Human Practices & Integration

Human Practices

Our human practices efforts started early in the iGEM year, more precisely during the first phase of project definition and went on until the very end of September. This enabled us to go through at least one iGEM Engineering Cycle in the area of human practices. We first started by building an idea in the area of celiac disease treatment, which was then tested via an interview with a local specialist. During this we learned that a lot of research on celiac disease is already in progress, but there is still a lot of research to do on non-celiac gluten sensitivity (NCGS) treatment. Therefore, we redesigned and rebuilt our initial idea to implement key features like the effect time and GMO (genetically modified organism) usage. These were then tested via patient interviews, a general survey and a talk with Prof. Rath, which resulted in a learning process concerning potentially upcoming problems and safety measures that need further development.

Shift from celiac disease to non-celiac gluten sensitivity & related disorders

Since the beginning of our project our scope and focus have shifted and have substantially been shaped by the influence of Human Practices (see also project description)

After researching potentially interesting topics, with which we could make a great impact with our project, our initial idea was to target celiac disease. With a prevalence of 1% among the world population, we thought that raising awareness for the disease and researching treatment could positively influence many people’s lives. To ensure that we were focusing our attention on the right direction, we contacted Univ.Prof. Harald Vogelsang, a professor at the Medical University of Vienna and former president of the “Darm Plus” initiative, an organization supporting patients with gastrointestinal diseases. After presenting our idea, Univ.Prof. Vogelsang was enthusiastic about our focus. However, he pointed us towards non-celiac gluten sensitivity (NCGS), as this disorder shows even a higher prevalence and only little is known on potential treatment and diagnostics. Starting from our previous findings for celiac disease, we now steered our project into a different but still related direction and came up with the approach of oral enzyme therapy. After further research on the topic, we identified FODMAPs (fermentable oligo-, di-, monosaccharides, and polyols) and ATIs (amylase trypsin inhibitors) as the main symptom triggers not only in NCGS, but also related disorders, such as irritable bowel disease (IBD) and inflammatory bowel syndrome (IBS). Consequently, we focused on these food ingredients, to establish the first potential treatment approach.

Combining oral enzyme therapy with living bacteria encapsulated in scaffolds

Having focused on oral enzyme therapy for NCGS, we evaluated the idea of combining this treatment option with a scaffold approach, to get the best possible effect. Since there are already quite a few oral enzyme therapies in clinical trials and we wanted to aim for a unique therapy, this novel combination intrigued us. Our idea was to use the scaffolds to encapsulate bacteria, which in turn could produce our enzymes at a constant rate. After further literature research on our new idea and talking to our supervisors, we decided to implement the scaffold approach in the project. The specifics of our therapy idea were largely shaped by lectures and discussions with supervisors and professors. One major question was, which bacteria to use to produce the enzymes. It was highly important to us to identify a strain, that would ensure the safety of our patients on the one hand, and provide the biotechnological feasibility needed on the other hand. After careful consideration, we decided to work with Lactobacillus strains, which belong to the class of GRAS (generally regarded as safe) bacteria and are already widely used in food technology, like dairy products. Another benefit of one of those bacteria strains was that they naturally secrete enzymes that break down ATIs.

One more question to be answered was the duration of the drug’s effect. Swallowing one pill before every meal to avoid discomfort did not appear to be the best solution for the patient. A lecture by one of our supervisors, Prof. Clemens Peterbauer, pointed us into the direction of mucoadhesion. Upon further research, we identified ways to ensure a mean attachment time of 24 hours in the human gastrointestinal tract, meaning that the patient would only have to swallow one pill per day. The interviews we conducted during the project with people suffering or are suspected to suffer from IBS, indeed gave us the feedback that they would prefer a 24-hour lasting treatment option, rather than a drug lasting only for one meal.

While refining our project idea, we contacted experts in the area for further advice and feedback on our approach. We were delighted to talk to Dr. Jane Muir, head of Translational Nutrition Science in the Department of Gastroenterology, at the University of Melbourne. She is currently working on the development of new diet therapies for diet-related gastrointestinal dysfunctions, focusing on FODMAPs. In this area she established techniques quantifying FODMAP sugars and is now in the process of designing FODMAP food composition tables, which are an essential tool for the dietary treatment of irritable bowel syndrome (IBS).
Due to her major contributions and work on IBS and FODMAPs our team was lucky to have the opportunity to talk to her and discuss our project. In our meeting we emphasized the importance and timeliness of research in this area. She not only made us concentrate on IBS, but also showed us the way to do so. She supported our efforts of adding ATI degradation to our treatment, since a lot of research is going into this direction. Moreover, she gave us hints on how to contact people suffering from IBS and assured us that we are going in the right direction.

