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    Sylvia Escott Stump - Nutrition and Genetics - New Practice Sylvia Escott Stump - Nutrition and Genetics - New Practice Presentation Transcript

    • Nutritional Genetics: Discovering New Practice Horizons Sylvia Escott-Stump, MA, RD, LDN escottstumps@ecu.edu 252-328-1352 © S. Escott-Stump1
    • Lecture Objectives • Participants will be able to • Describe the role of nutrition in genetics. • Identify key nutrients affecting gene expression or suppression • Folic acid • Vitamin B-12, Vitamin D • Describe new employment opportunities for dietitians © S. Escott-Stump2
    • Human Variome Project Objective: To collect variation causing disease (mutations) in all genes world wide © S. Escott-Stump3
    • Biosystems • Biosystem -- a group of molecules that interact in a biological system. • Biological pathway: interacting genes, proteins, and small molecules. • Disease: a biosystem which can involve components such as genes, biomarkers, and drugs. © S. Escott-Stump4
    • Genetic Complexity: We inherit two genomes Human Genome: • Inherited from both parents • Stable, never changed in composition Microbiome: • Inherited from the mother • Extremely dynamic • Changes from individual to individual and in the same individual over time © S. Escott-Stump5
    • 1000 Genomes Project • Purpose: • support the discovery and understanding of genetic variants that influence human disease Study goals: • single nucleotide variants at frequencies of 1% or higher in diverse populations • structural variants, such as copy number variants, other insertions and deletions, and inversions. © S. Escott-Stump6
    • Genome-Wide Association Studies (GWAS) • GWAS allow for a large number of samples to be assayed simultaneously • A genome-wide tagging single nucleotide polymorphism (SNP) approach • Proper and responsible study design • Rigorous data quality assessment of genomic matching of cases and controls © S. Escott-Stump7
    • Epigenetics • Gene activity – may be stable over long periods of time – persist through many cell divisions – may be inherited through several generations – all without any change to the primary DNA sequence. © S. Escott-Stump8
    • Epigenetic Programming • Epigenetic misprogramming during development – persistent effect on the health of the offspring – may be transmitted to the next generation. • Epigenetic alterations with gene expression dysregulation – accumulate during aging – important in tumorigenesis and age-related diseases. © S. Escott-Stump9
    • Gene Expression • Dietary factors, especially folate, can alter gene expression • Consequences for cell function affect health throughout life © S. Escott-Stump10
    • DNA Methylation • The first discovered epigenetic modification is methylation of cytosine residues in DNA molecules. • DNA methylation is linked to transcriptional silencing and is important for gene regulation, development, and tumorigenesis © S. Escott-Stump11
    • Methylation Dependent Activities • DNA synthesis and repair • Silencing of genes: viruses, cancer genes • Myelination and pruning • Conversion of tryptophan to serotonin • Conversion of serotonin to melatonin – Schneider, 2007 © S. Escott-Stump12
    • Aberrant DNA Methylation • Hypermethylation and silencing of tumor suppressor genes is a hallmark of many types of cancer cells. • Global hypomethylation alters the chromatin architecture, leading to the inappropriate activation of oncogenes. © S. Escott-Stump13
