Nutrigenomics in Clinical Practice: Challenges and Opportunities Lifestyle Genomics 2023;16:11–20 Nutrigenomics: Perceptions of South African Dietitians and General Practitioners Desiré Greyvensteyn a Corinna May Walsh a Mariette Nel b Elizabeth Margaretha Jordaan a aDepartment of Nutrition and Dietetics, School of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa; bDepartment of Biostatistics, School of Biomedical Sciences, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Received: February 3, 2022 Accepted: August 28, 2022 Published online: November 1, 2022 Correspondence to: Desiré Greyvensteyn, desire.botha @ parexel.com © 2022 The Author(s). Published by S. Karger AG, Basel Karger@karger.com www.karger.com/lfg DOI: 10.1159/000526898 Keywords Nutrigenomics · Perceptions · Registered dietitians · General practitioners Abstract Introduction: Although investigations into the emerging field of nutrigenomics are relatively limited and more re- search in this field is required, experts agree that there is po- tential for it to be incorporated into health care practice. If health care professionals can promote healthy dietary be- havior based on nutrigenomic testing, it can assist in ad- dressing the health consequences of poor diet and lightning the strain on the South African health care system. Methods: Registered dietitians (RDs) and general practitioners (GPs) registered with the Health Professions Council of South Af- rica (HPCSA) who obtained their qualification in South Africa (SA) were eligible to participate in this cross-sectional study. Participants were identified using convenience and snow- ball sampling. A self-administered electronic survey using EvaSys Software® was completed by those that agreed to participate. Results: Nearly all RDs (97.3%), but less than a third of GPs (30.4%), had heard of the term nutrigenomics. Approximately three-quarters of RDs (74.7%) and GPs (73.9%) had or would personally consider undergoing ge- netic testing. More than 40% (43.5%) of RDs ranked direct- to-consumer genetic testing companies as the most equipped, while 31.8% of GPs ranked RDs as the most equipped to provide patients with nutrigenomic services. Both RDs and GPs ranked similar reasons as “strongly agree” for why consumers were motivated to make use of nutrige- nomic services, which included “motivated by a desire to prevent or manage disease” (56.7%), “prevent a disease based on family history” (65.9%), “control health outcomes based on family history” (54.9%), and “improve overall health-related quality of life” (48.6%). Cost concerns were re- ported as the greatest barrier to implementing nutrigenom- ic services (75.7%). Other barriers included confidentiality is- sues (47.8%) and moral concerns (37.3%). Greater individu- alization of diet prescription (66.5%), stronger foundations for nutrition recommendations (62.4%), and dietary pre- scriptions that would manage or prevent certain diseases more effectively (59.0%) were all perceived as benefits of in- cluding nutrigenomics in practice. Conclusion: This study identified perceived consumer motivators and barriers that might affect the willingness to seek nutrigenomic services in SA. In addition, the need for more nutrigenomic training op- portunities, including the planning of personalized diets This is an Open Access article licensed under the Creative Commons Attribution-NonCommercial-4.0 International License (CC BY-NC) (http://www.karger.com/Services/OpenAccessLicense), applicable to the online version of the article only. Usage and distribution for com- mercial purposes requires written permission. Greyvensteyn/Walsh/Nel/JordaanLifestyle Genomics 2023;16:11–2012 DOI: 10.1159/000526898 based on genetic testing results and interpretation of re- sults, was confirmed. However, both RDs and GPs felt that the emerging field of nutrigenomics needs further develop- ment before it can be applied effectively in routine private and public health care in SA. © 2022 The Author(s). Published by S. Karger AG, Basel Introduction A large body of evidence has shown that a westernized lifestyle increases the risk for nutrition-related