Prevalence of Alpha-1 Antitrypsin Deficiency, Self-Reported Behavior Change, and Health Care Engagement Among Direct-to-Consumer Recipients of a Personalized Genetic Risk Report

Abstract

BackgroundAlpha-1 antitrypsin deficiency (AATD) is an autosomal co-dominant condition that predisposes to emphysema, cirrhosis, panniculitis, and vasculitis. Underrecognition has prompted efforts to enhance early detection and testing of at-risk individuals. Direct-to-consumer (DTC) genetic testing represents an additional method of detection.Research QuestionThe study addressed three questions: (1) Does a DTC testing service identify previously undetected individuals with AATD? (2) What was the interval between initial AATD-related symptoms and initial diagnosis of AATD in such individuals? and (3) What was the behavioral impact of learning about a new diagnosis of AATD through a DTC test?Study Design and MethodsIn this cross-sectional study, 195,014 individuals responded to a survey within the 23andMe, Inc. research platform.ResultsAmong 195,014 study participants, the allele frequency for the PI∗S and PI∗Z AATD variants was 21.6% (6.5% for PI∗Z and 15.1% for PI∗S); 0.63% were PI∗ZZ, half of whom reported having a physician confirm the diagnosis. Approximately 27% of those with physician-diagnosed AATD reported first becoming aware of AATD through the DTC test. Among those newly aware participants, the diagnostic delay interval was 22.3 years. Participants frequently shared their DTC test results with health care providers (HCPs) and the reported impact of learning a diagnosis of AATD was high. For example, 51.1% of PI∗ZZ individuals shared their DTC result with an HCP. The OR for PI∗ZZ smokers to report smoking reduction as a result of receiving the DTC result was 1.7 (95% CI = 1.4-2.2) compared with those without a Z allele and for reduced alcohol consumption this was 4.0 (95% CI = 2.6-5.9).InterpretationIn this largest available report on DTC testing for AATD, this test, in combination with clinical follow-up, can help to identify previously undiagnosed AATD patients. Moreover, receipt of the DTC AATD report was associated with positive behavior change, especially among those with risk variants. Alpha-1 antitrypsin deficiency (AATD) is an autosomal co-dominant condition that predisposes to emphysema, cirrhosis, panniculitis, and vasculitis. Underrecognition has prompted efforts to enhance early detection and testing of at-risk individuals. Direct-to-consumer (DTC) genetic testing represents an additional method of detection. The study addressed three questions: (1) Does a DTC testing service identify previously undetected individuals with AATD? (2) What was the interval between initial AATD-related symptoms and initial diagnosis of AATD in such individuals? and (3) What was the behavioral impact of learning about a new diagnosis of AATD through a DTC test? In this cross-sectional study, 195,014 individuals responded to a survey within the 23andMe, Inc. research platform. Among 195,014 study participants, the allele frequency for the PI∗S and PI∗Z AATD variants was 21.6% (6.5% for PI∗Z and 15.1% for PI∗S); 0.63% were PI∗ZZ, half of whom reported having a physician confirm the diagnosis. Approximately 27% of those with physician-diagnosed AATD reported first becoming aware of AATD through the DTC test. Among those newly aware participants, the diagnostic delay interval was 22.3 years. Participants frequently shared their DTC test results with health care providers (HCPs) and the reported impact of learning a diagnosis of AATD was high. For example, 51.1% of PI∗ZZ individuals shared their DTC result with an HCP. The OR for PI∗ZZ smokers to report smoking reduction as a result of receiving the DTC result was 1.7 (95% CI = 1.4-2.2) compared with those without a Z allele and for reduced alcohol consumption this was 4.0 (95% CI = 2.6-5.9). In this largest available report on DTC testing for AATD, this test, in combination with clinical follow-up, can help to identify previously undiagnosed AATD patients. Moreover, receipt of the DTC AATD report was associated with positive behavior change, especially among those with risk variants. Alpha-1 antitrypsin deficiency (AATD) is an autosomal co-dominant condition that predisposes to emphysema, cirrhosis, panniculitis, and vasculitis.1Strnad P. McElvaney N.G. Lomas D.A. Alpha-1-antitrypsin deficiency.N Engl J Med. 2020; 382: 1443-1455Google Scholar, 2American Thoracic Society, European Respiratory SocietyAmerican Thoracic Society/European Respiratory Society statement: standards for the diagnosis and