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OMICS A Journal of Integrative Biology

Volume 13, Number 1, 2009


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

Knowledge and Attitudes of Canadian Consumers


and 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 the
Internet. 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, and
naturopaths) 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 more
skepticism. Both groups agree that more public education about nutrigenomics is needed and that regulatory
oversight should ensure consumer protection.

Introduction the Government Accountability Office forewarned early pi-


oneers of direct-to-consumer nutrigenomic services that they

R ESEARCHERS ARE OPTIMISTIC that nutrigenomics will reveal


valuable understanding regarding individual genetic
risk of diet-modulated diseases and help maintain health,
are under scrutiny as the claims they have made regarding
their services were deemed to “mislead consumers by mak-
ing predictions that are medically unproven and so am-
prevent the onset of disease, and offer therapies (Kaput, 2007; biguous that they do not provide meaningful information to
Kaput and Rodriguez, 2004). Scientific researchers are not consumers” (U.S. Government Accountability Office, 2006).
the only ones foreseeing a transformation of nutrition, and It is against this background that qualitative research was
with it, of food consumption. The Institute for the Future in undertaken to assess the knowledge and attitudes of Cana-
a series of three reports published earlier this decade antic- dian consumers regarding nutritional genomics, as well as
ipated that nutrigenomics could have a significant impact on those of health care professionals, particularly regarding the
consumers’ food purchases (Cain and Schmid, 2003; Mas- risks and potential benefits of nutrigenetic tests offered di-
soud et al, 2001; Oliver, 2005). According to their assessment, rectly to consumers. The research would help elucidate
even if consumers are not familiar with the term “nutritional whether health care professionals and consumers hold sim-
genomics,” they can grasp the idea of personalized nutrition, ilar views regarding this new technology and also help in-
and are attracted to its benefits (Oliver, 2005). form regulators as to some of the ethical, legal, or social con-
Public health authorities and health product regulators are cerns identified by participants.
also noticing these advances. Health Canada has acknowl-
edged that there is a “Growing . . . awareness of the rela-
Method
tionship between food safety and nutritional quality and
chronic disease,” which must be accounted for in the mod- Between November 22 and 28, 2007, 12 focus groups were
ernization of regulatory strategies related to nutrition and conducted with members of the public in five cities across
food (Health Canada, 2007). In the United States, however, Canada. Participants were randomly recruited by telephone

University of Ottawa, Ottawa, Canada.

