The 5 A’s Approach to Promoting Nutrition Counseling in Primary Care

Abstract

Poor dietary habits are a major contributor to chronic disease burden, yet nutrition counseling remains underutilized in primary care settings despite proven effectiveness. This article presents a novel adaptation of the 5 A’s framework (Assess, Advise, Agree, Assist, Arrange) titled ‘The 5 A’s Approach to Promoting Nutrition Counseling in Primary Care’, by incorporating validated assessment tools and evidence-based strategies to support implementation in clinical settings. To address practical challenges, implementation approaches are proposed including alternative delivery and payment models. The 5 A’s adaptation can be a tool used to address the critical need for standardized nutrition counseling in primary care.

Introduction

Poor dietary habits are the leading modifiable risk factor for cardiometabolic diseases.^1,2 In the U.S., poor diet contributes to almost half of all cardiometabolic deaths. ³ Nutrition counseling in primary care settings has been shown to effectively improve diet quality, diabetes management, weight loss, and limit gestational weight gain.^4,5 However, it occurs in only about one-third of all primary care office visits. ⁶ Physicians face barriers to nutrition counseling, including time constraints, financial disincentives, and uncertainty of effectiveness.^6,7

Patients also face challenges including limited accessibility to fresh foods, insufficient meal preparation time, financial constraints, and limited culinary and nutrition knowledge. ⁸ Patients do have an interest in nutrition resources such as discounts at grocery stores, sample meal plans, and better guides on healthy recipes. ⁸ These needs align with physician-reported barriers—in a survey of internal medicine interns, 92% agreed specific dietary advice could help patients improve eating habits, though 86% felt they had insufficient nutrition training. ⁹ To help address these challenges, promising strategies include targeted continuing education based on newly developed nutrition competencies in medical training, ¹⁰ collaboration with Registered Dietitians (RDs), and interventions such as 5 A’s.

The 5 A’s

The 5 A’s framework (Assess, Advise, Agree, Assist, Arrange) has the highest empirical support by the U.S. Preventive Services Task Force (USPSTF) recommended lifestyle prevention strategies and is the national-level model adopted by the Centers for Medicare and Medicaid Services (CMS) for behavioral counseling.^{11 -15} This structured approach guides clinicians through 5 steps: (1) Assess health risks and behaviors, (2) Advise on behavior changes needed, (3) Agree on specific goals through collaborative decision-making, (4) Assist with skills and resources to achieve goals, and (5) Arrange follow-up support and referrals. ¹¹ Evidence indicates that each component contributes uniquely to behavior change.

When physicians provide ‘Advice’ about weight loss, patients show increased motivation to improve their diet and lose weight. ¹⁶ ‘Assess’ improves patient confidence to lose weight when implemented. ¹⁶ ‘Assist’ leads to measurable improvements in dietary behaviors, while ‘Arrange’ is associated with both improved dietary fat intake and weight loss. ¹⁶ For every additional 5 A’s practice employed, patients express a higher motivation to lose weight and increased intention to improve dietary habits. ¹⁴ Notably, the greatest benefits occur when all 5 components are collectively implemented.^15,17

Studies support a team-based approach to the 5A’s, where components can be distributed among various healthcare providers such as nurses, RDs, health coaches, and more.^{12,18 -20} Behavioral counseling interventions with similar principles to the 5 A’s have established sustained benefits, with improvements in blood pressure (BP), lipid levels, and adiposity measures at 12 to 24 months, and reduced cardiovascular events over 1 to 16 years. ¹²

Assess

In ‘Assess’, a provider evaluates behavioral health risks related to nutrition (Figure 1).^{15 -17} To standardize this component, clinicians can use the Rapid Eating Assessment for Participants-shortened version, (REAP-S v.2), ²¹ an American Heart Association (AHA) recommended dietary screener. ²²

Figure 1.

