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OPEN Development and psychometric

evaluation of nutrigenomics and
personalized nutrition-related
knowledge, attitude, and behavior
questionnaire in dietetic students
and professionals
Panchali Moitra , Janvi Nemani, Saba Madre & Jagmeet Madan

This study aimed to develop and test the psychometric properties of a questionnaire assessing
knowledge, attitudes, and behaviors (KAB) related to nutrigenomics and personalized nutrition (PN)
in dietetic students and professionals in India. A literature review, six focus group discussions (n = 37),
and nine in-depth interviews guided initial item generation. The face, item, and scale content validity
indices were calculated and a cross-sectional sample (n = 297) examined the item difficulty (IDI), item
discrimination (DI), and internal consistency. Test-retest reliability was estimated in a sub-sample
(n = 64) and confirmatory factor analysis method (CFA) using model fit indices - factor loadings,
Tucker Lewis Fit Index, and Root Mean Square Error of Approximation established construct validity.
The IDI ranged from 0.60 to 0.72 and the mean Cronbach α was 0.82. The CFA results presented four
constructs − 1) knowledge and understanding of nutrigenomics, 2) attitude, and willingness to learn
nutrigenomics, 3) behaviors toward gene-based dietary advice, 4) training and confidence to practice
PN. The intraclass correlation coefficients for knowledge, attitude, behavior, and training domains
were 0.74, 0.83, 0.72, and 0.81. The psychometric evaluation indicated that the 45-item KAB_PN is a
valid and reliable instrument to assess students’ and dietitians’ knowledge and perspectives toward
nutrigenomics and PN.

Nutrigenomics is a dynamic science that is constantly evolving to explain the inter-individual variability
in nutrient absorption, utilization, and thereby health outcomes1–3. At the crux of nutrigenomics is an
understanding that the influence of foods on health cannot be completely explained unless we delve deeper to
delineate the gene-nutrient-metabolism interactions at molecular and sub-cellular levels4,5. This understanding
has pertinent clinical nutrition applications as nutrigenomics can prove useful to align nutrient intakes with
the genetic profiles for optimum metabolic and cellular functions and design improved intervention strategies
aimed at preventing and managing chronic diseases through individualized diet plans and targeted lifestyle
modifications1,5,6.
Registered dietitians and nutritionists are qualified healthcare professionals tasked with developing nutrition
programs tailored to an individual’s lifestyle behaviors, and medical conditions7–9. So, they are likely to assume
an increasingly important role in delivering personalized nutrition (PN) strategies and contributing to the
emerging diet–gene interaction research. However, applying the principles of nutrigenomics to personalize
dietary recommendations and integrating nutritional genomics in clinical practice will require a thorough
understanding of the complex biological pathways, genetic predispositions, and metabolic phenotypes and a
degree of proficiency and competency to interpret and communicate the results of genetic testing. This will also
entail developing valid instruments that can reliably measure the existing level of understanding and awareness
regarding nutrigenomics among dietetic and nutrition professionals, and their attitudes, perceived values of PN

Department of Postgraduate Programs and Research, Sir Vithaldas Thackersey College of Home Science
(Empowered Autonomous Status), SNDT Women’s University, Juhu Tara Road, Santacruz West, Mumbai 400049,
Maharashtra, India. email: [email protected]; [email protected]

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strategies in practice, willingness to learn, and self-efficacy and confidence to apply nutrigenomics to personalize
dietary plans and recommendation for improved dietary outcomes.
Previous studies have reported limited knowledge and training regarding nutrigenomics among
dietitians7,10,11and inadequate emphasis on human genetics, genomic technologies, and diagnostic techniques in
traditional academic curricula of dietetic practice3,10,12. Most of these studies were conducted outside India using
researcher-designed questionnaires, typically developed by reviewing similar tools used in other countries and
then adapting the items to align with the specific objectives and target population of each study11–14. A recent
study assessed the knowledge and perceptions of a convenience sample of nutritionists and dietitians in India
using an online survey instrument that was tested for comprehension and usability through face validity and
pilot testing15. To the best of our knowledge, there are no studies that have performed a rigorous psychometric
evaluation of developed instruments to establish different measures of validity and reliability.
With the growing interest in nutrigenomics and its clinical applications for disease prevention and
management, it is crucial to explore the knowledge, perceived barriers, and behaviors related to personalized
nutrition (PN) among dietetic professionals, both globally and within India. Given the lack of validated
questionnaires tailored to the socio-cultural context of dietitians in India, we identified the need to conduct this
comprehensive investigation. The primary aim of our study was to develop a valid questionnaire that can reliably
measure current and future dietitians’ knowledge, attitudes, and behaviors (KAB) related to nutrigenomics and
PN in India. The specific objectives of this mixed methods study were to (1) explore the perceptions, values,
and beliefs regarding nutrigenomics among key stakeholders using a series of focus group discussions (FGD)
and in-depth interviews, (2) develop and test the psychometric properties of a novel questionnaire assessing
nutrigenomics and PN-related knowledge, attitudes, and behaviors of dietetic students and professionals in
India and (3) conduct a cross-sectional analysis of data to evaluate the knowledge, attitude, and behaviors (KAB)
related to PN in the participants.

