Creating Trust: A Proposal for Effective Communication of Genome Editing Hilary Gehin

Introduction

Imagine if discovering you had cancer meant that all you had to do for treatment was schedule an appointment to undergo gene therapy.   After one simple procedure, free from the painful side effects of chemotherapy, your cancer is eradicated.

This is a potential reality on the horizon of the medical field; one that could have a significant impact on global health. Considering that 39.6% of men and women will be diagnosed with cancer at some point in their lifetime (National Institute of Cancer), finding a cure would significantly improve many people’s quality of life.

An area of current research aimed at targeting cancer is genome editing. Genome editing is the process of inserting, deleting, or replacing genes using nucleases (Wikipedia). Much current research with genome editing specifically employs the CRISPR-Cas9 system. This technique involves clustered regularly interspaced short palindromic repeats (CRISPR) which guide RNAs in attaching to a targeted DNA sequence and recruit the Cas9 endonuclease to cleave DNA. Either the targeted gene is removed, or a new gene is inserted at the cleavage site (Hwang, 2013). Compared to other genome editing systems, CRISPR-Cas9 has the advantage of being easier and more precise in identifying cancer targets (CRISPR).

With its potential implications, genome editing affects a wide range of interest groups. Cancer patients, research institutes, and scientists all are impacted by genome editing. This technology could create a huge industry, allowing for patients to be cured of ailments, cut health costs of expensive cancer treatments, and establish funding for researchers on genome editing technology.

As a rapidly advancing technique, genome editing is quickly seeping into public discourse. The most current news related to genome editing is the Human Genome Editing Summit, which occurred in Washington DC December 1st—3rd, 2015. The purpose of the meeting was to bring together experts to gauge the varying attitudes and concerns behind genome editing. Additionally this gathering uncovered the most up-to-date perceived benefits and risks of genome editing. On the one hand, there was the opinion that genome editing has potential health benefits for targeting conditions such as HIV and blood diseases (Travis, 2015).

However, concerns were raised about using genome editing for cosmetic reasons. People expressed wariness over eugenics, or utilizing genome editing for enhancement. Additionally, there was some disagreement about editing germ line cells. One side argued that editing germ line cells could help eradicate inherited genetic disorders before conception while the opposing side argued that with much still unknown about how genes interact, this procedure might affect future generations in undetermined, potentially negative ways.   In the US, editing germ line cells is currently not supported by the government, although there are currently no policies outlawing it (Saey, 2015). Another issue posed at the summit was the possibility of affecting non-targeted genes, or creating a domino effect of potentially damaging healthy genes that interact with the targeted gene (Travis, 2015).

 

Overall, the summit raised awareness of general public and expert perceptions of genome editing. The key concern implied is that the excitement surrounding genome editing could overshadow the potential ethical implications. While for now the purpose is therapeutic, there is worry that this technology will be used unethically in the future. In addition to the concerns posed at the summit, some scientists worry about “designer babies,” or that one day we will be able to chose the intelligence, sexual orientation, physical traits, and personality of fetuses in vitro (Christensen, 2015). This could also have a negative impact on the poor. For example, could we start discriminating against people who cannot afford to change their genes for cosmetic reasons?

The other key issue raised at the summit was that experts should seek to find public acceptance of genome editing while acknowledging public concerns. As US Congressman Bill Foster announced at the summit:

“For many people outside this room, including most members of Congress, CRISPR is still an unknown term…I believe that it’s important that the first side of CRISPR presented to the public is a positive one. CRISPR and related technologies have the potential to revolutionize the treatment of diseases but could be used in many ways not beneficial to society” (Travis, 2015)

 

Despite their agreement that public acceptance is necessary as genome editing research moves forward, there were no guidelines given to scientists on how they could go about achieving this goal. With the knowledge of how people perceive and process risk, how technologies similar to genome editing have been evaluated by the public, and knowing what makes an effective risk communicator, I will outline a plan for how experts can effectively communicate the risks and benefits of genome editing. The goal is to keep the public informed, involved, and confident in the experts.

What is Risk?

Before exploring how people perceive risk, it is important to define “risk.” Renn (1992) defines risk as containing three elements: undesirable outcomes, possibility of occurrence, and state of reality. In this case, undesirable outcomes would be unknown effects of genes interacting and the ethics of editing germ line cells and designer babies. There are several ways risk can be evaluated. From a technical perspective, you can look at the estimated expected physical harm (unknown side effects of gene interactions). From an economic perspective, the expected utility is considered (how much money will this cost to do? Will the costs of this process cut down on health care spending in the future?).   It’s important to define risk because the definition can impact the outcome of policy debates and allocation of resources (Brossard, 2015). In the case of genome editing, defining the risks is crucial to create policies that both moderate ethical standards and fund therapeutic applications of genome technology.

Risk can further be defined as a combination of hazard and outrage (Brossard, 2015). On one hand, risk can be perceived in terms of hazards, which are the measured and quantified likelihoods of a risky event occurring (Brossard, 2015). Experts commonly definine risk in terms of hazards. In contrast, the public tends to form risk perceptions by focusing on outrage, or the perceived likelihood of how devastating an event would be if it occurred (Brossard, 2015). It is crucial for experts to keep this in mind when communicating the risks/benefits of genome editing, knowing that the public will not necessarily form opinions based on data or statistics.   A further definition of risk is as an event where the outcome is uncertain (Aven & Renn, 2009). By this definition, risk is an event where something of human value is at stake and the outcome is unknown. In this case, human safety and trust in science are at stake, and the outcomes of potential risks of genome editing are highly uncertain since the field is still in development.

Perception and Processing of Risk

Before proposing how to most effectively communicate the benefits and risks of genome editing, it is important to know how people perceive and process risk. There are many theories that explain the perception of risk. Slovic argues that risk is perceived by five factors: controllability, dread, conflict between experts, equity of risks/benefits, uncertainty (Slovic, 1988). Applying these factors to genome editing, one can estimate how people will perceive genome editing.

One study focused on nuclear energy found that action for or against nuclear power was directly influenced by perceived benefits/risks of nuclear technology, which then determined their acceptability for/against nuclear power (Gardner et al., 1982). Thus, whether someone feels in control of their situation affects whether they accept that technology or not. In the case of genome editing, the public has no direct control over where research is going and what it might enable scientists to do. Dread cannot be measured until this matter reaches the public arena. Uncertainty is the key issue here. When genome editing becomes more prevalent in public discourse, we might expect similar results: people who feel a sense of self-efficacy (or that they have control over whether they go through genome editing or not) could be more accepting of genome editing. In communicating risk then, genome editing should be framed as a potential option for cancer patients or people with a genetic disease seeking treatment, not as a tool to manipulate human genomes without awareness or consent.