management of individuals with alpha-1 antitrypsin deficiency.Am J Respir Crit Care Med. 2003; 168: 818-900Google Scholar, 3Stoller J.K. Aboussouan L.S. A review of α-1-antitrypsin deficiency.Am J Respir Crit Care Med. 2012; 185: 246-259Google Scholar With an estimated prevalence of 100,000 cases in the United States, AATD is severely underrecognized, with fewer than 10,000 individuals diagnosed.2American Thoracic Society, European Respiratory SocietyAmerican Thoracic Society/European Respiratory Society statement: standards for the diagnosis and management of individuals with alpha-1 antitrypsin deficiency.Am J Respir Crit Care Med. 2003; 168: 818-900Google Scholar,4Aboussouan L.S. Stoller J.K. Detection of alpha-1 antitrypsin deficiency: a review.Respir Med. 2009; 103: 335-341Google Scholar,5Stoller J.K. Brantly M. The challenge of detecting alpha-1 antitrypsin deficiency.COPD. 2013; 10: 26-34Google Scholar Individuals with AATD frequently experience long delays from initial symptom onset to diagnosis, consistently and persistently estimated to be 5 to 8 years.6Stoller J.K. Smith P. Yang P. Spray J. Physical and social impact of alpha 1-antitrypsin deficiency: results of a survey.Cleve Clin J Med. 1994; 61: 461-467Google Scholar, 7Stoller J.K. Sandhaus R.A. Turino G. Dickson R. Rodgers K. Strange C. Delay in diagnosis of alpha1-antitrypsin deficiency: a continuing problem.Chest. 2005; 128: 1989-1994Google Scholar, 8Greulich T. Ottaviani S. Bals R. et al.Alpha1-antitrypsin deficiency: diagnostic testing and disease awareness in Germany and Italy.Respir Med. 2013; 107: 1400-1408Google Scholar, 9Campos M.A. Wanner A. Zhang G. Sandhaus R.A. Trends in the diagnosis of symptomatic patients with alpha1-antitrypsin deficiency between 1968 and 2003.Chest. 2005; 128: 1179-1186Google Scholar Furthermore, individuals with AATD-attributable symptoms often see multiple health care providers (HCPs) before being diagnosed.6Stoller J.K. Smith P. Yang P. Spray J. Physical and social impact of alpha 1-antitrypsin deficiency: results of a survey.Cleve Clin J Med. 1994; 61: 461-467Google Scholar Finally, because the health conditions associated with AATD are progressive, delayed diagnosis is associated with worsened clinical status.10Tejwani V. Nowacki A.S. Fye E. Sanders C. Stoller J.K. The impact of delayed diagnosis of alpha-1 antitrypsin deficiency: the association between diagnostic delay and worsened clinical status.Respir Care. 2019; 64: 915-922Google Scholar Various strategies have been undertaken to enhance AATD awareness and detection.8Greulich T. Ottaviani S. Bals R. et al.Alpha1-antitrypsin deficiency: diagnostic testing and disease awareness in Germany and Italy.Respir Med. 2013; 107: 1400-1408Google Scholar,9Campos M.A. Wanner A. Zhang G. Sandhaus R.A. Trends in the diagnosis of symptomatic patients with alpha1-antitrypsin deficiency between 1968 and 2003.Chest. 2005; 128: 1179-1186Google Scholar Examples include presentations at academic meetings; courses directed to physicians, respiratory therapists, and nurses11Stoller J.K. Strange C. Schwarz L. Kallstrom T.J. Chatburn R.L. Detection of alpha-1 antitrypsin deficiency by respiratory therapists: experience with an educational program.Respir Care. 2014; 59: 667-672Google Scholar; embedding alerts within electronic medical records prompting physicians to order AATD testing for patients with fixed airflow obstruction on pulmonary function tests12Jain A. McCarthy K. Xu M. Stoller J.K. Impact of a clinical decision support system in an electronic health record to enhance detection of α1-antitrypsin deficiency.Chest. 2011; 140: 198-204Google Scholar; empowering respiratory therapists to order AAT testing when pulmonary function tests show obstruction13Rahaghi F.F. Sandhaus R.A. Brantly M.L. et al.The prevalence of alpha-1 antitrypsin deficiency among patients found to have airflow obstruction.COPD. 2012; 9: 352-358Google Scholar; and offering free home-based testing for AATD through groups such as the Alpha-1 Foundation.14Dickson R. Strange C. Lundquist R. Brantly M. Finn S. Alpha coded testing study: preserving the confidentiality of patients. In: Abstracts From the Twenty-Second Annual Education Conference of the National Society of Genetic Counselors.Journal of Genetic Counseling. 