The 5 A’s approach to promoting nutrition counseling in primary care (flowchart with all 5 components, actions, and scripts). ¹⁵

This 21-question tool is organized into 3 main dietary subscales to identify patients needing counseling, as detailed in Figure 2. REAP-S v.2 demonstrated acceptable reliability (Cronbach’s alpha = .71) and validity through factor analysis and food record comparisons. ²¹ Before administering REAP-S v.2, providers should screen for contraindications (eg, active eating disorders, pregnancy, or cancer) and make referrals to appropriate specialists. ²³

Figure 2.

REAP-S v.2 (rapid eating assessment for PARTICIPANTS, Shortened version, v.2). ²¹

For optimal clinical workflow, REAP-S v.2 can be integrated into Electronic Medical Record platforms like EPIC with automatic scoring functionality. ²¹ Ideally, patients would complete REAP-S electronically before visits, allowing providers to efficiently review in 1 to 2 min. ²¹ ‘Assess’, is supported by evidence that patients who are informed about their health status are 9 times more likely to perceive it as harmful to their health, ¹⁵ serving as a potential catalyst for behavior change.

Advise

In ‘Advise’, providers offer personalized dietary recommendations based on ‘Assess’ results (Figure 1).^{15 -17} Clinicians can utilize the ‘Reasonable Target Changes’ and ‘Realistic Small Substitutions’ (Figure 3) to guide patients toward dietary goals that align with REAP-S.^24,25 Figure 3 includes evidence-based guidelines from the 2025 Dietary Guidelines Advisory Committee (DGAC) Scientific report, AHA recommendations, and the American Institute for Cancer Research (AICR).^{26 -28} While ‘Advise’ typically takes 3 min, ¹⁴ the comprehensive nature of REAP-S may require 5 to 7 min.

Figure 3.

Reasonable target changes, small substitutions, and cultural adaptations for dietary counseling.^{24 -28,34}

Abbreviations: Increase (↑) Decrease (↓)

To address time constraints, physicians could focus on 1 to 2 priority dietary areas with substantial health impacts (eg, sugar-sweetened beverages) and: (1) delegate detailed dietary counseling to specialized team members including RDs, nurse practitioners, physician assistants, health educators, or trained medical assistants using standardized protocols, (2) refer to RDs for counseling, ²³ or (3) provide patients with take-home educational materials to review between visits.

Agree

In ‘Agree’, providers collaborate to select treatment goals based on the patient’s willingness to change (Figure 1).^{15 -17} After the ‘Advise’ stage, they ask if the suggested changes are realistic and achievable, then propose a specific goal based on the patient’s response.^{15 -17} Both ‘Agree’ and ‘Assist’ usually require 5 min to complete. ¹⁴

Assist

In ‘Assist’, patients receive self-help materials to support goals (Figure 1). This component is ideally implemented by team members such as medical assistants, nurses, health educators, or RDs.^16,19-20 While physicians typically excel at ‘Assess’ and ‘Advise’, ‘Assist’, which is associated with behavior change, is suitable for delegation to other healthcare team members.^{18 -20}

This team-based approach addresses a current implementation gap, as studies show that ‘Assist’ is provided in only 13% to 39% of encounters despite its importance for behavior change. ¹⁵ Practices can develop standardized workflows where support staff provide pre-selected evidence-based educational resources such as the We Can! Initiative, which includes nutrition guides, portion references, shopping and budgeting tips, and culturally-tailored recipes. ²⁹

Arrange

In ‘Arrange’, providers schedule follow-ups and make referrals to RDs for patients requiring more intensive nutritional support as needed (Figure 1).^{15 -17} This normally takes 2 min. ¹⁴ Currently, Medicare covers Medical Nutrition Therapy (MNT) for diabetes and kidney disease but not for dyslipidemia and other cardiometabolic risk factors. ³⁰

Major medical organizations, including the AHA and American Diabetes Association (ADA), do recommend referrals to RDs for treatment of dyslipidemia, hypertension, obesity, hyperglycemia, and type 2 diabetes. ³⁰ Research shows that ‘Arrange’ is rarely implemented (0%-10% of encounters) despite being 1 of the 2 most valued components by patients (along with ‘Assist’), ¹⁵ highlighting the importance of systematizing this component.

