordable cost. We conclude that patient-centric artificial intelligence through mobile chat improves glucose control in subjects with 366‑OR type 2 diabetes. At scale, this platform will enable physicians to achieve supe- Evaluation of the IDF Online Interactive Modules on D-NET rior health outcomes at a practice and population level. SAMEER PATHAN, DANIELA CHINNICI, Brussels, Belgium Aim: D-NET is the IDF’s online network of health professionals in diabetes 368‑OR care and prevention worldwide with the aim to provide evidence-based dia- A Social Media Learning Collaborative Approach to Competency- betes education via an online platform accessible to all health professionals Based Training in Diabetes worldwide. MARCIA A. TESTA, SERGIO SALDIVAR-SALAZAR, MAXWELL SU, LINDA G. Methods: Based on the existing IDF Diabetes Education Modules, IDF has MARC, DONALD C. SIMONSON, Boston, MA, Wellesley Hills, MA developed three online education modules for health professionals as part While there are many online courses explaining how clinical factors influ- of the D-Net platform titled 1. An introduction to diabetes (Nov. ’15), 2. An ence glycemic control, translating knowledge into practice poses a significant overview of diabetes management (Mar. ’16) and 3. Understanding diabe- challenge, especially when the focus is on patient-centered outcomes (PCO). tes kidney disease (Aug.’16). These online modules are interactive, free at We developed an online, case-based, interactive training toolkit as part of a source, evidence-based and accessible to all health professionals involved social media learning collaborative feasibility study to facilitate translating in diabetes management and care via D-NET online education zone. PCO knowledge into clinical practice. The toolkit’s learning objective was to Results: As of December 2016. improve clinical competency adhering to the 2016 ADA and AACE guidelines Conclusion: The one year post-launch evaluation of the online modules has for individualizing HbA1c targets based on patient-centered demographic, highlighted immense interest for online diabetes education across the globe. clinical, psychological and socio-economic differences and disparities. We The final self-evaluation results showed that more than 94% of the participants first modeled the probability of achieving HbA1c < 8% and < 7% in 2,927 T1D achieved all the learning objectives of the module. More than 89% agreed the and T2D patients from 8 pooled clinical trials in 413 clinics using 12 regimens modules met their expectation. To this effect, IDF plans to build upon its long of insulin and oral agents (metformin, SU, TZD) alone or in combination during track record of developing evidence-based educational and has launched the 24-52 wks. Subjects were 22.6% T1D (53% male, age 32 ± 14 yrs, HbA1c 8.0 ± IDF School of Diabetes. It will be a one stop portal providing high-quality, acces- 1.0%) and 77.4% T2D (58% male, age 56 ± 10 yrs, HbA1c 9.2 ± 1.2%, BMI 31 ± sible online learning for health professionals and for people with diabetes. 5 kg/m²). Endpoint HbA1c was 7.7 ± 1.2% with interquartile range of 6.9-8.3%, Table. (p = ns for T1D vs. T2D). Socio-demographics, treatment satisfaction (71 items) and quality of life (154 items) questionnaires were completed longitudinally. Module 1 2 3 Outcomes of HbA1c < 8% and < 7% were modeled with logistic regression, and Registered 2954 824 390 resulting estimators used to develop benchmarking calculators using WebOS, Successful Completion 1114 324 72 Android, iOS and Windows compatible WordPress software. Calculators were Key Statistics Average Score 80% 83% 83% field tested and optimized within case-based learning exercises allowing the user to simultaneously modify patient characteristics to explore and visual- Countries of origin 145 92 41 ize how individual patient profiles might influence the probability of reaching Nurse, Dietician and Educator 45% 52% 43% target glycemic goals. GP & PCP 13% 16% 14% Conclusion: Social media interactive learning collaboratives may be used ORALS Specialist 11% 12% 21% to help translate diabetes PCO research findings into clinical practice, while Participant Profile providing a novel approach to