disorders and that nutrition can have a significant effect on health outcomes [1–11]. According to the South African Demo- graphic and Health Survey, 68% of South African women and 31% of men aged 15 years and older are overweight and obese [12]. Obesity is closely linked to an increased risk of developing several noncommunicable diseases (NCDs) [13]. In South Africa (SA), the national health care budget increased by 95% between 2009 and 2016 [14–16]. Modifying unhealthy behaviors can address obesity and NCDs, with a resultant decrease in health care costs. Targeting nutritional intake is one of the most cost-effec- tive methods to encourage a healthy lifestyle to prevent the development of NCDs [17–19]. Compared to general recommendations made at a population level, applying a personalized approach has been shown to be more effec- tive in producing measurable positive improvements in nutritional intake and health outcomes of individuals [20]. If a predisposition to a specific disease is identified at an early stage, the development thereof could be pre- vented or delayed by making lifestyle changes relevant to the individual [19, 21]. Nutrigenomics is defined as the study of how nutri- ents affect gene function [22]. A better understanding of the benefits of including nutrigenomic services in the routine practice of health care professionals may trans- late to personalized care that has the potential to decrease the risk of developing obesity and the resultant NCDs, by preventing rather than managing these conditions. Four approaches to delivering nutrigenomic services have been described. These include the health care profession- al approach, the multidisciplinary team approach, the public health approach, and the consumer approach. Globally, the consumer approach, where individuals contact a direct-to-consumer (DTC) genetic testing company (often via a website), is currently the most pop- ular genetic testing approach [19]. Genetic testing is done on a sample that the consumer sends to the com- pany, and the results and recommendations are sent back to the consumer. The DTC method rarely entails face-to- face interaction. Despite the potential of nutrigenomic testing, several barriers prevent proper implementation. The success of nutrigenomic implementation is reliant on not only evi- dence-based science but also health professional and con- sumer acceptance [7]. Although research into nutrige- nomics is still a relatively new field, health care profes- sionals agree that the results of genetic testing could potentially be included in routine health care practice [22–24], including diagnosis and treatment of NCDs [25]. Only a limited percentage of genetic tests are pres- ently performed by health care providers. Health care providers appear to have little expertise and confidence in the use of nutrigenomic tests [25]. With genetic testing becoming more widely available, health care providers are required to comprehend and interpret the results of these tests, as well as convey these complex test results [26]. It is critical for health care professional organiza- tions and associations, as well as the genetic testing indus- try, to understand why health care professionals choose to use nutrigenomic tests in their practice or not [25]. A study about the perceptions and experiences of integrat- ing nutrigenomics into practice conducted by Abrahams et al. [9] among registered dietitians (RDs) from the UK, Canada, SA, Australia, Mexico, and Israel showed that the participants expressed positive perceptions of applying nutrigenomics in practice and felt that it motivated and improved compliance in their clients. The participants were aware of misperceptions regarding what nutrige- nomics entails, while they were also unsure in which health care professionals’ scope-specific nutrigenomic testing and outcomes fall [9]. Currently, no studies related to the perceptions of RDs and general practitioners (GPs) regarding nutrigenomics in SA are available. In view of the lack of information in SA and conflicting information from other countries about the feasibility of using nutrigenomics in practice, the