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Telomere length is not a main factor for the development of islet autoimmunity and type 1 diabetes in the TEDDY study

The Environmental Determinants of Diabetes in the Young (TEDDY) study enrolled 8676 children, 3–4 months of age, born with HLA-susceptibility genotypes for islet autoimmunity (IA) and type 1 diabetes (T1D). Whole-genome sequencing (WGS) was performed in 1119 children in a nested case–control study design. Telomere length was estimated from WGS data using five tools: Computel, Telseq, Telomerecat, qMotif and Motif_counter. The estimated median telomere length was 5.10 kb (IQR 4.52–5.68 kb) using Computel. The age when the blood sample was drawn had a significant negative correlation with telomere length (P = 0.003). European children, particularly those from Finland (P = 0.041) and from Sweden (P = 0.001), had shorter telomeres than children from the U.S.A. Paternal age (P = 0.019) was positively associated with telomere length. First-degree relative status, presence of gestational diabetes in the mother, and maternal age did not have a significant impact on estimated telomere length. HLA-DR4/4 or HLA-DR4/X children had significantly longer telomeres compared to children with HLA-DR3/3 or HLA-DR3/9 haplogenotypes (P = 0.008). Estimated telomere length was not significantly different with respect to any IA (P = 0.377), IAA-first (P = 0.248), GADA-first (P = 0.248) or T1D (P = 0.861). These results suggest that telomere length has no major impact on the risk for IA, the first step to develop T1D. Nevertheless, telomere length was shorter in the T1D high prevalence populations, Finland and Sweden.


Introduction
Telomeres consist of repetitive nucleoprotein tracts of sequence (TTAGGG)n that cap the ends of linear chromosomes. Telomeres prevent the loss of coding sequences and hinder major chromosomal rearrangements 1 . Each cell division causes progressive attrition (around 50-200 bp of the telomeres) and is part of determining the lifespan of cells 2 . Rapidly dividing cell types are those within the immune system that proliferate not only to self-renew but also to perform their biological function.
Telomere length is, in part, inherited with a stronger in uence on variation in telomere length from the father, de ned by the stronger correlation in telomere length between father-son and father-daughter 3,4 . In addition, paternal age is positively correlated with longer telomeres 5 . At the population level, there is no difference in telomere length at birth between boys and girls 6 ; however, in young children 7 and young adults (around 30 years), telomeres are longer in women than in men, although the attrition rate is higher in women 8 . The preservation of telomeres in women may, therefore, occur during the rst two decades of life 9 .
In healthy subjects, HLA-DRB1*04 alleles have been shown to be associated with shorter telomeres in CD4 + T-cells, although the difference in telomere length between HLA-DR4 + and HLA-DR4 − subjects was not identi ed at birth. Thus, during the rst 20 years of life, telomere attrition may be accelerated in subjects with HLA-DR4 + 10 .
Several mechanisms may contribute to the attrition of telomeres, but there is only one known mechanism in healthy individuals, beyond embryogenesis, that counteracts the shortening of telomeres. Some cell types, such as lymphocytes, are capable of activating telomerase, an enzyme that can elongate telomere sequences and thereby modulate cellular lifespan. Certain hormones can also stimulate telomerases. For example, estrogens have been shown to activate telomerase activity 11 while cortisol can decrease telomerase activity. In vitro experiments have shown that high concentrations of hydrocortisone (comparable to cortisol levels that may occur in vivo due to stress) can reduce telomerase activity by up to 50% 12 . Women with gestational diabetes (GDM), a condition of altered glucose metabolism and hormonal patterns during pregnancy, is associated with shorter telomeres in girls born to GDM mothers, but not in boys 13 .
Telomere length exhibits disease-speci c patterns in different autoimmune diseases 2,14,15 . Shorter telomere length in leukocytes has been reported in subjects with type 1 diabetes (T1D) compared to controls, although shorter telomere length was not associated with the duration of T1D 16 . In T1D, allcause mortality is also associated with a shorter telomere length 17 .
Here, we utilize the TEDDY nested case-control (NCC) cohort to estimate telomere length from wholegenome sequencing (WGS) data. Analyses of telomere length were performed to nd out if there was a relation to the development of islet autoimmunity (IA), type 1 diabetes (T1D), or both, as well as its association with HLA-DR-DQ haplogenotypes. Primary end-points in TEDDY included any IA, micro insulin autoantibody (mIAA)-rst, the 65kDa glutamate decarboxylase autoantibody (GADA)-rst, or T1D.
The rst blood sample for HLA-screening was obtained either as cord blood in the maternity clinic or as a dry blood spot (DBS) on day three or four. If the child was eligible for TEDDY, the family was contacted by a study nurse and invited to participate in the 15-year follow-up study with blood sampling for determining islet autoantibody (GADA, islet antigen-2 antibody (IA-2A) and mIAA) status every three months between 3 and 48 months of child's age and every six months thereafter (while a child with islet autoantibody positivity remained on the three months visit schedule). HLA-haplogenotypes were con rmed in a second blood sample at the 9-month visit. For the present study, blood samples were taken at the median age of 0.82 years (interquartile range (IQR): 0.75-5.43 years) for extraction of DNA and subsequent sequencing.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committees and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All procedures were approved by the ethics committees/institutional review boards including Colorado Multiple Institutional Review Board