    • Histones and Chromatin • Specific histone modifications by various effector proteins mediate gene activation or repression. • Altered histones induce localized structural changes in chromatin, allowing protein factors to access the DNA. • Changes in chromatin affect the accessibility of genes to transcription factors. © S. Escott-Stump14
    • Altered Chromatin • Genetic information is encoded by the linear sequence of DNA and by epigenetic modifications of chromatin structure – DNA methylation and modifications of the proteins that bind DNA – Epigenetic changes alter the structure of chromatin and influence gene expression • Misaligned, methylated cytosines promote distinct patterns specific for each tissue type and disease state – They are concentrated among genes that regulate transcription, growth, metabolism, differentiation, and oncogenesis. So What? DNA epigenetics is the missing link between genetics, disease, and the environment! © S. Escott-Stump15
    • Epigenetics Regulation of Gene Expression © S. Escott-Stump16
    • Important Terms Nutrigenomics • Effect of nutrients on health through altering genome, proteome and the metabolome with physiological changes Nutritional Genetics • Effect of genetic variations on the interaction between diet and health with implications for susceptible individuals © S. Escott-Stump17
    • We Need “Omic” Technologies • Interaction between nutrition and an individual's genome (nutrigenomics) • Dietary changes and gene polymorphisms (nutrigenetics) • DNA methylation (nutritional epigenomics) • Gene expression (nutritional transcriptomics) • Altered formation or bioactivation of proteins (proteomics) • Quantity and timing of exposure influence small molecular weight cellular constituents (metabolomics) © S. Escott-Stump 18
    • Folate Metabolism and DNA © S. Escott-Stump19
    • Folate Biochemistry • Folate (F) is reduced to dihydrofolate (FH2) then to tetrahydrofolate (FH4)…the biologically active form • Dihydrofolate reductase (DHFR) catalyses both reduction steps • 5,10-methylenetetrahydrofolate reductase (MTHFR) catalyzes the steps for methylation of homocysteine into methionine Homocysteine SAMe Methylation of B-12 Tetra-hydrofolate Di-hydrofolate FOLATE © S. Escott-Stump20
    • Folic Acid in Pregnancy 30,000 to 40,000 years ago -- spread of modern humans in Europe -- MTHFR mutant alleles C>T and A>C arose from two independent ancestral alleles Both alleles confer a selective advantage yet they also bring disease… Semmler A et al. Haplotype analysis of the 5,10- methylenetetrahydrofolate reductase (MTHFR) c.1298A>C (E429A) polymorphism. BMC Res Notes. 2011 Oct 24;4:439. Demands for folate increase during pregnancy; required for growth and development of the fetus Consider supplementation of l-methylfolate for the prevention of pregnancy- related complications other than neural tube defects Greenburg JA et al. Folic Acid supplementation and pregnancy: more than just neural tube defect prevention. Rev Obstet Gynecol. 2011 Summer; 4(2):52-9. © S. Escott-Stump21
    • MTHFR Deficiency Symptoms • Inborn Error of Metabolism: • Chromosome 1 Acute leukemia (Metayer et al, 2011; Yang et al, 2011) Cleft lip or palate Developmental delay Gait abnormality Gastric cancer (Zacho et al, Int J Cancer, 2011) Homocystinuria (rare) Infertility or miscarriage Mental retardation Pediatric stroke Peripheral artery disease Psychiatric manifestations Seizures © S. Escott-Stump22
