Evaluating online direct-to-consumer marketing of genetic tests: informed choices or buyers beware?

Commercialization of genetic technologies is expanding the horizons for the marketing and sales of genetic tests direct-to-consumers (DTCs). This study assesses the information provision and access requirements that are in place for genetic tests that are being advertised DTC over the Internet. Sets of key words specific to DTC genetic testing were entered into popular Internet search engines to generate a list of 24 companies engaging in DTC advertising. Company requirements for physician mediation, genetic counseling arrangements, and information provision were coded to develop categories for quantitative analysis within each variable. Results showed that companies offering risk assessment and diagnostic testing were most likely to require that testing be mediated by a clinician, and to recommend physician-arranged counseling. Companies offering enhancement testing were less likely to require physician mediation of services and more likely to provide long-distance genetic counseling. DTC advertisements often provided information on disease etiology; this was most common in the case of multifactorial diseases. The majority of companies cited outside sources to support the validity of claims about clinical utility of the tests being advertised; companies offering risk assessment tests most frequently cited all information sources. DTC advertising for genetic tests that lack independent professional oversight raises troubling questions about appropriate use and interpretation of these tests by consumers and carries implications for the standards of patient care. These implications are discussed in the context of a public healthcare system.     

Blurring lines

The research activities of direct-to-consumer genetic testing companies raise questions about consumers as research subjectsThe recent rise of companies that offer genetic testing directly to consumers, bypassing the traditional face-to-face consultation with a health-care professional, has created a steady stream of debate over the actual and potential value of these services (Hogarth et al, 2008). Despite the debates, however, the reality remains that these services are being offered and have genuine consequences for consumers. As opposed to the issues that have regularly been discussed regarding direct-to-consumer (DTC) genetic testing, the fact that these companies use consumers'' data to perform research has been given relatively little attention. This omission is misconceived as this practice—within the wider realm of DTC genetic testing services—raises its own questions and concerns. In particular, it is blurring the line between consumers and research subjects, which threatens to undermine the public trust and confidence in genetic research that the scientific community has been trying to build over the past decades.Even when a company is relatively transparent about its research activities, one might still be concerned by a lack of consumer awareness of these activitiesWith this in mind, we analysed the websites—including informed consent forms and privacy policies—of five companies that offer DTC full genome testing: 23andMe, deCODE, Navigenics, Gene Essence—the genetic testing service offered by the company BioMarker Pharmaceuticals—and SeqWright. Two questions guided our study: Are consumers aware that the data generated by the company to fulfil the terms of their service will later be used for research? Even if this is the case, is the process of consent provided by companies ethically acceptable from the point of view of academic research?As there are no empirical data available to answer the first question, we turned to the websites of the companies to understand how explicitly they present their research activities. At the time of the study—from July 2009 to January 2010—23andMe, deCODE and Navigenics candidly revealed on their websites that they conduct research using consumer data (Sidebar A). By contrast, SeqWright and Gene Essence provided what we identified as indirect and even ambiguous information about their research activities. For example, in a SeqWright online order form, the company notes: “Please volunteer any diseases from which you currently suffer (this can help us advance medical research by enabling us [sic] discover new SNP [single nucleotide polymorphism]/Disease associations)”. The information in Gene Essence''s privacy policy was similarly vague (http://geneessence.com/our-labs/privacy-policy.html), stating that “electing to provide Optional Profile Information may enable the Company to advance the science of genetics and provide you with an even better understanding of who you are genetically”.