Methods
Study design
The study was conducted in two phases. The first phase was to conduct a qualitative investigation of awareness
and perceptions regarding nutrigenomics among dietetic students, and practicing dietitians and nutritionists.
This formative research informed the development of the first draft of the questionnaire, grounded in the
participants’ understanding of nutrigenomic concepts and principles of PN, and perceived barriers and enabling
factors for interpreting and communicating PN-based recommendations to patients and clients. The next phase
was to test the psychometric properties of the draft questionnaire using item analysis, face, content and construct
validity, internal consistency, and test-retest reliability measures in a cross-sectional sample of dietetic students
and professionals in India. A summary of the steps involved is provided in Fig. 1.

Qualitative study protocol

Six FGDs with dietetic students (n = 37) and nine in-depth interviews with registered dietitians and practicing
nutritionists were conducted using a semi-structured guide comprising questions related to knowledge, beliefs,
and perceived facilitators and barriers of practicing PN in dietetic practice, on a video conferencing platform. For
this phase, a purposive sampling method was employed to recruit dietetic students (currently in their third year
of bachelor’s degree (n = 15) or first-year master’s degree in clinical nutrition(n = 22) and registered dietitians
and practicing nutritionists (n = 9) having at least postgraduate degrees and 15 + years of clinical experience.
The discussions and interviews were moderated by the principal investigator having a doctoral degree in clinical

Figure 1. Summary and steps involved in the development and psychometric evaluation of the KAB_PN
questionnaire. This figure provides a summarized description of the steps involved in the process of developing
and validating the questionnaire assessing the knowledge, attitude, and behaviors related to nutrigenomics and
personalized nutrition in dietetic students and professionals in India.

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nutrition and prior experience in conducting qualitative studies. All discussions were supported by a note-taker,
audio recorded, transcribed verbatim, and later reviewed by two investigators for quality and accuracy.

Item generation
The results of the FGDs and interviews along with an extensive review of literature informed the development
of the first draft of the KAB_PN instrument. The initial draft comprised a total of 58 items − 22 knowledge,
25 attitudes, and 11 behavior and training-related questions. The knowledge items were in a multiple-choice
question format (scored 0 for incorrect and 1 for correct responses), the attitude-related statements were on a
3-point Liker Scale (Disagree to Agree, scored 0–2), and the behavior and training-related questions employed a
5-point Likert scale (strongly disagree to strongly agree; scores 0–4) for participant responses.

Face and content validity

In the second phase of the study, the draft KAB_PN was administered among a sample of graduate nutrition
students (n = 12) and dietitians (n= 5) to determine face validity and receive feedback related to the length and
layout of the questionnaire, and general comprehension and appropriateness of questions. The item content
validity index (I-CVI) and scale CVI (S-CVI) for clarity and relevance of items were assessed based on the
responses of five experts having professional degrees in nutrigenomics and/ or > 5 years of experience in PN
counseling. Each item in the draft questionnaire was rated on a four-point Likert scale for clarity, simplicity,
and relevance (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = highly relevant). S-CVI was
calculated as the average of the I-CVI scores for all items on a particular scale or the average of proportion
relevance judged by all experts16–18.

