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INTRODUCTION
Genetically Modified foods (GM Foods) are in circulation in the European Union (and therefore also in the Portuguese market): mainly maize, soybeans and their derivatives1. The official position of the national government and the European Commission is that the authorized GM food is safe for human consumption2.
Genetically modified organism is an organism that has had its genome modified in the laboratory without necessarily receiving genetic material (RNA or DNA) from another organism. Transgenic is an organism that has been subjected to the specific technique of inserting genetic material from an organism belonging to a different species. Therefore it can be said that: every transgenic is a genetically modified organism, but not every genetically modified organism is a transgenic1-2.
These foods obtained from new genetic technologies have been questioned as to the dimensions of their benefits and risks3-5. The controversy also extends to the social dimension6 since innovations like this also have a direct impact on people’s lives, often leading to conflicts with their own visions and values7. This is especially relevant in the case of food and nutrition, where consumers are confronted with daily decisions about how best to feed their families. In this context, health professionals are called upon to intervene, sooner or later, and respond in the context of their clinical contact to questions of opinion, attitude and science8. Nutritionists, by the nature of their professional skills, are potentially at the center of this educational challenge in relation to GM food.
A number of studies have been published on the positioning of consumers9, farmers10, adolescents11, experts12, professors13, scientists12 and even university students14 in assessments covering the most diverse countries and cross-country comparisons. However, there are few studies that analyze the opinion and knowledge of health professionals regarding GM food. Their perception of the specific training required for this new food category is also unknown.
In short, it remains unknown whether health professionals -nutritionists in particular- are following the challenge of introducing GM food in human nutrition. Taking this into consideration, it is justified to explore the reality of nutritionists in relation to GM food in Portugal, particularly evaluating the possibility of including this theme in their university education. This case study in Portugal could be extended to other countries because, as far as we are concerned, this professional group has been poorly studied in relation to this subject.
MATERIAL AND METHODS
To obtain the nutritionists’ profile in relation to GM foods, a questionnaire was elaborated with the following structure: (i) a brief introductory note - contextualization of the thematic, objectives, identification of the institution where the investigation takes place, clarification of the concepts (genetically modified organism, transgenic food and genetically modified food), a declaration of confidentiality and anonymity; (ii) seven questions of socio-demographic characteristics of the respondents (Table 1); (iii) twelve issues of opinion focusing on nutritional features, impacts on environment and on consumer’s health (Figure 1); (iv) six knowledge issues related to cultivation, sale, and labeling of transgenic foods in Portugal (Figure 2); and (v) seventeen questions related to self-perception of training needs on GM foods. These last questions are related to usefulness of training during university education, type of training (Figure 3), topics to be covered (genetics, nutrition, health, labeling, legislation, ethics and environment), needs for deeper information on GM foods, and real applications (questions asked by patients on the topic).
Table 1. Characterization of study participants (n=248).
| Variables | n* | % |
|---|---|---|
| Gender | ||
| Male | 38 | 15.4 |
| Female | 209 | 84.6 |
| Age (years) | ||
| 22-25 | 83 | 35.3 |
| 26-30 | 66 | 28.1 |
| 31-35 | 34 | 14.5 |
| Above of 35 | 52 | 22.1 |
| Level of training | ||
| Graduation | 129 | 52.2 |
| Masters | 42 | 17 |
| Ph.D. | 17 | 6.8 |
| Post-graduate | 59 | 23.8 |
| Region of residence (NUTS II**) | ||
| North | 156 | 64.2 |
| Center | 39 | 16 |
| Lisbon | 44 | 18.1 |
| Alentejo | 1 | 0.4 |
| Algarve | 1 | 0.4 |
| Madeira | 2 | 0,8 |
| Frequency of contact with patients | ||
| Diary | 133 | 53.8 |
| Weekly | 37 | 15 |
| Monthly | 21 | 8.5 |
| Irregularly | 20 | 8.1 |
| Never or almost never | 36 | 14.6 |
| Institution of university graduation (graduation) | ||
| School of Biotechnology of the Portuguese Catholic University | 40 | 16.5 |
| Faculty of Nutrition and Food Sciences of the University of Porto | 125 | 51.4 |
| Higher Institute of Health Sciences Egas Moniz | 21 | 8.6 |
| University Institute of Health Sciences-North (CESPU) | 18 | 7.4 |
| Others | 39 | 16 |
| Conclusion year | ||
| < 2004 | 52 | 21.4 |
| 2005 - 2010 | 55 | 22.6 |
| 2011 - 2016 | 136 | 56 |
*n: do not always total sample size due to incomplete surveys.