37
38 MORIN

by an independent third party and invited to specialized fo- These findings closely matched those of health care pro-
cus group facilities in Halifax, Montreal, Toronto, Edmon- fessionals who similarly claimed that nutrition and/or diet,
ton, and Vancouver. Each session included approximately along with exercise, were significant factors in maintaining
eight participants, totaling over 90 adults representing a mix good health. The dieticians, nutritionists, and naturopaths
of gender, income, marital status, and ethnicity. At least half also tended to emphasize a “balanced lifestyle.” Health care
the participants in each group had children at home, con- professionals eventually considered genetics as a relevant
sumed natural health products, and used the Internet to look factor, but it was not first on their mind, as was the case with
for health-related information. Prior to the moderated focus members of the public.
group discussion, each participant completed a brief ques- Health care professionals were asked about their under-
tionnaire. Among other questions, participants were asked standing of the relationship between genetics health and
to provide a definition for the terms “nutrigenomics” and whether they had ever counseled patients on gene-based
“personalized nutrition.” The moderated, 2-h sessions cov- health risks. A small number reported they had based nu-
ered the following issues: contextual issues (e.g., importance tritional counselling on the patient’s family history, or in a
of food in relation to health, understanding of the role of few instances, on genetic test results. They commented on
genes); awareness and initial perception of nutrigenomics; the significance of genetic predisposition to certain chronic
reactions to a media article, a mock Web site selling nu- conditions, such as cardiovascular diseases, diabetes, obesity
trigenomic tests and services, and a summary document de- and cancer. Interestingly, physicians and pharmacists em-
scribing the current state of nutrigenomics; and communi- phasized the importance of genetic factors to health, while
cation issues. dieticians, nutritionists, and naturopaths placed more em-
Two focus groups were conducted with physicians and phasis on environmental factors. Both groups conceded that
pharmacists, and two more with dieticians, nutritionists, and much remains to be learned about the influence of gene–en-
naturopaths in Toronto and Vancouver, each with approxi- vironment interactions on health.
mately six participants, totaling over 20 professionals. Re-
cruited in the same manner as the members of the public, Awareness and perceptions of nutrigenomics
they were selected to represent various practice settings and
With only a few exceptions, members of the public were
included a mix of participants according to gender and age.
unfamiliar with the term “nutrigenomics.” However, in the
They, too, were asked to complete a brief questionnaire. The
questionnaires, some participants were able to provide a sim-
moderated sessions were similar to those with members of
ple definition that linked nutrition, genes, and health.
the public.
Among health care professionals, approximately half the di-
Sessions were either video or audio recorded; preliminary
eticians, nutritionists, and naturopaths were aware of the
analysis reported here are based on notes made by the re-
term “nutrigenomics,” but none of the physicians or phar-
searchers who acted as observers and a summary document
macists. Even in answers written in the questionnaires, pro-
prepared by the professional moderators hired to lead the
fessionals offered simple definitions of nutrigenomics, and
focus groups.
some did not refer to interactions between genes and nutri-
ents and their impact on health. Sample answers provided
Results
in writing or discussed during the moderated sessions are
Unlike most quantitative surveys, the focus groups were presented in Table 1.
not established to be representative of the Canadian pop- The term “personalized nutrition” was usually under-
ulation, but they suggest that members of the public, as stood to refer to an individually tailored nutritional plan.
well as many health care professionals, have very limited Some members of the public offered definitions related to
knowledge of current nutrigenomic practices. Yet, this lack healthy eating in general; others referred to “individualized”
of knowledge did not prevent many participants from ap- eating habits without linking it to the idea of optimizing nu-
preciating the potential value of better information about trition for health purposes. Only a few health care profes-
one’s own genetic profile and the implications in relation sionals related it to an individual’s genetic profile.
to healthy eating. Some skepticism also was expressed, After the moderator offered a brief explanation of nu-
particularly toward a model of nutrigenetic testing offered trigenomics, members of the public were generally optimistic
directly to consumers. In essence, members of the public that a tailored diet could help reduce the risk of disease.
and health care professionals shared many of the same at- Some expressed concern that nutritional guides, such as
titudes and perceptions, although some differences also Canada’s Food Guide, would become less meaningful or ir-
transpired, as shown in the preliminary results presented relevant. As one participant commented “It [nutrigenomics]
below. seems to usher out the ‘one size fits all’ approach to nutri-
tion.” Health care professionals generally were more skepti-
Nutrition and genetics as health factors cal since, in their view, many factors influence disease risk.
Members of the public generally identified diet and/or
Internet-based nutrigenomics services
nutrition, along with exercise, as the most important factors
in maintaining good health. They understood that a good All groups were shown a mock Web site, modeled on
diet and balanced nutrition can help avoid diseases. Many, those of existing firms, selling nutrigenomics services that
although not all participants, indicated that they are inter- consisted of a test kit and health questionnaire, nutritional
ested in the link between nutrition and health. When “fam- counseling, and supplements. These services and products
ily history” or genetics were identified as relevant to health, ranged in price from $275 to $2400. Some members of the
they were not among the first factors mentioned. public commented that companies are likely more interested
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 and • How certain foods affect our genes
genetics • How nutrition interacts with genetics to affect
• Using genetics to improve nutrition or using health
nutrition to improve one’s genetics • How genes influence nutrition
• Choosing foods specific to one’s genetic makeup • The study of food and how it affects our body
• The study of nutrition in humans • Nutrients necessary to health
• A branch of science focusing mainly on nutrition • Natural foods
and how it affects everyone’s health • Genetically modified foods
• Genetic changes in nutrients • Nutrition engineering
• The study/application of how nutrition affects • Person who deals with nutrition
genetic expression • Nutrition and economics
• The study of how nutrition/specific nutrients can
have an impact on individuals because of their
unique genetic makeup
• Creation of custom foods not naturally found in
nature
• Genetically modified to alter nutritional content