Survey

Aims of the survey

Throughout the iGEM year our team always aimed at communicating scientific topics and core values of iGEM to a broad audience (see Inclusivity and Social Media). Hence, our goal wasn’t only developing a novel therapeutic platform for food sensitivities, specifically FODMAP associated disorders, but also speaking up about these topics, which often seem stigmatized in our society. To convey more knowledge to our audience and to gather information, we designed a survey with the software tool “SoSci Survey”. As a further benefit, people participating were provided with an insight on food sensitivities and gastrointestinal diseases in general.

The survey was structured into five chapters, which contain the following topics:

Personal information (e.g., gender, age, and level of education)
Incidence of food sensitivities (e.g., incidence among the survey participants and their surrounding)
Possible stigma of food sensitivities
Education on food sensitivities
Questions concerning Inflammatory Bowel Disease (IBD) – Collaboration with the iGEM team TU-Eindhoven

We aimed to gain an insight into the prevalence of food sensitivities among our survey participants, as well as the view of society on different aspects of gastrointestinal disorders. Hence, we tried to answer the following main questions with this survey:

What is the incidence of food sensitivities among our survey subjects and was it diagnosed by an authorized physician?
Is there a stigma attached to food sensitivities?
How well educated is the public on food sensitivities?
Which would be the best channels for informing the public on food sensitivities?

With these questions, we wanted to ensure that our general project approach is planned optimally to really benefit the affected patients and further raise awareness for gastrointestinal diseases in public.

Collaboration with our partner iGEM team TU-Eindhoven

The survey provided a great opportunity to collaborate with our partner iGEM team TU-Eindhoven in a way in which both teams had great benefits. Firstly, we dedicated one chapter of our survey to questions about IBD which were designed by the iGEM team Eindhoven. Secondly, both teams mutually reviewed each other's survey questions before publishing the survey to confirm the understandability as well as the unbiasedness. Furthermore, the survey was kindly translated into Dutch by the iGEM team Eindhoven and distributed in the Netherlands in order to reach more people with our survey.

Ethics

To consider the ethics in our survey we started researching on the iGEM website and carefully read through the articles and the safety policies on the Human Practices Hub. This included an iGEM blog post from members of the Human Practices Committee on designing scientifically valid surveys as well as a guide for best practices for survey research by the AAPOR (American Association for Public Opinion Research). Furthermore, we took part in the zoom chat for Human Practices/Ethics at the iGEM opening weekend and talked to experts for Human Practices of iGEM. In the next step, we contacted a professor from the University of Natural Resources and Life Sciences (BOKU Vienna) to get more information about the right measures to consider when designing an ethically valid survey.

The following specific actions were considered in our survey:

Informed consent in the beginning of the survey
Gender-inclusive language
No biased questions
An option for “No answer” in any sensitive question
Anonymity

Furthermore, we received and considered the feedback for the survey from four different professors and supervisors before publishing.

Sample Size and Distribution

We wanted to ensure that the survey is scientifically valid by reaching as many people from different genders, age groups, and regions as possible. The survey was available in three different languages, including English, German, and Dutch, and was distributed via different social networks like Instagram, Facebook, WhatsApp Groups, as well as the iGEM 2021 global slack channel. In total, 344 participants took part in our survey. Among them, 60% identified as female, 40% as male and <1% as non-binary or preferred not to answer (Figure 1). We are aware that due to the circumstances the survey was created and propagated under, it doesn’t represent a random sample from the global population. We are also aware that, since most of the participants were from Europe, the results will probably not apply to other geographic areas. Additionally, young people between the ages of 18 and 25 were overrepresented in the collected samples (Figure 2). Further, data on the highest completed education was collected, showing that people with compulsory schooling as the highest completed education may be underrepresented in the study. (Figure 3) We tried to integrate this prior knowledge into our analysis as much as we could. When making statements about the data we will therefore refer to them as a sample from our audience, in the sense of people who follow us on our social media channels or were in other ways related to iGEM and were thereby able to receive and fill out our survey. We explicitly don’t want to make statements about e.g., the general population or the population of Europe.

Figure 1

Figure 2

Figure 3

Analysis

The survey data was analyzed using the statistical programming language R, which is commonly used for data science and data visualization. For creating the plots, we made use of the well-known “ggplot2” package, which allowed us to create our own plot theme in order to keep the style of the plots consistent. Additionally, we used the “plyr” and “gridExtra” packages on R version 3.6.3.