The 5 A’s as a Potential Solution

Our adaptation of the 5 A’s for nutrition counseling represents a novel application that addresses key barriers: (1) it standardizes ‘Assess’ via REAP-S v.2 that can be completed before visits and integrated into EMR; (2) it incorporates evidence-based dietary modification strategies with guidance; and (3) it integrates readily accessible educational resources addressing patient needs. Another strength of our approach is its flexibility in implementation.

Evidence supports implementation by non-physician team members and various delivery methods,^{12,18 -20} optimizing resource utilization while maintaining effectiveness. For example, the Goals for Eating and Moving (GEM) study leveraged physicians to endorse patient goals in <5 min (similar to our ‘Advise’), while health coaches handled the time-intensive ‘Agree’, ‘Assist’, and ‘Arrange’ components through counseling sessions and follow-up calls. ²⁰ GEM aligns with our proposed workflow where physicians focus on priority dietary areas while team members manage other components.

Similarly, the Peer-Assisted Lifestyle (PAL) intervention effectively used peer coaches with the 5 A’s framework to deliver weight management counseling through in-person visits plus 12 scheduled telephone calls. ¹⁹ The PAL remote delivery approach achieved clinically significant body mass loss by minimizing travel barriers and accommodating veterans with lower incomes or those living in rural areas. ¹⁹

Cultural Considerations

While our framework estimates 18 to 21 min total, implementation time may vary significantly based on cultural and linguistic needs. The Diabetes Prevention Program sessions ranged from 30 to 60 min with 15- to 45-min maintenance sessions, ³¹ suggesting time allocation should be flexible, especially when language assistance is needed. For ‘Assess’, clinicians may consider using alternative validated tools such as the Mediterranean Diet Adherence Screener (MEDAS), which has been translated and used in Brazil, Germany, Spain, Israel, and many more settings.^32,33

In ‘Advise’, dietary recommendations must be culturally tailored. The Puerto Rican Optimized Mediterranean-like Diet (PROMED) study showed successful cultural adaptation by replacing traditional Mediterranean foods with Puerto Rican alternatives. ³⁴ PROMED can be similarly adapted for populations with shared food traditions centered around rice, beans, root vegetables, and tropical fruits, especially across Afro-Caribbean and Latino communities (Figure 3). ³⁴

When implementing ‘Agree’ with Latino patients, emphasize family health to harness familismo—a cultural value prioritizing family-centered decisions that promotes well-being. ³⁵ For Black patients, trust-building must precede goal-setting, acknowledging historical medical injustices (eg the Tuskegee Syphilis Study), are imperative given that 51% of Black Americans believe healthcare systems are designed against them. ³⁶ When patients and clinicians form collaborative partnerships based on mutual respect and trust, patients become more engaged in their care, leading to better decision-making and adherence to their goals. ³⁷

‘Assist’ requires culturally appropriate resources. Beyond the We Can! Initiative’s Spanish materials, ²⁹ include resources reflecting specific food traditions. Apps like Lose It! (with customizable entries) and MyFitnessPal (with extensive international foods) can support diverse food tracking, ³⁸ while traditional handwritten dietary logs serve communities with technological barriers, ensuring equitable implementation.

In ‘’Arrange’, Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL) shows effective culturally responsive follow-up systems.^39,40 By embedding health coaches within clinics serving Black communities, this intervention ensured structured follow-up with high retention (83.4% completion rate), illustrating successful lifestyle interventions in real-world settings.^39,40

Thus, various follow-up modalities (in-person, telephone, digital) should be available to accommodate cultural preferences and technological access. While cultural adaptations improve our framework’s relevance, economic considerations remain crucial for adoption.

