Pub Date: Friday, Aug 07, 2020
Author: Angela Odoms-Young, PhD, MS
Affiliation: Department of Kinesiology and Nutrition, College of Applied Health Sciences University of Illinois at Illinois at Chicago
The role of nutrition in healthy growth and development and disease prevention has been recognized since the early/mid-1900s.1 Yet, over the last several decades, the substantial chronic disease burden in the United States (US) and globally has underscored the importance of diet not only for the health of individuals but also society as a whole.2,3 A recent article published as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), estimates that in 2017, approximately 11 million deaths and 255 million Disability Adjusted Life Years (DALYs) could be attributed to dietary risk factors, including suboptimal intakes of sodium, fruits and vegetables, and whole grains.3 In addition to the burden on physical health, studies show that suboptimal diets and diet-related conditions have significant implications for the economy based on their considerable contribution to health care costs and loss of productivity, as well as environmental sustainability through the effect on greenhouse gas emissions.2,4-6
In the American Heart Association Scientific Statement “Rapid Diet Assessment Screening Tool for Cardiovascular Disease Risk Reduction across Healthcare Settings”, the authors: 1) provide a rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, 2) discuss the theory- and practice-based criteria of a rapid diet screener tool that supports valid and feasible diet assessment and counseling in clinical settings, 3) review existing tools, and 4) discuss opportunities and challenges for integrating a rapid diet screener tool into clinician workflows through the electronic health record.7 This AHA Scientific Statement was “designed to accelerate efforts to make diet quality assessment an integral part of office-based care delivery by encouraging critical conversations among clinicians, individuals with diet/lifestyle expertise, and specialists in information technology.”7 As emphasized in this statement, research shows that small dietary changes have the potential to greatly improve health.8 Other reviews have also demonstrated that clinician-delivered diet assessment, education and counseling can result in modest improvements in dietary behaviors and cardiometabolic risk factors including improvements in body weight, total cholesterol, low density lipoprotein cholesterol and fasting glucose, blood pressure, and diabetes.9-14
Nevertheless, there continues to be a paucity of training and education for clinicians and other health professionals, specific guidelines related to dietary screening, and standardized approaches to dietary treatment and reimbursement in clinical practice.15-20 Even when clinicians are familiar with nutrition content, another obstacle to counseling may be the lack of knowledge about population-specific barriers and inability to apply recommendations to patients across different demographic and social characteristics.20 Studies have documented considerable disparities in dietary counseling based on access to care, insurance status, and gender.21 For example, as compared to women, men are almost four times more likely to report a limited understanding of daily calorie needs but less likely to receive messages from clinicians about diet.21-22 The rapid dietary assessment tools discussed in this AHA Scientific Statement have the potential to build the capacity of and provide resources to clinicians to evaluate dietary behavior and tailor counseling approaches based on patient needs, reducing the overall burden of diet-related conditions, as well as targeting those who are most at risk.23
Given emerging evidence implicating nutritional status and underlying metabolic health in COVID-19 disease susceptibility and severity, central to the intersection between communicable and non-communicable diseases, diet undoubtedly will be a key component of interventions to reduce the immediate and long-term impacts of this global pandemic on population health.24, 25 Particularly relevant to this AHA position statement, poor dietary behaviors associated with COVID-19 and shelter in place orders will require a rapid response from health care professionals to meet the emerging need for dietary advice related to energy imbalance and excessive weight gain.26,27 Moreover, the current spotlight on racial/ethnic and socioeconomic inequities in food access, food insecurity, and diet-related conditions additionally amplified by COVID-19, further highlights the urgent need to identify solutions that not only target individual diets, but the policy, systems, and environments that shape them, including systems of care.28-30 Rooted in the socioecological perspective, extensive evidence indicates that food choice behaviors are not only driven by personal ideals, preferences, and motivations but also social networks, historical/community contexts, and policy.31,32 COVID-19, as well as recent events, such as the civil unrest; stress the importance of clinicians understanding patient’s broader contexts and conditions outside of the clinical encounter such as employment status, access to food retail opportunities, income and race-related stress, and racial segregation, which commonly impact dietary decision making.30,33 Consequently, when implementing recommended rapid dietary assessment tools, clinicians and other health professionals, as well as health care systems more broadly, should have guidelines, policies, processes, and resources/incentives in place to not only identify but also adequately address barriers to dietary change. Efforts to change structures and systems are critical for AHA to meet its mission to, “create a world of longer, healthier lives”
Lastly, the limited data on the efficacy of intense dietary counseling/medical nutrition therapy from a dietitian for cardiovascular disease risk reduction is concerning.14 This lack of evidence is likely driven by policies that restrict widespread access to reimbursable nutrition services. Given, the positive impact of nutrition counseling by dietitians and trained nutrition professionals on maternal and child health in the context of community nutrition programs such as the Supplemental Nutrition Program for Women, Infants (WIC), this area is critical for exploration.36-38 Although a rapid diet assessment tool will start the conversation, considering the high chronic disease burden in the US previously discussed, understanding the best conditions, models/approaches, and context in which brief vs. long-term/in-depth dietary treatment is needed is essential for guiding the allocation of resources and training.
