Improving Prediction of Risk for the Development of Type 1 Diabetes-Insights From Populations at High Risk

Prevention of type 1 diabetes has been brought closer to reality through the ability to identify populations at increased risk and through therapies that can modify the disease course (1). Identification of those who are at risk is based on the detection of diabetes-related autoantibodies (Ab) that can be found many years before clinical diagnosis. Those identified as being at increased risk due to having a family member who lives with type 1 diabetes or who have an increased genetic risk based on high-risk HLA have been followed in a number of longitudinal cohort studies (2–8) The preclinical phase of type 1 diabetes is described as progression from genetic susceptibility and immune activation to the development of single and then multiple Ab, to early abnormalities of glucose tolerance, and finally to clinical diabetes (9). Those who are found to have multiple Ab almost inevitably progress to diabetes (10). However, the time from detection of multiple Ab to diagnosis varies widely. To move the goal of the prevention of type 1 diabetes from research to clinical reality, refinements of strategies to predict progression to diabetes are needed. Anand et al. (11) and Bonifacio et al. (12), in two articles in this issue of Diabetes Care, help to define characteristics of Ab development and diabetes progression in >24,000 children at risk.