Item analysis
The second draft of the questionnaire, developed after the evaluation of the face and content validity measures,
was administered among a sample of dietetic students, registered dietitians, and practicing nutritionists (n= 297)
to examine construct validity and reliability. The item difficulty index (IDI) related to the knowledge items of
the questionnaire was determined by dividing the number of participants who chose the correct answer by the
number of total participants, and the item discrimination index (DI) was calculated using the criteria of low and
high-scoring groups19–21.

Construct validity
Construct validity (a measure of the extent to which a questionnaire corresponds to theory or the premise
that the questionnaire is intended to measure) was determined by the confirmatory factor analysis (CFA)
method. The CFA is a well-established technique to evaluate how well the observed variables represent the latent
constructs or factors of interest and uses different measures of ‘Goodness of Fit’ to test the measurement model.
We studied the absolute fit indices such as the Chi-Squared test, Tucker Lewis Fit Index (TLI), Confirmatory Fit
Index (CFI), and Root Mean Square Error of Approximation (RMSEA) to establish construct validity22,23. The
sample adequacy for satisfactory factor analysis was determined using Bartlett’s test of sphericity (p < 0.001) and
the Kaiser-Meyer-Olkin (KMO) measurement of sampling adequacy (> 0.6).

Internal consistency and test-retest reliability

Internal consistency of the multiple-choice questions in the knowledge domain was evaluated using the Kuder
Richardson 20 (KR 20) formula and the Likert scale type items in the attitude, behavior, and training domains
were examined using Cronbach alpha coefficient values (α > 0.7). At a 5% level of significance, 80% power, and
an estimated minimum intra-class correlation value of 0.424,25, the sample size for test-retest reliability was
calculated as 49. In our study, we administered the questionnaire to a sub-sample of 64 participants (48 students
and 16 professionals) within a three-week window of the first administration, to establish test-retest reliability.
An interval of two weeks is generally considered sufficient to test the reproducibility of a questionnaire and
prevent the risk of recall bias26.

Ethics declaration
All procedures were followed as per the ethical standards of conducting research in human participants under
the Helsinki Declaration of 1975, as revised in 2000. Informed written consent was obtained from all participants
before the start of data collection. The study protocol, Version II (ISBEC/NR-91/KM-JJ/2021) was approved by
Intersystem Biomedica Ethics Committee, Mumbai.

Data analysis
The qualitative data transcripts were manually rearranged systematically in tables as per the protocol questions
and research objectives and then collaboratively reviewed and coded according to the sub-themes using a
thematic analysis method. A posteriori inductive approach of data analysis was used to derive emergent themes
and identify key ideas and quotes under each sub-theme. All statistical analyses were conducted using R, an
open-source statistical software environment. Descriptive statistics were used to present the demographic
and cross-sectional analysis results. The item content validity index (I-CVI ≥ 0.8) and scale content validity
index (S- CVI ≥ 0.9) were calculated using standard methods17,27. Similar to previous studies, we considered
an item difficulty index in the range of 30–70 as “good” with “average difficulty” and an item discrimination
index between the range of 0.25–0.34 as “good”. As indicated in the literature, the thresholds of acceptance of
the ‘Goodness of Fit’ indices included- CFI > 0.90, TLI > 0.90, and RMSEA < 0.08. When these thresholds are
achieved the model is considered to be an “excellent fit”. A RMSEA value ranging between 0.08 and 0.1 was
considered an “acceptable fit”21,23,28. Internal Consistency was calculated by Cronbach’s alpha coefficient values

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and the Test-retest reliability was estimated using intraclass correlation coefficients (ICC) with 95% confidence
interval (CI) values of ICC. The Cronbach α and ICC > 0.7 were considered as the threshold values to indicate
good internal consistency and retest reliability respectively20,26. All analyses were two-tailed with p < 0.05
considered statistically significant.

Results
A total of 365 dietetic students and professionals (46 in FGDs and interviews, 17 in face validity, 5 experts for
content validity, and 297 in the validation testing) participated in the study. In the qualitative study, 80.4% were
18–25 years old, and 19.6% had > 10 years of work experience. Out of 297 who completed the cross-sectional
survey 92.3% were women, 24.3% belonged to the age category > 35 years and 83.2% had at least a graduate
degree in clinical nutrition (Table 1).
The results of the qualitative and quantitative data are provided separately in this section.