Sidebar A | Information provided by direct-to-consumer genetic testing companies^*

23andMe“You understand that your genetic and other contributed personal information will be stored in 23andMe research databases, and authorized personnel of 23andMe will conduct research using said databases.” (https://www.23andme.com/about/consent; accessed 29 January 2010)deCODE“Information that you provide about yourself under the security of your account and privacy of your chosen username may be used by deCODEme only to gather statistical aggregate information about the users of the deCODEme website. Such analysis may include information that we would like to be able to report back to you and other users of deCODEme, such as in counting the number of users grouped by gender or age, or associating genetic variants with any of the self-reported user attributes. In any such analyses and in presenting any such statistical information, deCODE will ensure that user identities are not exposed.” (http://www.decodeme.com/faq; accessed 29 January 2010)Navigenics“Navigenics is continuously improving the quality of our service, and we strive to contribute to scientific and medical research. To that end, we might de-link Your Genetic Data and Your Phenotype Information and combine it with other members'' information so that we can perform research to: […] Discover or validate associations between certain genetic variations and certain health conditions or traits, as well as other insights regarding human health.” (http://www.navigenics.com/visitor/what_we_offer/our_policies/informed_consent/health_compass; accessed 29 January 2010)^*See main text for information from SeqWright and Gene Essence.If, as appears to be the case, these statements are the only declarations offered by these two companies alluding to their presumed research activities, it is virtually impossible for consumers to understand that their data will be used for research purposes. Moreover, despite the fact that the three other companies do state that they conduct research using consumer genotypes, even their declarations still give cause for concern. For instance, both Navigenics and deCODE ‘tuck away'' most of the information in their terms of service agreements, privacy policies, or in the informed consent sections of their websites. This is worrisome, as most consumers do not even read and/or understand the ‘legalese'' or ‘small print'' when signing online forms (ICO, 2008).…many studies show that participants who have agreed to have their tissue used for one type of research do not necessarily automatically agree to take part in other studies…Even when a company is relatively transparent about its research activities, one might still be concerned by a lack of consumer awareness of these activities. Between July and September 2009, 23andMe offered a new service called the “23andMe research edition”, which was prominently displayed on the company website. This version of their service, which was part of what the company calls the “23andMe research revolution”, was offered for US$99—one-quarter of the price of their traditional personal genome scan—and it offered less information to consumers than the “traditional” service. For instance, the abridged research edition neither offered information about carrier status, pharmacogenomic information and ancestry, nor could the customer browse or download the raw genomic data (https://www.23andme.com/researchrevolution/compare).At a glance, it seemed that 23andMe were marketing the “research edition” as a more affordable option, owing to the fact that the consumers were being given less information and because its name implied that the data would be used for research. Granted, the company did not explicitly express this last assumption, but the term “research edition” could have easily led consumers to this conclusion. However, what is particularly troubling about the two options—“research edition” and “traditional”, presented as distinct products—is that the consent forms for both services were identical. The issue is therefore whether, by calling one option “research edition”, 23andMe made it less clear to individuals purchasing the “traditional” service that their data would also be used for research purposes.Even were we assured that consumers are at least aware of the research being conducted, we must still ask whether the companies are obtaining adequate consent compared with that required from volunteers for similar research studies? To answer this question, we considered official guidelines covering consent, public views on the topic and information gleaned from the websites of DTC genetic testing companies.Concerning public opinion, many studies show that participants who have agreed to have their tissue used for one type of research do not necessarily automatically agree to take part in other studies (Goodson & Vernon, 2004; Schwartz et al, 2001). Furthermore, in a survey of more than 1,000 patients, 72% considered it important to be notified when leftover blood taken for clinical use was to be used for research (Hull et al, 2008). Most of those patients who wanted to be notified would require the researchers to get permission for other research (Hull et al, 2008).