Canadian Knowledge About Nutritional Genomics 01 | Nutrigenomics | Dietitian

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 services, nutritional advice, and dietary supplements “tailored” to match individual genetic predispositions. Although 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 undertaken to assess the current level of understanding of and receptivity toward this new genomic application. Additionally, focus groups with health care professionals (physicians, pharmacists, dieticians, nutritionists, and naturopaths) investigated their interest in integrating nutrigenomics into health care delivery, and their capacity to do so. Gauging knowledge and attitudes early in the introduction of a new technology serves to identify potential “blind spots” regarding the ethical, legal, and social implications. Preliminary results indicate consumers 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

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ESEARCHERS ARE OPTIMISTIC that nutrigenomics will reveal valuable 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 not the only ones foreseeing a transformation of nutrition, and with it, of food consumption. The Institute for the Future in a series of three reports published earlier this decade anticipated that nutrigenomics could have a significant impact on consumers’ food purchases (Cain and Schmid, 2003; Massoud 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 are also noticing these advances. Health Canada has acknowledged that there is a “Growing . . . awareness of the relationship between food safety and nutritional quality and chronic disease,” which must be accounted for in the modernization of regulatory strategies related to nutrition and food (Health Canada, 2007). In the United States, however,

the Government Accountability Office forewarned early pioneers of direct-to-consumer nutrigenomic services that they are under scrutiny as the claims they have made regarding their services were deemed to “mislead consumers by making predictions that are medically unproven and so ambiguous that they do not provide meaningful information to consumers” (U.S. Government Accountability Office, 2006). It is against this background that qualitative research was undertaken to assess the knowledge and attitudes of Canadian consumers regarding nutritional genomics, as well as those of health care professionals, particularly regarding the risks and potential benefits of nutrigenetic tests offered directly to consumers. The research would help elucidate whether health care professionals and consumers hold similar views regarding this new technology and also help inform regulators as to some of the ethical, legal, or social concerns identified by participants. Method Between November 22 and 28, 2007, 12 focus groups were conducted with members of the public in five cities across Canada. Participants were randomly recruited by telephone

University of Ottawa, Ottawa, Canada.

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38 by an independent third party and invited to specialized focus group facilities in Halifax, Montreal, Toronto, Edmonton, and Vancouver. Each session included approximately eight participants, totaling over 90 adults representing a mix of gender, income, marital status, and ethnicity. At least half the participants in each group had children at home, consumed natural health products, and used the Internet to look for health-related information. Prior to the moderated focus group discussion, each participant completed a brief questionnaire. Among other questions, participants were asked to provide a definition for the terms “nutrigenomics” and “personalized nutrition.” The moderated, 2-h sessions covered the following issues: contextual issues (e.g., importance of food in relation to health, understanding of the role of genes); awareness and initial perception of nutrigenomics; reactions to a media article, a mock Web site selling nutrigenomic tests and services, and a summary document describing the current state of nutrigenomics; and communication issues. Two focus groups were conducted with physicians and pharmacists, and two more with dieticians, nutritionists, and naturopaths in Toronto and Vancouver, each with approximately six participants, totaling over 20 professionals. Recruited in the same manner as the members of the public, they were selected to represent various practice settings and included a mix of participants according to gender and age. They, too, were asked to complete a brief questionnaire. The moderated sessions were similar to those with members of the public. Sessions were either video or audio recorded; preliminary analysis reported here are based on notes made by the researchers who acted as observers and a summary document prepared by the professional moderators hired to lead the focus groups. Results Unlike most quantitative surveys, the focus groups were not established to be representative of the Canadian population, but they suggest that members of the public, as well as many health care professionals, have very limited knowledge of current nutrigenomic practices. Yet, this lack of knowledge did not prevent many participants from appreciating the potential value of better information about one’s own genetic profile and the implications in relation to healthy eating. Some skepticism also was expressed, particularly toward a model of nutrigenetic testing offered directly to consumers. In essence, members of the public and health care professionals shared many of the same attitudes and perceptions, although some differences also transpired, as shown in the preliminary results presented below. Nutrition and genetics as health factors Members of the public generally identified diet and/or nutrition, along with exercise, as the most important factors in maintaining good health. They understood that a good diet and balanced nutrition can help avoid diseases. Many, although not all participants, indicated that they are interested in the link between nutrition and health. When “family history” or genetics were identified as relevant to health, they were not among the first factors mentioned.

