Canadian Knowledge About Nutritional Genomics 01

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OMICS A Journal of Integrative BiologyVolume 13, Number 1, 2009

Mary Ann Liebert, Inc.DOI: 10.1089/omi.2008.0047

Knowledge and Attitudes of Canadian Consumersand Health Care Professionals Regarding

Nutritional Genomics

Karine Morin

Abstract

With advances in the field of nutrigenomics, commercial laboratories have begun marketing genotyping ser-vices, nutritional advice, and dietary supplements tailored to match individual genetic predispositions. Al-

though primarily offered by American companies, these services are available to Canadian consumers via theInternet. Qualitative research in the form of focus groups with members of the Canadian public was under-taken to assess the current level of understanding of and receptivity toward this new genomic application. Ad-ditionally, focus groups with health care professionals (physicians, pharmacists, dieticians, nutritionists, andnaturopaths) investigated their interest in integrating nutrigenomics into health care delivery, and their ca-pacity to do so. Gauging knowledge and attitudes early in the introduction of a new technology serves to iden-tify potential blind spots regarding the ethical, legal, and social implications. Preliminary results indicate con-sumers believe potential benefits of nutrigenomics outweigh risks, while health care professionals express moreskepticism. Both groups agree that more public education about nutrigenomics is needed and that regulatoryoversight should ensure consumer protection.

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Introduction

RESEARCHERS ARE OPTIMISTIC that nutrigenomics will revealvaluable understanding regarding individual genetic

risk of diet-modulated diseases and help maintain health,prevent the onset of disease, and offer therapies (Kaput, 2007;Kaput and Rodriguez, 2004). Scientific researchers are notthe only ones foreseeing a transformation of nutrition, andwith it, of food consumption. The Institute for the Future ina series of three reports published earlier this decade antic-ipated that nutrigenomics could have a significant impact onconsumers food purchases (Cain and Schmid, 2003; Mas-soud et al, 2001; Oliver, 2005). According to their assessment,even if consumers are not familiar with the term nutritional

genomics, they can grasp the idea of personalized nutrition,and are attracted to its benefits (Oliver, 2005).

Public health authorities and health product regulators arealso noticing these advances. Health Canada has acknowl-edged that there is a Growing . . . awareness of the rela-tionship between food safety and nutritional quality andchronic disease, which must be accounted for in the mod-ernization of regulatory strategies related to nutrition andfood (Health Canada, 2007). In the United States, however,

the Government Accountability Office forewarned early pi-oneers of direct-to-consumer nutrigenomic services that theyare under scrutiny as the claims they have made regardingtheir services were deemed to mislead consumers by mak-ing predictions that are medically unproven and so am-

biguous that they do not provide meaningful information toconsumers (U.S. Government Accountability Office, 2006).

It is against this background that qualitative research wasundertaken to assess the knowledge and attitudes of Cana-dian consumers regarding nutritional genomics, as well asthose of health care professionals, particularly regarding therisks and potential benefits of nutrigenetic tests offered di-rectly to consumers. The research would help elucidatewhether health care professionals and consumers hold sim-

ilar views regarding this new technology and also help in-form regulators as to some of the ethical, legal, or social con-cerns identified by participants.

Method

Between November 22 and 28, 2007, 12 focus groups wereconducted with members of the public in five cities acrossCanada. Participants were randomly recruited by telephone

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by an independent third party and invited to specialized fo-cus group facilities in Halifax, Montreal, Toronto, Edmon-ton, and Vancouver. Each session included approximatelyeight participants, totaling over 90 adults representing a mixof gender, income, marital status, and ethnicity. At least halfthe participants in each group had children at home, con-sumed natural health products, and used the Internet to lookfor health-related information. Prior to the moderated focus

group discussion, each participant completed a brief ques-tionnaire. Among other questions, participants were askedto provide a definition for the terms nutrigenomics andpersonalized nutrition. The moderated, 2-h sessions cov-ered the following issues: contextual issues (e.g., importanceof food in relation to health, understanding of the role ofgenes); awareness and initial perception of nutrigenomics;reactions to a media article, a mock Web site selling nu-trigenomic tests and services, and a summary document de-scribing the current state of nutrigenomics; and communi-cation issues.

Two focus groups were conducted with physicians andpharmacists, and two more with dieticians, nutritionists, andnaturopaths in Toronto and Vancouver, each with approxi-

mately six participants, totaling over 20 professionals. Re-cruited in the same manner as the members of the public,they were selected to represent various practice settings andincluded a mix of participants according to gender and age.They, too, were asked to complete a brief questionnaire. Themoderated sessions were similar to those with members ofthe public.