competency-based training on ADA and AACE (M1: n=1002, M2: n=348, M3: n= 296) Others 31% 20% 22% guidelines. Clinical Exp. (1-5/>5 yrs.) 46%/54% 43%/57% 76%/24% Supported By: Patient-Centered Outcomes Research Institute Urban/Rural 78%/22% 44%/56% 81%/19% Evaluation Module satisfaction Rate 91% 90% 95% 369‑OR (M1: n= 864, M2: n=257, M3: n= 63) Module Usefulness 90% 91% 97% Outcomes of a Telehealth Initiative for Diabetes Management in Primary Care Supported By: Servier ANDERS L. CARLSON, JACKLYN M. KARBAN, CHRISTOPHER T. KODL, JODI M. LAVIN-TOMPKINS, Minneapolis, MN, St. Paul, MN, Bloomington, MN Introduction: Diabetes care is a challenge in the primary care setting, 367‑OR where most patients with diabetes are managed. Our program used remote Validation for Artificial Intelligence Leveraging Patient-Centric User video conferencing between a team of diabetes specialists and primary care Experience for Behavior Change in Subjects with Type 2 Diabetes providers (PCPs), aiming to improve diabetes outcomes in primary care. SOSALE R. ARAVIND, BANSHI D. SABOO, TEJAS SHAH, SHILPA S. JOSHI, MAAZ Methods: We used a team of 1 endocrinologist and 1 diabetes educator, SHAIKH, UTKARSH SUBNIS, ABHISHEK SHAH, JOTHYDEV KESAVADEV, VALUE meeting with a cohort of 7 PCPs for 2 hr sessions, for a total of 4 sessions. COLLABORATOR GROUP, Bangalore, India, Ahmedabad, India, Mumbai, India, Each PCP presented 2-3 patients not meeting glycemic targets per session, Trivandrum, India done via web-based software. The endocrinologist and diabetes educa- Continuity of care between physician appointments for subjects with tor then provided suggestions and opportunities for intervention. A 15 min type 2 diabetes (T2DM) may be achieved in a scalable and affordable way didactic presentation was also done each session. Each PCP participated by the application of patient-centric design and Artificial Intelligence (AI) voluntarily and was compensated. We present 6 month data on the first 7 systems. We validated an innovative platform to deliver a 16-week lifestyle cohorts, completed through end of 2015. coaching program exclusively through a mobile chat application (WhatsApp®)

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Results: After 6 months, the 296 patients presented saw HbA1c improve ment goals. Participants identified few challenges with sessions, but comments 1.4% on average, with a 31% increase in those meeting HbA1c target of suggested that non-evidence-based diabetes treatments (e.g., cinnamon) were <8%. There was a 4.3% increase per PCP in patients meeting overall goals sometimes discussed as beneficial during DSMS. Challenges for PL included for diabetes. There was an increase of 3.9 referrals per PCP to diabetes edu- using open-ended questioning techniques and motivating attendance. Results cation, compared to a 1.2 increase of referrals to endocrinology. All 49 PCPs suggest that peer-led DSMS in African American churches can motivate positive in the 7 cohorts showed satisfaction with the initiative, averaging 4.7 on a diabetes-management behaviors, in part via positive group dynamics that are 5.0 scale, with a 39% increase in the PCPs self-reported ability to apply new facilitated by the faith community setting. strategies for diabetes care. Supported By: Bristol-Myers Squibb Foundation Conclusion: A web-based telehealth partnership between endocrinology, diabetes education and primary care showed improvements in diabetes out- 372‑OR comes and PCP satisfaction 6 months after the cohorts ended. Our project is Global Patterns of Treatment Changes among Patients with Type 2 limited due to the lack of a control group, and long-term financial consider- Diabetes (T2DM) Treated with Insulin: Insights from the MOSA1c ations must be established. Telehealth may be an option to improve primary Observational Study care diabetes management, particularly in rural areas or those with limited MELANIE DAVIES, LUDI FAN, AYAD K. ALI, MUSTAFA ARAZ, STEPHEN C. BAIN, diabetes specialist resources. SALEM BESHYA, A. ENRIQUE CABALLERO, BRADLEY H. CURTIS, VIRGINIA FER- NANDES, BRUNO LINETZKY, RENAN M. MONTENEGRO, JR., LEONARDO MAN- 370‑OR CILLAS ADAME, IKURA MATSUBA, XIAOMEI PENG, WILLIAM H. POLONSKY, Mobile