purpose of the current study was to investigate the perceptions of RDs and GPs in SA regarding nutrigenom- ics. Materials and Methods A cross-sectional study design was applied. Convenience and snowball sampling were used to recruit participants registered with the Health Professions Council of South Africa (HPCSA) at the time of data collection. An electronic newsletter with the invi- tation and link to the survey was distributed to members by the Nutrigenomics: Perceptions of South African Dietitians and GPs 13Lifestyle Genomics 2023;16:11–20 DOI: 10.1159/000526898 Association for Dietetics in South Africa (ADSA). The invitation and link were also posted on Facebook groups for RDs and GPs. By clicking on the link to the survey and reading the first section, participants provided voluntary consent to participate in the cur- rent study. Before collecting data for the main study, a pilot study was conducted among three RDs and three GPs. Results of the pilot study were included in the main study since no changes were made to the survey. Data were collected during April 2020, for 4 weeks, through an electronic self-administered EvaSys survey. The survey consisted of open- and close-ended questions. Re- sponses were rated according to a dichotomous response set, as well as a four-point scale. The four-point scale was used to avoid including a neutral option, but this was not possible for all ques- tions; thus, a five-point scale was used for certain questions. The survey included multiple-choice questions with predetermined options as well as an “other” option. Open-ended questions re- garding the perceptions and experiences of the participants were also asked, and the most common answers were presented. Any personal experience involving nutritional genomics was deter- mined using open-ended responses and categorical scales. The 49 questions included in the survey were based on an in-depth lit- erature review. This analysis report does not present any of the open-ended question results, which included identifying infor- mation, including but not limited to the participants’ email ad- dresses and HPCSA registration numbers. Raw data were exported from the EvaSys Software®, verified and analyzed by the Department of Biostatistics at the University of the Free State. The data analysis for this paper was generated using SAS software. Copyright, SAS Institute Inc. SAS, and all oth- er SAS Institute Inc. product or service names are registered trade- marks or trademarks of SAS Institute Inc., Cary, NC, USA. De- scriptive statistics, namely, frequencies and percentages for cate- gorical data and medians and percentiles for numerical data, were calculated per group (RDs and GPs). Numerical data had skew distributions; therefore, the summary statistics median and per- centiles were used. Categorical variables were compared between the RDs and GPs using the χ2 test or Fisher’s exact test (when more than 20% of cells had expected frequencies had a value of less than 5). A p value below 0.05 was considered statistically significant. Results This study included 173 participants, of which 150 were RDs and 23 GPs with a median age of 30 years (min. 22 years; max. 59 years). Significantly more female (93%) than male participants completed the survey (Table 1). The last question in the survey was answered by 150 par- ticipants, which gives an overall survey completion rate of 86.7%. Overall, 47.7% of participants reported having an hon- or’s degree as the highest level of education. It is likely that these participants may have considered their 4-year bach- elor’s degree to be equivalent to an honor’s degree. Most participants (84.8%) were working in the field in which they obtained their degree. Almost half (47.4%) of the participants were working in the private sector. The RDs’ and GPs’ years of experience varied from 0 to 35 years and 0 to 17 years, respectively. There was no statistically sig- nificant difference regarding the years of experience be- tween the two professions (p = 0.1295). Nearly all RDs (97.3%), but less than a third of GPs (30.4%), had heard of the term nutrigenomics (Table 1). After briefly