As genome editing becomes focused on by news sources and is shared with the general public, scientists and other experts must keep in mind that lack of controllability and uncertainty might cause people to perceive genome editing as risky and not as a potential therapeutic tool.

Belief Gap Hypothesis

Another theory of risk perception is the belief gap hypothesis, which states that an ideology is a stronger predictor of risk perception than prior knowledge or gains in knowledge from the media on scientific issues (Nisbet, 2014). Thus, the challenge posed to experts is that merely informing the public of genome editing is not sufficient to promote acceptance. They will rather be more likely to rely on prior beliefs (political or religious, for example) when forming their own opinions of genome editing. This could be an issue, say for religious people who see tampering with genes as “playing God” and will overlook the potential health benefits.

Proof of the belief gap hypothesis is found throughout the literature. In one study, it was discovered that political ideologies have a large impact on beliefs in science (Hamilton 2013). No matter what degree of education, republicans remained steadfast in their beliefs on climate change (Hamilton, 2013). Another study found that party identification moderates the correlation between knowledge and concern about global warming (Malka, Krosnick & Langer, 2009). The challenge experts will face is how to frame genome editing in a way that does not cause it to become a politically charged, partisan issue like climate change(Nisbet, 2014).

Theory of Motivated Reasoning

Another theory of communication that pertaining to genome editing is motivated reasoning: the desire to arrive at conclusions consistent with previous beliefs leads to biased information processing (Nisbet, Cooper, & Ellithorpe, 2014). This is similar to the belief gap hypothesis in that humans tend to use previous convictions as short cuts when forming opinions. Thus when communicating benefits and risks of genome editing, it is important to consider that people will process information differently based on their moral values. If communication related to genome editing is counter to a group or person’s values, they will form a bias against genome editing based on previous biases. For example, people who are currently opposed to GMOs because they consider the technology to be “playing GOd might consider genome editing to be similarly immoral and will thus oppose it without considering the benefits. Thus, science communicators must address these values when forming a communication strategy.

Knowledge Gap Hypothesis

One common misconception in the field of science communication is that knowledge gaps account for higher risk perceptions. Many studies however have refuted this theory. Johnson (1993) made it clear that the tendency to equate lack of knowledge with ignorance is a mistake. Knowledge and ignorance are not two polar extremes because everyone has different levels of knowledge and ignorance on varying topics.

In communicating the risks/benefits of genome editing, experts should avoid the assumption that the general public will form their perceptions based on scientific knowledge. Evidence suggests people will process risk based on experiences. This idea is the foundation of the Heuristic Systematic model (HSM) (Trumbo, 2002). It states that humans process information using systematic processes, heuristic process, or both. Systematic processing examines arguments, past information, and statistics before forming an opinion. Heuristic processing occurs by using simple decision rules to arrive at a judgment. For example, gun violence is a highly polarized issue with republicans tending to support concealed carry licenses and democrats arguing for stricter gun control. Your political stance might cause you to automatically form an opinion on the risk of gun violence, based on either owning a gun yourself or watching the news of mass shootings, without actually researching the statistics behind gun violence risks. In other words, humans use shortcuts in forming risk perceptions (Trumbo, 2002). It can thus be concluded that when people evaluate the risks of genome editing, they will use heuristic processing as well.

Trust Gap Hypothesis

Another theory that explains public risk perception is the trust gap hypothesis. It states that risk perception can be predicted by measuring levels of trust in institutions. One particular study found that trust in institutions is more important than knowledge in predicting agreement with biotechnologies (Priest, Bonfadelli, & Rusanen, 2003). A further study found that trust in industry and of scientists predicts acceptance of genetically modified organisms field experiments (Siegrist, 2012). Since GMOs and genome editing are similar biotechnologies in that they are the manipulation of genes, these results are useful in forming risk/benefit communication campaigns. People may spend less time systematically processing a message, or use short cuts because it is easier for them to make a decision based on how they trust the experts.

While communicating risks/benefits of genome editing, this is crucial to consider because knowledge of the technology and the content of the message aren’t the most important aspects of whether people will accept genome editing or not. The crucial step in gaining public acceptance is creating and maintaining trust in the experts. It is also important to consider people with high moral convictions. A previous study found that people with high moral convictions were influenced by procedural fairness in their acceptance of GMO experiments (Siegrist, 2012). The process of genome editing must be presented as having fairness in the procedures and outcomes. For example, genome editing should be available to everyone once it becomes an established therapy, and the outcomes should be for increased health. To gain public support, genome editing should not be used now for controversial procedures such as germ-line cell editing and eugenics in order to gain public support.

Creating Trust in Experts

Trust has been proven to affect acceptance of technologies. The key to public acceptance of genome editing is building trust between the lay public and experts on genome editing. Engdahl and Lidskog (2012) suggest that trust is created when people are emotionally involved, take part, express their opinions, and recognize themselves as the recipients of trust. Communication of genome editing must be a conversation during which people express their concerns and opinions and scientists and other experts address these worries. Some ways this can be done are by interviewing experts within the field on TV about potential benefits and ethical questions of genome manipulation. Additionally, experts could utilize social media by having well known and trusted public figures prompt public discourse on genome editing, such as Bill Nye or Neil De Grasse Tyson. Lastly, having more opportunities for people to express their concerns would help in fostering an open dialogue. The Human Genome Editing Summit held in Washington, DC is one such example of providing a safe place for the public and experts to share their thoughts, expectations, and concerns regarding genome editing.

Media Amplification

After the Human Genome Editing Summit, and as more research is conducted with CRISPR-Cas9, it is likely the media will have an important influence on how the risks and benefits of genome editing are perceived by the public. While scientists can take responsibility for communicating the scientifically grounded information, the media tends to amplify risks and outrage factors when presenting news stories (Brossard, 2015).

Studies have shown that the news can easily change our risk perceptions. It was found that outrage factors or catastrophic potential determine coverage of health related food risks (Ju et al., 2015). A study on the Fukushima nuclear disaster analyzed how the media communicated the events to the public. Although the news used creative approaches to inform audiences, some TV sources over exaggerated the risks behind the nuclear disaster (Friedman, 2011). Television has the potential to be effective at presenting relevant information to the public in an easily accessible format, but excessive coverage of potential dangers can skew public perception towards focusing solely on risks. Experts must keep this information in mind, knowing that media sources tend to focus more on negative aspects of technology rather than benefits.