Diabetes Education for Fathers of Youth with Type 1 Diabe- MICHAEL TSOUKAS, ZHENXIANG ZHAO, KAUSIK RAY, Leicester, United Kingdom, tes: mDAD Indianapolis, IN, Gaziantep, Turkey, Swansea, United Kingdom, Abu Dhabi, United ANASTASIA ALBANESE-O’NEILL, MICHAEL J. HALLER, ANGELINA BERNIER, Arab Emirates, Boston, MA, Carmel, IN, Fortaleza, Brazil, Buenos Aires, Argentina, DESMOND SCHATZ, Gainesville, FL Kanagawa, Japan, Del Mar, CA, Montreal, QC, Canada, London, United Kingdom Introduction: Fathers of youth with type 1 diabetes (T1D) make unique con- Among insulin-treated patients with T2DM, treatment changes (TC) to tributions to their children’s health, but they infrequently attend clinic visits optimize glycemic control may not occur as recommended and global data are and thus miss opportunities for diabetes education. Mobile technology can scarce. MOSA1c, an 18-country observational study, followed insulin-treated be used to provide tailored education to these caregivers. The purpose of patients with T2DM for 2 years. TC were defined as (after the first elevated this study was to assess the usability and acceptability of a mobile diabetes HbA1c (FEH) above the physician-set personalized target): 1) addition of an education website, mDAD: Mobile Diabetes Advice for Dads (mDAD). insulin injection [ADDINS], 2) change in/additional insulin type [INSTYPE], 3) Methods: Exploratory research was conducted to determine the technol- addition of GLP-1 RA, 4) addition of an oral antidiabetes drug [OAD], or 5) insu- ogy preferences and educational needs of fathers of youth with T1D. These lin dose escalation [DE] >30% U/kg/day or >10 U/day. Kaplan-Meier analyses data were used to develop the mDAD site, which was then optimized for with log-rank tests assessed time to first TC stratified by difference between mobile devices. Study participants were advised to explore the mDAD site FEH and personalized target. Factors related to patient, physician, and health- on a mobile device, and then completed an anonymous, 20-item survey to care setting were compared between groups with and without TC. assess the site’s usability and acceptability. Responses were measured MOSA1c recruited 4,299 patients, 3,834 with a personalized HbA1c tar- using a 5 point Likert-like scale. Descriptive statistics were generated. get, of whom 95% (N=3624) had ≥1 HbA1c value above target. For 37.9% of Results: Thirty-three fathers of children with T1D participated in the study. patients, TC occurred within 6 months of an elevated HbA1c; 34.1% had no TC All participants (n=33) reported they would be “very likely” or “likely” to visit during follow-up. Patients with HbA1c >1.5% above target were more likely the site in the future; 97% (n=32) rated the overall quality of the site as to have TC (p = 0.012). Patients had >1 type of TC; the most common were DE “excellent” or “very good;” 91% reported they “strongly agreed” or “agreed” (59.9%), ADDINS (42.6%), and INSTYPE (40.4%). Patients with TC differed that the information on the site was useful to them; 97% (n=32) “strongly from those without (p<0.05) by age (60.5 vs. 61.8 yrs), white race (47.6% vs. agreed” or “agreed” the site was well organized; 100% (n=33) reported the 55.0%), married/cohabiting (79.1% vs. 75.7%), macrovascular complications overall layout and design of the site was attractive; 85% (n=28) reported (22.8% vs. 26.8%), heart failure (4.4% vs. 6.6%), and having public health they were “always” able to view the videos; and 91% (n=30) reported they insurance (50.0% vs. 58.1%). Physician-related differences included minutes “never” or “rarely” got lost when looking for information. spent with patients to manage diabetes care (27.5 vs. 30.4), and number of Conclusions: Few diabetes education sites are supported by evidence or diabetes patients treated in the last month (227 vs. 206). informed by end user input. This study of fathers of youth with T1D reported More than half of insulin-treated patients with T2DM with elevated high levels of usability and acceptability for the mDAD site. Further research HbA1c did not receive recommended TC within 6 months after exceeding is required to determine the site’s efficacy. Ease of access to diabetes edu- their personalized target. Some potentially modifiable barriers to appropri- cation and increased involvement by fathers in their children’s diabetes care ate treatment were identified. is critical for enhanced clinical and psychosocial outcomes. Supported By: Eli Lilly and Company

