Integrating Diet Screening Into Routine Clinical Care: The Time Is Now

Although lifestyle modification, particularly diet, is considered the cornerstone of cardiovascular disease prevention and treatment, ¹ it is not routinely integrated into standard clinical care. One mechanism to address this deficit is to implement a validated diet screening tool that could enable clinicians to assess patients' dietary patterns, develop actionable short‐term goals for improvement, and review progress longitudinally. This approach would facilitate the incorporation of evidence‐based dietary counseling from non–registered dietitian clinicians and other members of the health care team into routine clinical care. ²

Although some individuals require gold standard intensive registered dietitian–led counseling, or “medical nutrition therapy,” from a prevention perspective, most individuals would benefit from routine healthy dietary advice integrated into primary care setting. Although many non–registered dietitian clinicians agree that discussing diet‐related issues with their patients is important, barriers to implementing diet assessment into routine clinical care include insufficient time, knowledge, and training. ³

In 2020, the American Heart Association issued a Scientific Statement that emphasized a critical need to develop and validate a rapid diet screening tool that would be practical to implement in a clinical setting. ² Underscored was the need to have a tool that was: (1) valid relative to a reference dietary assessment measure, (2) brief, (3) feasible to be administered by non–registered dietitian clinicians, (4) able to evaluate total diet quality, ⁴ (5) embedded into the electronic medical record and combined with clinical decision support (ie, actionable, evidence‐based dietary advice based on patient responses), and (6) associated with improvements in diet quality correlated risk factor measures.

In the current issue of the Journal of the American Heart Association (JAHA), Lara‐Breitinger et al ⁵ reported on a validation study of the mini Eating Assessment Tool (EAT), a brief dietary questionnaire for use in clinical practice settings. ² Assessed was both the original 19‐item EAT and a condensed 9‐item mini‐EAT. Validation against a 156‐item dietary assessment reference measure indicated good test‐retest reliability. Scores were significantly associated with total diet quality, as measured by the Healthy Eating Index 2015. The EAT and mini‐EAT tools have not yet been assessed to evaluate longitudinal changes in diet quality and diet‐associated risk factors or integrate with clinical decision support. Because the mini‐EAT was validated in a relatively homogeneous cohort of mostly college‐educated women from one region of the United States, additional validation in diverse populations is needed.

In general, there are some important next steps before the mini‐EAT and other diet screener tools can be incorporated into routine clinical care. The clinical utility and patient understanding among historically underrepresented populations cannot be afterthoughts in the development and refinement of diet screening tools. Diet screeners must be developed and validated among adults across a spectrum of socioeconomic and cultural differences to determine whether culturally specific versions of diet screeners are necessary. Best practice alerts and inclusion of new screening questions into the electronic health record can be burdensome for clinicians. ⁶ When evaluating which factors to emphasize in a clinical encounter, the US Preventive Services Task Force recommends ⁷ using clinical judgment on the effectiveness of behavioral counseling. ⁸ The “C” evidence rating for counseling people without cardiovascular disease risk factors may unintentionally condone prioritizing other interventions outside of diet counseling. ⁹ , ¹⁰ For example, although diet counseling is associated with small, but significant, benefits in improving dietary intake and intermediate cardiovascular disease risk factors, ⁸ among individuals at low risk, such counseling is likely to be underprioritized relative to other clinical interventions.

Given the myriad of levers it takes to modify clinical practice, the burden a rapid diet screener tool may place on clinicians must be at the forefront of the design and implementation. Optimizing when clinicians receive diet quality information during their clinical encounter and ensuring clinically actionable diet modification information is available are integral to successful implementation. Lessons learned from adopting routine depression screening and, more recently, the American Heart Association Scientific Statement on a learning health care system should be applied to integration of a rapid diet screener tool. ¹¹ , ¹²

A distinct but related issue for overcoming barriers to diet quality screening is that both clinicians and patients must recognize its value for long‐term chronic disease risk reduction, including both primary and secondary prevention. For example, in a study evaluating oncologists' perceptions of a digital tool to improve cancer survivors' cardiovascular health, clinicians deemed the tool important for their patients, but experienced workflow integration as a barrier for use. ¹³ Low satisfaction or self‐efficacy can reduce adoption of a validated diet screener tool in clinical care. ¹⁴ , ¹⁵ , ¹⁶

It is encouraging to see progress in the development and validation of rapid diet screener tools. However, with the emergence of this tool and others, ¹⁷ further research is needed to assess implementation, including possible unintended consequences. For example, a diet screener tool may have research validity but not be adequately evaluated for the practical aspects of inclusion in the clinical setting. Testing clinical decision support strategies will be important for developing tools that can help clinicians provide actionable dietary information and counter ubiquitous nutrition misinformation. If a clinical decision support strategy is time‐consuming or complicated, it could reduce universal adoption and bias clinicians to counsel only highly motivated patients rather than consistently counseling all patients equitably. Integrating a diet screener with clinical decision support is a system‐level change that requires tremendous time and financial resources and, once adopted, can be challenging to modify. ¹⁸

Moving forward, development and universal adoption of a rapid diet screener tool in clinical care can help reinforce the importance of dietary modification intended to decrease cardiovascular risk and ultimately improve patient health outcomes. ¹⁹ Addressing both the theoretical and practice‐based criteria will facilitate successful integration into the electronic health record, and support clinical workflows and patient care. The link between diet and cardiovascular risk was recognized by the American Heart Association in the early 1960s. ²⁰ The time has now come when routine assessment and modification of diet quality become a standard part of preventive health care.

Disclosures

None.