This could also apply to the potential risks of genome editing. A risk with more outrage factors tends to get more news coverage (Brossard, 2015). Outrage factors thus amplify a story and can affect people’s risk perceptions (Brossard, 2015). For example, the popular blogger FoodBabe created public outrage when she wrote about Subway sandwiches containing azodicarbonamide, a chemical also found in yoga mats. Although completely safe to ingest, her negative spin created outrage among her followers, who were motivated to pressure Subway into taking the chemical out of its bread recipe (Tapper, 2014).

There seems to be many parallels between nanotechnology and genome editing. Both involve manipulation of genes within an organism. Studies have shown that people are hesitant to accept other technologies similar to genome editing, such as nanotechnology. In addition to the argument that such technologies are akin to “playing God,” the uncertainty of the potential risks of these procedures have caused people to have higher risk perception (Priest, 2003). For example the potential impacts of nanotechnology on human health and the environment are not well-established and cannot be anticipated (Grossman). Not fully knowing the risks of genome editing could cause people to assume what they perceive to be the worst-case-scenario without reassurance from experts on what the actual risks are.

Because genome editing is specifically related to humans, will this cause more or less outrage and amplification in the news? Although experts have so far agreed that the risks of genome editing are largely speculative and unknown, the media could use the uncertainty of the future implications of genome editing as an outrage factor. One article, for example, expressed concerns that genome editing could lead to a situation akin to the movie “Gattaca” where people create designer babies in utero, and as adults people are discriminated against based on their genomic profile (Friedman, 2015).  In “Gattaca,” the main character is at a disadvantage his whole life for being born before the surge of designer babies. Without considering environmental effects, a person’s worth, wealth, and ability to be hired is based on your genetic makeup (Nicoll). Could genetic discrimination turn into a reality? One issue with this is that if insurance companies can base coverage on your genetic profile, people with more money could afford to have healthier babies who would end up being the only ones able to afford health insurance.

While scientists can be as careful as possible about communicating the risks/benefits of genome editing, they must keep in mind that the media likes to latch onto the risks of technologies and has the power to amplify them (Brossard, 2015). This could tip the scale and lead to higher perception of genome editing risk and lower acceptance of that new technology. The amplification by the media alters risk perception, which further affects trust in science, which ultimatgely leads to acceptance or discouragement of emergent technologies (Siegrest et al., 2012).   Although it is important that the public is aware of genome editing for the effect it could have on the health field, the media could negatively affect perceptions of genome editing through lowering trust in experts.

It is clear that we need more effective ways to earn trust for scientists. Engdahl and Lidskog (2014) point out that the lay person uses contextual factors to form their view of risks. While keeping this in mind, risk communication should focus on earning trust from the public. This is important because the public gives legitimacy to the experts’ varying claims. They further argue that experts tend to form risk communication as rigid and not open to conversation and mutual understanding (Engdahl & Lidskog, 2014). Furthermore, experts forget that risks are socially embedded and don’t leave space for other people’s perspectives. This is especially important to keep in mind when communicating genome editing because this new technology will, if not now, in the future, affect the general public. If experts wish to be successful risk communicators, they must remember to keep open lines of communication with the public and accept their opinions and input.

One example on how this can be done was the panel on designer genes at UW Madison on October 24th, 2015. The panel brought experts and the public together to discuss the potential benefits and risks surrounding genome editing. Such events like these allow the public and experts to communicate and could significantly increase self-efficacy, reduce uncertainty, and make the balances of risks and benefits of genome editing clearer. As Engdahl and Lidskog (2014) note: “trust is created when people are emotionally involved, take part, express opinions, and recognize self in recipient of trust” (p. 714).

With these theories in mind, it is imperative to remember the importance of communicating risks. Risks imply that there is a potential for accidents or catastrophes, which can incur social and economical costs (Brossard, 2015). While genome editing can be framed as beneficial, scientists need to avoid improper risk estimation by eschewing overconfidence of benefits, avoiding potentially catastrophic low probabilities (crossing ethical boundaries into eugenics), and pressures from sponsors or political parties that try to push a technology without properly considering all the risks (Freudenburg, 1988).

A Plan for Communicating Genome Editing

In communicating genome editing risks/benefits, the goal should be to avoid the backlash GMOs have faced. The intention of creating GMOs was positive: make food that is insect resistant and more nutritionally dense. However, there has been significant backlash against GMOs. The moniker, “Frankenfood” that has been attributed to GMOs illustrates the uncertainty and fear behind GMOs (Guthrie, 2013). Thus people are opposed to GMOs and understand the uncertainties behind them, but are not well informed on the benefits.  With genome editing, the main goals should be to accurately present the risks and benefits associated with the procedure, and build trust in experts.

One error science communicators should avoid when discussing genome editing is overconfidence. As important players in the field of risk communication, media sources should also avoid overconfidence in presenting the results of genome editing studies. Focusing too much on the benefits ignores the any public concerns over uncertainties, potential risks and ethical implications of this emergent technology. On the other hand, knowing that people respond to negativity more strongly, the experts and media should avoid amplifying the uncertainty and promoting a sense of controllability. If the public does not feel in control with regard to genome editing, this could lead to fear, outrage, and higher perception of risk. For example, genome editing germ line cells or creating designer babies does not give the future child a choice in editing his/her genes. Experts should come together and have a unified outlook on genome editing. Disagreement among experts further amplifies public risk perception (Slovic, 1992).

Summary

With that, the question remains: how can risks and benefits of genome editing be effectively articulated? First, specialists should find out what people’s needs and expectations are related to genome editing. A study focused on nuclear energy found that although most lay people reported a negative view of nuclear energy, they wanted more accessible information on the topic (Skarlatidou, Cheng & Haklay, 2012). The findings show that although lay people had little knowledge of nuclear power, they were aware of their knowledge gap and were willing to seek more information if it was available and easy to digest. The authors suggested that information on nuclear power should have context organized according to the needs and expectations of lay people (Skarlatidou, Cheng & Haklay, 2012). Similarly, the same approach should be used for genome editing. In this case, public needs could include therapies for cancer and other genetic disorders. Expectations could include scientists adhering to ethical standards. This information will further guide experts in disclosing the risks and benefits of genome editing.

The first step in communicating genome editing should be to clearly articulate the magnitude of risks and ethical issues. Like all medical procedures, the risks need to be weighed against the benefits. Additionally, self-efficacy must be promoted. If people perceive that genome editing is something that could happen to them, but they would have no control of (for example, having their genes edited in vitro), they will have a higher risk perception (Brossard, 2015). Additionally, the risks and of genome editing should be compared accurately to similar risks. Risk perception can be greatly amplified is a risk is taken out of context (Brossard, 2015).