    • Folic Acid Allele: MTHFR C677T (C>T) Elevated homocysteine levels Increased risk of heart disease; elevated cholesterol, diabetes and insulin resistance Inflammatory bowel disease Autism: MTHFR levels only 40- 50% of normal Anencephaly and spina bifida; more often in males. Rates of spina bifida are highest in Ireland and Wales and their descendents around the world. • Schneider, 2007 • 21% of US Latinos • 20% of Italians • 13% of British Caucasians • 11% of Irish Caucasians • 10-14% of other Caucasians • 8% of German Caucasians • 11% of Asians • <1% of African Americans  Schneider, 2007 © S. Escott-Stump23
    • Folic Acid Allele: MTHFR A1298C (A>C) Prevalence of the MTHFR 1298A>C allele is significantly higher in Central Europe in comparison to African populations Selective advantages but also associated with diseases Facilitates conversion of dihydrobiopterin (BH2) to tetrahydrobiopterin (BH4,) through the action of dihydrofolate reductase 1. production of serotonin 2. neutralization of ammonia Relevant in autism, pediatric stroke, schizophrenia © S. Escott-Stump24
    • Folate-Drug Interactions Anticonvulsants Alcohol and tobacco Antacids Aspirin Sulfonamides: competitive inhibitors of para- aminobenzoic acid (PABA) in reactions with dihydropteroate synthetase Methotrexate : inhibits both folate reductase and dihydrofolate reductase Pyrimethamine and Trimethoprim: dihydrofolate reductase inhibitors © S. Escott-Stump25
    • Elevated Homocysteine (tHcy) • Elevated tHcy levels increases incidence of: – stroke (thrombosis) – cardiovascular disease (myocardial infarction and other cardiac effects) • SO WHAT? tHcy > 6 μmol/L = a warning sign. • We know about Folic acid, B-6, B-12… © S. Escott-Stump26
    • Riboflavin • Role in blood pressure management – Especially in TT genotype of C677T – Wilson CP et al. Postgraduate Symposium: The MTHFR C677T polymorphism, B-vitamins and blood pressure. Proc Nutr Soc. 2010 Feb;69(1):156-65. © S. Escott-Stump27
    • Betaine and Choline Betaine Methyl donor for transmethylation in the methionine cycle Primarily in the liver and kidney. Widely distributed in animals, plants, and microorganisms Richest: seafood, wheat germ or bran, and spinach. Choline Methylation of homocysteine to methionine Inadequate choline may also contribute to neural tube defect etiology Foods: Eggs, wheat germ © S. Escott-Stump28
    • Choline Metabolism
    • Sulfur Amino Acid Metabolism • Sulfur amino acid metabolism in gastrointestinal tissues – Linked to gut disease – The GI tract metabolizes 20% of dietary methionine – Metabolic fate is transmethylation to homocysteine and transsulfuration to cysteine • Burrin and Stoll, 2007 • Sulfonamide = folic acid antagonist • Sulfa allergy or folic acid allele?? © S. Escott-Stump30
    • Folic Acid Masks B-12 Deficiency Folic acid will not correct changes in the nervous system from vitamin B12 deficiency Permanent nerve damage could occur if vitamin B12 deficiency is not treated In seniors, test first for serum B-12 levels before giving folic acid supplements Supplemental folic acid should not exceed the UL of 1000 mcg (1 mg) per day. © S. Escott-Stump31
    • Available as L-Methylfolate Metagenics Fola-Pro® (800 mcg L-5-methylfolate) PamLabs – prescription only • Cerefolin ® (5.6 mg L-methylfolate, 2 mg methylcobalamin, 600 mg N- acetylcysteine) • Deplin ® (7.5 mg L-methylfolate) • Metanx ® (2.8 mg L-methylfolate; 2 mg methylcobalamin; 25 mg pyridoxal 5- phosphate) © S. Escott-Stump32
    • Nutrigenetics and nutrigenomics will transform our dietetics practice!! © S. Escott-Stump33
    • What Disorders Might Be Affected?