371‑OR ADA PRESIDENTS ORAL SESSION

ORALS Peer-Led Diabetes Self-Management Support in Faith Community Settings and Its Effect on Improvements in Diabetes Management: Qualitative Analysis from the PRAISE Study 373‑OR MARY R. JANEVIC, ROBIN NWANKWO, MARTHA M. FUNNELL, GRETCHEN A. Control of Glucose Counterregulation by the Hypothalamic Ventro- PIATT, Ann Arbor, MI medial Nucleus Limited access to Diabetes Self-Management Support (DSMS) poses a critical CHELSEA L. KASPER, MILES E. MATSEN, VINCENT DAMIAN, DANIEL ADAM, need to develop and evaluate DSMS models that are ongoing, patient-driven, MICHAEL W. SCHWARTZ, GREGORY J. MORTON, Seattle, WA, Omaha, NE and embedded in existing community infrastructures. The PRAISE study exam- We recently reported that activation of neurons in the hypothalamic ven- ined the effects of peer-led DSMS on clinical and patient-centered outcomes tromedial nucleus (VMN) that express the transcription factor SF1 (VMNSF1) is in 9 African-American churches in metro Detroit from 2013-2015. Following both necessary and sufficient for effective counterregulation (CR) in response professionally-delivered diabetes self-management education, 6 monthly DSMS to insulin-induced hypoglycemia. Since a majority of VMN neurons express groups were independently planned and facilitated by 12 trained peer leaders SF1, and since activation of these neurons can have non-specific behavioral (PL) (mean age: 62 years, 100% African American, 25% male). Using qualita- effects, we sought to identify the specific subset of these neurons involved in tive evaluation methods, we sought to describe group processes and dynam- glucose CR. Based on evidence that the subset of VMN neurons that express ics to gain insight into the program’s mechanisms of effect. We conducted neuronal nitric oxide synthase-1 (VMNNOS1 neurons) are sensitive to changes in focus groups with PRAISE participants in a sample of 6 churches and one-on- interstitial glucose, and that NOS1 activity is implicated in the cellular mecha- one interviews with 7 PL. Audio-recordings were transcribed and analyzed for nism whereby VMN neurons detect glucose, we hypothesized that activation themes. Participants and PL identified 3 key DSMS processes: goal-setting, of VMNNOS1 neurons would selectively trigger counterregulatory responses group problem-solving, and sharing experiences and information. Processes took and thereby raise circulating glucose levels. This hypothesis was tested using place in a context of mutual support, camaraderie, and a sense of safety that optogenetics in awake, freely moving mice. In support of our hypothesis, pho- were enabled, in part, by participants and PL all belonging to the same church. toactivation of VMNNOS1 neurons in otherwise normal mice elicited diabetes- Participants linked both group processes (e.g., goal-setting) and dynamics (e.g., range hyperglycemia (p<0.05) driven by responses normally reserved for the support) to improvements in their motivation and behavioral diabetes manage- response to hypoglycemia. These responses include inhibition of glucose-

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A98 ADA PRESIDENTS ORAL SESSION induced insulin secretion and increased secretion of the counterregulatory for >99% of the posterior probability of driving the association, with the most hormones glucagon and corticosterone. Since a subset of VMNNOS1 neurons precise resolution at JAZF1 (rs10226758), CDC123-CAMK1D (rs11257655), project to the anterior bed nucleus of the stria terminalis (aBNST), and since TCF7L2 (rs7903146), and KCNQ1 (rs2237884 and rs2237895). Integration of hypoglycemia activates neurons in this brain area, we next asked whether fine-mapping data and annotation revealed the posterior probability π( ) to be hyperglycemia is also elicited by activation of VMNNOS1 projections supplying significantly enriched in coding exons (p=1.4x10-5), for the first time