Sessions were either video or audio recorded; preliminaryanalysis reported here are based on notes made by the re-searchers who acted as observers and a summary documentprepared by the professional moderators hired to lead thefocus groups.

Results

Unlike most quantitative surveys, the focus groups werenot established to be representative of the Canadian pop-ulation, but they suggest that members of the public, aswell as many health care professionals, have very limitedknowledge of current nutrigenomic practices. Yet, this lackof knowledge did not prevent many participants from ap-preciating the potential value of better information aboutones own genetic profile and the implications in relationto healthy eating. Some skepticism also was expressed,particularly toward a model of nutrigenetic testing offereddirectly to consumers. In essence, members of the publicand health care professionals shared many of the same at-titudes and perceptions, although some differences also

transpired, as shown in the preliminary results presentedbelow.

Nutrition and genetics as health factors

Members of the public generally identified diet and/ornutrition, along with exercise, as the most important factorsin maintaining good health. They understood that a gooddiet and balanced nutrition can help avoid diseases. Many,although not all participants, indicated that they are inter-ested in the link between nutrition and health. When fam-ily history or genetics were identified as relevant to health,they were not among the first factors mentioned.

These findings closely matched those of health care pro-fessionals who similarly claimed that nutrition and/or diet,along with exercise, were significant factors in maintaininggood health. The dieticians, nutritionists, and naturopathsalso tended to emphasize a balanced lifestyle. Health careprofessionals eventually considered genetics as a relevantfactor, but it was not first on their mind, as was the case withmembers of the public.

Health care professionals were asked about their under-standing of the relationship between genetics health andwhether they had ever counseled patients on gene-basedhealth risks. A small number reported they had based nu-tritional counselling on the patients family history, or in afew instances, on genetic test results. They commented onthe significance of genetic predisposition to certain chronicconditions, such as cardiovascular diseases, diabetes, obesityand cancer. Interestingly, physicians and pharmacists em-phasized the importance of genetic factors to health, whiledieticians, nutritionists, and naturopaths placed more em-phasis on environmental factors. Both groups conceded thatmuch remains to be learned about the influence of geneen-vironment interactions on health.

Awareness and perceptions of nutrigenomics

With only a few exceptions, members of the public wereunfamiliar with the term nutrigenomics. However, in thequestionnaires, some participants were able to provide a sim-ple definition that linked nutrition, genes, and health.Among health care professionals, approximately half the di-eticians, nutritionists, and naturopaths were aware of theterm nutrigenomics, but none of the physicians or phar-macists. Even in answers written in the questionnaires, pro-fessionals offered simple definitions of nutrigenomics, andsome did not refer to interactions between genes and nutri-ents and their impact on health. Sample answers provided

in writing or discussed during the moderated sessions arepresented in Table 1.The term personalized nutrition was usually under-

stood to refer to an individually tailored nutritional plan.Some members of the public offered definitions related tohealthy eating in general; others referred to individualizedeating habits without linking it to the idea of optimizing nu-trition for health purposes. Only a few health care profes-sionals related it to an individuals genetic profile.

After the moderator offered a brief explanation of nu-trigenomics, members of the public were generally optimisticthat a tailored diet could help reduce the risk of disease.Some expressed concern that nutritional guides, such asCanadas Food Guide, would become less meaningful or ir-

relevant. As one participant commented It [nutrigenomics]seems to usher out the one size fits all approach to nutri-tion. Health care professionals generally were more skepti-cal since, in their view, many factors influence disease risk.

Internet-based nutrigenomics services

All groups were shown a mock Web site, modeled onthose of existing firms, selling nutrigenomics services thatconsisted of a test kit and health questionnaire, nutritionalcounseling, and supplements. These services and productsranged in price from $275 to $2400. Some members of thepublic commented that companies are likely more interested

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in financial gain than health promotion, although other in-dividuals retained a favorable view of companies. There wasgeneral discomfort with purchasing a test online and partic-ipants expressed a clear preference for in-person testing at aclinic or laboratory, especially where they could have directinteraction with a health care professional. Overall, Internet-

based nutrigenomic services raised buyer beware instincts.Health care professionals were skeptical of the informa-

tion and services presented on the mock Web site. Physiciansand pharmacists in particular questioned whether sufficientscientific evidence supported such tests. Professionals advo-cated regulatory oversight of direct-to-consumer nutrige-nomic services, and believed health care professionalsshould be involved in counseling patients. Nevertheless,there also was some recognition that nutrigenomics could

yield valuable information, foster more interest in health andnutrition among patients or clients, and favor preventive in-terventions. Finally, health care professionals stated that theyshould be familiar with nutrigenomics in order to respondto patient/client inquiries.