Results and Discussion

In the following, we want to give a short summary on the results of our survey and answer our proposed research questions.

Which would be the best educational channels for informing the public on food sensitivities?

Figure 4 displays a summary of the ratings of different channels for informing the society on gastrointestinal diseases, according to the answers of the participants. While channels like Newsletters, Events and Workshops don’t seem to be viewed as effective channels for education, schools and social media were rated as the most efficient. These two display the highest frequencies of being rated as “Effective” or “Very effective” and the lowest frequencies of being rated as “Not effective at all” or “Not effective”.

Figure 4

How well educated is the public on food sensitivities?

Figure 5 shows a summary of different gastrointestinal diseases and the proportion of participants which are familiar with the respective disease. More than 80% of our survey participants were familiar with IBS, which was followed by Crohn’s disease which is known to more than 70% of the survey’s participants, and celiac disease, with 58%. However, only around 40% of the participants stated to be familiar with non-celiac gluten sensitivity (NCGS) and even a lower number of around 36% with ulcerative colitis. These results thereby show a clear difference between well-known and less known disorders. However, the frequency of how well-known the disorders are, doesn’t necessarily correlate with a higher prevalence among the population. Among our survey participants, NCGS was known by less than half that stated to be familiar with irritable bowel syndrome. This doesn’t correlate with the prevalence of the disorders, as the international prevalence of IBS is estimated to be 11% (1), while the estimations for the prevalence of NCGS ranges from 0.6% up to 10.6% in the western population.(2) Since, we informed our followers about IBS and NCGS before distributing our survey via social media, people participating in our survey are more likely to have already heard about IBS before. Presuming we have already reached them about this topic over similar channels. Hence, the results for IBS and NCGS must be regarded with caution.

Figure 5

What’s the incidence of food sensitivities among our survey subjects and was it diagnosed by an authorized physician?

As can be seen in Figure 6, 24.4% of our survey participants indicated that they suffer from a food sensitivity with additional 13% that selected “I am not sure”. However only 55% of the survey subjects, who stated to suffer from a food sensitivity, were diagnosed. Here we again have to take into consideration that due to our focused content people suffering from food sensitivities or who experience digestion problems are more likely be click on our content and take part in the survey.

Figure 6

Is there a stigma attached to food sensitivities?

We asked our survey participants to rate several statements on a possible stigma attached to food sensitivities according to their degree of agreement or disagreement. That was in order to get to know whether they think that there is a stigma attached to food sensitivities. Due to the fact that 33% of the participants answered with “I strongly disagree” or “I disagree” while 36% selected “I strongly agree” or “I agree” (Figure 7), it gives the impression that there are different opinions regarding the statement “There is a stigma related to food sensitivities” in the general population.

Figure 7

A similar pattern was observed in the ratings to the statement “Food sensitivities are taken seriously enough by the society”. Here more people disagreed with the statement than agreed (Figure 8). This indicates that the participants wish that food sensitivities are taken more seriously.

Figure 8

Regarding a possible stigma attached to the symptoms of food sensitivities, 48% of the participants disagreed or strongly disagreed with the statement “There is a burden to talk about the symptoms of food sensitivities”, while only around 31% agreed or strongly agreed (Figure 9).

Figure 9

However, as shown in figures 10, 11 and 12, the majority of our survey participants think that there is a need to inform the public more on food sensitivities. These three figures show the results of three statements the participants had to give their opinions on. The statements given all relate to the need of education of the public on food sensitivities and were asked to find possible bias. For the first statement “There is a need to inform the general population more on food sensitivities” 60% of people clicked on agreed and additional 14% even strongly agreed. This outcome is reflected in the results of the ratings for the statement “The general society is informed well enough on food sensitivities” on which 64% of the participants disagreed or even strongly disagreed (Figure 11) and the statement “An effort has to be made to talk more about food sensitivities and the related symptoms in the public” to which 62% of the survey participants (strongly) agreed (Figure 12).

Figure 10

Figure 11

Figure 12

Summary

With this survey, we were able to get an insight into people’s opinions on different topics regarding food sensitivities and gastrointestinal diseases. We learned that nearly 1 in 4 of our survey’s participants (24.4%) do suffer from a food sensitivity while additionally 13% weren’t sure if they suffer from a food sensitivity. The opinions regarding a possible stigma attached to food sensitivities seem to differ a lot among our survey participants while other opinions such as the need to inform the public on food sensitivities was shared by the majority of the study subjects.