    • ALS and Homocysteine Study: 62 ALS patients and 88 age-matched controls –Homocysteine (Hcy) may be directly involved in the damage of motor neurons and in several pathways implicated in amyotrophic lateral sclerosis (ALS) pathogenesis. SO WHAT? Higher Hcy may be linked to faster progression of ALS. Zoccolella et al, 2008. © S. Escott-Stump35
    • Alzheimer’s Disease  Folate deficiencies: depression, cognitive impairment , dementia • DNA methylation and hydroxymethylation – Methylated cytosine (5mC) levels in AD -- Hydroxylated methylcytosine (5hmC)  So what? Supplementation with the active form, methyltetrahydrofolate may prevent and treat both depression and dementia – Mischoulon D, Raab MF. The role of folate in depression and dementia. J Clin Psychiatry. 2007;68 Suppl 10:28-33. 2007 © S. Escott-Stump36
    • Autism IgA deficiency is common; NK cell # and function is decreased TNF is produced in response to infection or exposure to casein, gluten, or soy Antibodies against serotonin receptors have been found  Schneider, 2007 So what? Periconceptional use of prenatal vitamins may reduce the risk of having children with autism in genetically susceptible mothers Schmidt et al. Prenatal vitamins, one- carbon metabolism gene variants, and risk for autism. Epidemiology. 2011 Jul; 22(4):476-85. © S. Escott-Stump37
    • Auto-Immune Disorders • Folate receptor beta (FRβ) – only detectable in placenta and some myeloid hematopoietic cells in healthy people • FRβ – over-expressed in activated macrophages in autoimmune diseases and some cancer cells • Feng Y et al. A folate receptor beta-specific human monoclonal antibody recognizes activated macrophage of rheumatoid patients and mediates antibody-dependent cell- mediated cytotoxicity. Arthritis Res Ther 2011 Apr 8;13(2):R59. © S. Escott-Stump38
    • Bone Turnover , Thiols, and Homocysteine (tHcy) • Cysteine (Cys) -- formed from tHcy – Involved in bone metabolism via incorporation into collagen and cysteine protease enzymes – Thiols: metabolically linked with homocysteine (tHcy) – So what? tHcy -- risk factor for developing osteoporosis – Baines et al, 2007 © S. Escott-Stump39
    • Cancer Epigenetics Normally, oncogenes are silent because of DNA methylation – Non-mutational changes to DNA can lead to alterations in gene expression. – DNA methyltransferases catalyze the addition of a methyl group from S-adenosyl-L-methionine to the 5- carbon position of cytosine. – Methylation at cytosine plays an important role in regulating transcription and chromatin structure. SO WHAT? Altered methylation can induce the aberrant expression of oncogenes, leading to cancer pathogenesis. © S. Escott-Stump40
    • Cancer and Methylation Nutritional transcription: Food components that increase or depress gene expression may account for variable response to foods. Milner, 2006 – So what? Variation in DNA methylation patterns and other epigenomic events influence the biological response to food components and vice versa. © S. Escott-Stump41
    • Cancers: Breast-Colon-Urinary • Genes involved in regulating slow, intermediate or fast acetylations • N-Acetyltransferase (NAT-1) gene – Allele NAT1*10 – Affects acetylation of heterocyclic aromatic amines in heated red meats © S. Escott-Stump42
    • Cancer -- Colon • Low folate status increases colorectal cancer risk. • Excessive folate supplementation might promote colorectal carcinogenesis by enhancing proinflammatory and immune response pathways – Protiva P et al. Altered folate availability modifies the molecular environment of the human colorectum: implications for colorectal carcinogenesis. Cacner Prev Res (Phila) 2011 Apr;4(4):530-43. © S. Escott-Stump43
    • Cancer and Nutrigenomics Nutrients, phytochemical, zoochemicals, fungochemical, and bacterochemicals have been implicated in cancer risk and tumor behavior, with mixed results. Not all individuals respond identically to a diet. The "one size fits all" approach must come to an end… Research will be required to identify those who will benefit most from dietary change and any who might be placed at risk because of an adjustment. – Riscuta G, Dunistrescu RG. Nutrigenomics: implications for breast and colon cancer prevention. Methods Mol Biol. 2012; 863:343-58. © S. Escott-Stump44