…requesting additional information could still be understood by consumers as an additional service that they purchased and not an explicit invitation to take part in researchAlthough some of the companies in our study do mention the diseases that they might study, they are not specific and do not describe the scope of the research that will be done. Indeed, beyond the initial customer signature required to complete the purchase of the genetic testing service, it is not always clear whether the companies would ever contact consumers to obtain explicit consent for internally conducted research. That said, if they were to send out surveys or questionnaires to request supplementary phenotype information, and consumers were to fill out and return those forms, the companies might consider this as consent to research. We would argue, however, that this blurs the line between individuals as consumers and as research participants: requesting additional information could still be understood by consumers as an additional service that they purchased and not an explicit invitation to take part in research.The issue of the identifiability of genomic data is inextricably related to the issue of consent as “[p]romises of anonymity and privacy are important to a small but significant proportion of potential participants” (Andrews, 2009). In the study performed by Hull and colleagues, 23% of participants differentiated between scenarios where samples and data were stored anonymously or with identifiers (Hull et al, 2008). The issue of anonymity is particularly important under the US Common Rule definition of ‘human subject'' research (HHS, 2009). It dictates that research conducted using samples from people that cannot be identified is not considered human subject research and as such does not require consent. Although this rule applies only to federally funded research, it might become pertinent if companies collaborate with publicly funded institutions, such as universities. More generally, regulations such as the Common Rule and the US Food and Drug Administration''s regulations for the protection of human subjects highlight the importance of the protection of individuals in research. Research activities conducted by companies selling DTC genetic tests should therefore be similarly transparent and accountable to a regulatory body.On the basis of the information from the websites of the companies we surveyed, it is not unambiguously clear whether the data used in their research is anonymized or not. That said, 23andMe claims it will keep consumers informed of future advancements in science and might ask them for additional phenotype information, suggesting that it maintains the link between genotype data and the personal information of its customers. As such, research conducted by 23andMe could be considered to involve human subjects. Thus, if 23andMe were to comply voluntarily with the Common Rule, they would have to obtain adequate informed consent.Even in cases in which data or samples are anonymized, studies show that people do care about what happens to their sample (Hull et al, 2008; Schwartz et al, 2001). Furthermore, it is becoming more and more apparent that there are intrinsic limits to the degree of protection that can be achieved through sample and data de-identification and anonymization in genomic research (Homer et al, 2008; Lin et al, 2004; McGuire & Gibbs, 2006; P3G Consortium et al, 2009). This further weakens the adequacy of companies obtaining broad-sense consent from consumers who, most probably, are not even aware that research is being conducted.The European Society of Human Genetics (ESHG) has recently issued a statement on DTC genetic testing for health-related purposes, which states that “[t]he ESHG is concerned with the inadequate consent process through which customers are enrolled in such research. If samples or data are to be used in any research, this should be clear to consumers, and a separate and unambiguous consent procedure should take place” (ESHG, 2010). Another document was recently drafted by the UK Human Genetics Commission (HGC), entitled ‘Common Framework of Principles for Direct-to-Consumers Genetic Testing Services'' (HGC, 2009). The principles were written with the intention of promoting high standards and consistency in the DTC genetic testing market and to protect the interests of consumers and their families. Although this document is not finalized and the principles themselves cannot control or regulate the market in any tangible way, this framework, along with the ESHG statement, constitute the most up-to-date and exhaustive documents addressing DTC genetic testing activities.On the basis of the information from the websites of the companies we