explaining what nutrigenomics entailed in the survey, almost three-quarters of both RDs (74.7%) and GPs (73.9%) stated that they had or would person- ally consider genetic testing. Nutrigenomics was included in the undergraduate curriculum of 44.7% of RDs and none of the GPs. A sig- nificantly higher percentage of RDs (58.9%) compared to GPs (8.7%) indicated that they had read any scientific lit- erature related to nutrigenomics (p < 0.0001). About a third of RDs reported that they had provided nutrigenomic-related counseling services (32.0%) com- pared to 13.0% of GPs (p = 0.0844). The majority of both RDs (95.3%) and GPs (87.0%) indicated that they were interested in learning more about nutrigenomics (p = 0.1567). Although most dietitians and GPs rated nutrition as “very important” in the medical or health industry, sig- nificantly more dietitians rated genetic testing as impor- tant (32.9%) compared to GPs (8.7%) (p = 0.02) (Table 2). Participants were asked to rate how equipped they felt that a primary physician, dietitian, professional nurse, and DTC genetic testing company interpreted nutrige- nomic information to patients (Table 2). More than forty percent (43.5%) of RDs ranked DTC genetic testing com- panies as the most equipped, while 31.8% of GPs ranked RDs as the “most equipped” and another 31.8% as “very equipped” to provide patients with nutrigenomic servic- es. More than half of the participants strongly agreed that the factors related to implementing nutrigenomics in health care practice mentioned in Table 2 would be ben- eficial. These factors are “greater individualization of diet prescription (personal nutrition),” “stronger foundations for nutrition,” and “dietary prescriptions that would ef- fectively manage or prevent certain diseases.” No statistically significant differences were observed for any of the possible benefits of applying nutrigenomics between RDs and GPs. Although more than half of the RDs believed that they were most likely to change certain aspects of their practice due to new knowledge regarding nutrigenomics, compared to only about a third of GPs, the difference was not statistically significant (p = 0.06). Greyvensteyn/Walsh/Nel/JordaanLifestyle Genomics 2023;16:11–2014 DOI: 10.1159/000526898 More than half of the RDs strongly agreed with the listed consumer motivators that could affect their willing- ness to use nutrigenomic services, while about a third of the GPs strongly agreed with all the listed consumer mo- tivators (Table 3). The highest ranked consumer motiva- tor was to “prevent a disease based on family history.” Significantly more RDs (68.0%) indicated that they “strongly agree” that disease prevention based on family history could affect the implementation of nutrigenomics compared to GPs (52.2%) (p = 0.01). About three-quarters of participants regarded cost concerns as the greatest barrier to implementing nutri- genomic testing (Table  3). Other perceived barriers to implementation were confidentiality issues (40.0% for RDs and 60.9% for GPs) and moral concerns (37.3% for RDs and 47.8% for GPs). None of the differences in the Table 1. Participant characteristics and previous experience with nutrigenomics by profession RDs GPs p value n % n % Sex (n = 172) – Male (n = 12) 6 4.0 6 27.3 Female (n = 160) 144 96.0 16 72.7 Highest level of education (n = 173) – Bachelor’s degree (n = 57) 39 26.0 18 78.3 Honor’s degree (n = 82) 79 52.7 3 13.0 Master’s degree (n = 26) 26 17.3 0 0.0 Doctoral/PhD degree (n = 1) 1 0.7 0 0.0 Othera (n = 7) 5 3.3 2 8.7 Working in the field in which degree was obtained (n = 171) – Yes (n = 145) 122 82.4 23 100.0 No (n = 10) 10 6.8 0 0.0 Unemployed (n = 16) 16 10.8 0 0.0 Sector of primary employment (n = 156) – Public/governmental (n = 61) 44 33.1 17 73.9 Private (n = 74) 69 51.9 5 21.7 University (n = 6) 5 3.8 1 4.4 Corporate/business (n = 15) 15 11.3 0 0.0 Have or would you personally consider genetic testing? (n = 173) 0.13 Yes (n = 129) 112 74.7 17 73.9 No (n = 24) 23 15.3 1 4.4 Unsure (n = 20) 15 10.0 5 21.7 Have you previously heard of the term nutrigenomics? (n = 173) <0.01b Yes (n = 153) 146 97.3 7 30.4 No (n = 