MORIN These findings closely matched those of health care professionals who similarly claimed that nutrition and/or diet, along with exercise, were significant factors in maintaining good health. The dieticians, nutritionists, and naturopaths also tended to emphasize a “balanced lifestyle.” Health care professionals eventually considered genetics as a relevant factor, but it was not first on their mind, as was the case with members of the public. Health care professionals were asked about their understanding of the relationship between genetics health and whether they had ever counseled patients on gene-based health risks. A small number reported they had based nutritional counselling on the patient’s family history, or in a few instances, on genetic test results. They commented on the significance of genetic predisposition to certain chronic conditions, such as cardiovascular diseases, diabetes, obesity and cancer. Interestingly, physicians and pharmacists emphasized the importance of genetic factors to health, while dieticians, nutritionists, and naturopaths placed more emphasis on environmental factors. Both groups conceded that much remains to be learned about the influence of gene–environment interactions on health. Awareness and perceptions of nutrigenomics With only a few exceptions, members of the public were unfamiliar with the term “nutrigenomics.” However, in the questionnaires, some participants were able to provide a simple definition that linked nutrition, genes, and health. Among health care professionals, approximately half the dieticians, nutritionists, and naturopaths were aware of the term “nutrigenomics,” but none of the physicians or pharmacists. Even in answers written in the questionnaires, professionals offered simple definitions of nutrigenomics, and some did not refer to interactions between genes and nutrients and their impact on health. Sample answers provided in writing or discussed during the moderated sessions are presented in Table 1. The term “personalized nutrition” was usually understood to refer to an individually tailored nutritional plan. Some members of the public offered definitions related to healthy eating in general; others referred to “individualized” eating habits without linking it to the idea of optimizing nutrition for health purposes. Only a few health care professionals related it to an individual’s genetic profile. After the moderator offered a brief explanation of nutrigenomics, members of the public were generally optimistic that a tailored diet could help reduce the risk of disease. Some expressed concern that nutritional guides, such as Canada’s Food Guide, would become less meaningful or irrelevant. As one participant commented “It [nutrigenomics] seems to usher out the ‘one size fits all’ approach to nutrition.” Health care professionals generally were more skeptical since, in their view, many factors influence disease risk. Internet-based nutrigenomics services All groups were shown a mock Web site, modeled on those of existing firms, selling nutrigenomics services that consisted of a test kit and health questionnaire, nutritional counseling, and supplements. These services and products ranged in price from $275 to $2400. Some members of the public commented that companies are likely more interested

KNOWLEDGE AND ATTITUDES OF CANADIANS REGARDING NUTRITIONAL GENOMICS TABLE 1. DEFINITIONS
OF THE

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TERM “NUTRIGENOMICS”

Definitions provided by participants in focus groups Health care professionals • The study of the link between nutrition and genetics • Using genetics to improve nutrition or using nutrition to improve one’s genetics • Choosing foods specific to one’s genetic makeup • The study of nutrition in humans • A branch of science focusing mainly on nutrition and how it affects everyone’s 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 their unique genetic makeup • Creation of custom foods not naturally found in nature • Genetically modified to alter nutritional content Members of the public • 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

in financial gain than health promotion, although other individuals retained a favorable view of companies. There was general discomfort with purchasing a test online and participants expressed a clear preference for in-person testing at a clinic or laboratory, especially where they could have direct interaction with a health care professional. Overall, Internetbased nutrigenomic services raised “buyer beware” instincts. Health care professionals were skeptical of the information and services presented on the mock Web site. Physicians and pharmacists in particular questioned whether sufficient scientific evidence supported such tests. Professionals advocated regulatory oversight of direct-to-consumer nutrigenomic services, and believed health care professionals should be involved in counseling patients. Nevertheless, there also was some recognition that nutrigenomics could

yield valuable information, foster more interest in health and nutrition among patients or clients, and favor preventive interventions. Finally, health care professionals stated that they should be familiar with nutrigenomics in order to respond to patient/client inquiries. Risks and benefits Although members of the public and health care professionals spoke of risks and benefits using different terms, there was considerable concordance of views (Table 2). For the lay participants, nutrigenomics was viewed as potentially providing tailored advice and removing guess work from nutrition. It also could lead to early diagnoses or disease prevention, and generally should encourage healthier
BY