Risks and benefits

Although members of the public and health care profes-sionals spoke of risks and benefits using different terms,there was considerable concordance of views (Table 2). Forthe lay participants, nutrigenomics was viewed as poten-tially providing tailored advice and removing guess workfrom nutrition. It also could lead to early diagnoses or dis-ease prevention, and generally should encourage healthier

KNOWLEDGE AND ATTITUDES OF CANADIANS REGARDING NUTRITIONAL GENOMICS 39

TABLE 1. DEFINITIONS OF THE TERM NUTRIGENOMICS

Definitions provided by participants in focus groups

Health care professionals Members of the public

The study of the link between nutrition andgenetics

Using genetics to improve nutrition or using

nutrition to improve ones genetics Choosing foods specific to ones genetic makeup The study of nutrition in humans A branch of science focusing mainly on nutrition

and how it affects everyones health Genetic changes in nutrients The study/application of how nutrition affects

genetic expression The study of how nutrition/specific nutrients can

have an impact on individuals because of theirunique genetic makeup

Creation of custom foods not naturally found innature

Genetically modified to alter nutritional content

How certain foods affect our genes How nutrition interacts with genetics to affect

health

How genes influence nutrition The study of food and how it affects our body Nutrients necessary to health Natural foods Genetically modified foods Nutrition engineering Person who deals with nutrition Nutrition and economics

TABLE 2. RISKS AND BENEFITS OF NUTRIGENOMIC TESTING IDENTIFIED BYHEALTH CARE PROFESSIONALS AND MEMBERS OF THE PUBLIC

Health care professionals Members of the public

Generating wider interest innutrition

Encouraging preventive care

BENEFITS Knowledge of predisposition as

trigger to behavioral change Targeted treatment for specific

conditions Potentially, health care savings

Validity of tests is not established Inaccurate results/misdiagnosis Self-treatment/overuse of

supplementRISKS Patients fail to consider other

interventions (i.e., tests areviewed as magic bullet)

Psychological risks Potential breach of privacy

Tailored approach could takeaway nutritional guesswork

Early diagnosis could lead tobetter diet, disease prevention,and overall healthier habits

NGx testing could have positive

impact on behavior

Science not yet robust enough Results are unclear Not worth the expense Individuals fail to consider other

interventions (i.e., nutrigenomicsshould not be seen as magic

bullet.) Cause anxiety Potential breach of privacy

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habits. Overall, many considered that nutrigenomic testingcould have a positive impact on behavior. For health careprofessionals, nutrigenomics could generate wider interestin nutrition, encourage preventive care, potentially trigger

behavioral change, and help target interventions. Taken to-gether, they believed these measures could result in healthcare savings.

All groups also expressed several concerns. The public

wanted to know if nutrigenomic services are backed by suf-ficient science and also whether results would be readilycomprehensible. They also expressed some concern that ser-vices may be overly expensive, and that some companiescould engage in fraudulent practices. Health care profes-sionals questioned the accuracy and validity of the tests, andworried about the risks of misdiagnosis, self-treatment, oroveruse of supplement.

Both groups cautioned that nutrigenomics should not beconsidered a magic bullet, and worried that some indi-viduals might not seek other medically oriented interven-tions if they overly relied on nutrigenetic test results and re-lated lifestyle changes to address health problems. They alsoexpressed concern about psychological risks (such as anx-

iety), and privacy aspects of turning over biological samplesand personal information to Internet-based companies.Overall, members of the public generally found that bene-fits would likely outweigh risks; health care professionalsappeared less favorable.

Delivery of nutrigenomics-related services

Members of the public were interested in nutrigenomicsservices. Their favorable views potentially would lead manyparticipants to get tested, depending on affordability of thetests. However, they expressed a strong preference for get-ting tested at a clinic rather than through tests purchased on-line and mailed back to a commercial entity. Notably, par-

ticipants did not expect their own physicians to be wellinformed about nutrigenomics, nor able to provide follow-up advice regarding results of tests purchased online.

Physicians and pharmacists generally did not believe theywere sufficiently qualified to give advice on nutrigenomictesting, and would refer patients to a dietician or nutrition-ist if they wanted follow-up on such results. Other healthcare professionals said they would counsel patients after re-searching information in peer-reviewed publications orthrough professional associations, or even by contacting anutrigenomic company.