2003; 12: 459-571Google Scholar Nevertheless, the persistence of AATD underrecognition suggests the need for additional identification approaches. Direct-to-consumer (DTC) genetic testing that reveals abnormal alleles in the SERPINA1 gene represents an additional strategy to identify AATD individuals. To date, millions of individuals have received DTC genetic tests; yet, the impact of providing results on clinical diagnosis or health behavior change has not been assessed. Although the Alpha-1 Coded Testing study examined the impact and behaviors related to at-home testing, including result sharing,15Strange C. Dickson R. Carter C. et al.Genetic testing for alpha1-antitrypsin deficiency.Genet Med. 2004; 6: 204-210Google Scholar the impact of DTC tests in the broader population, and whether these DTC test results lead to new, clinically confirmed diagnoses, remains unanswered. Because certain behaviors (eg, cigarette smoking, alcohol consumption) influence disease risk,2American Thoracic Society, European Respiratory SocietyAmerican Thoracic Society/European Respiratory Society statement: standards for the diagnosis and management of individuals with alpha-1 antitrypsin deficiency.Am J Respir Crit Care Med. 2003; 168: 818-900Google Scholar AATD provides an opportunity to study behavior change elicited by learning genetic results. Previous studies have shown that AATD individuals identified at birth show lower rates of smoking initiation than demographically matched groups.16Thelin T. Sveger T. McNeil T.F. Primary prevention in a high-risk group: smoking habits in adolescents with homozygous alpha-1-antitrypsin deficiency (ATD).Acta Paediatr. 1996; 85: 1207-1212Google Scholar Another study found that adult smokers who test as severely AAT deficient were more likely to report a quit attempt than those who tested normal,17Carpenter M.J. Strange C. Jones Y. et al.Does genetic testing result in behavioral health change? Changes in smoking behavior following testing for alpha-1 antitrypsin deficiency.Ann Behav Med. 2007; 33: 22-28Google Scholar but also that there was not a significant increase in quit attempts among carriers. The current study allows further examination of smoking and alcohol consumption behavior in the context of DTC testing. The current study surveyed a sample of DTC test recipients regarding their reactions and reported health behavior responses to their results to assess: (1) the prevalence of AATD in this large sample, (2) clinical features, including the prevalence of respiratory illnesses across the sample, (3) the reported diagnostic delay among those who newly received a diagnosis of AATD from a physician vs those with physician-diagnosed AATD when the DTC test, the of genetic results with and and behavior regarding cigarette and alcohol to receiving the DTC a by the for the of review from this study are not available the review study Participants were in the on the of as at the were were from who to in research The study those who the as the as as the of whom were on the of who the of genetic including genetic and on genetic variants associated with risk for conditions including who the not genetic health risk In among research participants, the DTC becoming aware of their AATD newly about their genetic risk for AATD through the DTC allows for between these the impact of DTC testing on diagnostic delay in Participants were to the survey in of to the sample with physician-diagnosed AATD individuals or those with risk variants. an to the AATD survey was within the research of research among available but with for those who physician-diagnosed AATD in or for those found to have a PI∗S or PI∗Z from the test. received an to the (1) those who having an diagnosis of AATD in (2) who previously their AATD report and who a PI∗S or PI∗Z (3) with or PI∗ZZ who not having a AATD diagnosis, and who not have received AATD results from but previously to about research on genetic risk in their Participants in this who the survey = were a free to the to about their AATD with regarding for to research 2012; Scholar The survey was within the research as et studies genetic for 6: D.A. et of genetic with medical 2011; 6: Scholar Among those who received a diagnosis of AATD from a physician in a clinical as a diagnostic among the participants, whether the diagnosis was received before vs their DTC who their AATD report were whether shared their genetic result with and with who their report and reported alcohol or cigarette were whether consumption and whether this to receiving the DTC In with L.S. Stoller J.K. Detection of alpha-1 antitrypsin deficiency: a review.Respir Med. 2009; 103: 335-341Google Scholar, J.K. Brantly M. The challenge of detecting alpha-1 antitrypsin deficiency.COPD. 2013; 10: 26-34Google Scholar, J.K. Smith P. Yang P. Spray J. Physical and social impact of alpha 1-antitrypsin deficiency: results of a survey.Cleve Clin J Med. 1994; 61: 461-467Google Scholar, 7Stoller J.K. Sandhaus R.A. Turino G. Dickson R. Rodgers K. Strange C. Delay in diagnosis of alpha1-antitrypsin deficiency: a continuing problem.Chest. 