20) 4 2.7 16 69.6 Was nutrigenomics taught as a part of your qualification? (n = 173) <0.01b Yes (n = 67) 67 44.7 0 0.0 No (n = 106) 83 55.3 23 100.0 Provided counseling to clients/patients related to nutrigenomics in the past year (n = 170) 0.08 Yes (n = 50) 47 32.0 3 13.0 No (n = 120) 100 68.0 20 87.0 Read scientific literature related to nutrigenomics in the past year (n = 169) <0.01 Yes (n = 88) 86 58.9 2 8.7 No (n = 81) 60 41.1 21 91.3 Interested in learning more about nutrigenomics (n = 172) 0.16 Yes (n = 162) 142 95.3 20 87.0 No (n = 3) 2 1.3 1 4.4 Unsure (n = 7) 5 3.4 2 8.7 a The “other” included seven postgraduate diplomas in various field-related topics. b p value for percentage difference between RDs and GPs using χ2 or Fisher’s exact tests, as appropriate, p < 0.05 considered statistically significant. Nutrigenomics: Perceptions of South African Dietitians and GPs 15Lifestyle Genomics 2023;16:11–20 DOI: 10.1159/000526898 Table 2. Perceptions of RDs and GPs regarding different aspects of nutrigenomics RDs GPs p value n % n % Perception of importance of genetic testing and nutrition in the medical or health industry How important do you think genetic testing is in the medical/health industry? (n = 172) 0.02a Not important at all (n = 0) 0 0.0 0 0.0 Not important (n = 40) 31 20.8 9 39.1 Important (n = 81) 69 46.3 12 52.2 Very important (n = 51) 49 32.9 2 8.7 How important do you think nutrition is in the medical/health industry? (n = 173) 1.00 Not important at all (n = 0) 0 0.0 0 0.0 Not important (n = 0) 0 0.0 0 0.0 Important (n = 13) 12 8.0 1 4.4 Very important (n = 160) 138 92.0 22 95.7 Rating of how equipped various professions are to provide nutrigenomic counseling Primary physician (n = 169) 0.97 Not at all equipped (n = 59) 50 34.3 9 39.1 Not equipped (n = 52) 44 30.1 8 34.8 Neutral (n = 38) 34 23.3 4 17.4 Equipped (n = 16) 14 9.6 2 8.7 Very equipped (n = 4) 4 2.7 0 0.0 Dietitian (n = 172) 0.03a Not at all equipped (n = 17) 15 10.0 2 9.1 Not equipped (n = 27) 26 17.3 1 4.6 Neutral (n = 52) 49 32.7 3 13.6 Equipped (n = 50) 41 27.3 9 40.9 Very equipped (n = 26) 19 12.7 7 31.8 Professional nurse (n = 167) 0.47 Not at all equipped (n = 108) 95 65.5 13 59.1 Not equipped (n = 41) 36 24.8 5 22.7 Neutral (n = 14) 11 7.6 3 13.6 Equipped (n = 4) 3 2.1 1 4.6 Very equipped (n = 0) 0 0.0 0 0.0 Private Co. (n = 169) 0.06 Not at all equipped (n = 4) 3 2.0 1 4.6 Not equipped (n = 17) 12 8.2 5 22.7 Neutral (n = 30) 24 16.3 6 27.3 Equipped (n = 49) 44 29.9 5 22.7 Very equipped (n = 69) 64 43.5 5 22.7 Factors that will be a benefit from the application of nutrigenomics by profession Greater individualization of diet prescription (personal nutrition) (n = 173) 0.16 Strongly disagree (n = 3) 2 1.3 1 4.4 Disagree (n = 8) 6 4.0 2 8.7 Agree (n = 47) 39 26.0 8 34.8 Strongly agree (n = 115) 103 68.7 12 52.2 Stronger foundations for nutrition (n = 173) 0.43 Strongly disagree (n = 3) 2 1.3 1 4.4 Disagree (n = 8) 8 5.3 0 0.0 Agree (n = 54) 46 30.7 8 34.8 Strongly agree (n = 108) 94 62.7 14 60.9 Dietary prescriptions that would effectively manage or prevent certain diseases (n = 173) 0.35 Strongly disagree (n = 3) 2 1.3 1 4.4 Disagree (n = 8) 8 5.3 0 0.0 Agree (n = 60) 50 33.3 10 43.5 Strongly agree (n = 102) 90 60.0 12 52.2 Likeliness to change aspects of practice due to new knowledge by profession How likely are you to change aspects of your practice due to new knowledge regarding nutrigenomics (n = 168) 0.06 Least likely (n = 5) 3 2.1 2 8.7 Not likely (n = 10) 8 5.5 2 8.7 Somewhat likely (n = 68) 56 38.6 12 52.2 Most likely (n = 85) 78 53.8 7 30.4 a p value for percentage difference between RDs and GPs using χ2 or Fisher’s exact tests, as appropriate, p < 0.05 considered statistically significant. Greyvensteyn/Walsh/Nel/JordaanLifestyle Genomics 2023;16:11–2016 DOI: 10.1159/000526898 Table 3. Perceptions of RDs and GPs regarding motivators and barriers to consumers using nutrigenomics RDs GPs p value n % n % Consumer motivators that affect the implementation of nutrigenomics by profession Motivated by desire to prevent or manage disease (n = 173) 0.01a Strongly disagree (n = 3) 1 0.7 2 8.7 Disagree (n = 