A small number of health care professionals reported ex-perience assisting patients or clients with nutrigenomic test-ing: two had previously helped individuals get tested, and

one had helped with the interpretation of results. In one in-stance, a health care professional had advised a patientagainst the need for such tests. Finally, health care profes-sionals who would refer a patient or client for nutrigenomictesting would do so as a last resort, in circumstances wherea family history of risk would support genetic testing. Theseattitudes appear to conform to the Canadian Guide to Clin-ical Preventive Health Care, which states:

While there is evidence that nutritional counselling iseffective in changing diet, the role of the physician hasnot been adequately evaluated. Based on the effective-

ness of dietary advice and the association between poordiet and disease, it is reasonable to provide general di-etary advice. For those at increased risk, it is prudent toconsider referral to a clinical nutritionist or other pro-fessional with specialized nutritional expertise (Cana-dian Task Force on the Periodic Health Examination,2008).

Discussion

Although social scientists, legal scholars and bioethicistshave begun turning their attention toward nutrigenomics(Levesque et al., 2008; Ozdemir and Godard, 2007; Ries, 2008;Ronteltap, 2008), little empirical work has been conducted todate. In the United States, as part of the 2006 Behavioral RiskFactor Surveillance System, Michigan, Oregon, and Utahmeasured awareness of direct-to-consumer nutrigenomictests. Results ranged between 7.6% in Michigan, where thequestion referred to a test whereby one receives a personalhealth profile and lifestyle recommendations, to 19.7% and24.4% in Utah and Oregon, respectively, where the questionsreferred more broadly to DNA tests to improve health andprevent disease (Goddard et al., 2008). A 2007 survey by theInternational Food Information Council indicates an evengreater response to a question related to genetic informationthat can be used to provide important nutrition and/or diet-related recommendation. Of 1,000 respondents, 67% claimedto have heard of this possibility (IFIC, 2007). Awareness ofnutrigenomics, along with other questions such as under-standing, favorability, and interest also have been measuredas part of broader surveys on genomics or functional foods(Schmidt et al, 2008). Results from the focus group researchpresented in this article generally echo findings from theseother initiatives. Yet, it is important to clarify that this qual-itative research cannot be generalized to the full Canadianpopulation nor to all health care professionals across the

country. Nevertheless, it helps identify public and profes-sional perceptions about and attitudes toward nutrige-nomics, including potential benefits and risks.

Members of the public and health care professionals bothrecognized their limited knowledge about nutrigenomicsand expressed the need for educational material. Among var-ious potential sources of educational material, they gener-ally recognized that government agencies play an importantrole in educating the public regarding nutrition, through theCanada Food Guide and Web sites such as HealthyCanadi-ans.gc.ca. If such channels could inform the public about nu-trigenomics, it is worth noting that Canadians confidence invarious sources promoting healthy eating varies acrossprovinces and age groups, suggesting that a single educa-

tional strategy would likely be insufficient (Marquis et al.,2005).Educating health professionals presents additional chal-

lenges, especially since knowledge of genetics and nutritionvaries widely among professional groups. In recent surveys,practicing physicians have rated their nutrition knowledgeand skills as inadequate and felt unprepared to counsel pa-tients about nutrition (Adams et al., 206). Time constraintspresent another challenge to providing nutritional counsel-ing in the primary care office (Eaton et al., 2003). Similar find-ings have resulted from a systematic review of the literatureregarding primary care providers views regarding genetic

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services in general (Suther and Goodson, 2003): respondentsbelieved their knowledge was inadequate to provide geneticinformation or services, that time was limited to obtain a de-tailed family history, and that there was a lack of relevantguidelines. Overall, it appears that general practitioners lackinformation about genetic services and options available topatients, which in turn, decreases their confidence to referpatients to appropriate testing services. Other professional

groups, such as dieticians, nutritionists, and naturopathshave expertise in nutrition and would likely be able to re-ceive complementary targeted training in genetics to im-prove their capacity to counsel clients on nutrigenomics.

In light of the concerns that were identified regarding nu-trigenomic tests, particularly services offered directly to con-sumers via the Internet, focus group participants stated thatnutrigenomic practices should not be left to an unregulatedmarketplace; rather, government oversight is needed to en-sure consumer protection. At present, however, nutrigenetictests typically have been outside the purview of regulatoryagencies such as the U.S. Food and Drug Administration orHealth Canadas Health Products and Food Branch (Ries,2008).

The findings of this focus group research point to con-sumers general acceptance of nutrigenomics while healthcare professionals expressed more reservations. If profes-sional skepticism persists, uptake of nutrigenomics may re-main limited. However, additional evidence of the potentialpublic and personal health benefits of nutrigenomics maychange this situation as the field evolves. Therefore, regula-tors in collaboration with other experts should undertake toassess whether potential benefits of this new genomic ap-plication outweigh its risks, beginning with those discussed

by participants in the focus groups. They also should deter-mine whether the current consumer protection frameworkthat governs health products and services is adequate to ad-dress the ethical, legal, and social issues that may arise from

the expansion of nutrigenomics.