While the public should be aware of potential hazards and ethical issues of genome editing, it is important that they are kept in perspective. Sensationalist information should be limited as experts and media communicate genome editing. Sensationalist information includes worst-case scenarios and loaded words (Brossard, 2015). If experts want the public to accept the potential therapeutic benefits of genome editing, sensationalism should be avoided. Lastly, genome editing should be presented as a thematic event. Genome editing is not an isolated discovery but an emerging technology from the wide field of genomics and gene therapy. While informing the public of this new research, it is crucial to show how genome editing has evolved from years of work within the genetics field.

Conclusion

While experts have shown that genome editing has the potential to significantly improve public health, it is important to acknowledge the potential concerns and risk perceptions the public might harbor. Given what is known about similar technologies, how people perceive risk, and what comprises effective risk communication, I have outlined what experts need to know in order to accurately present genome editing. Additionally, I have stressed the importance of creating trust between the public and experts in regards to genome editing. What we can learn from past failures in scientific communication is that uncertainty of a technology creates mistrust in experts, which causes higher risk perceptions. Building trust is a crucial step towards public acceptance of genome editing. Trust in experts will show that the public is confident that scientists are taking proper precautions to ensure that genome editing is used ethically and responsibly.

In sum, clear communication of genome editing as a potentially beneficial medical procedure that requires further research and raises ethical questions will help citizens make informed decisions and opinions. The ultimate goal is to create trust in experts. Unsuccessful science communication has lead to mistrust, which has in turn affected government policies; as has been the case with climate change (Brownell, 2013). With a clear communication campaign based on what has and hasn’t worked in the past, experts can work towards a public understanding, thus promoting trust in genome editing experts. Ultimately, how successful scientists are at communicating genome editing will affect government decisions on policies, funding, and regulation, which in turn has the potential to significantly impact human health.

 

 

 

 

References

Aven, T. & Renn, O. (2009). On risk defined as an event where the outcome is uncertain. Journal of Risk Research, 12:1, 1-11.

doi: 10.1080/13669870802488883

Brossard, D. (2015). Defining risk [Power point].

Brossard, D. (2015). Media and risk perception[Power point].

Brownell, S. E., Price, J. V., & Steinman, L. (2013). Science communication to the general public: Why we need to teach undergraduate and graduate students this skill as part of their formal scientific training. Journal of Undergraduate Neuroscience Education, 12(1), E6–E10.

Christensen, J. (2015). The slow crawl to designer babies. CNN. Retrieved from: http://www.cnn.com/2015/12/03/health/designer-babies-gene-editing/

Engdahl, E. & Lidskog, R. (2014). Risk, communication and trust: Towards an emotional understanding of trust. Public Understanding of Science: 23:6, 703–717. doi: 10.1177/0963662512460953

Freudenburg, W. (1988). Perceived risk, real risk: Social science and the art of probabilistic risk assessment. Science, New Series, 242:4875, 44—49.

Freudenburg, W. (1992). Heuristics, biases, and the not-so general publics: Expertise and error in the assessment of risks. In S. Krimsky & D. Golding (Ed.), Social Theories of Risk (pp. 229–249). Westport, CT: Praeger.

Friedman, L. (2015). These are the countries where it’s ‘legal’ to edit human embryos (hint: the US is one). Business Insider. Retrieved December 8th, 2015 from: http://www.businessinsider.com/china-edited-human-genome-laws-2015-4

Friedman, S. (2011). Three Mile Island, Chernobyl, and Fukushima: An analysis of traditional and new media coverage of nuclear waste accidents and radiation. Bulletin of the Atomic Scientists, 67:5, 55–65.

doi: 10.1177/0096340211421587

Gardner, G., Tiemann, A., Gould, L., DeLuca, D., Doob, L., & Stolwijk, J. (1982). Risk and benefit perceptions, acceptability judgments, and self-reported actions toward nuclear power. The Journal of Social Psychology, 116, 179–197.

Genome editing (n.d.). In Wikipedia. Retrieved December 8, 2015, from: https://en.wikipedia.org/wiki/Genome_editing

Grossman, E. (n.d.). Tiny materials in countless products raise big questions for environment and health. Ensia. Retrieved December 8th, 2015 from: http://ensia.com/features/tiny-materials-in-countless-products-raise-big-questions-for-environment-and-health/

Guthrie, C. (2013). Frankenfood=genetically modified foods. Experience Life. Retrieved from: https://experiencelife.com/article/frankenfood-genetically-modified-foods/

Hwang, W., Du, W., Reyon, D.,…, Joung, J. (2013). Efficient in vivo genome editing using RNA-guided nucleases. National Biotechnology, 31(3) 227-229. doi: 10.1038/nbt.2501

Johnson, B. (1993). Risk: Issues in Health & Safety: 189, 189–212.

Ju, Y., Lim, J., Shim, M., & You, M. (2015). Outrage factors in government press releases of food risk and their influence on news media coverage. Journal of Health Communication, 20, 879–887. doi: 10.1080/10810730.2015.1018602

Malka, A., Krosnick, J., & Langer, G. The association of knowledge with concern about global warming: Trusted information sources shape public thinking. Risk Analysis: 29:5, 633–647. doi: 10.1111/j.1539-6924.2009.01220.x

National Cancer Institute (n.d.). CRISPR: Genome editing comes of age. Retrieved December 8th, 2015 from: http://www.cancer.gov/about-cancer/causes-prevention/research/crispr

Nicoll, A. (n.d.). Gattaca movie review summary. AllReaders.com. Retrieved December 8th, 2015 from: http://allreaders.com/movie-review-summary/gattaca-9346

Nisbet, E., Cooper, K., & Ellithorpe, M. (2014). Ignorance or bias? Evaluating the ideological and informational drivers of communication gaps about climate change. Public Understanding of Science: 24:3, 285–301.

doi: 10.1177/0963662514545909

Priest, S., Bonfadelli, H., & Rusanen, M. (2003). The “trust gap” hypothesis: Predicting support for biotechnology across national cultures as a function of trust in actors. Risk Analysis: 23:4, 751–766.

Renn, O. (1992). Concepts of Risk: A Classification. In S. Krimsky & D. Golding (Ed.), Social Theories of Risk (pp. 53–79). Westport, CT: Praeger.