Results of the thematic analysis of FGD and IDI data

The FGD participants (n = 37) were between 20 and 23 years old, with a mean age of 21.61 (1.6) years. The
majority of the experts in the in depth interviews (IDI) were women (95.7%), with at least a postgraduate degree
(92.3%) and > 15 years of experience working either in public hospitals (69.5%), private hospitals (23.8%), or
own dietetic practice (6.7%). A summary of the main themes that emerged from the FGDs and IDIs is provided
below:

Theme 1: Knowledge and understanding about nutrigenomics

The majority defined nutrigenomics as “the effect of food on your genes”, “interaction between the genes and
nutrients”, and ‘mechanisms that show how food affects the gene expression”. When prompted to describe the
specific genes that the participants were familiar with, the dietetic students mentioned “FTO gene for obesity”,
“genes that are unique in people with caffeine sensitivity” and “OB gene”. Different chronic diseases where an
application of PN might prove helpful were pointed out as “cancer”, “diabetes”, “cardiovascular diseases”,

Variables Qualitative study (n = 46) Quantitative study (n = 297) Test-retest reliability study (n = 64)
Sex
Male 2 (4.5) 23 (7.7) 3 (4.7)
Female 44 (95.7) 274 (92.3) 61 (95.3)
Age category
37 (80.4) 234 (78.8) 48 (75.0)
18–25 years
0 (0.0) 11 (3.7) 5 (7.8)
26–35 years
9 (19.6) 52 (24.3) 11 (17.2)
> 35 years
Highest academic degree
Third Year of Bachelor’s Degree 15 (32.6) 79 (26.6) 22 (34.4)
Bachelor’s degree 22 (47.8) 155 (52.2) 24 (37.5)
Master’s degree 2 (4.3) 48 (16.2) 12 (18.8)
Doctorate or higher 7 (15.2) 15 (5.1) 4 (6.3)
Present Occupation
Dietetic/ Nutrition Student 37 (80.4) 234 (78.8) 48 (75.0)
Registered Dietitian 4 (8.7) 22 (7.4) 10 (15.6)
Practicing dietitian/ nutritionist 5 (10.9) 41 (13.8) 6 (9.4)
Number of years of work experience
< 2 years 32 (69.6) 234 (78.8) 48 (75.0)
3–9 years 5 (10.9) 9 (3.0) 5 (7.8)
10–15 years 0 (0.0) 38 (12.8) 3 (4.7)
> 15 years 9 (19.6) 15 (5.1) 8 (2.5)
Training/certificate/degree in nutrigenomics
Yes 12 (26.1) 56 (18.9) 12 (18.8)
No 34 (73.9) 241 (81.1) 52 (81.3)
What kind of training in nutrigenomics have you received?
Course (> 30 academic hours)- offline 0 (0.0) 3 (1.0) 2 (3.1)
Course (> 30 academic hours)-online 4 (8.7) 4 (1.3) 3 (4.7)
Short workshop (< 5 days) 5 (10.9) 39 (13.1) 3 (4.7)
On-the-job training 3 (6.5) 17 (5.7) 4 (6.3)
No formal training 34 (73.9) 234 (78.8) 52 (81.3)

Table 1. Participant characteristics for focus groups, interviews, and cross-sectional study phases in KAB_
PN questionnaire development and validation. *KAB_PN- Knowledge, Attitude and Behaviors related to
Personalized Nutrition. Data is presented as numbers (percentages).

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“autoimmune diseases”, “PCOS”, “Down syndrome” and “amino acid metabolic disorders”. A practicing dietitian
mentioned PN as “a tailored nutrition strategy that allows an individual to personalize meals and diets to stay
fit, reduce weight and prevent chronic diseases”, and another participant referred to PN as “nutrition for the
self ….diet that is compatible with an individuals’ genotype’. In summary, the discussions revealed a growing
interest but limited knowledge regarding principles of molecular biology and genetics, as well as a lack of clarity
regarding the concepts of nutrigenetics, nutrigenomics, and personalized nutrition. Participants reported
minimal familiarity with genetic testing techniques and had little to no experience in genetic counseling or
interpreting genetic test reports— regardless of their educational level or years of experience as practicing
nutritionists or registered dietitians.