14) 10 6.7 4 17.4 Agree (n = 58) 48 32.0 10 43.5 Strongly agree (n = 98) 91 60.7 7 30.4 Prevent a disease based on family history (n = 173) 0.01a Strongly disagree (n = 2) 0 0.0 2 8.7 Disagree (n = 10) 7 4.7 3 13.0 Agree (n = 47) 41 27.3 6 26.1 Strongly agree (n = 114) 102 68.0 12 52.2 Control health outcomes based on family history (n = 173) 0.01a Strongly disagree (n = 1) 0 0.0 1 4.4 Disagree (n = 17) 12 8.0 5 21.7 Agree (n = 60) 51 34.0 9 39.1 Strongly agree (n = 95) 87 58.0 8 34.8 Improve overall health-related quality of life (n = 173) 0.09 Strongly disagree (n = 1) 1 0.7 0 0.0 Disagree (n = 28) 20 13.3 8 34.8 Agree (n = 60) 53 35.3 7 30.4 Strongly agree (n = 84) 76 50.7 8 34.8 Rating of perceived barriers to the implementation of nutrigenomics Cost concerns (n = 173) 0.66 Strongly disagree (n = 3) 3 2.0 0 0.0 Disagree (n = 7) 7 4.7 0 0.0 Agree (n = 32) 26 17.3 6 26.1 Strongly agree (n = 132) 114 76.0 17 73.9 Not enough experts to convey professional expertise (n = 172) 0.06 Strongly disagree (n = 9) 9 6.0 0 0.0 Disagree (n = 23) 22 14.8 1 4.4 Agree (n = 62) 48 32.2 14 60.9 Strongly agree (n = 78) 70 47.0 8 34.8 The lack of continuing education for health care professionals regarding nutrigenomics (n = 172) 0.07 Strongly disagree (n = 11) 11 7.4 0 0.0 Disagree (n = 22) 22 14.8 0 0.0 Agree (n = 64) 52 34.9 12 52.2 Strongly agree (n = 75) 64 43.0 11 47.8 The lack of continuing education for consumers regarding nutrigenomics (n = 173) 0.39 Strongly disagree (n = 11) 11 7.3 0 0.0 Disagree (n = 21) 19 12.7 2 8.7 Agree (n = 71) 58 38.7 13 56.5 Strongly agree (n = 70) 62 41.3 8 34.8 Limited access to nutrigenomics for clients or patients (n = 173) 0.06 Strongly disagree (n = 17) 17 11.3 0 0.0 Disagree (n = 30) 29 19.3 1 4.4 Agree (n = 51) 43 28.7 8 34.8 Strongly agree (n = 75) 61 40.7 14 60.9 Confidentiality issues (n = 173) 0.37 Strongly disagree (n = 74) 60 40.0 14 60.9 Disagree (n = 66) 59 39.3 7 30.4 Agree (n = 19) 18 12.0 1 4.4 Strongly agree (n = 14) 13 8.7 1 4.4 Moral concerns (n = 173) 0.51 Strongly disagree (n = 67) 56 37.3 11 47.8 Disagree (n = 59) 50 33.3 9 39.1 Nutrigenomics: Perceptions of South African Dietitians and GPs 17Lifestyle Genomics 2023;16:11–20 DOI: 10.1159/000526898 percentage of the two groups of health professionals about perceived barriers to the implementation of nutri- genomics were statistically significant. Discussion The current study identified perceptions of RDs and GPs regarding implementing nutrigenomics in SA. Compared to a previous study conducted in SA on a similar topic [27], a higher percentage of respondents in the current study in- dicated that they had heard of the term “nutrigenomics” before, probably because of the recent increase in informa- tion available about this topic. Despite this, nutrigenomics was included in the curriculum of fewer than half of RDs and none of the GPs that participated in the study. A study conducted among health care professionals in Canada found that those who had less than or equal to 10 years in health care practice had greater exposure to nutrigenomics as part of their educational training [28]. The number of peer review publications regarding nutrigenomics contin- ues to increase; however, nutrigenomics offered as a course in undergraduate programs/curricula remains low [26]. Thus, several dietitians might have qualified without receiv- ing any undergraduate training regarding nutrigenomics. Almost all participants indicated that they were interested in learning more about nutrigenomics. The earlier study conducted about the involvement, confidence, and knowledge of South African RDs regard- ing genetics and nutrigenomics in 2010 reported that more than a third of RDs ranked genetic testing as “very important” [27] similar to that of the RDs included in the current study. Compared to that study, more RDs in the current study indicated that they had read any scientific literature related to nutrigenomics [27], probably due to the subsequent expansion of the field. In terms of the perception of being equipped to de- liver nutrigenomic counseling to their clients, a total of 43.5% of RDs ranked private companies (DTC