Study outcomes: IA and T1D
The primary outcome of the TEDDY study is the development of persistent con rmed IA assessed every three months. In the U.S.A., all sera were assayed at the Barbara Davis Center for Childhood Diabetes at the University of Colorado, Denver, CO; in Europe all sera were assayed at the University of Bristol, Bristol, U.K. GADA, IA-2A and mIAA were all measured using radio-binding assays [19][20][21] . IA was con rmed if an autoantibody was identi ed in a sample at both Reference Laboratories. All samples positive for IA and 5% of negative samples were re-tested for con rmation in both Reference Laboratories. Persistent autoimmunity was de ned by the presence of con rmed IA (GADA, IA-2A or mIAA) on two or more consecutive visits. The date of persistent con rmed IA was de ned as the rst blood draw date at which the child was found positive for at least one islet autoantibody. As children may be born with maternal IA, positive results due to maternal transmission via placenta were excluded when de ning the child's IA status. If the child was IA-positive at 3 or 6 months of age, the IA status of the mother was assessed at the 9-month visit in order to distinguish maternal autoantibody from IA in the child. If maternal autoantibody was present, the child was not considered persistently IA-positive unless the child had a negative sample prior to the rst positive sample.
The threshold for positivity differed by the laboratory. Positivity was de ned by Bristol (GADA ≥ 33 DK-U/mL, IA-2A ≥ 5 DK-U/mL and mIAA > 0.95 Local Units) and Denver (GADA > 20 DK-U/mL, IA-2A > 5 DK-U/mL and mIAA > 0.010 index). Both Reference Laboratories have shown high sensitivity and speci city as well as concordance for de ning the presence of con rmed IA 10,21 . HLA typing HLA genotype screening was performed using either a dried blood spot (DBS) punch or a small volume blood specimen format 18, 22 . After polymerase chain reaction (PCR) ampli cation of exon 2 of the HLA class II genes (DRB1, DQA1 or DQB1), alleles were identi ed either by direct sequencing, oligonucleotide probe hybridization or other genotyping techniques. Typing to certify speci c HLA-DR-DQ haplogenotypes was determined for each clinical center. Con rmation of the HLA haplogenotypes was performed by the central HLA Reference Laboratory at Roche Molecular Systems, Oakland, CA on the eligible subjects using the 9-month sample.
Estimation of telomere length from the WGS data WGS was performed on the subjects in the nested case-control (NCC) study for IA and T1D. In the NCC study, the "cases" were those subjects that had developed any IA or T1D as of 30 June 2018 and "controls" were randomly selected from those autoantibody-negative children in the index case's risk set, matched for sex, clinical site and rst-degree relative (FDR) status 23 . Matching was performed in a 1:1 format (one control was matched to each case). FastQ Screen 25 were used to identify low-quality sequences and contaminants in the raw sequence data.
The raw sequences were aligned to the Genome Reference Consortium Build 37 (GRCh37d5) for qMotif and to the Genome Reference Consortium Build 38 (GRCh38DH) for Computel, Telseq, Telomerecat and Motif_counter. Post-alignment processing was performed by utilizing the University of Michigan's (UM) Docker-alignment pipeline (https://github.com/statgen/docker-alignment) based on Burrows-Wheeler Aligner (BWA) 26 . Variant concordance analysis was performed by comparing the variants identi ed from the WGS data to the T1DExomeChip array (Illumina, CA) data to determine mislabeled, swapped or contaminated samples.
Estimation of the telomere length from the WGS data was performed using ve different tools: Computel, Telseq, Telomerecat, qMotif and Motif_counter (Supplementary methods). Pairwise Spearman correlation analysis was used to compare performance of these tools against each other. All subsequent statistical analysis on telomere length was conducted using estimates from Computel which is based on aligning raw sequence data in FASTQ format to a telomeric reference sequence.
SNPs associated with the telomere length Single nucleotide polymorphisms (SNPs) were genotyped by the Center for Public Health Genomics at the University of Virginia, VA, U.S.A., using the T1DExomeChip array on the full TEDDY cohort (n = 8,093) ( Figure 1). The T1DExomeChip is a custom genotyping array with more than 90,000 custom content SNPs added to the In nium® CoreExome-24 v.1.1 BeadChip (Illumina, CA). Genotype calling and the following quality control steps were applied to the dataset: (1) individuals with low call rate (< 95%), or discordance with reported sex and prior genotyping were not considered in the analysis, (2) SNPs with low call rates (< 95%) were excluded, (3) SNPs from autosomal chromosomes with allele distributions strongly deviating from Hardy-Weinberg equilibrium in controls with the European ancestry (P < 10 − 6 ) were discarded (except for chromosome 6 with the Hardy-Weinberg equilibrium in controls with the European ancestry (P < 10 − 20 ) due to HLA eligibility requirements), (4) SNPs on chromosome X were excluded with heterozygosity > 1% in men, (5) SNPs on chromosome Y were excluded with genotypes > 2% in women, (6) Monomorphic SNPs were excluded, (7) SNPs were discarded for which the concordance rate among duplicates was < 99% and (8)