2005; 128: 1989-1994Google Scholar, 8Greulich T. Ottaviani S. Bals R. et al.Alpha1-antitrypsin deficiency: diagnostic testing and disease awareness in Germany and Italy.Respir Med. 2013; 107: 1400-1408Google Scholar, 9Campos M.A. Wanner A. Zhang G. Sandhaus R.A. Trends in the diagnosis of symptomatic patients with alpha1-antitrypsin deficiency between 1968 and 2003.Chest. 2005; 128: 1179-1186Google Scholar, V. Nowacki A.S. Fye E. Sanders C. Stoller J.K. The impact of delayed diagnosis of alpha-1 antitrypsin deficiency: the association between diagnostic delay and worsened clinical status.Respir Care. 2019; 64: 915-922Google Scholar the delay was as the reported between the first AATD-attributable symptom L.S. Stoller J.K. Detection of alpha-1 antitrypsin deficiency: a review.Respir Med. 2009; 103: 335-341Google Scholar, J.K. Brantly M. The challenge of detecting alpha-1 antitrypsin deficiency.COPD. 2013; 10: 26-34Google Scholar, J.K. Smith P. Yang P. Spray J. Physical and social impact of alpha 1-antitrypsin deficiency: results of a survey.Cleve Clin J Med. 1994; 61: 461-467Google Scholar, 7Stoller J.K. Sandhaus R.A. Turino G. Dickson R. Rodgers K. Strange C. Delay in diagnosis of alpha1-antitrypsin deficiency: a continuing problem.Chest. 2005; 128: 1989-1994Google Scholar, 8Greulich T. Ottaviani S. Bals R. et al.Alpha1-antitrypsin deficiency: diagnostic testing and disease awareness in Germany and Italy.Respir Med. 2013; 107: 1400-1408Google Scholar, 9Campos M.A. Wanner A. Zhang G. Sandhaus R.A. Trends in the diagnosis of symptomatic patients with alpha1-antitrypsin deficiency between 1968 and 2003.Chest. 2005; 128: 1179-1186Google Scholar, V. Nowacki A.S. Fye E. Sanders C. Stoller J.K. The impact of delayed diagnosis of alpha-1 antitrypsin deficiency: the association between diagnostic delay and worsened clinical status.Respir Care. 2019; 64: 915-922Google Scholar and the initial diagnosis of V. Nowacki A.S. Fye E. Sanders C. Stoller J.K. The impact of delayed diagnosis of alpha-1 antitrypsin deficiency: the association between diagnostic delay and worsened clinical status.Respir Care. 2019; 64: 915-922Google Scholar when an was with AATD before symptoms (eg, when tested in the diagnostic delay interval was (1) or on birth (2) providing responses across survey (eg, to be than the reported of diagnosis of a and (3) providing responses (eg, to have tested for To that identify fewer than are not in this risk in the results are broader in but not in tests of association were in A and for for Scholar are for and three and in was not for because of sample especially for for these groups were For that on to the result and behavior are also for this and in the of diagnostic delay were for and of test are in A was at a for The to genetic risk for AATD were and from was on as P. Smith S. et of prevalence and health of in individuals from the J 2019; Scholar in for the were and to a of the in the antitrypsin for Scholar can be found in as as on the for antitrypsin for Scholar The survey was available from to the and the sample 195,014 of whom the The allele frequency for the PI∗S and PI∗Z variants among was 21.6% for or or or at in to alcohol consumption in of AATD, have to in a new have because The prevalence of physician-diagnosed AATD was 0.63% in The of physician-diagnosed AATD was among those with PI∗S or PI∗Z variants and was the for and PI∗ZZ Among who physician-diagnosed AATD at the of the reported receiving this diagnosis their AATD report and the of of sample (95% by a by a by a = not in a new = not Although the prevalence of physician-diagnosed AATD was among PI∗ZZ having this diagnosis was more among PI∗ZZ individuals who shared their DTC result with a care physician than among those who not shared their result of AATD was associated with with more than a of PI∗ZZ of AATD The reported frequency of respiratory was among those with risk variants than those without the prevalence of was across the and PI∗ZZ individuals reported having more with individuals have risk the OR of having was (95% for and (95% for PI∗ZZ individuals. The of among PI∗ZZ is shown in Among with physician-diagnosed AATD who to about of first symptom and first diagnosis = were before the estimated was with the of first symptom at years. who were aware of their AATD before their DTC report reported an of first diagnosis than who were their DTC report = = The of symptom onset not between these = = = the estimated was among the than the 22.3 = vs = = = = The of between initial symptom and first diagnosis among was vs among = = = were also more likely to report a of AATD than OR = = Delay Among AATD AATD of first of first diagnosis, delay of between symptom onset and diagnosis, of in a new Among participants, their AATD of these reported their report result with The prevalence of physician-diagnosed AATD was among those who their DTC report more than before the survey with PI∗Z variants were more likely to report their result with than those without a PI∗Z of PI∗ZZ individuals reported their genetic result with a or compared with and of With Care and by report and responded to health care health care care report and responded to of receiving testing results in a new with was more than with of the study who their DTC result reported their result with a and was among with with of PI∗ZZ their result with a compared with of AATD testing as a result of their DTC test results. The reported of to testing was among those with a PI∗Z compared with those without a PI∗Z = = Among current cigarette smokers and alcohol who their AATD report smokers with a PI∗Z were more likely to report a in smoking than without a PI∗Z OR = 1.7 (95% the OR for PI∗ZZ to report a in alcohol consumption was (95% compared with with a PI∗Z were more likely to report that receiving the DTC report their decision to alcohol consumption OR = (95% compared with associated with behavior change are in by Among report and current alcohol alcohol report and current smoking, smokers and alcohol who their AATD report were whether alcohol or cigarette consumption the who reported consumption were whether this to the report in a new smokers and alcohol who their AATD report were whether alcohol or cigarette consumption the who reported consumption were whether this to the report The current study to the first study to the prevalence of AATD and risk variants among DTC test and the behavioral impact of DTC genetic for study available by a sample of AATD individuals. that because of the prevalence of risk variants in this study is not of the of individuals from the J. J. Stoller J.K. E. Alpha-1 antitrypsin deficiency PI∗Z and PI∗S allele frequency in a genetic In: and 2019; Scholar reported allele of and and of and prevalence M.L. for alpha1-antitrypsin T. disease in alpha1-antitrypsin deficiency by of Engl J Med. Scholar AATD and respiratory illnesses were more among those with risk variants compared with those the prevalence of respiratory among those with the was between those with and PI∗ZZ Among the from this study is that more than a of those with physician-diagnosed AATD received this diagnosis receiving their genetic that the DTC report to identify individuals who have who were the DTC result were likely to report a of AATD and estimated diagnostic delays than previously J.K. Smith P. Yang P. Spray J. Physical and social impact of alpha 1-antitrypsin deficiency: results of a survey.Cleve Clin J Med. 1994; 61: 461-467Google Scholar, 7Stoller J.K. Sandhaus R.A. Turino G. Dickson R. Rodgers K. Strange C. Delay in diagnosis of alpha1-antitrypsin deficiency: a continuing problem.Chest. 2005; 128: 1989-1994Google Scholar, 8Greulich T. Ottaviani S. Bals R. et al.Alpha1-antitrypsin deficiency: diagnostic testing and disease awareness in Germany and Italy.Respir Med. 2013; 107: 1400-1408Google Scholar, 9Campos M.A. Wanner A. Zhang G. Sandhaus R.A. Trends in the diagnosis of symptomatic patients with alpha1-antitrypsin deficiency between 1968 and 2003.Chest. 2005; 128: 1179-1186Google Scholar half of PI∗ZZ reported having received a diagnosis of AATD by a that a by the medical The of a diagnostic delay interval of among with an AATD diagnosis is with J.K. Brantly M. The challenge of detecting alpha-1 antitrypsin deficiency.COPD. 2013; 10: 26-34Google Scholar and the of the interval among those who were aware of their AATD before the DTC test was to that of the for those who newly of their AATD the DTC test was than J.K. Smith P. Yang P. Spray J. Physical and social impact of alpha 1-antitrypsin deficiency: results of a survey.Cleve Clin J Med. 1994; 61: 461-467Google Scholar, 7Stoller J.K. Sandhaus R.A. Turino G. Dickson R. Rodgers K. Strange C. Delay in diagnosis of alpha1-antitrypsin deficiency: a continuing problem.Chest. 2005; 128: 1989-1994Google Scholar, 8Greulich T. Ottaviani S. Bals R. et al.Alpha1-antitrypsin deficiency: diagnostic testing and disease awareness in Germany and Italy.Respir Med. 2013; 107: 1400-1408Google Scholar, 9Campos M.A. Wanner A. Zhang G. Sandhaus R.A. Trends in the diagnosis of symptomatic patients with alpha1-antitrypsin deficiency between 1968 and 2003.Chest. 