**NUTS II: Nomenclature of Territorial Units for statistical purposes, level 2.
These 35 questions were closed in qualitative scales, Likert type, with 5 levels that later were grouped into 3 levels (“disagree”, “neither disagree nor agree”, “agree”) and multiple choice with a single possibility of response.
The questionnaire was developed by the authors, based on Hill & Hill (2008) guidelines15. It had been previously validated by 24 individuals (13 physicians and 11 nutritionists) in terms of clarity, structure, presentation, relevance, efficacy, and interactivity. Additionally, the questionnaire was evaluated by two specialists with experience in the elaboration of these instruments, also having relevant scientific production related to transgenic foods and nutrition.
The questionnaire was implemented in the online platform of LimeSurvey (version 1.91+) and released from March to July 2016 through the Portuguese Association of Nutritionists, in scientific meetings and in social and professional networks. The dissemination potentially covered a population of 2,347 nutritionists, the number of nutritionists enrolled in the Association at the time of this work. The study was approved by the Scientific Council of the Biotechnology School, Universidade Católica Portuguesa and evaluated ethics committee. The professionals who participated in the survey had informed consent. Survey respondent data was exported from LimeSurvey to Microsoft® Excel® (Microsoft Corporation, version 14.5.7) and subsequently analyzed in the IBM SPSS Statistics 23 for Windows® program (SPSS Inc., Chicago, USA).
In addition to the descriptive calculations, a multiple correspondence analysis (MCA) was also performed aiming at obtaining associations of the nominal and ordinal qualitative variables so that they could be represented in a few dimensions through the most discriminative variables. The number of dimensions was based on inertia, discrimination measures and higher internal consistencies16. The internal consistency was evaluated based on the Cronbach’s Alpha value15, which was 0.83 and 0.77 for dimensions 1 and 2, respectively.
RESULTS
Characterization of participants
The study included 248 nutritionists, 209 (84.6%) being women. The participants’ age ranged between 22 and 59 years of age, with 64.2% of those living in the northern region of the country. It was found that a considerable proportion of the professionals had other training beyond the degree: 23.8% had a postgraduate degree, 17% had a master’s degree and 6.8% a Ph.D. degree. Regarding the place where they completed their academic training, 51.4% referred to Faculdade de Ciências da Nutrição e Alimentação of University of Porto, with Universidade Católica Portuguesa emerging as the second most cited institution (16.5%) and Instituto Superior de Ciências Médicas Egas Moniz in third place (8.6%). Regarding the years of completion of the course, 56.0% concluded between 2011 and 2016. When asked how often they contacted patients, 53.8% of the professionals reported doing it daily (Table 1).
Identification of nutritionists’ opinions regarding GM Food
Results of nutritionists’ opinions regarding GM foods are in Figure 1. Most participants (77.6%) agree that genetic engineering can be used in the production of foods that bring benefits to mankind (Question OP12). However, 59.8% agree that consumption of GM food may lead to health problems (Question OP11). In addition, 70.3% answer that consuming GM food is not equivalent to consuming non-transgenic foods (Question OP8).
When asked whether the consumption of GM food can induce an adverse clinical or nutritional picture (Question OP7) and if there is scientific evidence that GM food has negative health impacts (Question OP4), most participants did not have a clear position: the majority reported not agreeing or disagreeing (46.6% and 48.2% for OP7 and OP4, respectively).
When asked whether GM food is likely to be associated with some kind of symptom or pathology, even if it is not yet scientifically established (Question OP2), 51.7% agree, opposing 35.6% who “neither agree nor disagree”. Relatively to the sentence which states that current standards are sufficient to protect people from possible risks of GM food (Question OP10), it is found that a large proportion (61.4%) of respondents disagree with it.
Almost unanimity appeared in Question OP9, where 97.2% of participants understood that the population was not adequately informed about GM food consumption. Concerning the usefulness of GM food in the fight against hunger in the world (Question OP6), 62.9% of the respondents agree with it although they also think (45,8%) that genetically modified seeds do not allow a greener agriculture (Question OP5).
Finally, the vast majority (59.5% and 60.5% respectively) disagree that GM food currently in the Portuguese market is more nutritious than their conventional or biological counterparts (Question OP3) and that GM seeds result in healthier food (Question OP1).