including the aBNST. Consistent with this prediction, we found that photoactivation of an index variant at the APOE-TOMM40 locus, APOE p.Cys130Arg (rs429358, VMNNOS1 terminals in the aBNST mimics the hyperglycemia elicited by activat- π=99.2%). After accounting for coding variation, the posterior probability was ing VMNNOS1 neuronal cell bodies (p<0.05). These results support the hypothe- also significantly jointly enriched for transcription factor binding sites for PDX1 sis that VMNNOS1 neurons are key components of a VMN→aBNST neurocircuit (p=2.6x10-6) and FOXA2 (p=1.8x10-5), highlighting potential regulatory signa- that is activated by hypoglycemia and enables effective glucose CR. tures that are predictive of causal variants for T2D in non-coding sequence. Supported By: National Institutes of Health (DK089056) Supported By: National Institutes of Health (U01DK105535)

374‑OR 376‑OR Activating Pyruvate Kinase M2 to Prevent the Development of Dia- Program ACTIVE II: A Comparative Effectiveness Trial to Treat betic Nephropathy Major Depression in T2DM WEIER QI, AIMO KANNT, THORSTEN SADOWSKI, QIAN LI, ISHIKADO ATSU- MARY DE GROOT, GUY HORNSBY, CHANDAN SAHA, ZIYI YANG, YEGAN PIL- SHI, I-HSIEN WU, SAMUEL LOCKHART, MARK A. YOREK, CHONG WEE LIEW, LAY, KAREN FITZPATRICK, KIEREN J. MATHER, JAY SHUBROOK, Indianapolis, IN, ISSAC STILLMAN, LIANE TINSLEY, DAVID POBER, ROBERT STANTON, EDWARD Morgantown, WV, Athens, OH, Vallejo, CA FEENER, HILLARY KEENAN, GEORGE L. KING, Boston, MA, Frankfurt, Germany, Program ACTIVE II (R18DK092765) is a multi-state comparative effec- Iowa City, IA, Chicago, IL tiveness study of cognitive behavioral therapy (CBT) and community-based The Joslin Medalist Study characterizes a cohort of 1000 individuals with exercise (EXER) on depression and glycemic outcomes in adults with major type 1 diabetes for over 50 years. Remarkably, only 12% of Medalists have depressive disorder (MDD) and type 2 diabetes (T2DM). diabetic nephropathy (DN; eGFR<45 ml/min/1.73m2.) despite extreme duration Using a 2X2 factorial repeated measures RCT design, participants were ran- diabetes, suggesting the presence of endogenous protective factors. To iden- domized to: CBT (10 individual sessions), EXER (12 weeks), CBT+EXER (concur- tify these protective factors we conducted proteomic analysis of glomeruli iso- rent interventions over 12 weeks) or usual care (UC). Participants were recruited lated from post-mortem Medalists’ kidneys with no-mild DN (n=7) vs. severe from 3 states using a community-engaged research (CEnR) approach. Commu- DN (n=11). Multiple enzymes in the glycolytic, sorbitol, methylglyoxal (MG) and nity partners in mental health and exercise conducted the interventions. mitochondrial pathways were elevated in patients without DN (p<0.05). Spe- N=140 T2DM adults, aged M=56 years (SD=10.7), 77% female, 71% cifically, pyruvate kinase M2 (PKM2) expression and activity was significantly white, 52% married and 34% completed high school or trade school were upregulated by 2.7 fold and 40%, respectively and correlated with eGFR. enrolled. At post-intervention, CBT, EXER, or CBT+EXER groups reported PKM2 activity was decreased in glomeruli from STZ-induced diabetic fewer depressive symptoms (all p<.05), reduction in negative automatic mice. Diabetic PKM2 podocyte-specific KO (PPKM2KO) mice developed thoughts (all p<.03), improved physical quality of life (QoL; all except CBT significantly greater albuminuria, mesangial expansion and glomerular fibro- only p<.03), and decreased diabetes distress (p<.01) compared to UC. EXER nectin expression compared to diabetic wild type mice. Oral treatment with and CBT+EXER reported improved diabetes-specific QoL (p<.01) compared a small molecule selective activation of PKM2 reduced both albuminuria and to UC. After controlling for change in antidepressant medications, the odds renal glomerular pathology in diabetic DBA2/J mice at 6 months of diabetes. of partial or full remission from MDD for CBT and EXER groups were 12.6 PKM2 activation decreased sorbitol, DAG (C16:0/18:0) and MG by 28%, 47% and 5.8 times the odds for UC, respectively (p<.03), assessed using the and 45%, respectively in diabetic mice and, notably, restored these