A new scientific statement from the American Heart Association (AHA) recommends incorporating a rapid diet-screening tool into routine primary care visits to inform dietary counseling and integrating the tool into patients’ electronic health record (EHR) platforms across all healthcare settings.
The statement authors evaluated 15 existing screening tools and, although they did not recommend a specific tool, they did present advantages and disadvantages of some of the tools and encouraged “critical conversations” among clinicians and other specialists to arrive at a tool that would be most appropriate for use in a particular healthcare setting.
“The key takeaway is for clinicians to incorporate discussion of dietary patterns into routine preventive care appointments because a suboptimal diet is the number 1 risk factor for cardiovascular disease,” Maya Vadiveloo, PhD, RD, chair of the statement group, told theheart.org | Medscape Cardiology.
“We also wanted to touch on the fact the screening tool could be incorporated into the EHR and then used for clinical support and for tracking and monitoring the patient’s dietary patterns over time,” said Vadiveloo, who is an assistant professor of nutrition and food sciences in the College of Health Science, University of Rhode Island, Kingston.
The statement was published online August 7 in Circulation: Cardiovascular Quality and Outcomes.
Poor dietary quality has “surpassed all other mortality risk factors, accounting for 11 million deaths and ~50% of cardiovascular disease (CVD) deaths globally,” the authors write.
Diets deficient in fruits, vegetables, and whole grains and high in red and processed meat, added sugars, sodium, and total energy are the “leading determinants” of the risks for CVD and other conditions, so “strategies that promote holistically healthier dietary patterns to reduce chronic disease risk are of contemporary importance.”
Most clinicians and other members of healthcare teams “do not currently assess or counsel patients about their food and beverage intake during routine clinical care,” the authors observe.
Reasons for this may include lack of training and knowledge, insufficient time, insufficient integration of nutrition services into healthcare settings, insufficient reimbursement, and “competing demands during the visit,” they note.
Vadiveloo said that an evidence-based rapid screening tool can go a long way toward helping to overcome these barriers.
“Research shows that when primary care practitioners discuss diet with patients, the patients are receptive, but we also know that clinical workloads are already very compressed, and adding another thing to a routine preventive care appointment is challenging,” she said. “So we wanted to look and see if there were already screening tools that showed promise as valid, reliable, reflective of the best science, and easy to incorporate into various types of practice settings.”
The authors established “theoretical and practice-based criteria” for an optimal diet screening tool for use in the adult population (aged 20 to 75 years). The tool had to:
Be developed or used within clinical practice in the past 10 years;
Be evidence-based, reliable, and valid;
Assess total dietary pattern rather than focusing on a single food or nutrient;
Be able to be completed and scored at administration without special knowledge or software;
Give actionable next steps and support to patients;
Be able track and monitor dietary change over time;
Be brief; and
Be useful for chronic disease management.
Of the 15 tools reviewed, the three that met the most theoretical and practice-based validity criteria were the Mediterranean Diet Adherence Screener (MEDAS) and its variations; the modified, shortened Rapid Eating Assessment for Participants (REAP), and the modified version of the Starting the Conversation Tool. However, the authors noted that the Powell and Greenberg Screening Tool was the “least time-intensive.”
One Size Does Not Fit All
No single tool will be appropriate for all practice settings, so “we would like clinicians to discuss what will work in their particular setting,” Vadiveloo emphasized.
For example, should the screening tool be completed by the clinician, a member of the healthcare team, or the patient? Advantages of a tool completed by clinicians or team members include collection of the information in real time, where it can be used in shared decision-making during the encounter and increased reliability because the screen has been completed by a clinician. On the other hand, the clinician might not be able to prioritize administering the screening tool during a short clinical encounter.
Advantages of a tool completed by the patient via an EHR portal is that the patient may feel less risk of judgment by the clinician or healthcare professional and patients can complete the screen at their convenience. Disadvantages are limited reach into underserved populations and, potentially, less reliability than clinician-administered tools.
“It is advantageous to have tools that can be administered by multiple members of healthcare teams to ease the demand on clinicians, if such staff is available, but in other settings, self-administration might be better, so we tried to leave it open-ended,” Vadiveloo explained.
“The EHR is the ideal platform to prompt clinicians and other members of the healthcare team to capture dietary data and deliver dietary advice to patients,” the authors observe.
EHRs allow secure storage of data and also enable access to these data when needed at the point of care. They are also important for documentation purposes.
The authors note that the use of “myriad EHR platforms and versions of platforms” have created “technical challenges.” They recommend “standardized approaches” for transmitting health data that will “more seamlessly allow rapid diet screeners to be implemented in the EHR.”
They also recommend that the prototypes of rapid diet screeners be tested by end users prior to implementation within particular clinics. “Gathering these data ahead of time can improve the uptake of the application in the real world,” they state.
Vadiveloo added that dietary counseling can be conducted by several members of a healthcare team, such as a dietitian, not just by the physician. Or the patient may need to be referred to a dietician for counseling and follow-up.
The authors conclude by characterizing the AHA statement as “a call to action…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.”
Vadiveloo has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper.
Circ Cardiovasc Qual Outcomes. Published online August 7, 2020. Abstract