genetic testing companies) as “very equipped,” while more GPs (31.8%) ranked RDs as “very equipped” to deliver nutri- genomic counseling. In contrast, a previous study by Mitchell [29] conducted among 20 health care profes- sionals, including doctors, nurses, and dietitians in San Diego County in the USA, reported that private compa- nies (DTC genetic testing company) were rated by none of the health care professionals in their study as “definite- ly” equipped to deliver nutrigenomic information. In the current study, very few RDs (12.7%) considered them- selves as “very equipped” to provide nutrigenomic coun- seling to clients or patients, which could be why only a third had given nutrigenomics-related counseling to pa- tients. Despite this, 58.9% reported reading scientific lit- erature related to nutrigenomics during the previous year. Feeling equipped to deliver nutrigenomic counsel- ing can significantly affect the confidence to do so, em- phasizing the need for improved training of health care professionals about nutrigenomics, if this field is to be RDs GPs p value n % n % Agree (n = 27) 25 16.7 2 8.7 Strongly agree (n = 20) 19 12.7 1 4.4 Too many environmental influences to give a definite connection (effect) (n = 173) 0.96 Strongly disagree (n = 13) 12 8.0 1 4.4 Disagree (n = 63) 54 36.0 9 39.1 Agree (n = 69) 59 39.3 10 43.5 Strongly agree (n = 28) 25 16.7 3 13.0 No clinical trials to prove the efficacy of the personalized interventions (n = 172) 0.14 Strongly disagree (n = 18) 18 12.0 0 0.0 Disagree (n = 57) 52 34.7 5 22.7 Agree (n = 60) 49 32.7 11 50.0 Strongly agree (n = 37) 31 20.7 6 27.3 a p value for percentage difference between RDs and GPs using χ2 or Fisher’s exact tests, as appropriate, p < 0.05 considered statistically significant. Table 3 (continued) Greyvensteyn/Walsh/Nel/JordaanLifestyle Genomics 2023;16:11–2018 DOI: 10.1159/000526898 expanded. Findings from a qualitative study conducted among 14 RDs from the UK, Canada, SA, Australia, Mex- ico, and Israel found that those dietitians who were work- ing with nutrigenomics believed that dietitians do have the skills to provide nutrigenomics services [9]. The mul- tidisciplinary team approach is considered the best stan- dard of practice to interpret the results of a nutrigenomic testing and develop a personalized care plan [30]. The benefits of a multidisciplinary team approach were em- phasized by Karamanoglu and Nielsen [28], who also em- phasized that the demand for nutrigenomic testing is growing, but it is important that health care professional competence is carefully assessed. Horne et al. [31] created a nutrigenomics care map; the care map provides a first step toward facilitating best practice in the field of nutri- genomics. All factors related to the application of nutrigenomics were perceived as a possible benefit, with percentages ranging from 59.0% to 66.5%. A study conducted by Rosen et al. [32] in the USA among 913 RDs found simi- lar results compared to the current study, with most of the RDs in their study being optimistic about the benefits of the application of nutrigenomics. The higher ranking of “strongly agree” from RDs in the current study could be due to RDs being more invested in nutrition or dietary prescriptions of patients than GPs are, as it is not their primary field of focus. In the current study, a lack of continuing professional education about nutrigenomics for health care profes- sionals was reported by 43.6% of participants. Similar barriers were identified for using nutrigenomic services by Rosen et al. [32] regarding the needs of RDs regarding nutrigenomics in the USA. Significantly more RDs than GPs in the current study “strongly agreed” that the desire to prevent or manage disease, prevent a disease based on family history, and control health outcomes based on family history motivated consumers to make use of nu- trigenomic services. In terms of barriers to accessing nutrigenomic servic- es, three-quarters of participants considered cost con- cerns to be the greatest barrier. Financial restraints have a major impact on the kinds of services that consumers choose to access, with