TABLE 2. RISKS AND BENEFITS OF NUTRIGENOMIC TESTING IDENTIFIED HEALTH CARE PROFESSIONALS AND MEMBERS OF THE PUBLIC Health care professionals • Generating wider interest in nutrition • Encouraging preventive care • 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 supplement • Patients fail to consider other interventions (i.e., tests are “viewed as magic bullet”) • Psychological risks • Potential breach of privacy

Members of the public • Tailored approach could take away nutritional guesswork • Early diagnosis could lead to better 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., nutrigenomics “should not be seen as magic bullet.”) • Cause anxiety • Potential breach of privacy concerns

BENEFITS

RISKS

40 habits. Overall, many considered that nutrigenomic testing could have a positive impact on behavior. For health care professionals, nutrigenomics could generate wider interest in nutrition, encourage preventive care, potentially trigger behavioral change, and help target interventions. Taken together, they believed these measures could result in health care savings. All groups also expressed several concerns. The public wanted to know if nutrigenomic services are backed by sufficient science and also whether results would be readily comprehensible. They also expressed some concern that services may be overly expensive, and that some companies could engage in fraudulent practices. Health care professionals questioned the accuracy and validity of the tests, and worried about the risks of misdiagnosis, self-treatment, or overuse of supplement. Both groups cautioned that nutrigenomics should not be considered a “magic bullet,” and worried that some individuals might not seek other medically oriented interventions if they overly relied on nutrigenetic test results and related lifestyle changes to address health problems. They also expressed concern about psychological risks (such as anxiety), and privacy aspects of turning over biological samples and personal information to Internet-based companies. Overall, members of the public generally found that benefits would likely outweigh risks; health care professionals appeared less favorable. Delivery of nutrigenomics-related services Members of the public were interested in nutrigenomics services. Their favorable views potentially would lead many participants to get tested, depending on affordability of the tests. However, they expressed a strong preference for getting tested at a clinic rather than through tests purchased online and mailed back to a commercial entity. Notably, participants did not expect their own physicians to be well informed about nutrigenomics, nor able to provide followup advice regarding results of tests purchased online. Physicians and pharmacists generally did not believe they were sufficiently qualified to give advice on nutrigenomic testing, and would refer patients to a dietician or nutritionist if they wanted follow-up on such results. Other health care professionals said they would counsel patients after researching information in peer-reviewed publications or through professional associations, or even by contacting a nutrigenomic company. A small number of health care professionals reported experience assisting patients or clients with nutrigenomic testing: two had previously helped individuals get tested, and one had helped with the interpretation of results. In one instance, a health care professional had advised a patient against the need for such tests. Finally, health care professionals who would refer a patient or client for nutrigenomic testing would do so as a last resort, in circumstances where a family history of risk would support genetic testing. These attitudes appear to conform to the Canadian Guide to Clinical Preventive Health Care, which states: While there is evidence that nutritional counselling is effective in changing diet, the role of the physician has not been adequately evaluated. Based on the effective-