    • Congenital Heart Disease • Current guidelines recommend counseling about inheritance and transmission of congenital heart disease (CHD) to offspring, yet: – Only 33% of patients recalled receiving information about inheritance of CHD from their cardiologist, and 13% had consulted a clinical geneticist. – Thus, many adult CHD patients lack knowledge and desire more information about inheritance, indicating a need for better patient education. » Van Engelen et al. Adults with congenital heart disease: patients' knowledge and concerns about inheritance. Am J Med Genet A. 2011 Jul;155A(7):1661-7. © S. Escott-Stump45
    • Depression • Major depressive disorder (MDD) – High mortality – Lifetime risk of 10-25% in women, 5-12% in men Current treatments • SSRIs, Tricyclic antidepressants • MAJORITY never achieve symptom remission with first medication treatment L-methylfolate (7.5 mg) effective in managing depressive episodes. Unlike folic acid, L- methylfolate UNMASKS vitamin B-12 anemia. • Zajecka JM. Webconference: Evidence for a trimonoamine modulator as an antidepressant agent.2007. © S. Escott-Stump46
    • Diabetes (Type 2) • Genes involved in regulating insulin sensitivity and lipid metabolism • Sterol response binding protein (SREBP-1c ) – Affects uptake of cholesterol and fatty acids – Implications for lipid intake in T2DM patients © S. Escott-Stump47
    • Down Syndrome Maternal risk for Down syndrome (DS): – Presence of 3+ polymorphic alleles increased the risk 1.74 times. – Elevated maternal risk observed when plasma Hcy concentration > 4.99 micromol/L. So what? MTHFR and homocysteine markers are important • Biselli et al, 2008 © S. Escott-Stump48
    • Essential Hypertension Essential hypertension (EH) –influenced by multiple genes, including MTHFR –In C677T genotypes: Homocysteine level is higher in some genotypes • SO WHAT? MTHFR gene polymorphism is an independent risk factor for EH but not for CAD © S. Escott-Stump49
    • Inflammatory Bowel Disease Moderate elevated tHcy is commonly associated with IBD. Of the MTHFR polymorphisms, A>G is most associated with risk of IBD. – Zintzaras E. Genetic variants of homocysteine/folate metabolism pathway and risk of inflammatory bowel disease: a synopsis and meta-analysis of genetic association studies. Biomarkers. 2010 Feb;15(1):69-79. So what? Screen and treat folate and vitamin B(12) deficiencies in IBD patients © S. Escott-Stump50
    • Inflammatory Bowel Disease Curcumin affects gene expression of colonocytes by inhibiting interferon gamma signaling – Curcumin inhibits interferon gamma signaling in colonic epithelial cells. Am J Physiol Gastrointest Liver Physiol. 2011 Oct 28. © S. Escott-Stump51
    • Metabolic Syndrome MTHFR activity and tHcy Increased risk of cardiovascular disease Metabolic syndrome and insulin resistance in SCZ: 2-4x higher than the general population. So what? C677 T allele carriers are at greater risk for insulin resistance with increasing central adiposity, independent of age, gender, BMI, or metabolic syndrome diagnosis. Ellingrod et al, 2008 © S. Escott-Stump52
    • Neural Tube Defects (NTDs): Anencephaly & Spina Bifida • Anencephaly : upper end of the neural tube fails to close. Brain either never completely develops or is totally absent. • Prognosis: Spontaneous loss, Stillborn, Neonatal death Spina bifida: occurs by the 28th day of gestation Photo: days 23-28 when the lower end of the neural tube fails to close. © S. Escott-Stump53
    • Food for Thought… OBESITY: Gene-Diet-Disease © S. Escott-Stump54
    • Obesity and Mast Cells • Mast cells are essential in allergic responses. – White adipose tissue from obese humans contains large numbers of mast cells. • Serum mast cell tryptase levels are also significantly higher, suggesting a role of these inflammatory cells in obesity and diabetes. • Mast cells affect energy expenditure, protease expression, angiogenesis, apoptosis, and pre-adipocyte differentiation. – Mast cell deficiency or pharmacological stabilization may reduce body weight gain and improved glucose and insulin sensitivities. – Wang and Shi. Mast cell stabilization: novel medication for obesity and diabetes. Diabetes Metab Res Rev. 2011 Nov;27(8):919-24. © S. Escott-Stump55
    • Obesity in Childhood Interactions of variants in 4 genes (FTO, MC4R, NPC1 and APOA2) with high-fat foods or with high saturated-fat foods may lead to targeted treatments – Garver WS. Gene-diet interactions in childhood obesity. Curr Genomics. 2011 May;12(3):180-9. © S. Escott-Stump56