Theme 2: Perceived role and relevance of PN in dietetic practice

The discussions revealed mixed responses such as “I think nutrigenomics is as personalized as one can get with
nutrition management’, “PN is more important with regards to diseases that are hereditary” and that ‘we cannot
change our genes but we can modify our choices and environment, so they are critical aspects to be considered
while diet planning and counseling”. The gene-nutrient interactions were perceived to be “definite”, “adamant”,
“irreversible”, and “likely to change according to one’s lifestyle and environment”. While a student voiced concern
that ‘Knowing what my genes say is in fact scary….’, a registered dietitian mentioned that ‘results of genetic
testing can make patients more anxious, so it can be counter-intuitive if not communicated properly’ and another
participant expressed ‘why mess up your present by knowing what may happen in the future due to faulty genes’.

Theme 3: Confidence and competency to practice

Overall, all participants showed poor confidence in practicing nutritional genomics and acknowledged that they
do not have enough knowledge and training to plan, interpret, and counsel patients based on the genetic testing
results. Dietetic students showed eagerness to learn about basic genetics and applications in nutrition, and the
nutritionists mentioned that “dietitian is the right person to practice nutritional genomics” and ‘they need to seize
the opportunity and get trained in PN’.

Theme 4: Barriers and Facilitators of integrating PN into practice

Furthermore, the discussions explored the perceived barriers and facilitators of improved knowledge and
practice in the fraternity. A few excerpts related to barriers to PN practice are provided below:
“Lack of knowledge of the practitioner itself is the main barrier here.” (Knowledge).
“It’s not a very common practice and it’s not very publicized, so the people do not even know or ask for it.”
(Public Awareness).
“Only a handful of them are actually trained or specialized in this field.” (Training).
“There is a lack of exposure to nutrigenomics and precision nutrition in the curriculum.” and ‘We were never
taught about genetics and applications in nutrition in school (curricular deficits).
“For me personally cost plays a very important role’ (Cost of testing).
“Most of the people will not be comfortable giving the genetic information, even if it’s for their personal
benefit.” (Ethics and Safety).
The perceived facilitators of behavior change included “integrate nutritional genomics in our syllabus”, “spread
awareness through case studies”, “include testimonials of people who have practiced, followed, and observed
improvements”, “create infomercials to demystify pros and cons of genetic testing”, “sensitize the entire medical
fraternity about applications of PN beyond inborn errors of metabolism” and ‘design credited, full time academic
programs in higher education settings of India that can provide skills and required training to students and dietitians’.

Theme 5: Behaviour and practice of incorporating gene-based PN in patient counseling

Of all participants, there were only a few who had prior training in nutritional genomics, and all these
certifications were either gained through online courses or a self-administered review of the literature. None of
the participants were actively practicing PN in their routine dietetic practice.

Results of development and validation of KAB- PN

Based on the analyses of the qualitative data and a review of the existing instruments, the first draft of 58 item
KAB_PN including four sections- knowledge, attitudes, behavior, and willingness to practice was developed.
Demographic characteristics such as sex, age, highest academic degree, occupation, and number of years of work
experience were also included.

Face validity
The results of the pilot testing of the first draft suggested that a majority of the items were relevant, clear, and
easy to understand except for 3 items related to the ‘exosomes’, “omics technology, and the concepts of ‘candidate
genes and genome-wide association studies’ in the knowledge section. These items were removed after mutual
discussions and review of the questionnaire. The time taken by the participants of the face validity exercise
(n = 17) to complete the questionnaire was approximately 10–15 minutes.

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Content validity
The content validity of the instrument was tested by an expert panel (n = 5). Each item in the questionnaire was
graded separately for clarity, simplicity, and relevance, with a score of 1 indicating excellent content validity.
Table 1 provides the item content validity index (I-CVI) and scale content validity index (S-CVI) scores for clarity,
simplicity, and relevance for each item on the questionnaire. Based on the set criteria ICVI > 0.8 and SCVI > 0.9,
an additional two knowledge, and 4 attitude items were excluded, resulting in a 48-item questionnaire. INSERT
SUPPLEMENTARY Table 1.

Item analysis
The results of the item analysis showed that the item difficulty indices ranged from 0.60 to 0.72 and the mean
item discrimination index was 0.32 (Supplementary Table 1). INSERT SUPPLEMENTARY Table 2.