Statistical analyses
Multiple linear regression analysis was performed to examine the association between the telomere length and other factors including HLA-categories (HLA-DR3/3 or HLA-DR3/9 (as reference), HLA-DR3/4 and HLA-DR4/4, HLA-DR4/X), sex, parental age, mother´s gestational diabetes status, FDR status and the country of residence (as strata). The age at sample collection and the indicator of the long-distance protocol sample collection (yes vs. no) were also included in the model. Telomere length data were available on a total of 1,119 TEDDY children.
Primary analyses were focused on examining the association between telomere length with the risk of any IA and/or T1D. A conditional logistic regression model was used to consider the matching criteria in the NCC study for any IA or T1D, adjusting for the HLA-categories (HLA-DR3/3 or HLA-DR3/9 (as reference), HLA-DR3/4 and HLA-DR4/4, HLA-DR4/X). In the analysis, telomere length was age-adjusted by using the residuals from the linear regression of telomere length on the age at sample collection. Subgroup analyses were conducted with respect to the type of rst appearing autoantibody (mIAA-rst and GADA-rst). The magnitude of the association was estimated by odds ratio (OR), with 95% con dence internal (CI).
Secondary analyses were performed to examine the effect of SNPs associated with telomere length on the risk of any IA, mIAA-rst, GADA-rst and T1D. A total of 244 SNPs with minor allele frequency (MAF) > 0.05 were included (Figure 1). Cox proportional hazard models were used to study the association between each SNP and the risk of any IA, mIAA-rst, GADA-rst and T1D, respectively, adjusting for sex, the country of residence (as strata), FDR, HLA-haplogenotype and accounting for population strati cation (ancestral heterogeneity) (using the top three principal components estimated from the T1DExomeChip).
Of the 8,676 enrolled children, 583 were excluded: indeterminate HLA haplogenotypes (n = 14), HLA ineligible (n = 112), and no SNP data available (n = 457). A total of 7,093 families had one child, 476 families had 2 children, and 16 families had 3 children who were included in the analysis. A robust

Results
Telomere lengths from the WGS data were calculated from 1,119 TEDDY children (Figure 1). Descriptive data on the estimation of the telomere lengths is shown in Table 1. The estimated median telomere length was 5.10 kb (IQR: 4.52 kb -5.68 kb) using Computel. The estimations of the telomere lengths were strongly correlated between Computel and Telseq (r = 0.97, P < 0.001) as well as between Computel and Motif_counter (r = 0.93, P < 0.001) (Supplemental Figure S1). variance estimate was used to account for the dependence within families in the Cox proportional hazard model 39 . The magnitude of each estimated association was de ned by the Hazard ratio (HR), with 95% con dence intervals (CIs). To correct for multiple hypothesis testing, the false discovery rate adjusted Pvalues were calculated 40 . SNPs with nominal signi cance can be found in Supplementary Table S3 through S6.