Furthermore, we got a great insight into the public view on the efficiency of different channels by which the public should be informed on food sensitivities.

Patient interviews

The patient interviews were one of the main parts of our Human Practice work, since the one-on-one interviews allowed us to have an interactive conversation with people suffering from IBS and related disorders. They were helpful to get insights into the daily struggles those people must go through and what they need concerning possible treatment.

By asking patients about their experiences with their disorders we wanted to find out how much impact the disorder has on their lives. Furthermore, we wanted to learn if they had difficulties with getting a related diagnosis. Another point of interest is the satisfaction with already available treatments. This is especially relevant as our therapy would not be necessary if enough satisfying treatments would be available to patients. We want to know if our therapeutical approach (a daily pill) would be accepted among patients. Moreover, we asked patients about the stigma surrounding food sensitivities. This is of interest to us since one of our project goals was to educate the general public in order to minimize the stigma surrounding food sensitivities and irritable bowel syndrome (IBS). Lastly, we wanted to get their input on the approach of our partner team TU-Eindhoven, who was working on a tool to make the diagnosis of inflammatory bowel disease (IBD) easier.

The interviews let to the collection of personal data, which made privacy concerns relevant. We therefore collected an informed consent from the patients pervious to every interview, informing them of our data usage and presentation of the results. Furthermore, patients were informed that we are only working on a proof-of-concept and that the establishment of our approach as therapy is very unlikely. To guide each interviewer and to make sure that all the necessary information and consent are given, we created a guideline every interviewer had to follow. This also included guide questions to make sure all the important topics were discussed.

After grate effort we were able to find six persons either suffering from IBS or having related symptoms. A lot of them contacted us after listening to the Science Busters podcast (see Featured) where we talked about our project. Many of them have not been diagnosed yet and have just discovered that their symptoms fit to IBS by virtue of our outreach.

The end results gave us a good overview of the challenges many of them must master and how their lives are impacted. In the following paragraphs the results regarding the treatment of the disorder, our approach, and the stigma and necessary education covered by our questions are summarized. However, due to privacy reasons the exact answers will not be given at this point.

Disorder-Treatment

ive out of six participants have not been diagnosed and therefore have no idea what specifically causes their symptoms. However, 83% have narrowed their problems down to certain kinds of food even going as far as to creating lists of ingredients, which they need to stay away from. Here it was sad to hear that this was mostly happening without supervision from a practitioner or dietitian. Unfortunately, 5 out of 6 have suffered from problems for a long time having to deal with weight loss and other related medical problems on their way. Depending on their individual conditions, some participants even describe negative effects on their mental health and feel uncomfortable eating out, which in turn reduces their social interactions. This is especially the case for those who couldn’t be diagnosed yet, since they were unsure of what might cause problems.
Approach

Four of six participants already stick to a very restricted diet and would therefore at least try a low-FODMAPs diet, which is currently the only available treatment option for IBS. However, the consensus was that this diet leads to social constraints for them and their families over the long term. Therefore, all participants would be up to taking the medication our approach could end up in, especially since there is no other drug option for them available. They all would prefer a long-lasting pill but would settle for anything that helps in the slightest to not limit their food selection.
Education-Stigma

Depending on their families and friends many of them have different experiences with the general topic of food sensitivities and on how people react to them being careful with certain ingredients. However, four of six participants described people calling them picky or telling them that they just have an “upset” stomach. Nearly all of them still feel uncomfortable talking about their problems. Therefore, they agree that better education would make this topic easier to discuss, understand and believe. In this connection it is important to note that they all either have not been diagnosed yet or had real difficulties getting diagnosed. This is due to different reasons, such as being uncomfortable talking about it, wanting to deal with it on their own, or the fact that they themselves would have to put extreme efforts and time into getting a diagnosis. Furthermore, it isn’t even guaranteed that they could get any medical help to ease their condition after all. Therefore, they agree that more research needs to be done and more information needs to go out to practitioners on how to support similar patients.

All the participants were happy to get a chance to talk to us and to receive some information on IBS, its diagnosis, and symptoms. At this point, we again want to thank all of them for taking part in our interviews and helping us to get a better idea about what it feels like to suffer from IBS and food sensitivities.