surveyed, it is not unambiguously clear whether the data used in their research is anonymized or not…companies should be completely transparent with the public about whether people purchasing their tests are consumers or research subjects or bothPrinciple 4.5 states: “If a test provider intends to use a consumer''s biological samples and/or associated personal or genetic data for research purposes, the consumer should be informed whether the research has been approved by a research ethics committee or other competent authority, whether the biological sample and data will be transferred to or kept in a biobank or database, and about measures to ensure the security of the sample. The consumer should be informed of any risks or potential benefits associated with participating in the research.” Principle 5.6 of the HGC''s draft states that a “[s]eparate informed consent should be requested by the test provider before biological samples are used for any secondary purposes, e.g research, or before any third party is permitted access to biological samples. Consumers'' biological samples and personal and genetic data should only be used for research that has been approved by a research ethics committee (REC) or other relevant competent authority.”None of the companies we surveyed reveal on their websites whether internal research protocols have been approved by a REC or by an independent “competent authority”. Furthermore, no such independent body exists that deals specifically with the research activities of commercial companies selling DTC genetic tests. Additionally, if a company did claim to have internal ethical oversight, it would be questionable whether such a committee would really have any power to veto or change the company''s research activities.Moreover, while all five companies do state what will happen to the DNA sample—in most cases, unless asked otherwise by the consumer, the DNA sample will be destroyed shortly after testing—not enough is revealed about what will happen to the data. Some companies say where data is kept and comment on the security of the website, but as mentioned previously, companies are not clear about whether data will be anonymized. Traditionally, a great deal of focus has been placed on the fate and storage of biological samples, but genome-wide testing of hundreds of thousands of individuals for thousands or even millions of SNPs generates a lot of data. This information is not equivalent, of course, to a full genome sequence, but it can fuel numerous genomic studies in the immediate and medium-term future. As such, additional issues above and beyond basic informed consent also become a concern. For instance, what will happen to the data if a company goes bankrupt or is sold? Will the participants be sent new consent forms if the nature of the company or the research project changes drastically?The activities of companies offering DTC genetic testing have not only blurred the lines between medical services and consumer products, but also between these two activities and research. As a consequence, the appropriate treatment and autonomy of individuals who purchase DTC genetic testing services could be undermined. Paramount to this issue is the fact that companies should be completely transparent with the public about whether people purchasing their tests are consumers or research subjects or both. Although an individual who reads through the websites of such companies might be considered a simple ‘browser'' of the website, once the terms and conditions are signed—irrespective of an actual reading or comprehension—the curious consumer becomes a client and a research subject.…consumers who become research participants should be treated with the same respect and under the same norms as those involved in biobank researchCompanies using consumer samples and data to conduct research are in essence creating databases of information that can be mined and studied in the same way as biobanks and databases generated by academic institutions. As such, consumers who become research participants should be treated with the same respect and under the same norms as those involved in biobank research. As stated by the Organization for Economic Co-operation and Development, research should “respect the participants and be conducted in a manner that upholds human dignity, fundamental freedoms and human rights and be carried out by responsible researchers” (OECD, 2009). On the basis of our analysis of the websites of five companies offering DTC full genome testing, there is little evidence that the participation of ‘consumers'' in research is fully informed.The analysis of company websites was conducted in 2009 and early 2010. The information offered to consumers by the companies mentioned in this Outlook might have changed following the study''s completion or the article''s publication.? Open in a separate windowHeidi C. HowardOpen in a separate windowPascal BorryOpen in a separate windowBartha Maria Knoppers     