Construct validity
The initial CFA results indicated a model misfit for the hypothesized model comprising 48 items across 4 factors-
knowledge, attitude, behavior, and training ((χ2)387.38, p-value = 0.000, CFI = 0.816, and RMSEA = 0.081). The
model was readjusted by excluding three attitude items having low factor loadings (< 0.4). In psychometric
testing, factor loads below 0.4 are typically considered low indicating weak associations between factors and
variables20,28,29.The final refitted CFA model of 45 items showed satisfactory goodness of fit indices. These factors
were identified as (1) level of knowledge of nutrigenomics (16 items), (2) attitude and willingness to adopt
personalized nutrition (18 items), (3) behaviors related to applications of nutrigenomics in disease management
(7 items), and (4) training and confidence to practice PN (4 items). Tables 2 and 3 represent the results of CFA
analysis with their associated factor loadings and fit indices of Comparative Fit Index (CFI), Tucker Lewis Fit
Index (TLI), and Root Mean Square Error of Approximation (RMSEA) measure values (Table 2). The results of
our study showed acceptable construct validity across the four domains of the questionnaire.

Internal consistency and test-retest reliability

The mean Cronbach alpha coefficient was 0.82, indicating acceptable to excellent internal consistency of
the questionnaire. All items within the four factors in the questionnaire had acceptable to excellent internal
consistency (α > 0.76). To test the reliability, a sub-sample (n = 64, 95.3% women, 75.0% between 18 and 25
years, 37.5% with graduate degrees in nutrition, and 17.2% having > 10 years of experience) completed the
questionnaire twice with a mean duration of 17.3 (3.2) days between first and second administration of the
KAB-PN. The intraclass correlation coefficients for knowledge, attitude, behavior, and training domains were
0.74 (95% CI 0.57–0.84), 0.83 (95% CI 0.71–0.90), 0.72 (95% CI 0.63–0.87), and 0.81 (95% CI 0.69–0.89),
respectively, indicating good to excellent reliability. Table 3 shows the results of the internal consistency and
test-retest reliability. INSERT Table 4.

Results of cross-sectional data analysis for KAB related to nutrigenomics and PN

Overall, the knowledge regarding the basics of genetics such as genes, polymerase chain reaction, chromosomes,
transcription, genotype, and phenotype was reported as adequate. However, the awareness regarding epigenetic
modifications, omics techniques, histone modifications, SNPs and DNA methylation, the difference between
the terms- nutrigenomics vs. nutrigenetics, and names of genetic variants associated with obesity and caffeine
metabolism was inadequate. The majority (83.2%) mentioned that PN should be a critical component of
customized diet counseling, 77.2% agreed that nutrigenomics merits inclusion in the nutrition curriculum
in universities, and 35.8% showed concerns regarding ethics in genetic testing. Around 43.8% agreed that the
patients’ adherence to dietary recommendations may improve with the application of genotype-based PN in
dietetic practice, though 63.6% mentioned that the medical fraternity is still not ready to transition to genetic
profile-led nutritional care unless evidence-based and explicit practice guidelines are drafted and implemented
(Table 5). Two-thirds (68%) showed a willingness to update themselves regarding nutrigenomics, 79.8% were
not confident to discuss the pros and cons of personalized nutrition with clients, and 59% mentioned that they
may consider collecting genetic information as part of a family or disease history (Table 6).

Discussion
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

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Factors Factor loading CFI TLI RMSEA

Knowledgea 0.929 0.915 0.022
Gene 0.454
Chromosome 0.771
Allele 0.418
Phenotype and Genotype 0.500
Polymorphism
0.448
Heritability
Genetic variation/ mutation 0.435
Transcription and translation 0.601
Epigenetic modification 0.787
Genomic imprinting disorder 0.331
Nutrigenetics 0.605
Function of MTHFR gene 0.419
Genetic variant for obesity 0.608
Caffeine Gene Variants- CYP1A2 and ADORA2A 0.451
Application of Omics technology 0.601
The Human Genome Project 0.550
Attitudeb 0.816 0.787 0.081
Dietitians are the best qualified professionals for PN 0.585
Importance of personalized nutrition in practice 0.447
Confidence to incorporate nutrigenomics in practice 0.785
Learn more about nutrigenomics 0.626
Willingness to include genetic history in assessments 0.666
Discuss the genetic basis of a disease with patients 0.784
Discuss the diet’s interaction with genes 0.806
Refer a patient to genetic counseling 0.732
Provide patient education on nutrigenomics 0.785
Adherence may improve with personalized nutrition 0.525
PN will improve dietary and health outcomes 0.582
PN can help to achieve a longer and healthier life 0.447
Personalized dietary recommendations are more effective than conventional approaches 0.598
PN enables more precise dietary advice 0.565
The medical fraternity is still not ready for PN 0.524
Ethics and pricing related to genetic risk assessments need clear policies and regulations 0.389
Genetic testing is an invasion of patient data privacy 0.408
Nutrigenomics must be included in the dietetic curriculum in college education 0.843