    • Parkinson’s Disease (PD) Prospective, population-based cohort study --5,920 participants aged 55+ MTHFR C>T polymorphism (TT): increased risk for Parkinson's disease in smokers Increased plasma levels of tHcy have neurotoxic effects -- accelerate selective dopaminergic cell death underlying PD So what? Elevated tHcy plays a role in the pathogenesis of PD. – De Lau et al, 2005 © S. Escott-Stump57
    • Renal Dialysis and CRP levels • Randomized, prospective study - 341 hemodialysis patients, 2 groups: • 1) received 50 mg of 5-MTHF intravenously • 2) received 5 mg/day folic acid • Both received intravenous vitamins B6 and B12. • RESULTS: High-dose IV supplementation with 5-MTHF reduced inflammation and improved survival. • SO WHAT? Intravenous 5-MTHF seems to improve survival in HD patients independent from homocysteine lowering, especially by lowering CRP. • Cianciolo et al, 2008 © S. Escott-Stump58
    • Rheumatoid Arthritis (RA) • Methotrexate (MTX): – MTHFR A1298C polymorphism protects against overall MTX toxicity – So what? Genetic polymorphisms and MTX transporters modify toxicity but not efficacy of MTX » Bohanec Grabar et al, 2008 © S. Escott-Stump59
    • Nutrition Care Process Example NUTRITION DIAGNOSIS Problem: Altered nutrient utilization Etiology: related to inability to metabolize oral folic acid Signs/Symptoms: as evidenced by MTHFR (C>T) polymorphism and elevated tHcy INTERVENTION • Nutrient delivery: – L-methylfolate © S. Escott-Stump60
    • Principles of Nutrigenomics Common dietary chemicals alter gene expression and/or genome structure The influence of diet on health depends upon an individual's genetic makeup Genes or normal common variants are regulated by diet Improper diets in some individuals and under some conditions promote some chronic diseases Kaput, 2005 © S. Escott-Stump61
    • Implications for Dietitians: Diet-Gene Interactions Understand the molecular mechanisms underlying gene-nutrient interactions Understand their modification by genetic variation Provide dietary recommendations and nutritional interventions that optimize individual health. Stover, 2006 © S. Escott-Stump62
    • Trans-Disciplinary Genetics Training • We need a trans-disciplinary approach to public health that would examine how environmental exposures to diet and pollution and other factors influence gene expression and a person's susceptibility to chronic disease. » Olden K et al. Discovering how environmental exposures alter genes could lead to new treatments for chronic illnesses. Health Aff (Millwood). 2011 May;30(5):833-41. © S. Escott-Stump63
    • Genomics Education Resources • Trans-disciplinary repository using a Web-based learning management system » National Institutes of Health, National Cancer Institute, Center for Cancer Research, Genetics Branch, Bethesda, MD 20892, USA. » Genetic counseling programs: http://www.kumc.edu/gec/prof/soclist.html
    • Rogers' Diffusion of Ideas
    • Sample Application of Theory Applied Diffusion of Ideas/Innovation Theory: adoption of genetics and genomics as the central science in health care: Genetics/genomics competencies – Demonstrate an understanding of basic genetic and genomic concepts – Include genetic histories in assessments and case coordination – Provide and explain genetic and genomic information – Refer to appropriate genetics professionals and services – Identify the limits of one's own genetics and genomics expertise © S. Escott-Stump66
    • Requirements • Communication skills • Critical thinking skills • Interpersonal, counseling and psychosocial assessment • Professional ethics and values assessment © S. Escott-Stump67
    • SKILLS • Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. • Communicating effectively in writing as appropriate for the needs of the audience. • Understanding written sentences and paragraphs in work related documents. • Being aware of others' reactions and understanding why they react as they do. • Talking to others to convey information effectively. • Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. • Adjusting actions in relation to others' actions. • Using scientific rules and methods to solve problems. • Actively looking for ways to help people. • Understanding the implications of new information for both current and future problem-solving and decision-making. © S. Escott-Stump68