DNA sampling and banking in clinical genetics and genetic research

Health-related direct-to-consumer (DTC) genetic testing has been a controversial practice. Especially problematic is predictive testing for Alzheimer disease (AD), since the disease is incurable, prevention is inconclusive, and testing does not definitively predict an individual's future disease status. In this paper, I examine two contrasting cases of subjects who learn through genetic testing that they have an elevated risk of developing AD later in life. In these cases, the subject's emotional response to the result is related to how well prepared she was for the real-life personal implications of possible test results. Analysis leads to the conclusion that when groups of health-related genetic tests are offered as packages by DTC companies, informed consumer choice is rendered impossible. Moreover, I argue, this marketing approach contravenes US Federal Trade Commission policies for non-deceptive commercial communications. I conclude by suggesting ways to improve the prospects for informed consumer choice in DTC testing.     

Communication is the key.: Part 2 : Direct to consumer genetics in our future daily life ?

The considerable advances of genome sequencing over the past decades have had a profound impact on our daily life and opened up new avenues for the public to have access to their genetic information and learn more about their ancestry, genealogy and other traits that make each of us unique individuals. A very large number of individual single nucleotide polymorphisms (SNPs) have been associated to diseases whereas others have no known phenotype. For example, among the SNPs mapped within ccn1(cyr61), ccn2(ctgf), ccn3(nov), ccn4(wisp-1), ccn5(wisp-2) and ccn6 (wisp-3), only mutations within ccn4 were associated to PPD (the autosomal recessive skeletal disorder Progressive Pseudorheumatoid Dysplasia). On the occasion of this JCCS special issue on the roles of hormetic responses in adaptation, and response of living species to the modifications of their environment, it appeared that it was a good time to briefly review a topic that has been the subject of passionate discussions for the past few years, that is Direct to Consumer genetic tests (DTC GT). Based on the use of DNA analysis and identification of polymorphisms, DTC GT have been developed by several companies in the USA and in countries where there was no legal obstacle for customers to have direct access to their genetic information and manage their healthcare. Problems that arose and decisions that have been taken by regulatory agencies are presented and discussed in this editorial. The « freeze » of health-oriented DTC GT in the USA neither implies the end of DNA analysis nor « fun » applications, which are not aimed at providing risks estimates for particular illnesses. As shown in the example which is discussed in this editorial, DTC GT for cosmetic applications might be considered a fun application of great interest for companies such as L’Oréal, who recently developed the Makeup Genius mobile application. Other fun applications of DTC GT are discussed but there is no doubt that nothing will stop progress and it is most probable than within a few years from now all the tensions raised about these procedures will vanish to the profit and benefit of consumers. In any case, this will only be possible through an intensive communication effort, because …communication is the key !     

The future of direct-to-consumer clinical genetic tests

In light of the meeting of the US Food and Drug Administration (FDA) in March 2011 to discuss the regulation of clinical direct-to-consumer (DTC) genetic tests, we have invited five experts to consider the best means of overseeing the ordering and interpretation of these tests. Should these tests be regulated? If so, who, if anyone, should communicate results to consumers?     

A randomized trial of genetic information for personalized nutrition

Personal genetic information has become increasingly accessible to the public as a result of direct-to-consumer (DTC) genetic tests; however, concerns have been raised over their value and potential risks. We compared the effects of providing genotype-based dietary advice with general recommendations on behavioral outcomes using a randomized controlled study. Participants were men and women from the Toronto Nutrigenomics and Health Study between the ages of 20–35 years (n = 149) who completed a survey to assess their awareness of DTC genetic tests and nutrigenomics, as well as potential motivations for undergoing genetic testing. Participants were then randomized into an intervention (I) or control (C) group and were given either genotype-based personalized dietary advice or general dietary advice, respectively. A second survey was administered to assess the participants’ opinions of the dietary reports they received. A greater proportion of participants in the intervention group agreed that they understood the dietary advice they were given (93% (I) vs. 78% (C); p = 0.009). Participants in the intervention group were more likely to agree that the dietary recommendations they received would be useful when considering their diet (88% (I) vs. 72% (C); p = 0.02) and wanted to know more about the recommendations (95% (I) vs. 76% (C); p < 0.0001). Only 9% of participants in the intervention group reported feeling uneasy about learning their genetic information. These findings suggest that individuals find dietary recommendations based on genetics more understandable and more useful than general dietary advice. Very few feel uneasy about receiving their genetic information that relates to personalized nutrition.     

Informed Choice in Direct-to-Consumer Genetic Testing for Alzheimer and Other Diseases: Lessons from Two Cases

Health-related direct-to-consumer (DTC) genetic testing has been a controversial practice. Especially problematic is predictive testing for Alzheimer disease (AD), since the disease is incurable, prevention is inconclusive, and testing does not definitively predict an individual's future disease status. In this paper, I examine two contrasting cases of subjects who learn through genetic testing that they have an elevated risk of developing AD later in life. In these cases, the subject's emotional response to the result is related to how well prepared she was for the real-life personal implications of possible test results. Analysis leads to the conclusion that when groups of health-related genetic tests are offered as packages by DTC companies, informed consumer choice is rendered impossible. Moreover, I argue, this marketing approach contravenes U.S. Federal Trade Commission policies for non-deceptive commercial communications. I conclude by suggesting ways to improve the prospects for informed consumer choice in DTC testing.     