Acknowledgments

This research was made possible through funding supportfrom the Network of Centres of Excellence for AdvancedFoods & Materials (www.afmnet.ca). The author acknowl-edges the helpful comments provided by Nola M. Ries andDavid Castle, as well as research assistance from JulianaAiken, Sarah Scott, and Jennifer Farrell.

Author Disclosure Statement

No competing financial interest exists.

References

Adams, K.M., Lindell, K.C., Kohlmeier, M., and Zeisel, S.H.(2006). Status of nutrition education in medical schools. Am JClin Nutr 83, 941S944S.

Cain, M., and Schmid, G. (2003). From nutrigenomic science topersonalized nutrition: the market in 2010 (A report of the In-stitute for the Future, Palo Alto, CA).

Canadian Task Force on the Periodic Health Examination.(2008). Canadian Guide to Clinical Preventive Health Care, Chap-ter 49: Nutritional Couneselling for Undesirable Dietary Pat-terns and Screening for Protein/Calorie Malnutrition Disor-

ders in Adults. Available at: http://www.phac-aspc.gc.ca/publicat/clinic-clinique/index.html. (Accessed June 13, 2008).

Eaton, C.B., McBride, P.E., Gans, K.A., and Underbakke, G.L.(2003). Teaching nutrition skills to primary care practitioners.

J Nutr 133, 563S566S.Goddard, K.A.B., Duquette, D., Zlot, A., Johnson, J., Annis-

Emeott, A., Lee, P.W., et al. (2008). Public awareness and useof direct-to-consumer genetic tests: Results from three StatePopulation-Based Surveys, 2006. Am J Public Health.

Health Canada, Health Products and Food Branch. (2007). To-wards a regulatory modernization strategy for food andnutrition. Available at: http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/consultation/rmsfn-smran-eng.pdf (Accessed June 10, 2008).

IFIC. (2007). Consumer attitudes toward functional foods/foods forhealthExecutive summary. (A Report of the InternationalFood Information Council). Available at: http://www.ific.org/research/funcfoodsres07.cfm. (Accessed August 6, 2008).

Kaput, J. (2007). Nutrigenomics2006 update. Clin Chem LabMed 45, 279287.

Kaput, J., and Rodriguez, R.L. (2004). Nutritional genomics: thenext frontier in the postgenomic era. Physiol Genomics 16,166177.

Lvesque, L., Ozdemir, V., Gremmen, B., and Godard, B. (2008).Integrating anticipated nutrigenomics bioscience applicationswith ethical aspects. OMICS 12, 116.

Marquis, M., Dubeau, C., and Thibault, I. (2005). Canadianslevel of confidence in their sources of nutrition information.Can J Diet Pract Res 3, 170175.

Massoud, M., Ragozin, H., Schmid, G., and Spalding, L. (2001).The future of nutrition: consumers engage with science (A re-port of the Institute for the Future, Palo Alto, CA).

Oliver, D. (2005). The future of nutrigenomics: from the lab to thedining room. (A report of the Institute for the Future, Palo Alto,CA).

Ozdemir, V., and Godard, B. (2007). Evidence based manage-ment of nutrigenomics expectations and ELSIs. Pharmacoge-nomics 8, 10511062.

Ries, N.M. (2008). Regulating nutrigenetic tests: an internationalcomparative analysis. Health Law Rev 16, 920.

Ronteltap, A, Van Trijp, J.C.M., and Renes, R.J. (2008). Consumeracceptace of nutrigenomics-based personalised nutrition. Br JNutr (Published online by Cambridge University Press 15May 2008 doi:10.1017/S0007114508992552).

Schmidt, D.B., White, C., Kapsak, W.R, Conway, J., and Baily,E. (2008). U.S. consumer attitudes toward personalized nutri-tion. In Personalized Nutrition: Principles and Applications Kok,F., Bouwman, L., Desiere, F. eds. (CRC Press, Boca Raton, FL),pp. 205219.

Suther, S., and Goodson, P. (2003). Barriers to the provision ofgenetic services by primary care physicians: a systematic re-view of the literature. Genet Med 5, 7076.

U.S. Government Accountability Office. (2006). Nutrigenetictesting: tests purchased from four Web sites mislead con-sumers. Washington, DC. Available at: http://www.gao.gov/new.items/d06977t.pdf. (Accessed June 10, 2008).

Address reprint requests to:Karine Morin

University of Ottawa60 University

Ottawa, ON, K1N 6N5, Canada

E-mail: [email protected]

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