    • KNOWLEDGE OF… • Human behavior and performance; individual differences ; learning and motivation; psychological research methods; assessment and treatment of behavioral and affective disorders. • Principles and processes for customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction. • Information and techniques needed to diagnose and treat human injuries, diseases, and deformities--including symptoms, treatment alternatives, drug properties and interactions, and preventive health-care measures. • Principles, methods, and procedures for diagnosis, treatment, and rehabilitation of physical and mental dysfunctions, and for career counseling and guidance. • Structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar. • Group behavior and dynamics, societal trends and influences • Human migrations, ethnicity, cultures and their history and origins. • Principles and methods for curriculum and training design, teaching and instruction for individuals and groups, and the measurement of training effects. © S. Escott-Stump69
    • ABILITIES • Listen to and understand information and ideas presented through spoken words and sentences. • Communicate complex information and ideas so others will understand. • Recognize when something is wrong or is likely to go wrong. • Combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events). • Apply general rules to specific problems to produce answers that make sense. • Read and understand information and ideas presented in writing. • Identify and understand speech of another person. • Communicate information and ideas in writing so others will understand. © S. Escott-Stump70
    • TASKS • Provide information and support to families who have members with birth defects or genetic disorders and to families who may be at risk for a variety of inherited conditions. • Identify families at risk, investigate the problem present in the family, interpret information about the disorder, analyze inheritance patterns and risks of recurrence and review available options with the family. • Provide supportive counseling to families. • Serve as patient advocates and refer individuals and families to community or state support services. • Serve as educators and resource people for other health care professionals and for the general public. • Engage in research activities related to the field of medical genetics and genetic counseling. © S. Escott-Stump71
    • Characteristics: Social, Investigative, Artistic • Social — Social occupations frequently involve working with, communicating with, and teaching people. These occupations often involve helping or providing service to others. • Investigative — Investigative occupations frequently involve working with ideas, and require an extensive amount of thinking. These occupations can involve searching for facts and figuring out problems mentally. • Artistic — Artistic occupations frequently involve working with forms, designs and patterns. They often require self- expression and the work can be done without following a clear set of rules. • The National Society of Genetic Counselors: http://www.nsgc.org/resourcelink.asp • American College of Medical Genetics: http://www.acmg.net/# © S. Escott-Stump72
    • According to Ruth DeBusk… • “For registered dietitians to be recognized as the nutritional genomics experts within health care, the profession must assist in positioning practitioners on equal footing with other members of the health care team, including physicians….” • “we need…a fresh look at the influence that a team of health professionals, each accomplished and expert within his or her chosen field, could have on chronic disease management and prevention and at the autonomy, training, and skills that would be needed for this team to function optimally.” – Ruth DeBusk. Diet-Related Disease, Nutritional Genomics, and Food and Nutrition Professionals. J Am Diet Assoc 109: 410-413, 2009. © S. Escott-Stump73
    • From the Beginning to the End of Life
    • Website References CDC Family History: http://www.cdc.gov/genomics/famhistory/highriskfamily.htm Genomics http://www.cdc.gov/genomics/ Human Variome Project: http://www.humanvariomeproject.org/ Metagenics: http://www.metagenics.com/ National Society of Genetic Counselors: http://www.nsgc.org/consumer/familytree/tree_images.cfm Pan Am Labs: Deplin, Metanx, Cerefolin http://www.pamlabs.com/ Penn State University: http://nutrigenomics.psu.edu/nuclear_receptors_as_nutria.html Transmethylation: http://www.biology- online.org/dictionary/Transmethylation University of California at Davis, Center of Excellence: http://nutrigenomics.ucdavis.edu/ USDA Nutrient Database. Website http://www.ars.usda.gov/Services/docs.htm?docid=9673 © S. Escott-Stump75