in financial gain than health promotion, although other in- yield valuable information, foster more interest in health and
dividuals retained a favorable view of companies. There was nutrition among patients or clients, and favor preventive in-
general discomfort with purchasing a test online and partic- terventions. Finally, health care professionals stated that they
ipants expressed a clear preference for in-person testing at a should be familiar with nutrigenomics in order to respond
clinic or laboratory, especially where they could have direct to patient/client inquiries.
interaction with a health care professional. Overall, Internet-
based nutrigenomic services raised “buyer beware” instincts.
Risks and benefits
Health care professionals were skeptical of the informa-
tion and services presented on the mock Web site. Physicians Although members of the public and health care profes-
and pharmacists in particular questioned whether sufficient sionals spoke of risks and benefits using different terms,
scientific evidence supported such tests. Professionals advo- there was considerable concordance of views (Table 2). For
cated regulatory oversight of direct-to-consumer nutrige- the lay participants, nutrigenomics was viewed as poten-
nomic services, and believed health care professionals tially providing tailored advice and removing guess work
should be involved in counseling patients. Nevertheless, from nutrition. It also could lead to early diagnoses or dis-
there also was some recognition that nutrigenomics could ease prevention, and generally should encourage healthier

TABLE 2. RISKS AND BENEFITS OF NUTRIGENOMIC TESTING IDENTIFIED BY


HEALTH CARE PROFESSIONALS AND MEMBERS OF THE PUBLIC

Health care professionals Members of the public

• Generating wider interest in • Tailored approach could take


nutrition away nutritional guesswork
• Encouraging preventive care • Early diagnosis could lead to
• Knowledge of predisposition as better diet, disease prevention,
BENEFITS
trigger to behavioral change and overall healthier habits
• Targeted treatment for specific • NGx testing could have positive
conditions impact on behavior
• Potentially, health care savings

• Validity of tests is not established • Science not yet robust enough


• Inaccurate results/misdiagnosis • Results are unclear
• Self-treatment/overuse of • Not worth the expense
supplement • Individuals fail to consider other
RISKS • Patients fail to consider other interventions (i.e., nutrigenomics
interventions (i.e., tests are “should not be seen as magic
“viewed as magic bullet”) bullet.”)
• Psychological risks • Cause anxiety
• Potential breach of privacy • Potential breach of privacy
concerns
40 MORIN