Direct-to-consumer genetic testing through Internet: marketing, ethical and social issues

We probably did not anticipate all the consequences of the direct to consumer genetic tests on Internet, resulting from the combined skills of communication and genomic advances. What are the commercial strategies used by the companies offering direct-to-consumer genetic tests on Internet and what are the different social expectations on which they focus? Through a quantitative and qualitative analysis of the web sites offering such tests, it seems that these companies target a triple market based on: the "healthism" which raises health and hygiene to the top of the social values; the contemporary demands of the users to become actual actors of health decisions; and finally on the need for bio-social relationships. These three commercial strategies underlie various ethical and societal issues justifying a general analysis.     

A survey of state insurance commissioners concerning genetic testing and life insurance.

Rapid advances in genetic testing have stimulated growing concern about the potential for misuse of genetic data by insurance companies, employers, and other third parties. Thus far, reports of genetically based discrimination in life insurance have been anecdotal. Reasoning that state insurance commissioners were likely to be aware of (1) the extent of current use of and interest in genetic tests by life insurers and (2) consumer complaints about insurance being denied because of genetic condition or because of genetic test results, we conducted a survey of that group. We received responses from 42 of the 51 jurisdictions. Our results suggest (1) that those who regulate the life insurance industry do not yet perceive genetic testing to pose a significant problem in how insurers rate applicants, (2) that life insurers have much legal latitude to require genetic tests, and (3) that so far few consumers have formally complained to commissioners about the use of genetic data by life insurers.     

In need of counseling?

Moves to clamp down on companies offering direct-to-consumer genetic tests are out of step with personal genomics and its potential to empower individuals' role in their own healthcare.     

The sense and nonsense of direct-to-consumer genetic testing for cardiovascular disease

Expectations are high that increasing knowledge of the genetic basis of cardiovascular disease will eventually lead to personalised medicine—to preventive and therapeutic interventions that are targeted to at-risk individuals on the basis of their genetic profiles. Most cardiovascular diseases are caused by a complex interplay of many genetic variants interacting with many non-genetic risk factors such as diet, exercise, smoking and alcohol consumption. Since several years, genetic susceptibility testing for cardiovascular diseases is being offered via the internet directly to consumers. We discuss five reasons why these tests are not useful, namely: (1) the predictive ability is still limited; (2) the risk models used by the companies are based on assumptions that have not been verified; (3) the predicted risks keep changing when new variants are discovered and added to the test; (4) the tests do not consider non-genetic factors in the prediction of cardiovascular disease risk; and (5) the test results will not change recommendations of preventive interventions. Predictive genetic testing for multifactorial forms of cardiovascular disease clearly lacks benefits for the public. Prevention of disease should therefore remain focused on family history and on non-genetic risk factors as diet and physical activity that can have the strongest impact on disease risk, regardless of genetic susceptibility.     

Should direct-to-consumer personalized genomic medicine remain unregulated?: a rebuttal of the defenses

Direct-to-consumer personalized genomic medicine has recently grown into a small industry that sells mail-order DNA sample kits and then provides disease risk assessments, typically based upon results from genome-trait association studies. The companies selling these services have been largely exempted from FDA regulation in the United States. Testing kit companies and their supporters have defended the industry's unregulated status using two arguments. First, defenders have argued that mere absence of harm is all that must be proved for mail-order tests to be acceptable. Second, defenders of mail-order testing have argued that there is an individual right to the tests' information. This article rebuts these arguments. The article demonstrates that the direct-to-consumer market has resulted in the sidelining of clinical utility (medical value to patients), leading to the development of certain mail-order tests that do not promote customers' interests and to defenders' downplaying of a potentially damaging empirical study of mail-order genomic testing's effects on consumers. The article also shows that the notion of an individual right to these tests rests on a flawed reading of the key service provided by mail-order companies, which is the provision of medical interpretations, not simply genetic information. Absent these two justifications, there is no reason to exempt direct-to-consumer personalized genomic medicine from stringent federal oversight.     

Direct-to-consumer testing: if consumers are not anxious,why are policymakers?

