Promoting Rapid Diet Assessment Screening and Counseling in Health Care Settings: A Pathway for Creating a “World of Longer, Healthier lives”

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.