2005; 128: 1179-1186Google Scholar that have in in this these newly aware individuals have been symptomatic at the of diagnosis or study is A of the study is the of genetic and health behaviors in a sample than on C. A. et with the responses to J. 2013; et genetic testing for and the Med. 2020; Scholar including the Alpha Coded Testing than C. Dickson R. Carter C. et al.Genetic testing for alpha1-antitrypsin deficiency.Genet Med. 2004; 6: 204-210Google Scholar learning that risk variants to a influence on and on behaviors that can the health associated with AATD, with a report on smoking quit M.J. Strange C. Jones Y. et al.Does genetic testing result in behavioral health change? Changes in smoking behavior following testing for alpha-1 antitrypsin deficiency.Ann Behav Med. 2007; 33: 22-28Google Scholar who high-risk were more likely to their result with a their physicians to a diagnosis of AATD and to early diagnosis and of long diagnostic delay J.K. Brantly M. The challenge of detecting alpha-1 antitrypsin deficiency.COPD. 2013; 10: 26-34Google Scholar these to for to identify individuals at risk for DTC testing can clinical diagnostic strategies to enhance detection of individuals who be with the of result with the of result with was Although of those with PI∗Z variants shared their results with a of those with also shared their result with of genetic results with awareness in to prompting at-risk to testing. Although this study provides from a large of DTC regarding AATD diagnosis, and be in the results. The are by who to in and not to the population, as has been shown in of sample S. and among research Scholar were to those who were by vs those because was to those with AATD risk alleles or of AATD, method with Furthermore, were to the by the survey because also have through the Participants not about the of with whom results be or about with related to result and diagnosis. are and social of behavior the cross-sectional survey of the study, the reported not be as Finally, because clinically about symptoms were available in this study, about the diagnostic delay in this study was than that in studies is not In these results that DTC in combination with clinical follow-up, identify individuals with AATD who The in the AATD report within about for AATD and prompted positive behavior change, especially among those with genetic research is to the continuing impact of DTC on genetic risk for a (DTC) genetic testing service identified individuals at risk for alpha-1 antitrypsin deficiency (AATD) who have undetected by medical and recipients of this DTC test with the in the in of result and behavior Approximately of high-risk PI∗ZZ individuals with physician-diagnosed AATD were first learning their genetic risk from the DTC also a diagnostic delay interval and of AATD than those who an AATD diagnosis before the DTC and was associated with reported in alcohol consumption and cigarette smoking the DTC The study provides that DTC testing in the identification of at-risk individuals and that the in the AATD report within about for AATD, and that the report prompted positive behavior change, especially among those with genetic a (DTC) genetic testing service identified individuals at risk for alpha-1 antitrypsin deficiency (AATD) who have undetected by medical and recipients of this DTC test with the in the in of result and behavior change? Approximately of high-risk PI∗ZZ individuals with physician-diagnosed AATD were first learning their genetic risk from the DTC also a diagnostic delay interval and of AATD than those who an AATD diagnosis before the DTC and was associated with reported in alcohol consumption and cigarette smoking the DTC The study provides that DTC testing in the identification of at-risk individuals and that the in the AATD report within about for AATD, and that the report prompted positive behavior change, especially among those with genetic J. R. A. is the of the of the and and was for study and and and and J. and S. J. Y. and and and of the S. L. of research J. K. and the of the The have reported to the J. R. J. S. S. L. and J. Y. T. are and of 23andMe, Inc. is a of J. K. S. is a of study was by 23andMe, was for the and in the decision to the for K. L. M. A. E. M. A. K. C. J. E. L. V. S. A. G. J. Y. and the research and of for this also for and to this The and can be found in the of the with

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