Vadiveloo M, Lichtenstein AH, Anderson C, Aspry K, Foraker R, Griggs S, Hayman LL, Johnston E, Stone NJ, Thorndike AN; on behalf of the American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council. Rapid diet assessment screening tools for cardiovascular disease risk reduction across healthcare settings: a scientific statement from the American Heart Association [published online ahead of print August 7, 2020]. Circ Cardiovasc Qual Outcomes. doi: 10.1161/HCQ.0000000000000094.
- Mozaffarian D, Rosenberg I, Uauy R. History of modern nutrition science-implications for current research, dietary guidelines, and food policy. s. BMJ. 2018;361:k2392
- Buttorff, Christine, Teague Ruder, and Melissa Bauman, Multiple Chronic Conditions in the United States. Santa Monica, CA: RAND Corporation, 2017. Retrieved from https://www.rand.org/pubs/tools/TL221.html. July 30, 2020
- GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2019;393(10184):1958-1972.
- Finkelstein E.A., Trogden J.G., Cohen J.W., Dietz W. Annual medical spending attributable to obesity: Payer- and service specific estimates. Health Affairs. 2009; 28: w822-w831.
- Aleksandrowicz L, Green R, Joy EJ, Smith P, Haines A. The Impacts of Dietary Change on Greenhouse Gas Emissions, Land Use, Water Use, and Health: A Systematic Review. PLoS One. 2016;11(11):e0165797.
- Boehm R, Wilde PE, Ver Ploeg M, Costello C, Cash SB. A comprehensive life cycle assessment of greenhouse gas emissions from US household food choices. Food Policy. 2018 Aug 1;79:67-76.
- Vadiveloo M, Lichtenstein AH, Anderson C, Aspry K, Foraker R, Griggs S, Hayman LL, Johnston E, Stone NJ, Thorndike AN; on behalf of the American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council. Rapid diet assessment screening tools for cardiovascular disease risk reduction across healthcare settings: a scientific statement from the American Heart Association [published online ahead of print August 7, 2020]. Circ Cardiovasc Qual Outcomes. doi: 10.1161/HCQ.0000000000000094.
- Hills AP, Byrne NM, Lindstrom R, Hill JO. 'Small changes' to diet and physical activity behaviors for weight management. Obes Facts. 2013;6(3):228-238.
- Patnode CD, Evans CV, Senger CA, Redmond N and Lin JS. U.S. Preventive Services Task 529 Force Evidence Syntheses, formerly Systematic Evidence Reviews Behavioral Counseling to Promote a 530 Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Systematic Review for the US Preventive Services Task 532 Force Rockville (MD): Agency for Healthcare Research and Quality (US); 2017
- Ockene IS, Hebert JR, Ockene JK, Saperia GM, Stanek E, Nicolosi R, Merriam PA and Hurley 541 TG. Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Archives of Internal Medicine. 1999;159:725-544 31.
- U.S. Preventitive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale. American Journal of Preventive Medicine. 2003;24:93-100.
- Lin JS, O'Connor E, Evans CV, Senger CA, Rowland MG and Groom HC. Behavioral counseling to promote a healthy lifestyle in persons with cardiovascular risk factors: a systematic review for the U.S. 549 Preventive Services Task Force. Annals of Internal Medicine. 2014;161:568-78.
- Patnode CD, Evans CV, Senger CA, Redmond N and Lin JS. Behavioral Counseling to Promote 514 a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known 515 Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US 516 Preventive Services Task Force. JAMA 2017;318:175-193
- Brauer P, Royall D, Li A, et al. Nutrient Intake and Dietary Quality Changes within a Personalized Lifestyle Intervention Program for Metabolic Syndrome in Primary Care. Applied Physiology, Nutrition, and Metabolism. 2019;Apr 30:1-8.
- Aspry KE, Van Horn L, Carson JAS, et al. Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association. Circulation. 2018;137:e821-e841
- Kahan S, Manson JE. Nutrition Counseling in Clinical Practice: How Clinicians Can Do Better. JAMA. 2017;318(12):1101-1102.
- Pallazola VA, Davis DM, Whelton SP, et al. A Clinician's Guide to Healthy Eating for Cardiovascular Disease Prevention. Mayo Clin Proc Innov Qual Outcomes. 2019;3(3):251-267.