those services that are considered to be nonessential suffering most during financially chal- lenging times. Similarly, the earlier Rosen et al. [32] study identified the lack of certainty that costs related to nutri- genomics would be covered by medical insurance as a major constraint. Since 75.7% of participants identified cost concerns as a barrier to implementing nutrigenom- ics, the high costs of genetic testing and coverage of those costs by medical insurance will need to be addressed be- fore nutrigenomics can be provided to a broader base of clients. Confidentiality issues (42.8%) and moral concerns (38.7%) were also identified as barriers to accessing nu- trigenomic services [32]. Similar concerns were reported in the USA by Mitchell et al. [29]. In contrast to some findings of the abovementioned study [32], confidential- ity issues (8.1%) and moral concerns (11.6%) were seen as issues reported by the smallest percentage of partici- pants in the current study. The differences in these find- ings between the current study and those done in other countries could be due to a long time between the studies and that recent technological advances have made it eas- ier to keep information confidential. Other significant concerns identified in the current study included a perception that there are not enough ex- perts to convey professional expertise (45.4%) and limit- ed access to nutrigenomics for clients and patients (43.4%). Abrahams et al. [9] found that, among dietitians working in the field of nutrigenomics, the availability of unregulated websites offering tests and diets along with the lack of a sustainable public health model for the deliv- ery of nutrigenomics were barriers to dietitians embrac- ing nutrigenomics. Limitations We acknowledge certain limitations. The participants who agreed to participate in the survey may have already been interested in nutrigenomics, thus introducing a se- lection bias. The survey respondents may not be repre- sentative of RDs and GPs in SA. The small number of GP participants and the fact that the same recruitment meth- od could not be used for RDs and GPs are considered limitations of the study. The survey was not validated, but was developed based on questions used in previous stud- ies on the topic. Conclusion This study identified the perceived consumer motiva- tors that might affect the implementation of nutrigenom- ics in SA. RDs and GPs perceived the same barriers to implementation of nutrigenomics. Findings of the study were mostly consistent with previous research, which found that RDs and GPs felt that nutrigenomics may pro- vide significant benefits but that it needs further develop- ment with more training opportunities, provided before it can be widely applied effectively in routine private and Nutrigenomics: Perceptions of South African Dietitians and GPs 19Lifestyle Genomics 2023;16:11–20 DOI: 10.1159/000526898 public health care in SA. The feasibility of genetic testing in SA will need to be explored in future research to ensure that the benefits of these genetic tests will outweigh the cost implications thereof. Acknowledgments The authors acknowledge the participants for their willingness to participate in the study. Statement of Ethics Written informed consent was obtained from the participants to participate in this study. The study protocol was approved by the Health Sciences Research Ethics Committee (UFS- HSD2020/0112/2403) of the University of the Free State, Bloem- fontein, Free State, South Africa. Conflict of Interest Statement The authors have no conflicts of interest to declare. Funding Sources This study received no funding from any organization or insti- tute. Author Contributions Desiré Greyvensteyn was a master’s student supervised by Eliz- abeth Margaretha Jordaan and co-supervised by Corinna May Walsh. Desiré Greyvensteyn was responsible for the coding of data, and Mariette Nel was responsible for the statistical analysis of the data. All authors read and approved the final manuscript. Data Availability Statement Data cannot be shared for confidentiality reasons. 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