Table 2. Results of confirmatory factor analysis with factor loadings and model fit indices. PN, Personalized
Nutrition, MTHRF, Methylenetetrahydrofolate reductase, CFI, Confirmatory Fit Index, TLI, Tucker Lewis Fit
Index; RMSEA, Root Mean Square Error of Approximation,. aChi-square = 74.379, p-value = 0.199; bChi-
square = 187.388, p-value 0.101.

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

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Factors Factor loadings CFI TLI RMSEA

Behaviourc 0.951 0.903 0.236
Frequency of updating myself about nutrigenomics 0.893
Consider collecting genetic information as part of a family or disease history 0.908
Discuss with patients how diet may interact with genes to influence the risk of disease 0.912
Confidence to suggest appropriate genetic tests 0.915
Confidence to discuss the pros and cons of nutrigenomics and PN with patients 0.689
Incorporate genetic test results to personalize dietary advice in routine practice 0.979
Trainingd 0.990 0.992 0.001
Obtained any training in nutrigenomics 0.728
Type of training you received 0.850
What should be an ideal training duration 0.456
What kind of training is most suitable for dietitians 0.405

Table 3. Results of confirmatory factor analysis of behavior and training-related items in the questionnaire
with factor loadings and model fit indices. PN, Personalized Nutrition, MTHRF, Methylenetetrahydrofolate
reductase,. CFI, Confirmatory Fit Index, TLI, Tucker Lewis Fit Index; RMSEA, Root Mean Square Error of
Approximation. cChi-square = 87.685, p-value 0.210; dChi-square = 0.838, p-value = 0.658.

Domains Mean SD KR −20 / Cronbach α ICC 95% CI for ICC

Knowledge (16 items) 5.66 3.44 0.81 0.74 0.57 to 0.84
Attitude (18 items) 19.90 10.70 0.76 0.83 0.71 to 0.90
Behavior (7 items) 12.93 9.09 0.79 0.72 0.63 to 0.87
Training (4 items) 2.94 2.69 0.84 0.81 0.69 to 0.89

Table 4. Measures of internal consistency and test-retest reliability for the KAB_PN questionnaire. KR, Kuder
Richardson-20; ICC, Intra Class Coefficient; CI, Confidence Interval. Scoring of Items- Knowledge (0–1);
Attitude (0–2), Behavior and Training (0–4). Internal consistency was measured using Cronbach’s alpha and
test-retest reliability was assessed using the intra-class correlation coefficient (ICC) with 95% confidence
intervals. All analyses were performed using the R software.