Discussion
The key nding in this study was that children from high incidence countries for T1D i.e., Finland and especially from Sweden had shorter telomeres in white blood cells as compared to children from other TEDDY sites (Germany and three sites in the U.S.A.). The age when the blood sample was drawn had a signi cant negative correlation with telomere length, consistent with previous reports 41 . Interestingly, children that carried HLA-DR4/4 or HLA-DR4/X had signi cantly longer telomeres compared to children with HLA-DR3/3 or HLA-DR3/9 haplogenotypes. Also, paternal age was signi cantly correlated with telomere length. Children with HLA-DR3/4 had a signi cantly increased risk to develop any IA as compared to children with HLA-DR3/3 or HLA-DR3/9 haplogenotypes. Moreover, there were signi cantly increased risks for children with HLA-DR3/4 and HLA-DR4/4 or HLA-DR4/X to develop mIAA as the rst autoantibody as compared to those with HLA-DR3/3 or HLA-DR3/9 haplogenotypes. In contrast, GADA as the rst autoantibody or T1D were not associated with any of the HLA-DR-DQ haplogenotypes.
To our knowledge, there has been no reports on the risk for IA, mIAA-rst or GADA-rst in relation to telomere length. The estimations of the telomeres were highly correlated between Computel, Telseq and Motif_counter with R 2 values ranging from 0.85 to 0.94 (Supplemental Figure 1). The nding of similar telomere lengths in young boys and girls con rms a previous study of telomere length taken at birth 6 .
There has been a previous report on shorter telomere length in children with T1D 16 , a nding that was not reproduced here. This discrepancy could be explained by the older age of the participants in the previous report (17 to 48 years), compared with the TEDDY study in which the oldest children with T1D were 14.16 years. We could not reproduce the ndings of shorter telomeres in children born to mothers with GDM, although this could be due to the older age (9 to 16 years) in the earlier study 13 . In addition, we detected a signi cant effect of paternal age but not maternal age on the length of telomeres 5 . The SNPs that had nominally signi cant association to our primary and secondary outcomes -any IA, mIAA-rst, GADA-rst or T1D -were mainly from genes coding for proteins involved in double DNA strand repair and maintenance of telomeres (MRE11 and RAD50) 42 , DNA replication and repair (BLM) 43 , genome stability (ATM) 44 or degradative endocytic tra cking (PIK3C3) 45 . The BLM gene has gene ontology including nucleic acid binding and ATPase activity also involved in DNA replication and repair.
The major strength of the present study is the use of both IA and T1D as endpoints. Additional strengths of this study are the inclusion of unrelated subjects from both the general population and FDRs without islet autoantibodies or T1D from the same countries in the same age ranges as the subjects with outcome events. One limitation of the present study is the relatively low number of subjects with IA, particularly those with GADA-rst or with T1D, raising concerns for statistical power of the association analysis. Nevertheless, the screening of more than 400,000 newborns in four different countries to identify those with an increased genetic risk for T1D, de ned by high-risk HLA-DR-DQ haplogenotypes, followed with blood draws every three months for the rst four years and every six months thereafter is a unique effort. The proportional hazard ratio identi es risk for time-to-event in this longitudinal study, thereby increasing the power compared with cross-sectional case-control study design.
We concluded that genes in the HLA-region particularly HLA-DR3/4 and HLA-DR4/4, HLA-DR4/X remain the most important genetic risk factors for IA, the rst step towards T1D. Children with the high-risk genotypes for T1D from Finland and Sweden had shorter telomeres and telomere length is associated with HLA-DR4/4 or HLA-DR4/X haplogenotype as compared to HLA-DR3/3 or HLA-DR3/9. Moreover, paternal age was positively associated with telomere length.

Competing interests
The authors declare no competing interests associated with this study.

Availability of data and material
The datasets generated and analyzed during the current study will be made available in the NIDDK Central Repository at https://repository.niddk.nih.gov/studies/teddy/. The TEDDY Whole Genome Sequencing (WGS) data that support the ndings of this study have been deposited in NCBI's database of Genotypes and Phenotypes (dbGaP) with the primary accession code phs001442.v3.p2.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. TornMP140SupplementaryMethods20211025.docx SuppFigure120211106.pdf TEDDYStudyGroup20211025.docx