Saey, T. (2015). White House hits pause on editing human germ line cells. Science News. Retrieved December 8th, 2015 from: https://www.sciencenews.org/blog/science-ticker/white-house-hits-pause-editing-human-germ line-cells

Siegrist, M., Connor, M., & Keller, C. (2012). Trust, confidence, procedural fairness, outcome fairness, moral conviction, and the acceptance of GM field experiments. Risk Analysis: 32:8, 1394–1403.

doi: 10.1111/j.1539-6924.2011.01739.x

Skarlatidou, A., Cheng, T., & Haklay, M. (2012). What do lay people want to know about the disposal of nuclear waste? A mental model approach to the design and development of an online risk communication. Risk Analysis: 32, 1496–1509. doi: 10.1111/j.1539-6924.2011.01773.x

Slovic, P. (1992). Perception of Risk: Reflections on the psychometric paradigm. In S. Krimsky & D. Golding (Ed.), Social Theories of Risk (pp. 117–152). Westport: CT, Praeger.

Tapper, J. (2014). Meet the ‘food babe’ who helped convince Subway to remove chemical from bread. Lead the Tapper. Retrieved December 8th, 2015 from: http://thelead.blogs.cnn.com/2014/02/06/meet-the-food-babe-who-helped-convince-subway-to-remove-chemical-from-bread/

Travis, J. (2015). Inside the summit on human gene editing: A reporter’s notebook. Science Insider. Retrieved from: http://news.sciencemag.org/scientific-community/2015/12/inside-summit-human-gene-editing-reporter-s-notebook

Trumbo, C. (2002). Information processing and risk perception: An adaption of the heuristic-systematic model. Journal of Communication: 52:2, 367–381.

Wade, S. (2015, March 19). Scientists Seek Ban on Method of Editing the Human Genome. The New York Times. Retrieved from: http://www.nytimes.com/2015/03/20/science/biologists-call-for-halt-to-gene-editing-technique-in-humans.html?_r=2

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Kneaded Transparency: Ethical Perspectives on the Rise of Gluten-free Blogs

Below is a paper I wrote for my Ethics in Journalism class last semester.  This is my response to pseudoscience that persists on gluten-free blogs

 

        

“Imagine a world in which you could freely communicate with anyone you chose, but you could never be sure that what others told you was truthful or accurate, or even whether anyone ever actually cared about such things”—Plaisance

 

Introduction

         Gluten-free Industry

In the US today, we are bombarded with messages from “experts” that claim innocuous foods are the cause of various illnesses; from obesity and gastrointestinal issues, to diseases such as Alzheimer’s. Although scientific research can readily disprove these “pseudoscientists,” and invalidate their credibility, they maintain a dedicated following. In particular, the gluten-free movement has gained a bandwagon-like following after the publication of books such as “Wheat Belly” and “Grain Brain.” The gluten-free industry has proliferated over the years as the demand for gluten-free food products has skyrocketed (Kluger, 2014).

Studies have shown that unless a person has celiac disease or a wheat allergy, a gluten-free diet could actually be harmful, resulting in nutrient deficiencies (Strawbridge, 2013). Yet bloggers and writers alike who praise the benefits of a gluten-free diet are biased in that they have a gluten related medical condition or an industry built on gluten-free products. This causes cherry picking and exaggerating scientific research that could ultimately be damaging to unsuspecting, healthy lay people. Ignoring the credibility principles laid out by Plaisance (2013) and journalism ethics, these bloggers are amplifying the pseudoscience behind gluten intolerance.

Blogging

Blogging started as the emergence of various online journals with the purpose of sharing thoughts and ideas with others. The number of blogs has risen from 23 in 1999 to over 1.5 billion in 2014 (eZaroorat). Today 23% of Internet time is spent on blogs and 77% of Internet users read blogs (McGrail, 2013). Blogs are an influential form of communication as they rank favorably with consumers for trust, popularity, and influence (Redsicker, 2013). Additionally, 90% of 18—24 year olds reported that they would trust medical information shared by others on social media (Appendix A). Lastly, NPR reported that 1/3 of Americans are currently trying to go gluten-free (Shute, 2013). The data suggests that blogs can have a prominent impact on public health and diet trends. Gluten-free blogs in particular have the potential to motivate the general public to adopt the author’s diet and lifestyle. For example, even though Dr. William Davis, author of “Wheat Belly,” acknowledges on his blog that his posts should not be taken as medical advice, the comments on his blog show that people do follow his teachings and think that his recommendation to cut out all grains is sound medical advice.

This illustrates alarming evidence that blogs tend to be biased, ideological, and written by people who have similar interests to them. Because blogs have the potential to influence people’s opinions and perceived risks, they can play a large role in amplifying the pseudoscience and confusion existing behind gluten intolerance.

The gluten-free fad has taken what is a terrible disease for a small portion of the population and turned it into a trendy, multibillion-dollar industry. The Internet, including gluten-free blogs, has socially amplified the risks of gluten consumption. This movement brings up key ethical issues in journalism: bias, conflict of interest, and failure to seek truth in reporting. Gluten-free bloggers have an ethical duty as journalists to reduce the economic and health related harms caused by gluten-free living to those without a medically confirmed wheat allergy or celiac disease.

The Pseudoscience of Gluten Intolerance

As three distinct conditions related to gluten (Sanghavi, 2013) have become more apparent to the general public, the public perception of gluten has turned negative. The first condition, celiac, is a genetic, autoimmune disease. People who have this condition must avoid eating gluten because they experience extreme pain and small intestine damage when they consume food containing gluten (Celiac Disease Foundation, 2015). One percent of the US population has celiac disease, but only a small portion of those afflicted have been properly diagnosed (Sanghavi, 2013). The second medical condition related to gluten is wheat allergy: “an allergic reaction to foods containing wheat” (Mayo Clinic, 2015). The wheat specific antibody IgE causes an allergic reaction when someone with the allergy consumes food containing gluten (Sanghavi, 2013). Like patients with celiac disease, those with a wheat allergy must completely eliminate foods with gluten from their diet to avoid serious allergic reactions.

The third ailment related to gluten is supported by little peer-reviewed science, and no universally accepted diagnosis: gluten intolerance. According to Sanghavi, gluten intolerance is “not either an autoimmune disorder, like celiac disease, nor an allergy, like true wheat allergy” (2013). Other synonyms of gluten intolerance are: “gluten sensitivity” and “non-celiac gluten sensitivity.” Unlike celiac disease, gluten intolerance does not damage the small intestine. However, patients who claim to have GI report having gastro-intestinal issues, fatigue, and headaches as a consequence of gluten consumption (Web MD, 2015). The issue with diagnosing this condition is that there is no blood test (how people with celiac get diagnosed) or any scientifically grounded medical procedure that can confirm or deny a gluten intolerance/sensitivity. Thus, people who claim to be GI base their diagnosis on their “subjective feelings of bloating, bowel changes, or mental fogginess after eating gluten” (Sanghavi, 2013). Without a well-established diagnosis, it’s impossible to either confirm or deny whether someone is legitimately GI.