habits. Overall, many considered that nutrigenomic testing ness of dietary advice and the association between poor
could have a positive impact on behavior. For health care diet and disease, it is reasonable to provide general di-
professionals, nutrigenomics could generate wider interest etary advice. For those at increased risk, it is prudent to
in nutrition, encourage preventive care, potentially trigger consider referral to a clinical nutritionist or other pro-
behavioral change, and help target interventions. Taken to- fessional with specialized nutritional expertise (Cana-
gether, they believed these measures could result in health dian Task Force on the Periodic Health Examination,
care savings. 2008).
All groups also expressed several concerns. The public
wanted to know if nutrigenomic services are backed by suf- Discussion
ficient science and also whether results would be readily
Although social scientists, legal scholars and bioethicists
comprehensible. They also expressed some concern that ser-
have begun turning their attention toward nutrigenomics
vices may be overly expensive, and that some companies
(Levesque et al., 2008; Ozdemir and Godard, 2007; Ries, 2008;
could engage in fraudulent practices. Health care profes-
Ronteltap, 2008), little empirical work has been conducted to
sionals questioned the accuracy and validity of the tests, and
date. In the United States, as part of the 2006 Behavioral Risk
worried about the risks of misdiagnosis, self-treatment, or
Factor Surveillance System, Michigan, Oregon, and Utah
overuse of supplement.
measured awareness of direct-to-consumer nutrigenomic
Both groups cautioned that nutrigenomics should not be
tests. Results ranged between 7.6% in Michigan, where the
considered a “magic bullet,” and worried that some indi-
question referred to a test whereby one receives a personal
viduals might not seek other medically oriented interven-
health profile and lifestyle recommendations, to 19.7% and
tions if they overly relied on nutrigenetic test results and re-
24.4% in Utah and Oregon, respectively, where the questions
lated lifestyle changes to address health problems. They also
referred more broadly to DNA tests to improve health and
expressed concern about psychological risks (such as anx-
prevent disease (Goddard et al., 2008). A 2007 survey by the
iety), and privacy aspects of turning over biological samples
International Food Information Council indicates an even
and personal information to Internet-based companies.
greater response to a question related to genetic information
Overall, members of the public generally found that bene-
that can be used to provide important nutrition and/or diet-
fits would likely outweigh risks; health care professionals
related recommendation. Of 1,000 respondents, 67% claimed
appeared less favorable.
to have heard of this possibility (IFIC, 2007). Awareness of
nutrigenomics, along with other questions such as under-
Delivery of nutrigenomics-related services
standing, favorability, and interest also have been measured
Members of the public were interested in nutrigenomics as part of broader surveys on genomics or functional foods
services. Their favorable views potentially would lead many (Schmidt et al, 2008). Results from the focus group research
participants to get tested, depending on affordability of the presented in this article generally echo findings from these
tests. However, they expressed a strong preference for get- other initiatives. Yet, it is important to clarify that this qual-
ting tested at a clinic rather than through tests purchased on- itative research cannot be generalized to the full Canadian
line and mailed back to a commercial entity. Notably, par- population nor to all health care professionals across the
ticipants did not expect their own physicians to be well country. Nevertheless, it helps identify public and profes-
informed about nutrigenomics, nor able to provide follow- sional perceptions about and attitudes toward nutrige-
up advice regarding results of tests purchased online. nomics, including potential benefits and risks.
Physicians and pharmacists generally did not believe they Members of the public and health care professionals both
were sufficiently qualified to give advice on nutrigenomic recognized their limited knowledge about nutrigenomics
testing, and would refer patients to a dietician or nutrition- and expressed the need for educational material. Among var-
ist if they wanted follow-up on such results. Other health ious potential sources of educational material, they gener-
care professionals said they would counsel patients after re- ally recognized that government agencies play an important
searching information in peer-reviewed publications or role in educating the public regarding nutrition, through the
through professional associations, or even by contacting a Canada Food Guide and Web sites such as HealthyCanadi-
nutrigenomic company. ans.gc.ca. If such channels could inform the public about nu-
A small number of health care professionals reported ex- trigenomics, it is worth noting that Canadians’ confidence in
perience assisting patients or clients with nutrigenomic test- various sources promoting healthy eating varies across
ing: two had previously helped individuals get tested, and provinces and age groups, suggesting that a single educa-
one had helped with the interpretation of results. In one in- tional strategy would likely be insufficient (Marquis et al.,
stance, a health care professional had advised a patient 2005).
against the need for such tests. Finally, health care profes- Educating health professionals presents additional chal-
sionals who would refer a patient or client for nutrigenomic lenges, especially since knowledge of genetics and nutrition
testing would do so as a last resort, in circumstances where varies widely among professional groups. In recent surveys,
a family history of risk would support genetic testing. These practicing physicians have rated their nutrition knowledge
attitudes appear to conform to the Canadian Guide to Clin- and skills as inadequate and felt unprepared to counsel pa-
ical Preventive Health Care, which states: tients about nutrition (Adams et al., 206). Time constraints
present another challenge to providing nutritional counsel-
While there is evidence that nutritional counselling is ing in the primary care office (Eaton et al., 2003). Similar find-
effective in changing diet, the role of the physician has ings have resulted from a systematic review of the literature
not been adequately evaluated. Based on the effective- regarding primary care providers’ views regarding genetic
KNOWLEDGE AND ATTITUDES OF CANADIANS REGARDING NUTRITIONAL GENOMICS 41