Agree Neutral Disagree

Attitude related statements n (%) n (%) n (%)
Dietitians are the best-qualified professionals for PN 243 (81.8) 47 (15.8) 7 (2.4)
PN must become a critical component of customized diet counseling 247 (83.2) 34 (11.4) 16 (5.4)
I would like to incorporate nutrigenomics and PN into my dietetic practice 155 (52.2) 123 (41.4) 19 (6.4)
I would like to learn more about nutrigenomics 236 (79.5) 50 (16.8) 11 (3.7)
I am willing to include genetic history as part of routine assessments 178 (59.9) 87 (29.3) 32 (10.8)
Dietitians should discuss the genetic basis of a disease with patients 85 (28.6) 123 (41.4) 89 (30.0)
Dietetic counseling can include a discussion on an individual’s diet and nutrient interaction with genes 176 (59.3) 81 (27.3) 40 (13.5)
I may consider referring a patient to genetic counseling 95 (32.0) 112 (37.7) 90 (30.3)
Dietitians need to develop patient education resources on nutrigenomics 167 (56.2) 102 (34.3) 28 (9.4)
Adherence to dietary recommendations will improve through personalized nutrition 130 (43.8) 109 (36.7) 58 (19.5)
PN will improve dietary and health outcomes 231 (77.8) 55 (18.5) 11 (3.7)
PN will allow an individual to have a longer life with a better quality of life 80 (26.9) 85 (28.6) 132 (44.4)
Personalized dietary recommendations are more effective than conventional approaches 215 (72.4) 71 (23.9) 11 (3.7)
Nutrigenomics will enable more precise advice about dietary intake, supplement use and disease prevention and management 209 (70.4) 76 (25.6) 12 (4.0)
The medical fraternity is still not ready for PN 189 (63.6) 78 (26.3) 30 (10.1)
I am worried that genetic testing will result in an invasion of patient data privacy 98 (33.0) 78 (26.3) 121 (40.7)
Ethics and pricing related to genetic risk assessments need clear policies and regulations 106 (35.8) 115 (38.7) 76 (25.6)
Nutrigenomics must be included in the nutrition curriculum in HEI 229 (77.2) 40 (13.5) 28 (9.4)

Table 5. Attitudes towards nutrigenomics and personalized nutrition in dietetic students and professionals
(n = 297). Data is presented as numbers (percentages).

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Strongly Strongly
Statements indicating behavior and confidence to integrate PN into practice Disagree Disagree Neutral Agree Agree
I frequently update myself in professional literature regarding nutrigenomics 38 (12.8) 10 (3.4) 47 (15.8) 120 (40.4) 82 (27.6)
I consider collecting genetic information as part of a family or disease history 40 (13.5) 5 (1.7) 78 (26.3) 110 (37) 64 (22)
I discuss/ would like to discuss with patients how diet may interact with genes to influence the risk of
40 (13.5) 10 (3.4) 53 (17.8) 121 (41) 73 (25)
disease
I am confident enough to suggest appropriate genetic tests to patients 45 (14.1) 6 (2.1) 56 (18.8) 81 (27) 112 (38)
I often refer patients to dietitians who are proficient in PN 34 (11.5) 170 (57.2) 38 (12.8) 40 (13.5) 15 (5.1)
I am confident in discussing the pros and cons of nutrigenomics with clients/ patients 202 (68.0) 35 (11.8) 19 (6.4) 34 (11.4) 7 (2.4)
I try/ would like to incorporate genetic test results to personalize dietary advice in my routine practice 198 (66.6) 32 (10.7) 34 (11.4) 21 (7.1) 12 (4.0)

Table 6. Participant (n = 297) responses to behavior and confidence to integrate PN in clinical practice-related
items in the KAB_PN questionnaire. Data is presented as numbers (percentages).

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.

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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.

Data availability
Data is provided within the manuscript or supplementary information files.

Received: 19 May 2024; Accepted: 2 December 2024

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Acknowledgements
The authors would like to acknowledge the Indian Dietetics Association for assisting with the circulation of
the study pamphlets to invite volunteers for participation in the study. Our thanks are also due to Ms. Priyanka
Sakhardande for assisting in the statistical analyses and the dietitians, practicing nutritionists, and students of
the Department of Food, Nutrition, and Dietetics for participating in this research and providing their valuable
input.

Author contributions
PM was involved in the Conceptualization and design of the study, conduct of all investigations, development,
and validation of the questionnaire, writing the original draft, and editing of the final manuscript as per the feed-
back of other authors. JN and SM were the project research assistants who contributed to the field investigation,
data entry and analysis, and review and editing of the manuscript. JM contributed to permissions and approvals,
data curation, and review of the final manuscript. All authors approve of the final manuscript submitted for
consideration.

Declarations

Competing interests
The authors declare no competing interests.

Additional information
Supplementary Information The online version contains supplementary material available at ​h​t​t​p​s​:​/​/​d​o​i.​ ​o​r​g​/​1​
0​.​1​03​ ​8​/​s​4​1​5​9​8​-0​ ​2​4​-​8​2​0​8​0​-​9​​​​.​ ​​
Correspondence and requests for materials should be addressed to P.M.
Reprints and permissions information is available at www.nature.com/reprints.

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