Nutrigenomics has emerged as an exciting area within the nutrition science that can pave the way for better management of diseases through applications and principles of personalized nutrition30. Information regarding the knowledge and attitudes of dietitians regarding nutrigenomics is generally limited across the world3,7,31,32, particularly in low-income countries such as India where genetic testing and omics technology are still gaining momentum and personalized nutrition is yet to be integrated with traditional dietetic training and practice. In this context, we believe ours to be a one-of-its-kind study that comprehensively investigated knowledge, perceptions, beliefs, and willingness to learn and practice PN among dietetic students and professionals in India using a mixed methods research design. As a part of our study, we developed and validated a 45-item instrument that can reliably measure the existing level of understanding, perceived barriers, and behaviors regarding nutrigenomics.
The psychometric testing of the questionnaire was conducted using several measures of validity and reliability. Similar to previous methodological studies, we used the scale and item content validity indices to determine the clarity, relevance, and simplicity of the content33, a detailed item analysis to examine the difficulty and discrimination indices34,35, and the confirmatory factor analysis method of construct validity to extract the underlying factors of interest and explain the observed data21,28.The process of item analysis involved an evaluation of item difficulty and discrimination to refine items for clarity, relevance, and effectiveness. Face validity assessed the appropriateness and relevance of the items and the expert-driven content validity confirmed that the included items were comprehensive and represented the intended constructs, reducing the risk of missing important dimensions. Determining the construct validity was essential to confirm that the items were accurately measuring the appropriate concept rather than capturing unrelated or tangential attributes. In our study, a good model fit was reported with the use of various fit indices such as chi-square, RMSEA, CFI, and TLI, indicating that the measurement model accurately represented the data structure and observations. In addition to the validity measures, we evaluated the extent to which items within a scale were correlated using internal consistency. Our results showed excellent internal consistency of items (Cronbach α > 0.7) in the questionnaire, suggesting that the items within the four domains of KAB and training were correlated with each other. Finally, the test-retest reliability analysis helped determine the temporal quality of the questionnaire contributing to the overall validity of research findings. Together, these measures provided a comprehensive evaluation of the questionnaire’s quality, supporting its validity and reliability for robust data collection.
Due to the lack of validated instruments in an Indian context, we compared our findings to a few questionnaires developed in other countries to assess the dietitians’ knowledge and attitudes toward nutrigenomics. Similar to our study, one questionnaire was developed using a review of existing tools followed by focus group discussions13. Another study assessed health-related genetics knowledge and perceived self-efficacy following personal genomic testing, measuring knowledge through True/ False items and self-efficacy on a Likert scale from strongly disagree to strongly agree36. Additionally, a nationwide postal survey in the UK examined dietitians’ knowledge of genetics and nutritional genomics12while an online survey explored perceptions of genetic testing and personalized nutrition among European consumers37. However, none of these studies assessed the psychometric properties of the questionnaires beyond face validity and pilot testing.
The analyses of our qualitative (FGD and interview transcripts) and quantitative (cross-sectional analysis) data highlighted limited knowledge regarding principles and applications of nutrigenomics, poor confidence to practice PN, and a robust willingness to learn about nutrigenomics in students and practicing professionals. These findings align with previous evidence6,7,31, suggesting a need to design training and sensitization programs and capacity-building opportunities for dietetic students and professionals to learn, train, and practice nutrigenomics in the clinical settings of India. Several barriers to integrating gene-based nutritional advice in dietetic practice were also reported. Lack of adequate training and exposure to basic concepts of genetics and nutrigenomics in the dietetic curriculum, dearth of professionals with required qualifications and experience in nutrigenomics and PN in the clinical and research settings, an overwhelming influx of scientific interest and information in the field, a consumer and market-driven expectation that the dietetic professionals will be able to embrace the new role and adapt promptly to deliver genetic testing led PN and dietary recommendations emerged as critical challenges and also opportunities to intervene.
Furthermore, the data revealed perceived apprehensions regarding the lack of transparency in ethical regulations for safeguarding an individual’s genetic data, limited access to context and disease-specific nutritional care guidelines for advancing evidence generation and clinical counseling practices, and most importantly, a gap between current and expected competencies of the participants in PN due to the complex, rapidly evolving and multifaceted approaches that underpin the science of nutritional genomics, genotype-based PN and evidence regarding genetic variants that may alter dietary and health outcomes. While some of these perceived barriers have been reported in previous studies conducted in the US, Europe, and Australia7,10,13,38, the findings of our study provide a unique stakeholder perspective to the ongoing deliberations and discussions in India around the transition of dietetic practice from conventional phenotype and lifestyle-based individualizations to genetic information-based personalization of dietary advice.