The pseudoscience behind GI stems from reliance on individuals’ perceptions of what they consider to be symptoms of GI, rather than peer-reviewed science. As Sanghavi puts it: “This is a set-up for all manner of pseudo-scientific self-diagnoses, especially when you consider that 2 percent of people believe they have illnesses caused by magnetic fields” (2013). With no one to be able to fairly refute otherwise, and with vague symptoms that could be attributed to countless other ailments, anybody can claim to be GI. To further complicate matters, a study found that non-celiac wheat sensitivity is a distinct clinical condition (Carroccio, A., et al., 2012). To date, this is the only study to suggest gluten intolerance is indeed a medical condition, and has not been tested or repeated by any other researchers to date. Although this is the first and only study providing evidence that supports the legitimacy of GI, this article is often cited by gluten-free blogs as scientific confirmation that their diet is the best choice for people who don’t necessarily have a confirmed disease or wheat allergy.

When exactly the gluten-free fad diet started is not known, but what is clear is that the amplification of the risks of eating gluten took off when health bloggers started promoting gluten-free diets to lose weight. As with any fad diet, the promise of shedding pounds and looking healthier is much more appealing than adopting a healthy lifestyle that includes proper nutrition and exercise. The gluten-free movement appeals to people because it is framed like a cure-all for numerous health issues. In an article that explains why fad diets exist, Robyn A. Osborn, RD, PhD, states that:

“People are very much intrigued by those things that seem to demystify the whole thing — there’s some magic hormone, or there’s something in your blood type, you have to eat certain foods together because of how they’re metabolized. That has to be it. It couldn’t be something as simple as I need to eat less and I need to exercise more” (Downs, M., 2005).

Marketers have taken advantage of the gluten-free craze as an opportunity to make money while providing consumers with gluten-free products. The ease of buying gluten-free foods has steadily increased as food companies replace gluten containing products and clearly label their products as gluten-free. According to Kluger, the gluten-free industry is a lucrative, multi-million dollar business. From 2010 to 2014, sales of products in the U.S. labeled as “gluten-free” rose from $11.5 billion to $23 billion (Kluger, 2014). Advocates of gluten-free diets are profiting too. Dr. Perlmutter, author of the bestseller “Grain Brain,” has created an empire on top of his book earnings by selling things from Coconut oil to an $8,500 brain detoxification retreat (Levinovitz, 2003). Going gluten-free however, is expensive. A study found that on average, gluten-free products cost 242% more than regular products (Stevens, 2008).

One may question why meeting the demands of consumers is necessarily harmful. If people chose to go gluten-free because they report feeling better on a gluten-free diet, does it matter that these companies are profiting from meeting public demand?

The answer, in short, is yes.

Not only are gluten-free foods not beneficial to your health if you do not have a medically diagnosed, gluten related condition, gluten-free products lack vital nutrients. For example, gluten-free spaghetti and pancake mix have less fiber and protein, but more sugar and sodium than the original products (Kluger, 2014). Additionally, the increasing availability of gluten-free foods gives consumers the impression that just because something is gluten-free, it is healthy. As Kluger puts it: “The gluten-free fad has actually undermined people’s health because now there are gluten-free varieties of all that junk food. Whether your doughnut is gluten-free or not, it’s still a doughnut” (2014). “Gluten-free” has joined the ranks of other buzzwords such as “all natural” and “organic” that imply a food is healthy and nutritious, but is not always the case.

Bias in Media

Dr. Davis, who profits off of his gluten-free brand, is one example of how the gluten-free industry is run by supporters biased towards a gluten-free lifestyle. Bias in media occurs when a journalist “slant[s] the news in favor of a political or ideological perspective, or covertly push an agenda” (Plaisance, 2013). Whether a journalist is acting ethically or not is often based on the presence of a bias influencing the contents of a story (Plaisance, 2013). In the case of gluten-free bloggers, a bias among the writers becomes apparent. Results of a Google search of the top gluten-free blogs revealed that many websites have a common factor: most bloggers had either an autoimmune disorder or wheat related disease (Table 1). However, out of the top five bloggers with the most combined Facebook, Twitter, and Pinterest followers, only one has celiac disease. The other four most followed bloggers have, respectively: eating disorder, adrenal burnout, carrier (but not diagnosed) for celiac, and a family member with celiac. These results make it clear that although many gluten-free bloggers have a medical reason for going gluten-free, the most followed ones do not have a gluten related illness themselves.

The main dilemma is that although the majority of gluten-free bloggers on the internet have celiac disease or a confirmed wheat allergy, making it necessary for them to completely cut gluten out of their diet, the most followed bloggers do not. On the one hand, those with celiac disease or a wheat allergy benefit from these sites to find products and advice for easily adapting to a gluten-free life. The more popular blogs however, are run by people who do not have a confirmed gluten related diagnosis. For the small portion of the US population that must be gluten-free, no matter who the author is, these websites are helpful in forming a community of similar citizens to foster support and guidance on how to live with their strict dietary requirements. However, someone who decides to go gluten-free because they have been misled to believe they will lose weight or obtain better health would have to put work into investigating and finding out the reason the blogger is gluten-free. The unsuspecting reader might thus be tricked into buying expensive products promoted by the blogger.