Discussion

Economic Impact and Coverage Barriers

Nutrition counseling plays a vital role in disease prevention, but reimbursement barriers continue to limit its implementation. Suboptimal diet leads to $50.4 billion in annual US healthcare expenditure for cardiometabolic diseases. ⁴¹ Despite the high costs of diet-related diseases, only 21% of obesity visits include nutrition counseling, far below the 32.6% Healthy People 2030 target. ⁴² Insurance coverage for nutrition services varies widely by state, with only 26 Medicaid fee-for-service programs and 28 Medicaid managed-care programs covering nutrition counseling. ⁴³

Evidence for Nutrition Interventions

An evidence report from USPSTF (113 RCTs, N = 129 993) found behavioral counseling improves BP (systolic: −0.80 mm Hg; diastolic: −0.42 mm Hg), LDL-C (−2.20 mg/dL), and BMI (−0.32). ⁴⁴ Food is Medicine programs project $13.6 billion annual savings, ⁴⁵ while MNT for dyslipidemia reduces total cholesterol (4.64-20.84 mg/dL), LDL-C (1.55-11.56 mg/dL), and triglycerides (15.9-32.55 mg/dL) with medication savings of $638 to 1450 per patient annually. ³⁰

These nutrition interventions remain relevant even in the emerging glucagon-like peptide-1 receptor agonists (GLP-1RAs) era. While GLP-1RAs produce significant weight loss, they are costly ($6500-$16 000 annually), have low long-term adherence (27% after 1 year), and are inaccessible. ⁴⁶ Innovative approaches combining GLP-1RA therapy with nutritional interventions like the 5 A’s framework may provide more sustainable outcomes as an adjunct, especially given common weight regain after medication discontinuation. ⁴⁶

Implementation Challenges

Implementation challenges include administrative buy-in, time constraints, workflow changes, and resource mobilization. ¹⁸ Attrition rates vary from 3.7% to 36.5%, highlighting the need for retention strategies. ¹⁸ Our framework requires approximately 18 to 21 min total, exceeding the average 18-min primary care visit. ⁴⁷

Approaches to address time constraints include (1) pre-visit electronic REAP-S completion; (2) capitated models (which reduce incentives to minimize visit time)^48,49; and (3) dividing the 5 A’s across multiple visits under CMS split-visit rules. ⁵⁰ Under the split-visit approach, the initial visit focuses on ‘Assess’ using REAP-S, with the physician reviewing results and offering either a dedicated follow-up appointment to complete the remaining components, or a referral to an RD. ⁵⁰ This approach complies with CMS regulations when the same practice completes all components, while RD referrals are processed as separate services. ⁵⁰

Future Directions

Compelling evidence supports implementing on our adapted 5 A’s framework with further evaluation. Future implementation should consider focusing on 4 key areas. First, expanding provider training through brief modules (shown to significantly improve use of underutilized components with just 15 min of education) ¹⁷ to promote wider adoption. Second, developing and testing specialized workflows that strategically distribute components based on team members’ strengths—physicians leading ‘Assess/Advise’ while team members manage ‘Assist/Arrange’.

Third, evaluating technology integration for remote delivery, building on evidence showing equal effectiveness between in-person and digital interventions.^{18 -20} Research priorities should include measuring REAP-S v.2 EMR integration outcomes, analyzing cost-effectiveness across different practice settings, and conducting longitudinal studies to establish sustained benefits. Fourth, expanding cultural adaptations for diverse populations, following approaches like PROPEL (83.4% retention and −4.99% weight loss)^39,40 by developing and validating population-specific implementation strategies.

Conclusion

‘The 5 A’s Approach to Promoting Nutrition Counseling in Primary Care’ provides a structured framework to standardize nutrition counseling with the potential to reduce diet-related chronic disease burden. This evidence-based approach could accelerate healthcare towards promoting preventive nutrition. While offering concrete tools, successful implementation requires broader systemic changes including dedicated funding, policy support, and alternative payment models. Such transformative initiatives may be necessary to address the significant burden of diet-related diseases and sustainably improve patient outcomes.