metabo- Structured Clinical Interview for the DSM-IVTR. In those with a baseline A1c lites to nondiabetic levels (p<0.05). In cultured podocytes, PKM2 activation ≥ 7.0%, EXER resulted in a clinically meaningful 0.7% improvement in HbA1c prevented high glucose-induced changes in sorbitol, DAG and PKC activa- (p<.04) compared to those receiving CBT or UC after controlling for baseline tion, whereas knockdown of PKM2 enhanced high glucose induced elevation education levels and changes in diabetes medications. of these metabolites and apoptosis. Program ACTIVE is a set of manualized interventions that has demonstrated In summary, PKM2 is a novel protective factor that in patients with clinically meaningful improvements in both depression and glycemic outcomes extreme duration of type 1 diabetes. Activation of PKM2 prevents the accu- in adults with T2DM. These interventions enable behavioral health and exer- mulation of toxic metabolites and subsequent podocyte apoptosis induced cise professionals to extend the availability of depression treatment options by high glucose and diabetes in vitro and in vivo. Our results suggest that for T2DM patients in ways that are complementary to medical care. PKM2 is a novel therapeutic target for the treatment of DN. Supported By: National Institutes of Health (R18DK092765) Supported By: National Institute of Diabetes and Digestive and Kidney Dis- eases; JDRF 377-OR Hospitalization for Heart Failure and Death in New Users of SGLT2 375‑OR Inhibitors in Patients With and Without Cardiovascular Disease:

Discovery and Fine-Mapping of Type 2 Diabetes Susceptibility Loci CVD-REAL Study ORALS across Diverse Populations MATTHEW A. CAVENDER, ANNA NORHAMMAR, KÅRE I. BIRKELAND, MARIT HIDETOSHI KITAJIMA, ANUBHA MAHAJAN, XUELING SIM, MAGGIE C.Y. NG, EIKA JØRGENSEN, JOHN P.H. WILDING, KAMLESH KHUNTI, ALEX Z. FU, JOHAN WEIHUA ZHANG, JENNIFER E. BELOW, DANIEL TALIUN, KYLE J. GAULTON, BODEGARD, BETINA T. BLAK, ERIC T. WITTBRODT, MARCUS THURESSON, ANDREW P. MORRIS, DIAMANTE CONSORTIUM, Oxford, United Kingdom, Sin- PETER FENICI, NIKLAS HAMMAR, MIKHAIL N. KOSIBOROD, THE CVD-REAL gapore, Singapore, Winston-Salem, NC, London, United Kingdom, Houston, TX, Ann INVESTIGATORS AND STUDY GROUP, Chapel Hill, NC, Stockholm, Sweden, Arbor, MI, La Jolla, CA, Liverpool, United Kingdom Oslo, Norway, Gentofte, Denmark, Liverpool, United Kingdom, Leicester, United We conducted trans-ethnic meta-analysis of genome-wide association Kingdom, Washington, DC, Luton, United Kingdom, Wilmington, DE, Uppsala, studies of type 2 diabetes (T2D) in 99,265 cases and 545,212 controls from Sweden, Cambridge, United Kingdom, Mölndal, Sweden, Kansas City, MO diverse populations. We identified 110 loci at genome-wide significance A reduction in CV death and heart failure (HF) is reported with a SGLT2i (p<5x10-8), including 37 mapping outside regions previously implicated in the in patients with T2D and established CV disease (CVD). Using observational disease, with the strongest novel associations at/near INHBB (rs58884021, data from clinical practice, we compared HF and death in patients with and p=2.8x10-12), PLEKHA1 (rs2421016, p=3.2x10-12), and EIF5A2 (rs6804915, without prior CVD or HF in new users of SGLT2i and other glucose lowering p=3.8x10-12). We identified 156 distinct association signals (p<10-5) across the drugs (oGLD) in the U.S., UK, Sweden, Norway and Denmark. 1:1 propensity 110 loci, including 11 at KCNQ1, 5 at INS-IGF2, and 4 each at CDKN2A-B and score matching was applied. HF and death were collected via medical records CCND2. Whilst allelic effects on T2D risk of index variants were predominantly (UK), medical claims, electronic health and death records (U.S.), and national consistent across populations, for the first time we observed strong evi- registers (Nordics). Hazard ratios (HR) for HF, death, and the composite were dence of heterogeneity that was correlated with ancestry at LEP (rs7778167, estimated by country and pooled as a weighted average. After matching, -16 -11 pHET=8.2x10 , East Asian specific), UBE2E2 (rs35352848, HETp =4.2x10 , effect baseline characteristics were balanced between groups. 306,156 patients, -10 strongest in East Asians), and KCNQ1 (rs11819853, pHET=2x10 , varying direc- >150,000 person years (PY) (100,947 PY for SGLT2i; 89,208 PY for oGLD) and tion and magnitude of effect between ethnic groups). Fine-mapping analyses 950 new HF events were analyzed. SGLT2i, when compared to oGLD, was substantially improved localisation of potential causal variants compared with associated with lower rates of HF in patients with and without CVD (HR 0.69; previous efforts, highlighting 17 signals for which a single variant accounted 95% CI 0.59-0.80; HR 0.55 95% CI 0.34-0.88). Similar results were seen for

