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Factors Determining the Integration of Nutritional Genomics Into Clinical Practice by Registered Dietitians

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Factors Determining the Integration of Nutritional Genomics Into Clinical Practice by Registered Dietitians Trends in Food Science & Technology 59 (2017) 139e147 Contents lists available at ScienceDirect Trends in Food Science & Technology journal homepage: http://www.journals.elsevier.com/trends-in-food-science- and-technology Review Factors determining the integration of nutritional genomics into clinical practice by registered dietitians * Mariette€ Abrahams a, Lynn J. Frewer b, Eleanor Bryant a, Barbara Stewart-Knox a, a Division of Psychology, Faculty of Social Sciences, University of Bradford, UK b School of Agriculture, Food and Rural Development, Newcastle University, UK article info abstract Article history: Background: Personalized nutrition has the potential to improve health, prevent disease and reduce Received 17 October 2015 healthcare expenditure. Whilst research hints at positive consumer attitudes towards personalized Received in revised form nutrition that draws upon lifestyle, phenotypic and genotypic data, little is known about the degree to 2 November 2016 which registered dietitians (RD) are engaged in the delivery of such services. This review sought to Accepted 16 November 2016 determine possible factors associated with the integration of the emerging science of Nutritional Ge- Available online 24 November 2016 nomics (NGx) into the clinical practice setting by practicing registered dietitians. Scope: Search of online databases (Pubmed; National Library of Medicine; Cochrane Library; Ovid Keywords: Dietitians Medline) was conducted on material published from January 2000 to December 2014. Studies that Nutritional genomics sampled practicing dietitians and investigated integration or application of NGx and genetics knowledge Involvement into practice were eligible. Articles were assessed according to the American Dietetic Association Quality Personalized nutrition Criteria Checklist. Key findings: Application of nutritional genomics in practice has been limited. Reluctance to integrate NGx into practice is associated with low awareness of NGx, a lack of confidence in the science sur- rounding NGx and skepticism toward Direct to consumer (DTC) products. Successful application to practice was associated with knowledge about NGx, having confidence in the science, a positive attitude toward NGx, access to DTC products, a supportive working environment, working in the clinical setting rather than the public health domain and being in private rather than public practice. Conclusions: There is a need to provide RGs with a supportive working environment that provides ongoing training in NGx and which is integrated with clinical practice. © 2016 Elsevier Ltd. All rights reserved. 1. Background which is poised to revolutionize healthcare toward personalized treatment plans. Although personalized nutrition is not explicitly Since the completion of the Human Genome Project in 2003 mentioned within the plans, diet and lifestyle play a key role in the (Venter, 2011), vast progress has been made in the field of identi- prevention of non-communicable diseases, the European Com- fying human genetic variations which may play a role in the mission (EC) has pledged make personalized diets a priority by development of obesity and chronic diseases such as diabetes, 2050 (EC, 2014). As a consequence, nutrition is expected to become cardiovascular disease and dementia (Nielsen & El-Sohemy, 2012). a key focus for prevention. It has been speculated that wide With regards to modernizing healthcare, the United Kingdom (UK) adoption of personalized nutrition could result in health care government, in particular, is aiming to lead genomic research and expenditure reduction of 13% (Marsh & McLennan, 2014). its application within the NHS. According to the 5-Year Forward Rapid developments in genomic research have led to the Review Report (2014), personalized healthcare will be delivered emerging field of nutritional genomics (NGx), which encompasses using digital technologies and will be informed by genomic data, both nutrigenomics (the study of the impact of diet on gene expression) and nutrigenetics (which looks at how our genetic make-up affects nutrient response) (Müller & Kersten, 2003). Rosen, Earthman, Marquart, and Reicks (2006, p1243) defined the * Corresponding author. Division of Psychology, Faculty of Social Sciences, Uni- application of NGx as “the interpretation of genetic profile infor- versity of Bradford, Richmond Road, Bradford, West Yorkshire, BD71DP, UK. E-mail address: [email protected] (B. Stewart-Knox). mation with subsequent therapeutic prescription of an http://dx.doi.org/10.1016/j.tifs.2016.11.005 0924-2244/© 2016 Elsevier Ltd. All rights reserved. 