The significant strength of our study is the development of the KAB-PN questionnaire informed by qualitative research insights and a rigorous evaluation of the psychometric properties of the developed questionnaire to establish face, content, and construct validity, and internal consistency, and test-retest reliability using different statistical methods. It is well established that a validated questionnaire that is specific to a target population enhances the quality, accuracy, and relevance of the research conducted within that group. The evaluation of knowledge, attitudes, and behaviors using questionnaires that were developed for a different setting or population is challenging unless the unique characteristics, experiences, and perspectives of that group are taken into consideration and the validity and reliability of the questionnaires are established to accurately reflect the constructs being measured. As such, only a few studies have investigated the knowledge and attitudes of healthcare professionals regarding the applications of nutrigenomics in clinical practice. These studies were conducted in relatively smaller sample sizes7,10,38, with the intent to compare the variables between different groups of professionals15or were in the context of prevention and management of NCDs4,39,40. None of these studies included a thorough exploration of awareness and attitudes using qualitative investigation or conducted a scientific process to develop and validate the instruments that were used to measure dietitians’ knowledge and perceptions. This knowledge gap was attempted to be bridged in our study.
However, it must be noted that our study has a few limitations. First, due to female dominance in the dietetic and nutrition profession in India as elsewhere, the representation of male students and professionals was minimal, which might have induced certain biases in the data, especially for the focus group discussion and interviews. Second, the nature of our study objectives called for a purposive method of sample selection to engage with the participants having a specific qualification, number of years of experience, and a level of digital literacy to complete the online survey and provide inputs during the virtually conducted qualitative investigations. The purposive sampling method ensured depth and relevance, and the representativeness was addressed through inclusion criteria, diversity of perspectives, and data saturation. Despite these efforts, the process might not have covered the total demographic of the country and can be construed as a limitation. We used a posteriori inductive method of qualitative data analysis, allowing the themes and concepts to emerge from the data, rather than applying preconceived theories or fitting the data into predefined constructs of theoretical frameworks. Future researchers interested in understanding the factors influencing the adoption of new technologies or practices may consider the use of social change adoption theories such as Innovations Diffusion theory and others, to guide their thematic analysis and subsequent design of their questionnaires.
Third, we estimated the required sample size for development and validation purposes, not the cross-sectional analysis of dietitians’ knowledge, attitudes, and behaviors. Though the sample sizes were adequate for the psychometric testing of the questionnaire, the modest sample size and involvement of participants, primarily from the urban clinical and education settings may limit the generalizability of the findings to the dietetic students and professionals across and outside India. Additional research is warranted with larger and more diverse samples to further confirm the results of our study. Finally, the target population of our study was the dietetic profession, so further investigations are required to test the applicability of the developed questionnaire among other healthcare professionals who are the first point of contact for patients and might be involved in referrals to dietitians and genetic counselors.
Clinical nutrition practice is evolving at a rapid pace and with every scientific advancement and technological innovation, there is a need to evaluate how aware and prepared is the fraternity to acquire new skills and knowledge and apply the emerging evidence into practice and counseling. Dietitians are at the forefront of delivering PN interventions adapted to an individual’s genetic factors, lifestyle behaviors, and medical conditions, yet limited validated questionnaires exist to assess their nutrigenomics and PN-related awareness, perceptions, and practices. The final 45-item questionnaire developed as a part of this study exhibited excellent validity and acceptable reliability in assessing knowledge, attitudes, and behaviors related to nutrigenomics and personalized nutrition in dietetic students and professionals in India. This brief self-administered questionnaire can be used as a research tool to evaluate the impact of curricular and training-related interventions aimed at improving knowledge and fostering positive attitudes and behaviors toward the integration of PN into mainstream nutrition care processes. The qualitative investigations identified several barriers and facilitators of integrating PN into routine practice, providing a context-specific lens for designing future intervention strategies. Furthermore, the results of the cross-sectional data analyses provided preliminary evidence of existing awareness and attitudes, that can serve as a base to develop appropriate capacity-building and training programs required to translate nutrigenomics knowledge into clinical practice.
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