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A99 ADA PRESIDENTS ORAL SESSION

death and death/HF irrespective of CVD or HF history. Findings were consistent sensitivity and reduce ambient glycemia, we aimed to determine whether they across countries with varying SGLT2i class composition. In this large cohort lower hepatic glucose production (HGP). A single oral dose of 5- and 9-PAHSA of patients with and without CVD, SGLT2i was associated with a significant (30 mg/kg) in chow-fed mice decreased glycemia during a pyruvate tolerance reduction in HF and death vs. oGLD. This suggests that the benefit of SGLT2i test without changing serum insulin levels, suggesting an effect on hepatic applies to a broad population of patients with T2D. gluconeogenesis. 5- or 9-PAHSA treatment of primary hepatocytes ex vivo inhibited basal HGP by 34%-49% but did not augment insulin suppression of HGP. However, 9-PAHSA decreased glucagon-stimulated HGP and hepatocyte cAMP levels by ~39%. PAHSAs did not alter 8-Bromo-cAMP-stimulated HGP suggesting they act upstream of protein kinase A. 9-PAHSA suppression of basal HGP in hepatocytes was abolished with pertussis toxin suggesting Gα/i involvement. Intravenous infusion of 9-PAHSA for 3 hrs decreased ambient HGP in both chow- and HFD-fed mice 5 hrs after food removal (Chow: vehicle 20±1 vs. PAHSA 15±1 mg/kg/min; HFD: vehicle 22±2 vs. PAHSA 16±1) without altering serum insulin levels. Mechanistic studies showed 9-PAHSA infusion reduced phosphorylation of cAMP Responsive Element Binding Protein by 74% and expression of glucose-6 phosphatase catalytic subunit in liver by 78%. 9-PAHSA infusion decreased hepatic G6pase activity in both chow- and HFD-fed mice compared to vehicle infusion (Chow: vehicle 85±4 vs. PAHSA 66±2 nmol/mg/min; HFD: vehicle 121±8 vs. PAHSA 78±12). Sum: PAHSAs inhibit basal and glucagon-stimulated HGP directly in hepatocytes and reduce HGP and hepatic G6pase activity in vivo. These effects on HGP appear to be mediated by a cAMP dependent pathway involving Gα/i protein-coupled receptors. Therefore, PAHSAs could be effective antidiabetic agents and the pathways they engage could provide novel drug targets for type 2 diabetes. Supported By: National Institutes of Health; JPB Foundation

Supported By: AstraZeneca 380‑OR Efficacy and Safety of Oral Basal Insulin: Eight-Week Feasibility 378-OR Study in People with Type 2 Diabetes (T2DM) REMD-477, a Human Glucagon Receptor (GCGR) Antibody, Reduces LEONA PLUM-MÖRSCHEL, TIM HEISE, ERIC ZIJLSTRA, KARSTEN LYBY, Daily Insulin Requirements and Improves Glycemic Control in People KARSTEN WASSERMANN, LISE BRØNDSTED, INGE BIRK HALBERG, Mainz, with Type 1 Diabetes (T1D) Germany, Neuss, Germany, Søborg, Denmark JEREMY PETTUS, DOMINIC REEDS, TRICIA SANTOS CAVAIOLA, SCHAFER Oral insulin 338 formulated into a GIPET® I tablet (OI338GT) is a basal, BOEDER, MICHELLE LEVIN, EDDA CAVA, DUNG THAI, JIM SHI, HAI YAN, EDGAR acylated insulin analog with a half-life of ~70 hours. We investigated effi- BAUTISTA, JOHN MCMILLAN, ROBERT R. HENRY, SAMUEL KLEIN, La Jolla, CA, cacy and safety of OI338GT in comparison to subcutaneous insulin glargine St. Louis, MO, San Diego, CA, Camarillo, CA, Del Mar, CA U100 (IGlar) in 50 insulin naïve T2DM subjects (mean±SD age 61±7 years, Studies conducted in rodent models of T1D have shown that glucagon BMI 30.5±3.7 kg/m²) insufficiently controlled (HbA1c 7-10%) on metformin receptor blockade normalizes plasma glucose concentration without the need alone or in combination with other oral agents. Patients were randomized 1:1 for exogenous insulin. We conducted a randomized, double-blind, placebo to OI338GT