services in general (Suther and Goodson, 2003): respondents ders in Adults. Available at: http://www.phac-aspc.gc.ca/
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tailed family history, and that there was a lack of relevant (2003). Teaching nutrition skills to primary care practitioners.
guidelines. Overall, it appears that general practitioners lack J Nutr 133, 563S–566S.
information about genetic services and options available to Goddard, K.A.B., Duquette, D., Zlot, A., Johnson, J., Annis-
patients, which in turn, decreases their confidence to refer Emeott, A., Lee, P.W., et al. (2008). Public awareness and use
patients to appropriate testing services. Other professional of direct-to-consumer genetic tests: Results from three State
Population-Based Surveys, 2006. Am J Public Health.
groups, such as dieticians, nutritionists, and naturopaths
Health Canada, Health Products and Food Branch. (2007). To-
have expertise in nutrition and would likely be able to re-
wards a regulatory modernization strategy for food and
ceive complementary targeted training in genetics to im-
nutrition. Available at: http://www.hc-sc.gc.ca/fn-an/alt_
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In light of the concerns that were identified regarding nu- eng.pdf (Accessed June 10, 2008).
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The findings of this focus group research point to con- Lévesque, L., Ozdemir, V., Gremmen, B., and Godard, B. (2008).
sumers’ general acceptance of nutrigenomics while health Integrating anticipated nutrigenomics bioscience applications
care professionals expressed more reservations. If profes- with ethical aspects. OMICS 12, 1–16.
sional skepticism persists, uptake of nutrigenomics may re- Marquis, M., Dubeau, C., and Thibault, I. (2005). Canadians’
main limited. However, additional evidence of the potential level of confidence in their sources of nutrition information.
public and personal health benefits of nutrigenomics may Can J Diet Pract Res 3, 170–175.
change this situation as the field evolves. Therefore, regula- Massoud, M., Ragozin, H., Schmid, G., and Spalding, L. (2001).
The future of nutrition: consumers engage with science (A re-
tors in collaboration with other experts should undertake to
port of the Institute for the Future, Palo Alto, CA).
assess whether potential benefits of this new genomic ap-
Oliver, D. (2005). The future of nutrigenomics: from the lab to the
plication outweigh its risks, beginning with those discussed
dining room. (A report of the Institute for the Future, Palo Alto,
by participants in the focus groups. They also should deter-
CA).
mine whether the current consumer protection framework Ozdemir, V., and Godard, B. (2007). Evidence based manage-
that governs health products and services is adequate to ad- ment of nutrigenomics expectations and ELSIs. Pharmacoge-
dress the ethical, legal, and social issues that may arise from nomics 8, 1051–1062.
the expansion of nutrigenomics. Ries, N.M. (2008). Regulating nutrigenetic tests: an international
comparative analysis. Health Law Rev 16, 9–20.
Acknowledgments Ronteltap, A, Van Trijp, J.C.M., and Renes, R.J. (2008). Consumer
acceptace of nutrigenomics-based personalised nutrition. Br J
This research was made possible through funding support
Nutr (Published online by Cambridge University Press 15
from the Network of Centres of Excellence for Advanced
May 2008 doi:10.1017/S0007114508992552).
Foods & Materials (www.afmnet.ca). The author acknowl-
Schmidt, D.B., White, C., Kapsak, W.R, Conway, J., and Baily,
edges the helpful comments provided by Nola M. Ries and
E. (2008). U.S. consumer attitudes toward personalized nutri-
David Castle, as well as research assistance from Juliana tion. In Personalized Nutrition: Principles and Applications Kok,
Aiken, Sarah Scott, and Jennifer Farrell. F., Bouwman, L., Desiere, F. eds. (CRC Press, Boca Raton, FL),
pp. 205–219.
Author Disclosure Statement Suther, S., and Goodson, P. (2003). Barriers to the provision of
No competing financial interest exists. genetic services by primary care physicians: a systematic re-
view of the literature. Genet Med 5, 70–76.
U.S. Government Accountability Office. (2006). Nutrigenetic
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