140 M. Abrahams et al. / Trends in Food Science & Technology 59 (2017) 139e147 individualized dietary regimen that was tailored to the prevention Ahlgren, & Nordstrom,€ 2013). Professional guidelines, therefore, or management of one or more specific diseases or conditions do not yet explicitly recommend that nutrigenetic testing is applied identified by the genetic profile”. In addition, the position paper of in routine dietetic practice (Camp & Trujillo, 2014). Meanwhile, the Academy of Nutrition and Dietetics (AND) on NGx states “The there is a growing expectation that RD's should be competent in application of NGx in clinical practice requires that healthcare genetics (BDA, 2013; HCPC, 2013), have a basic knowledge of professionals understand, interpret and communicate complex test nutritional genomics (NHS Genetics education centre, 2014) and be results in which the actual risk of developing a disease may or may prepared to integrate NGx into their practice (Collins et al., 2013). not be known” (Camp & Trujillo, 2014, p. 299). The purpose of There has also been an education drive for front-line healthcare nutritional genomics is to enable the delivery of a personalized practitioners to become familiar with genomics (DeBusk, 2009; approach to nutrition intervention which is based on lifestyle, ge- Public Health Genomics Education, 2015). Only a few research notype and/or phenotype and in doing so, to prevent or mitigate studies, however, appear to have examined healthcare pro- the development of chronic diseases (Fenech et al., 2011). fessionals' (including RD's) engagement in the field of nutritional The clinical utility of genetic tests designed to inform person- genomics (Lapham, Kozma, Weiss, Benkendorf, & Wilson, 2000; alized nutrition plans have been widely criticized mainly because of Rosen et al., 2006; McCarthy, Pufulete, & Whelan, 2008; Whelan, a lack of evidence for strong gene-nutrient interactions as well as McCarthy, & Pufulete, 2008; Collins et al., 2013). With an inter- lack of effectiveness regarding (short and long term) behavior ested potential consumer market (Fischer et al., 2016; Stewart- change (Ries & Castle, 2008; Fraker & Mazza, 2010; Burke, 2014; Knox et al., 2016), it is essential to identify and address any bar- Pavlidis et al., 2015; Hollands et al., 2016). Against this, there is riers that may affect the integration of nutrigenomic science into mounting evidence regarding the benefits of a personalized practice. Any lack of engagement and/or understanding of the sci- nutrition approach with regards to dietary behavior change ence by nutrition providers, may impact negatively upon public (Arkadianos et al., 2007; Chao et al., 2008; Tierney et al., 2011; perception which could have a knock-on effect on public health. Nielsen & El-Sohemy, 2012; Nielsen & El-Sohemy, 2014; Fallaize The aim of this review, therefore, has been to identify and under- et al., 2015; Frankwich et al., 2015; Celis-Morales et al., 2016; Liv- stand factors that are associated with the integration and applica- ingstone et al., 2016). tion of NGx by registered dietitians in clinical practice. Clinical The term ‘personalized nutrition’ has, at times, been used syn- dietetic practice refers both to advising clients or patients, who may onymously with ‘nutritional genomics’. Personalized nutrition, or may not have medical conditions, on nutrition (BDA, 2013). The however, has been defined more broadly. The Food4me project application or integration of NGx is defined as the use of informa- (Food4me.org) was a European-wide research effort that looked tion (including genetics), to assess an individuals' predisposition or extensively into public perceptions of, attitudes towards, and risk of developing a disease and maintain health (Collins et al., preferences for delivery of different types of personalized nutrition 2013; Camp & Trujillo, 2014). (Stewart-Knox et al., 2009). The potential of different business models for delivering personalized nutrition were also examined (Ronteltap, van Trijp, Berezowska, & Goossens, 2012; Stewart-Knox 2. Method et al., 2013; Berezowska et al., 2014; Poínhos et al., 2014; Bere- zowska, Fischer, Ronteltap, van der Lans, & van Trijp, 2015; Fallaize Databases searched were: Pubmed; Ovid Medline; Nat Lib Med; et al., 2015; Fischer et al., 2016; Rankin et al., 2016). Gene-based Cochrane Library). Keyword strategy included a combination of personalized nutrition was extensively researched in previous Dietitian or Dietician AND Nutritional Genomics OR Nutrigenomics large studies such as LIPGENE and PREDIMED, and has already been OR Nutrigenetics OR Diet- Gene Interaction AND Integration OR commercialized through various avenues (Ronteltap et al., 2012). Application OR Translation OR Involvement OR Attitude OR Clinical For the purpose of the Food4me project, personalized nutrition was Practice. defined on three levels: dietary analysis; dietary
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