- Kris-Etherton PM, Akabas SR, Douglas P, et al. Nutrition competencies in health professionals' education and training: a new paradigm. Adv Nutr. 2015;6(1):83-87.
- DiMaria-Ghalili RA, Mirtallo JM, Tobin BW, Hark L, Van Horn L, Palmer CA. Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action. Am J Clin Nutr. 2014;99(5 Suppl):1184S-93S.
- Kolasa KM and Rickett K. Barriers to providing nutrition counseling cited by physicians: a survey of primary care practitioners. Nutrition in Clinical Practice. 2010;25:502-9.
- Ahmed NU, Delgado M and Saxena A. Trends and disparities in the prevalence of physicians' counseling on diet and nutrition among the U.S. adult population, 2000-2011. Preventive Medicine. 496 2016;89:70-75.
- McKinnon RA, Oladipo T, Ferguson MS, Jones OE, Maroto ME, Wolpert B. Reported Knowledge of Typical Daily Calorie Requirements: Relationship to Demographic Characteristics in US Adults. J Acad Nutr Diet. 2019;119(11):1831-1841
- Curtis SM, Willis MS. "Are you eating healthy?" Nutrition discourse in Midwestern clinics for the underserved. Patient Educ Couns. 2016;99(10):1641-1646.
- Butler MJ, Barrientos RM. The impact of nutrition on COVID-19 susceptibility and long-term consequences. Brain Behav Immun. 2020;87:53-54.
- Munshi R, Hussein MH, Toraih EA, et al. Vitamin D insufficiency as a potential culprit in critical COVID-19 patients [published online ahead of print, 2020 Jul 27]. J Med Virol. 2020;10.
- Parekh N, Deierlein A. Health Behaviors during the COVID-19 Pandemic: Implications for Obesity [published online ahead of print, 2020 Aug 4]. Public Health Nutr. 2020;1-14.
- Ashby NJS. The Impact of the COVID-19 Pandemic on Unhealthy Eating in Populations with Obesity [published online ahead of print, 2020 Jun 26]. Obesity (Silver Spring). 2020
- Shanks CB, Hingle MD, Parks CA, Yaroch AL. The COVID-19 Pandemic: A Watershed Moment to Strengthen Food Security Across the US Food System. Am J Public Health. 2020;110(8):1133-1134.
- Holmes L Jr, Enwere M, Williams J, et al. Black-White Risk Differentials in COVID-19 (SARS-COV2) Transmission, Mortality and Case Fatality in the United States: Translational Epidemiologic Perspective and Challenges. Int J Environ Res Public Health. 2020;17(12):4322. Published 2020 Jun 17. doi:10.3390/ijerph17124322
- Clark E, Fredricks K, Woc-Colburn L, Bottazzi ME, Weatherhead J. Disproportionate impact of the COVID-19 pandemic on immigrant communities in the United States. PLoS Negl Trop Dis. 2020;14(7).
- Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health. 2008;29:253-272.
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- Goodman M, Lyons S, Dean LT, Arroyo C, Hipp JA. How Segregation Makes Us Fat: Food Behaviors and Food Environment as Mediators of the Relationship Between Residential Segregation and Individual Body Mass Index. Front Public Health. 2018;6:92. Published 2018 Mar 29. doi:10.3389/fpubh.2018.00092
- Richardson AS, Arsenault JE, Cates SC, Muth MK. Perceived stress, unhealthy eating behaviors, and severe obesity in low-income women. Nutr J. 2015;14:122. Published 2015 Dec 3. doi:10.1186/s12937-015-0110-4
- Jackson, K. For Minnesotans of color, A New Food Desert Underscores Disparities. Twin Cities PBS. June 24, 2020. Retrieved from https://www.tptoriginals.org/for-minnesotans-of-color-a-new-food-desert-underscores-disparities/, July 25, 2020.
- Ritchie LD, Whaley SE, Spector P, Gomez J, Crawford PB. Favorable impact of nutrition education on California WIC families [published correction appears in J Nutr Educ Behav. 2011 Jan-Feb;43(1):72]. J Nutr Educ Behav. 2010;42(3 Suppl):S2-S10.
- Ikeda JP, Pham L, Nguyen KP, Mitchell RA. Culturally relevant nutrition education improves dietary quality among WIC-eligible Vietnamese immigrants. J Nutr Educ Behav. 2002;34(3):151-158.
- Gerstein DE, Martin AC, Crocker N, Reed H, Elfant M, Crawford P. Using learner-centered education to improve fruit and vegetable intake in California WIC participants. J Nutr Educ Behav. 2010;42(4):216-224
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