Table 1. Content Analysis of Gluten-free Blogs

Followers
Blog name Disease Advertisements on Page Facebook Twitter Pinterest Total
Oh She Glows recovered eating disorder cook book 282,626 68,500 1,166,000 1,517,126
Elana’s Pantry celiac cook book 252,984 261,000 328,000 841,984
Whole New Mom adrenal burnout Promotes products 77,672 117,000 441,000 635,672
Gluten-free Goddess carrier for celiac gene promotes GF baking products on Amazon 122,151 3,358 507,000 632,509
Gluten-free on a shoestring none, but son has celiac books 422,160 3,522 28,000 453,682
Gluten-free Girl celiac books 114,883 198,000 0 312,883
Wuthering Bites unknown none 3,743 303,000 657 307,400
My Darling Lemon Thyme self reported gluten intolerance cook book 17,139 2,626 249,000 268,765
Cannelle et vanille Meniere’s Disease cook book, classes 0 25.4K 151,000 151,000
Gluten-free Mom child has celiac promotes products 10,144 1,614 86,000 97,758
CAFÉ by Jackie Ormann celiac contributor to other websites/magazines 4,270 1,205 32,000 37,475
Art of gluten-free baking confirmed wheat allergy cook books, classes 5,376 7,081 432 12,889
Gluten-free Doctor self reported gluten intolerance classes 371 8,318 7.6K 8,689
Gluten-free for Good celiac book 5,731 2,407 0 8,138
Poor and Gluten-free Oral Allergy Syndrome, self reported gluten intolerance cook books, product reviews 1,396 646 3,000 5,042
Sondi Bruhner Crohns cookbooks, consultations 748 1,216 410 2,374
Baking Backwards unknown Book 328 159 129 616

 

Credibility Principles and Gluten-free Bloggers

Bloggers with wheat related medical conditions, but no credibility to make diet recommendations, are playing a role in amplifying the risks of consuming gluten and using their websites as platforms to sell personal products. Their biases are affecting their credibility as writers, journalists, and media creators. This has potential negative ramifications because credibility is the key to establishing trust with readers and reducing harm to the public (Plaisance, 2013).

Many newspapers and journals have a code of credibility principles because “serious communicators are concerned about being perceived as credible sources of information” (Plaisance, 2013). Bloggers, even independent ones, are still communicators. If they want people to pay attention to their message, establishing credibility is important. Credibility is a building block of professionalism (Plaisance, 2013). Journalists protect their credibility by having “an unflinching commitment to the pursuit of the truth, even when that pursuit becomes unpopular, and a scrupulous avoidance of sensationalism and conflicts of interest” (Plaisance, 2013).

Bloggers are journalists in that they write and publish articles that are intended to be viewed by others. Thus, they should also be committed to communicating the truth and avoid biases. The fact that most gluten-free bloggers are gluten-free for medical reasons that are not applicable to the general public, and the top bloggers do not have a gluten-related condition, undermines their credibility and proves their conflicts of interest.

According to Plaisance, there are five key principles that are embraced by all media groups. Three of these principles that relate to gluten-free bloggers are: responsibility to society; decency, honesty and truth; and avoidance of deception and misrepresentation (Plaisance, 2013). Applying these principles to bloggers, their acts of self-publication on the Internet come with an implicit responsibility to their followers. The information that they post is not contained within a vacuum, but has the potential to reach and influence a wide audience.

Secondly, as media producers, bloggers must be honest and truthful to their readers. Failing to acknowledge that their diet and lifestyle is not only not beneficial to the majority of the population, but also potentially harmful, is in contrast to this principle. Bloggers who are gluten-free for non-medical reasons are not truthful in that they ignore the science discounting gluten intolerance and the alleged “benefits” of a gluten-free diet. This leads into the last principle, which is avoiding deception and misrepresentation. The gluten-free food industry is aimed at making money rather than seeking to improve public health. Gluten-free bloggers play a role in this deception by promoting their own products and not being transparent about the reasons why few people require a gluten-free diet while others should avoid it.

Ethical theory considerations

In addition to failing to follow Plaisance’s credibility principles, these gluten-free bloggers are acting unethically as journalists.

Looking at the actions of these bloggers from a virtue ethic perspective, gluten-free bloggers are not demonstrating responsible journalism practices. Virtue ethics is based on the principle that our behaviors should help people flourish (Culver, 2015). While it is true that gluten-free blogs would indeed help people with autoimmune diseases or wheat allergies flourish, the lack of transparency counters the good one might argue they are achieving. Since most people do not benefit from a gluten-free diet, these blogs are not helping the population as a whole benefit.

Gluten-free bloggers further fail to act ethically from a deontological perspective. Deontological ethics looks at what our duties are, and how well we are adhering to our duties determines whether our actions are ethical (Culver, 2015). In this case, bloggers have a duty to be transparent and tell the truth. Because most bloggers either do not disclose that going gluten-free is not healthy for everyone and that non-celiac or wheat allergic bloggers ignore the science of gluten intolerance, they are not adhering to their duties as ethical journalists.

Lastly, gluten-free bloggers to do not act ethically from a consequential framework. Consequential ethics looks at the outcomes of an action (Culver, 2015). The outcomes determine whether an action is ethical or not (Culver, 2015). Possible ramifications of gluten-free blogs are the promotion of a lifestyle that deprives people of nutrients and confers no benefits if you do not have a rare and serious allergy. Gluten-free bloggers are either using their own harrowing medical emergencies to push a lifestyle that works for them but not everyone else, or have joined the gluten-free bandwagon while ignored peer reviewed science. Overall, It is clear from analyzing gluten-free bloggers using these three theories that they are not acting as ethical journalists.

First Amendment Considerations

In 2014, the case of Obsidian Finance Group v. Crystal Cox resulted in a ruling that bloggers have the same First Amendment rights as journalists (Meyer, 2014). Couldn’t one argue then that because bloggers have the freedom of the press that they should be allowed to write about whatever they want?

Two theories of the First Amendment would argue that criticizing gluten-free bloggers for lack of transparency is not a valid argument because freedom of speech gives them the right to full control over the content of their blogs.

The first theory, The Marketplace of Ideas, argues that everyone should be able to voice their own opinions (Culver, 2015). The assumption is that with everyone’s ideas being out in the open, the truth will eventually emerge. A person who supports this theory would agree that with all the gluten-free blogs, the truth that gluten-free living isn’t for everyone and will eventually come to light, and health effects of a gluten-free diet will organically become apparent.

The second theory, absolutist theory, states that we shouldn’t restrain free speech for any reason (Culver, 2015). The potential harm caused by gluten-free blogs is irrelevant. Free speech is free speech. They would thus argue that gluten-free bloggers have a right to show as little transparency as they want because their blogs are protected by the First Amendment.

Freedom of speech is an important aspect of the US constitution and should not limit the topics and contents of blogs. To counter refutes utilizing the First Amendment: this is not a legal issue, but an ethical dilemma. Though anyone with a computer and Internet access can create a blog and write about anything they would like, as a journalist they have ethical obligations towards their readers that they should consider before posting articles that lack honesty and transparency.