Direct-to-consumer genetic testing continues to receive significant attention from both the popular press and policymakers. While the demand for these services has not, to date, been significant, it nevertheless seems likely that more and more individuals will be accessing DTC services. As a result, commentators have suggested that the DTC industry requires more oversight. A common rationale for policy action is that DTC services might cause undue anxiety. However, emerging evidence suggests that this is not the case. Indeed, it appears that genetic risk information has little impact on individual behavior or anxiety levels. Though more research is clearly needed, this type of research should inform the regulatory response to DTC services.     

Genetic tests obtainable through pharmacies: the good,the bad,and the ugly

Genomic medicine seeks to exploit an individual’s genomic information in the context of guiding the clinical decision-making process. In the post-genomic era, a range of novel molecular genetic testing methodologies have emerged, allowing the genetic testing industry to grow at a very rapid pace. As a consequence, a considerable number of different private diagnostic testing laboratories now provide a wide variety of genetic testing services, often employing a direct-to-consumer (DTC) business model to identify mutations underlying (or associated with) common Mendelian disorders, to individualize drug response, to attempt to determine an individual’s risk of a multitude of complex (multifactorial) diseases, or even to determine a person’s identity. Recently, we have noted a novel trend in the provision of private molecular genetic testing services, namely saliva and buccal swab collection kits (for deoxyribonucleic acid (DNA) isolation) being offered for sale over the counter by pharmacies. This situation is somewhat different from the standard DTC genetic testing model, since pharmacists are healthcare professionals who are supposedly qualified to give appropriate advice to their clients. There are, however, a number of issues to be addressed in relation to the marketing of DNA collection kits for genetic testing through pharmacies, namely a requirement for regulatory clearance, the comparative lack of appropriate genetics education of the healthcare professionals involved, and most importantly, the lack of awareness on the part of both the patients and the general public with respect to the potential benefits or otherwise of the various types of genetic test offered, which may result in confusion as to which test could be beneficial in their own particular case. We believe that some form of genetic counseling should ideally be integrated into, and made inseparable from, the genetic testing process, while pharmacists should be obliged to receive some basic training about the genetic tests that they offer for sale.     

Global Reporting Initiative's environmental reporting: A study of oil and gas companies

In this paper, we ask if the use of a voluntary standard assessment system for environmental reporting could help mitigate the damage caused by oil and gas companies to developing nations. What level of data reporting by these companies is needed to allow the assessment of environmental practices? To answer these questions, we evaluate the environmental practices of eight oil and gas companies against the Sustainability Reporting Guidelines issued in 2006 by the Global Reporting Initiative (GRI). Content analysis of their environmental reports 2009 indicates that they made reasonable efforts to disclose their environmental performance in accordance with the GRI Sustainability Reporting Guidelines. These guidelines appear to provide a robust and readily available tool for reporting comprehensive progress concerning all aspects of environmental activities. The voluntary adoption of the guidelines by a vast majority of the oil and gas companies increases transparency, credibility and comparability in sustainability reporting. In addition, five of the eight oil and gas companies disclosed that they had obtained third-party assurance of their sustainability reports.     

"Be ready against cancer, now": direct-to-consumer advertising for genetic testing

A recent addition to the debate about the benefits and harms of direct-to-consumer (DTC) advertising of medicines and pharmaceuticals is a growing critique of DTC marketing and sale of genetic tests. Academic and policy literatures exploring this issue have, however, tended to focus on the sale of genetic tests, paying rather less attention to the particular implications of advertising. The globalization of broadcast media and ever increasing access to the Internet mean that public exposure to advertising for medical technologies is a reality that national regulatory bodies will be hard pressed to constrain. Working through a case study detailing Myriad Genetics' 2002 pilot advertising campaign for their BRACAnalysis genetic susceptibility test for hereditary breast and ovarian cancer, this paper highlights some of the diverse and often overlooked and unregulated approaches to DTC advertising, and the associated social, ethical and policy implications.     