Identification of the nutritionists’ knowledge in relation to GM food
Figure 2 presents the results regarding the knowledge revealed by nutritionists about GM food. On average, only 32.0% of the respondents hit the six issues and 22.0% failed the answers. A considerable number of nutritionists assumed their illiteracy about the reality of GM foods in Portugal, averaging 46% of the respondents. Among the participants, 38.9% got a correct answer to the question of whether transgenic foods were being labeled in Portugal (Question C1, which is true). The highest mistake was related to Question C5; 38.3% failed the answer to the question of whether in Portugal several horticultural transgenic are sold, which is actually false.
Self-perception of training needs of nutritionists in relation to GM food
Almost all of the respondents (95.6%) consider it useful to have some type of training on genetically modified foods during university education. When questioned about what type of training they considered more appropriate to receive, the vast majority (82.6%) preferred a module within a subject during the degree, which is clearly more than one class but leaves open the exact number of hours devoted to the theme (Figure 3).
Regarding the type of topics they would like to see covered in this training, all aspects suggested in the survey, genetics, nutrition, health, labeling, legislation, were considered very important (chosen by more than 80% of the participants) except for topics related to ethics and environment (chosen by 76.1 and 69.2% of nutritionists, respectively).
The need for more information is also evident in the 70.2% who stated that they had already researched some kind of information about GM food. In addition, 89.1% also affirmed to be useful throughout the professional life the existence of continuous training to update on GM food. The knowledge to be acquired will have real application: in the previous year, 21% of clients had asked nutritionists questions about GM food.
Identification of nutritionists’ profiles
The multiple correspondence analysis (MCA) allowed the identification of two dimensions with high internal consistency. Dimension 1 included 17 questions and dimension 2 included 10 questions, which allowed each dimension to be characterized. The dimensions resulted as follows:
-
The first dimension integrates in the 1A profile people with the opinion that consuming GM food is not equivalent to consuming non-transgenic foods and that these are no longer more nutritious nor healthier than their conventional or biological counterparts. They consider that genetic engineering does not allow greener agriculture, that it is not an important tool in the fight against hunger in the world and it does not bring benefits to humanity. They also believe that the consumption of GM food may imply health problems and induce an adverse clinical or nutritional picture. They also admit that these foods are associated with some type of symptom or pathology with negative health impacts and that this is scientifically proven. They consider that the population is not adequately informed about the consumption of GM food and that the standards are not sufficient to protect people from possible risks. These nutritionists consider it important to receive health and nutrition training on GM food in the form of a module within a subject during the degree. In terms of knowledge, they agreed that in Portugal there is no labeling of products coming from animals fed with transgenic feeds.
By contrast, there is profile 1B, with nutritionists who consider that genetic engineering allows for a more ecological agriculture, being an important tool in the fight against hunger in the world and bringing benefits to humanity. These individuals consider that the current standards are sufficient to protect people from possible risks. They also reveal indifference about training during the degree and do not consider it important to include topics in GM food-related to health and nutrition in training. This indifference is transversal to the other aspects of opinion, training, and knowledge mentioned for the first profile (1A).
-
The second dimension includes, in profile 2A, the individuals who consider that the population is not properly informed about the consumption of GM food but agree that these foods allow a more ecological agriculture. These nutritionists are interested in training which addresses the topics of health, nutrition, genetics, environment, labeling, legislation, and ethics.
Profile 2B includes a group of nutritionists who neither agree nor disagree on the level of information of the population and who disagree that these foods allow a greener agriculture. Their interest in GM food is minimal, not seeing any advantage in specialized training.
Although most nutritionists are suspicious of GM food, the method of multiple correspondence analysis has allowed the identification of other relevant profiles that represent subsets of the professionals studied. The two primary characteristics in the differentiation of the large nutritionists’ profiles found are confidence / non-confidence versus usefulness / non-usefulness of GM food training. Table 2 presents these four sets and classifies them according to the respective variables meeting. Those who trust in the may have more interest (and in this case the specific formation is) or a more distant relationship (and there does not recognize usefulness to the study of the subject). The same is true of those who regard GM food with suspicion.