Gut-on-a-chip

Naturally we wanted to test our scaffolds and drugs concerning their safety. Due to our connections to the Technical University of Vienna and Professor Peter Ertl, we asked him and his research group if using a gut-on-a-chip for our project would be possible. Since organ-on-a-chip technologies are promising alternatives for animal experiments as they mimic the physical complexity of native tissue in vitro. Such models provide improved platforms to study physiology, pathology, and pharmacology. We were informed that he was working together with the Medical University of Vienna on a gut-on-a-chip we could possibly use. During our first meetings via Zoom we became acquainted with Doris Roth, who later helped us doing research in the TU laboratory together with Silvia Schobesberger. We discussed which experiments we could do in order to show that our approach works. They suggested using Caco-2 cells for regular cytotoxicity testing and additionally performing membrane permeability tests of our polymer in a transwell system. They pointed out that a gut-on-a-chip system would have been too small and too elaborate to use for our capsules in this limited time frame. We changed our earlier plans according to these considerations and Peter Ertl and his group kindly provided us with the opportunity to work within the cell culture lab of his research group.(3)

Meeting with Prof. Johannes Rath

Prof. Dr. Johannes Rath has a background in toxicology, microbiology, and law and has previously worked for the United Nations. Currently, he is working in the Netherlands and is giving a lecture at the University in Vienna on Ethics in Research. We contacted him to get a better understanding of possible safety and ethical issues our projects could face. He also gave us some feedback on the outreach and research we already achieved.

This meeting was held in collaboration with our partner iGEM team TU-Eindhoven. Therefore, we both met prior to the meeting and collected interesting questions regarding Ethics and Biosafety in relation to GMOs (= Genetically modified organisms) to later discuss with him.

In the following paragraphs, we want to state a summary of Prof. Raths explanations and suggestions to some of the ethical and safety problems which were discussed.

Is treating/diagnosing/monitoring a disorder or disease with the use of GMOs desired in human beings?

Dr. Rath agreed that in general diagnosis and treatment of diseases is always desired, but it can get very complicated concerning the use of GMOs. It can be argued that the use of GMOs is less intrusive than somatic gene therapy, which is already in use. Before continuing with further safety considerations, a proof of concept would need to be established. However, safety considerations could be done on three different levels:

Safety in relation to the human subject
Safety assessment in relation to possible horizontal gene transfer in the gut
Environmental risk assessment

For these, advice can be given by the local Agency for Health and Food Safety. In the case of high risks due to GMOs in the medication, one of the measures which were discussed excessively would be to consider stabilizing the enzymes in our drug and directly administering them. Thereby, the biosafety of GMOs would not need to be considered outside of the production.

How can we determine the threshold/amount of risk that is considered acceptable?

Dr. Rath stated that there must be significant benefits in comparison to the risks. Our drug system would need to be tested against the best-established system, which in our case would be a placebo. However, the final decision if the risk is acceptable needs to be taken by the national authorities.

Which possibilities could be considered to lower the biosafety risks of our drug?

A stable integration of our construct into the genome of the Lactobacillus can be taken as one of the first steps to make the system safer.
To add further safety measurements, a kill switch could be introduced to lower the risks involved.
Proving that it is possible to contain the GMOs after being released into the environment.

What is important to take into consideration when educating people? How do we not get the hopes of our patients up?

Dr. Rath stressed that it is our responsibility to clearly describe that “potential treatment” in the medical area doesn’t mean that something is going to happen, it is actually very unlikely that our approach will result in any medication. Moreover, it needs to be emphasized that no testing is involved in our project and that one of our main goals is to kick off further research in the area as well as to better the understanding for the patients.

Further details and more insight into what this exactly mean for the project can be found on our here.

We would like to take this opportunity to thank Dr. Rath again kindly for the great discussion and very valuable suggestions!

References

(1) Canavan, C., West, J., & Card, T. (2014). The epidemiology of irritable bowel syndrome. Clinical epidemiology, 6, 71–80. https://doi.org/10.2147/CLEP.S40245

(2) Shahbazkhani, B., Fanaeian, M. M., Farahvash, M. J., Aletaha, N., Alborzi, F., Elli, L., Shahbazkhani, A., Zebardast, J., & Rostami-Nejad, M. (2020). Prevalence of Non-Celiac Gluten Sensitivity in Patients with Refractory Functional Dyspepsia: a Randomized Double-blind Placebo Controlled Trial. Scientific Reports, 10(1). https://doi.org/10.1038/s41598-020-59532-z

(3) Ashammakhi, N., Nasiri, R., Barros, N. R. D., Tebon, P., Thakor, J., Goudie, M., Shamloo, A., Martin, M. G., & Khademhosseini, A. (2020). Gut-on-a-chip: Current progress and future opportunities. Biomaterials, 255, 120196. https://doi.org/10.1016/j.biomaterials.2020.120196

Team:BOKU-Vienna/Human Practices