Ethical, legal and social issues in nutrigenomics: the challenges of regulating service delivery and building health professional capacity

Nutrigenomics, the conjunction of molecular nutrition with human genomics, is among the first publicly available applications of the human genome project. Nutrigenomics raises ethical, legal and social issues particularly with respect to how the public may access nutrigenetic tests and associated nutritional and lifestyle advice. Current regulatory controversy focuses on potential harms associated with direct-to-consumer (DTC) marketing of nutrigenetic tests and especially the need to protect consumers from unreliable tests, false claims and unproven dietary supplements. Nutrigenomics does, however, offer the potential of important health benefits for some individuals. The regulation of nutrigenomic services is slowly evolving, but there is little indication of increased professional capacity to support service delivery. Primary care physicians have minimal training in nutrition and genetics, and medical geneticists are in high demand and short supply. Dietetic practitioners are experts in nutrition science and interest in nutrigenomics is growing among members of this professional group. However, as with physicians, dietetics practitioners would require considerable training to bring nutrigenomics into their practice capacity. A downside of regulatory restrictions on direct consumer access to nutrigenomics companies is that responsible businesses may be hindered in meeting emergent public demand while health care professional groups have not yet developed capacity to provide nutrigenomics services.     

Quality Assessment of Commercially Produced Entomopathogenic Nematodes

The quality of the most widely commercialized entomopathogenic nematodes, Steinernema carpocapsae (Weiser) and Heterorhabditis bacteriophora Poinar, was assessed from 30 shipments from six United States suppliers mailed to three locations. These suppliers comprise a cottage industry aimed in large part at a mail-order market. Most companies were accessible and reliably shipped pure populations of the correct species on time, in sturdy containers, and often with superb accompanying instructions. Nematodes were received in satisfactory condition with acceptable levels of viability. Consistency, however, was a problem, with each supplier having one or more weak spots to bolster. Most shipments did not contain the expected nematode quantity, and one shipment had no nematodes. Pathogenicity of several products against Galleria mellonella (L.) larvae was not equivalent to our controls. H. bacteriophora was not always available when ordered. A few products contained mixed populations of both nematode species. Application rate recommendations provided by some suppliers appeared unsound. We conclude that (1) the entomopathogenic nematode cottage industry lacks rigorous quality control, (2) self-regulation is problematic without feedback on quality, and (3) consumers are rarely able to provide this feedback. Improved reliability by the nematode industry will most likely be achieved via industry-generated agreement on standards for quality.     

A critical appraisal of the scientific basis of commercial genomic profiles used to assess health risks and personalize health interventions

Predictive genomic profiling used to produce personalized nutrition and other lifestyle health recommendations is currently offered directly to consumers. By examining previous meta-analyses and HuGE reviews, we assessed the scientific evidence supporting the purported gene-disease associations for genes included in genomic profiles offered online. We identified seven companies that offer predictive genomic profiling. We searched PubMed for meta-analyses and HuGE reviews of studies of gene-disease associations published from 2000 through June 2007 in which the genotypes of people with a disease were compared with those of a healthy or general-population control group. The seven companies tested at least 69 different polymorphisms in 56 genes. Of the 56 genes tested, 24 (43%) were not reviewed in meta-analyses. For the remaining 32 genes, we found 260 meta-analyses that examined 160 unique polymorphism-disease associations, of which only 60 (38%) were found to be statistically significant. Even the 60 significant associations, which involved 29 different polymorphisms and 28 different diseases, were generally modest, with synthetic odds ratios ranging from 0.54 to 0.88 for protective variants and from 1.04 to 3.2 for risk variants. Furthermore, genes in cardiogenomic profiles were more frequently associated with noncardiovascular diseases than with cardiovascular diseases, and though two of the five genes of the osteogenomic profiles did show significant associations with disease, the associations were not with bone diseases. There is insufficient scientific evidence to conclude that genomic profiles are useful in measuring genetic risk for common diseases or in developing personalized diet and lifestyle recommendations for disease prevention.