Table 2. Synthesis of the profiles obtained in the MCA based on the differentiating variables and matching with the nomenclature of Roberts et al. (2006) and Wilkins et al. (2008).
| WANTS TRAINING | DOES NOT WANT TRAINING | |
|---|---|---|
| TRUSTS GM FOOD | Profile 2A FAVORABLE AND INTERESTED | Profile 1B FAVORABLE AND UNINTERESTED |
| (Discerning supporter) * | Promoting | |
| DOES NOT TRUST GM FOOD | Profile 1A SUSPICIOUS AND INTERESTED | Profile 2B SUSPICIOUS AND UNINTERESTED |
| Precautionary | Precautionary |
*Wilkins et al. (2008) used the expression “Cautiously supportive” instead of “Discerning supporter”.
DISCUSSION
As far as the authors are concerned, this study is the first to evaluate the opinion, knowledge, and training of nutritionists in relation to GM food, particularly in the professional environment, in Portugal. The tested hypotheses that (i) nutritionists do not have sufficient knowledge about GM food, (ii) that there is no unanimity of opinions, and (iii) that there is a need for university education were largely supported by results.
Regarding opinion and knowledge, the figures obtained show that nutritionists are mostly unfavorable to transgenic foods, even without knowing the technology in detail. Lack of knowledge is felt by themselves and it became evident in the answers to objective questions about national reality. These results paralleled those of Vogliano17, who identified a lack of knowledge and varied perceptions in American dietitians. In this study, most respondents also revealed a cautious attitude towards genetically modified organisms. Schmidt et al.18 have reached similar conclusions about the knowledge and attitude of American health professionals, including dieticians, showing that in this survey knowledge about applications of food biotechnology and genetic engineering is equally inadequate.
Nutritionists agree that consumers are not properly informed about the consumption of transgenic foods. This is also due to the fact that 21% have already been questioned by their clients on this subject, which points at the same time to the search for information from credible sources by attentive consumers. It should be noted that in the most recent Eurobarometer19 Portugal is the second most uninformed country in the European Union, with 44% of respondents seeking information about it at least once. The literature shows that, in fact, consumers trust and seek health professionals for health and food responses18,20-21, which effectively attributes to nutritionists the responsibility of interface between GM food and society. However, they do not feel and are not prepared to respond and to mediate the construction of this knowledge.
The curricular inclusion of GM food requires not only a scientific-technological approach but also a social and environmental one, as this is a complex theme. Some contributions to the pedagogical approach can be found in the literature, but there is scarce scientific material that includes pluridimensionality, with the dominant tendency being the refuge in the essentially technical description22-23. Perhaps as a result of this limitation, both consumers in general and health professionals, in particular, are ultimately dependent on the media, social networks and other informal channels whose rigor is far from being guaranteed24-25. The GM food theme is not the only one requiring such treatment, but it is one of the most recent. The space chosen by the respondents -a module within a subject- can create a model of an open methodology, of reflection and production of knowledge about GM food, which serves interested nutritionists well beyond the validity period of the knowledge itself.
The result of nutritionists’ profiles classification took the aggregations already published relative to dietitians26 and teachers27 even farther. These two studies have identified three main groups: (i) the Discerning Supporter, (ii) the Promoting and Prompt, and (iii) the Precautionary. Table 2 matches this nomenclature with Portuguese nutritionists’ profile classified in our study. The level of correspondence found is interesting, especially considering that the mentioned works did not use the MCA method. The set of cautious people is, in the present work, unfolded in two distinct profiles depending on the proximity and interest in the subject (and respective training).
The variances of perspective characterized in each sample can be attributed to differences in professional experiences/assignments as well as personal perceptions of a more ethical nature. Overall, these results demonstrate the need for a GM food approach that is inclusive, multidisciplinary and sensitive to changers that transcend mere biomaterial reading.
Limitations: The present study employed a convenience sample, so caution is needed in any generalization. Still, the data presented represent the best portrait available in the literature and leave no doubt as to the value of relevant university education.
CONCLUSIONS
This exploratory and indicative study aimed to contribute to the understanding of the actual training needs of nutritionists in relation to transgenic foods. The identified lack of knowledge is a mirror of what is happening in society in general but, if reversed, can trigger a chain reaction that benefits all citizens thanks to the key role of nutritionists. It is concluded and recommended the insertion in the curriculum of the subject of GM food, in an inclusive and multidimensional logic that takes into account both what is known and what is still to be discovered. This can be supported by associations of health professionals, lifelong learning and interdisciplinary training supported by specific research, and interference in public policies.