or IGlar once daily for 8 weeks in a double-blind, double-dummy (PBO) controlled trial in 21 subjects with T1D (8 men,13 women) to evaluate fashion as add-on to existing metformin with or without DPP-4 inhibitor. the effect of a single 70 mg SC injection of REMD-477, a human monoclonal Insulin doses were uptitrated weekly on an individualized basis aided by a antibody against the GCGR, on daily insulin requirements and glycemic pre-specified algorithm aiming at achieving fasting plasma glucose (FPG) in control. After obtaining baseline insulin use and data from Continuous Glucose the target range of 80-126 mg/dL. Both treatments substantially improved Monitoring (CGM), subjects were admitted to the Clinical Research Unit for 5 glycemic control as indicated by FPG (primary endpoint), HbA1c and fruc- days. Insulin was provided by continuous IV infusion to maintain postabsorptive tosamine with no significant differences between treatments at 8 weeks and postprandial plasma glucose between 90-120 mg/dl and <180 mg/dl, (Table). C-peptide was comparable at end of treatment (EOT). The incidence respectively. Standard meals were provided to ensure the same daily energy of treatment-emergent hypoglycemia was low (OI338GT: 7 events in 6 sub- and macronutrient contents were consumed during the inpatient study. Drug/ jects, IGlar: 11 events in 6 subjects). No severe hypoglycemia occurred. The PBO was given on the second day of admission. The primary endpoint was rate of adverse events was similar. the comparison between groups in the change in daily insulin requirements In conclusion, this study demonstrated for the first time that an oral basal on day 4 from day 1. An interim analysis of the first 17 subjects found REMD- insulin safely improves glycemic control to a similar extent as does IGlar. 477 treatment reduced daily insulin use by 32% (4.2%, 60%) vs. PBO on Day

ORALS Table. 4 (p=0.027). Average daily glucose assessed by CGM was 19 mg/dL (6.2, 31; p=0.006), and 26 mg/dL (8.2, 45; p=0.008) lower in the REMD-477 group than Parameter OI338GT IGlar Treatment in the PBO group at Weeks 2 and 3 after treatment, respectively. Glucose time- difference*/ + in-range (70-180 mg/dL) for REMD-477 was 9.5% (2.7%, 16%; p=0.009) and Baseline EOT Baseline EOT ratio [95% CI] p-value 13% (1.9%, 25%; 0=0.026) greater in the REMD-477 group than in the PBO FPG (mg/dl) 175±50 129±33 164±31 121±17 5.2* 0.4567 group during Weeks 2 and 3 after treatment, respectively. REMD-477 therapy [-8.8;19.1] & was well tolerated and no episodes of severe hypoglycemia were noted. These HbA1c (%) 8.1±0.6 7.3±0.8 8.2±0.8 7.1±0.6 0.30* 0.0774 data demonstrate that a single SC injection of REMD-477 reduces daily insulin [-0.03;0.63] requirements while simultaneously improving glucose control, as measured by Fructosamine (µmol/l)& 275±44 235±45 273±50 223±34 9.6* 0.3700 average glucose concentration and glucose time-in-range, without increasing [-11.7;30.9] hypoglycemia in subjects with T1D. Fasting C-peptide (nmol/l)& 1.02±0.37 0.64±0.29 0.97±0.29 0.65±0.27 -0.02* 0.6799 Supported By: National Institute of Diabetes and Digestive and Kidney Diseases [-0.13;0.08] Daily insulin dose (nmol/kg 30±11# 114±51 0.11±0.03# 0.33±0.15 347+ — 379-OR OI338GT, U/kg IGlar)& [262;459] nmol/U Palmitic Acid Esters of Hydroxy Stearic Acids Reduce Hepatic Table shows mean±SD values at baseline and end of treatment (EOT). Glucose Production in Chow and High-Fat Diet (HFD)-Fed Mice Treatment difference/ratio, 95% CI and p-value are based on a linear mixed PENG ZHOU, PERONI D. ODILE, ISMAIL SYED, MATTHEW J. KOLAR, PRATIK model for repeated measurements. *Treatment difference OI338GT - IGlar; + # & ARYAL, ANDREW T. NELSON, DIONICIO SIEGEL, ALAN SAGHATELIAN, BARBARA Treatment ratio OI338GT/IGlar; Initial dose; Post-hoc statistical analysis. B. KAHN, Boston, MA, La Jolla, CA, San Diego, CA We recently discovered structurally novel lipids, branched Palmitic Acid esters of Hydroxy Stearic Acids (PAHSAs), with potent antidiabetic and antiinflammatory effects. Since PAHSAs improve glucose tolerance and insulin

For author disclosure information, see page A751. ADA-Supported Research

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