MORIN ness of dietary advice and the association between poor diet and disease, it is reasonable to provide general dietary advice. For those at increased risk, it is prudent to consider referral to a clinical nutritionist or other professional with specialized nutritional expertise (Canadian Task Force on the Periodic Health Examination, 2008). Discussion Although social scientists, legal scholars and bioethicists have begun turning their attention toward nutrigenomics (Levesque et al., 2008; Ozdemir and Godard, 2007; Ries, 2008; Ronteltap, 2008), little empirical work has been conducted to date. In the United States, as part of the 2006 Behavioral Risk Factor Surveillance System, Michigan, Oregon, and Utah measured awareness of direct-to-consumer nutrigenomic tests. Results ranged between 7.6% in Michigan, where the question referred to a test whereby one receives a personal health profile and lifestyle recommendations, to 19.7% and 24.4% in Utah and Oregon, respectively, where the questions referred more broadly to DNA tests to improve health and prevent disease (Goddard et al., 2008). A 2007 survey by the International Food Information Council indicates an even greater response to a question related to genetic information that can be used to provide important nutrition and/or dietrelated recommendation. Of 1,000 respondents, 67% claimed to have heard of this possibility (IFIC, 2007). Awareness of nutrigenomics, along with other questions such as understanding, favorability, and interest also have been measured as part of broader surveys on genomics or functional foods (Schmidt et al, 2008). Results from the focus group research presented in this article generally echo findings from these other initiatives. Yet, it is important to clarify that this qualitative research cannot be generalized to the full Canadian population nor to all health care professionals across the country. Nevertheless, it helps identify public and professional perceptions about and attitudes toward nutrigenomics, including potential benefits and risks. Members of the public and health care professionals both recognized their limited knowledge about nutrigenomics and expressed the need for educational material. Among various potential sources of educational material, they generally recognized that government agencies play an important role in educating the public regarding nutrition, through the Canada Food Guide and Web sites such as HealthyCanadians.gc.ca. If such channels could inform the public about nutrigenomics, it is worth noting that Canadians’ confidence in various sources promoting healthy eating varies across provinces and age groups, suggesting that a single educational strategy would likely be insufficient (Marquis et al., 2005). Educating health professionals presents additional challenges, especially since knowledge of genetics and nutrition varies widely among professional groups. In recent surveys, practicing physicians have rated their nutrition knowledge and skills as inadequate and felt unprepared to counsel patients about nutrition (Adams et al., 206). Time constraints present another challenge to providing nutritional counseling in the primary care office (Eaton et al., 2003). Similar findings have resulted from a systematic review of the literature regarding primary care providers’ views regarding genetic

KNOWLEDGE AND ATTITUDES OF CANADIANS REGARDING NUTRITIONAL GENOMICS services in general (Suther and Goodson, 2003): respondents believed their knowledge was inadequate to provide genetic information or services, that time was limited to obtain a detailed family history, and that there was a lack of relevant guidelines. Overall, it appears that general practitioners lack information about genetic services and options available to patients, which in turn, decreases their confidence to refer patients to appropriate testing services. Other professional groups, such as dieticians, nutritionists, and naturopaths have expertise in nutrition and would likely be able to receive complementary targeted training in genetics to improve their capacity to counsel clients on nutrigenomics. In light of the concerns that were identified regarding nutrigenomic tests, particularly services offered directly to consumers via the Internet, focus group participants stated that nutrigenomic practices should not be left to an unregulated marketplace; rather, government oversight is needed to ensure consumer protection. At present, however, nutrigenetic tests typically have been outside the purview of regulatory agencies such as the U.S. Food and Drug Administration or Health Canada’s Health Products and Food Branch (Ries, 2008). The findings of this focus group research point to consumers’ general acceptance of nutrigenomics while health care professionals expressed more reservations. If professional skepticism persists, uptake of nutrigenomics may remain limited. However, additional evidence of the potential public and personal health benefits of nutrigenomics may change this situation as the field evolves. Therefore, regulators in collaboration with other experts should undertake to assess whether potential benefits of this new genomic application outweigh its risks, beginning with those discussed by participants in the focus groups. They also should determine whether the current consumer protection framework that governs health products and services is adequate to address the ethical, legal, and social issues that may arise from the expansion of nutrigenomics. Acknowledgments This research was made possible through funding support from the Network of Centres of Excellence for Advanced Foods & Materials (www.afmnet.ca). The author acknowledges the helpful comments provided by Nola M. Ries and David Castle, as well as research assistance from Juliana Aiken, Sarah Scott, and Jennifer Farrell. Author Disclosure Statement No competing financial interest exists. References
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Address reprint requests to: Karine Morin University of Ottawa 60 University Ottawa, ON, K1N 6N5, Canada E-mail: kmorin@uottawa.ca

This article has been cited by: 1. Vural Ozdemir , Arno G. Motulsky , Eugene Kolker , Béatrice Godard . 2009. Genome–Environment Interactions and Prospective Technology Assessment: Evolution from Pharmacogenomics to Nutrigenomics and EcogenomicsGenome–Environment Interactions and Prospective Technology Assessment: Evolution from Pharmacogenomics to Nutrigenomics and Ecogenomics. OMICS: A Journal of Integrative Biology 13:1, 1-6. [Abstract] [PDF] [PDF Plus]

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