Transparency

Blogging is a form of online conversation, and communication is crucial for obtaining information, participating in discussions, and sharing ideas. A key component of effective correspondence is trust. Without trust, communication fails to unite people in mutual understanding and cooperation. According to Plaisance (2013), the key to honest exchange is transparency. Transparency, he states, is about what we say and why we say it (Plaisnace, 2013). The term implies that communication necessitates respect for the audience. Someone who wants to be an ethical reporter must have respect for who is receiving the message and therefore disclose their motivations and intentions behind their statements. With the rise of technology as a tool for information transmission, it has become a challenge to trust the messages we receive from the media because bloggers are not held accountable to the strict ethics and regulations of traditional journalists (Plaisance, 2013). Thus it is especially important for bloggers to be transparent to prove respect for their followers and establish trust. If bloggers aren’t perceived as trustful sources of information, their credibility as journalists is tainted. Additionally, this could affect the blogging world as a whole. Losing trust in bloggers, people might not want to read blogs, engage in meaningful conversations online, and seek out information in a private, accessible manner.

Conclusion

Blogging is a new field of journalism that has the potential to influence people’s perceptions of risk and health. Because of the influence they have on society, bloggers should be held to the same ethical standards as any other journalist.  Not doing so, how can we trust any blogger to tell the truth, be transparent, and avoid causing harm? Although bloggers have a right to free expression and speech, they have an ethical responsibility towards their readers.  If bloggers are to be considered journalists, they need to adhere to ethical practices to establish credibility, trust, avoid bias, and reduce harm.

As journalists, it is the ethical responsibility of these bloggers to disclose why they are gluten-free, whether it be that they have a condition that requires them to be gluten-free, or that they are doing so for dietary reasons. The top bloggers going gluten-free for non-medical reasons should be clear that the science behind going gluten-free and gluten intolerance is murky and inconclusive. By adhering to these ethical standards, they will avoid spreading the harmful pseudoscience behind gluten intolerance and the gluten-free fad diet. Given that around 23% of Internet time is spent on blogs/social networks (Kessler, 2011), bloggers, with their influence on media users, have the ethical to duty to confirm that their messages are clear and unbiased. Recent cases have demonstrated the dire costs of pseudoscience, including the 59 people who caught measles in California (Salzberg, 2015) as a result of the anti-vaccine movement. This is one of many cases that serve as a dire warning of the hazardous impact pseudoscience can have on society. Bloggers have the power and potential to influence public opinion and provide a platform for credible, transparent exchange that can be trusted. It is the bloggers’ responsibility and duty as journalists to rise to the occasion.

Appendix A

Trust in social media by age range

age-health-trust-share-engage-social-media

 

source: http://searchenginewatch.com/sew/news/2169462/-consumers-social-media-health-care-info-survey#

        (Miller, 2012)

 

References

Bruins, Maaike J. The Clinical Response to Gluten Challenge: A Review of the Literature. Nutrients 5.11 (2013): 4614–4641. PMC. Web. 3 Dec. 2015.

Carroccio, A., Mansueto, P., Iacono, G., Soresi, M., D’Alcamo, A., Cavataio, F., … Rini, GB. (2012). Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. The American Journal of Gastroenterology, 107 (12), 1898-1906. doi: 10.1038/ajg.2012.236.

Celiac Disease Foundation. (2015). What is celiac disease? Retrieved from: https://celiac.org/celiac-disease/what-is-celiac-disease/

Mayo Clinic. (2015). Diseases and conditions: Wheat allergy. Retrieved from: http://www.mayoclinic.org/diseases-conditions/wheat-allergy/basics/definition/con-20031834

Culver, K. (2015). Legal basics I: Law and theory [Power point presentation]. Retrieved from: https://drive.google.com/file/d/0B_1nbQhebBB4UG5OWTNKdjRDaWM/view

Culver, K. (2015). Ethics basics [Power point presentation]. Retrieved from: https://drive.google.com/file/d/0B_1nbQhebBB4TDdaaGJ3T2llXzQ/view

Downs, M. (2005). Why Do We Keep Falling for Fad Diets? Retrieved November 9, 2015, from WebMD website: http://www.webmd.com/diet/why-do-we-keep-falling-for-fad-diets?page=1

eZaroorat (n.d.). 10 Interesting facts about blogging. Retrieved from: http://www.ezaroorat.com/blogging/facts-about-blogging

Kluger, J. (2014). Eat More Gluten: The Diet Fad Must Die. Time. Retrieved from: http://time.com/2912311/eat-more-gluten-the-diet-fad-must-die/

Levinovitz, A. (2015). The Problem With David Perlmutter, the Grain Brain Doctor. Science of Us. Retrieved from: http://nymag.com/scienceofus/2015/06/problem-with-the-grain-brain-doctor.html

McGrail, M. (2013). The Blogconomy: Blogging stats. Social Media Today. Retrieved from: http://www.socialmediatoday.com/content/blogconomy-blogging-stats-infographic

Meyer, R. (2014). U.S. Court: Bloggers Are Journalists. The Atlantic. Retrieved from: http://www.theatlantic.com/technology/archive/2014/01/us-court-bloggers-are-journalists/283225/

Miller, M. (2012). 33% of U.S. Consumers Use Social Media for Health Care Info [Survey]. Retrieved from: http://searchenginewatch.com/sew/news/2169462/-consumers-social-media-health-care-info-survey#

Mobile. (2011). Social Media Report Spending Time, Money and Going Mobile. Nielsen. Retrieved from: http://www.nielsen.com/us/en/insights/news/2011/social-media-report-spending-time-money-and-going-mobile.html

Plaisance, P. (2013). Media Ethics: Key Principles for Responsible Practice (2nd ed.). New York, NY: SAGE.

Redsicker, P. (2013). Blogs outrank social networks for consumer influence: New research. Social Media Examiner. Retrieved from: http://www.socialmediaexaminer.com/blogs-outrank-social-networks-for-consumer-influence-new-research/

Sanghavi, D. (2013, February 26). Why Do So Many People Think They Need Gluten-Free Foods? Slate. Retrieved from: http://www.slate.com/articles/health_and_science/medical_examiner/2013/02/gluten_free_diet_distinguishing_celiac_disease_wheat_allergy_and_gluten.html

 

Shute, N. (2013). Gluten goodbye: One-third of Americans say they’re trying to shun it. National Public Radio. Retrieved from: http://www.npr.org/sections/thesalt/2013/03/09/173840841/gluten-goodbye-one-third-of-americans-say-theyre-trying-to-shun-it

Steven, L. & Rashid, M. (2008). Gluten-free and regular foods: a cost comparison. Canadian Journal of Dietetic Practice and Research. 69(3):147-50.

Strawbridge, H. (2013). Going gluten-free just because? Here’s what you need to know. Harvard Health Publications. Retrieved from: http://www.health.harvard.edu/blog/going-gluten-free-just-because-heres-what-you-need-to-know-201302205916