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Am Fam Physician. 2022;106(4):427-438

Patient information: See related handout on making healthier nutritional food choices, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

About 60% of adults in the United States have one or more diet-related chronic diagnoses, including cancer, cardiovascular and cerebrovascular diseases, diabetes mellitus, and obesity. It is imperative to address nutrition health in the clinical setting to decrease diet-related morbidity and mortality. Family physicians can use validated nutrition questionnaires, nutrition-tracking tools, and smartphone applications to obtain a nutrition history, implement brief intervention plans, and identify patients who warrant referral for interdisciplinary nutrition care. The validated Rapid Eating Assessment for Participants–Shortened Version, v.2 (REAP-S v.2) can be quickly used to initiate nutrition history taking. Patient responses to the REAP-S v.2 can guide physicians to an individualized nutrition history focused in the four areas of nutrition: insight and motivation, dietary intake pattern, metabolic demands and comorbid conditions, and consideration of other supplement or substance use. Family physicians should refer to the U.S. Department of Agriculture 2020-2025 Dietary Guidelines for Americans when assessing patient nutrient intake quality and pattern; however, it is also essential to assess nutrition health within the context of an individual patient. It is important to maintain a basic understanding of popular diet patterns, although diet pattern adherence is a better predictor of successful weight loss than diet type. Using various counseling and goal-setting techniques, physicians can partner with patients to identify and develop a realistic goal for nutrition intervention.

Nutrition is a well-recognized and vital component of medical treatment, health promotion, and disease prevention.1 After tobacco use, poor nutrition and inadequate physical activity are the most significant modifiable risk factors impacting mortality in the United States.2 About 60% of U.S. adults have one or more diet-related chronic diagnoses, including breast cancer, colorectal cancer, cardiovascular and cerebrovascular disease, diabetes mellitus, and obesity.3 Because patients with normal weight can still be at risk of diet-related chronic diagnoses, family physicians should obtain nutrition history for all patients, regardless of body mass index.4 Nutrition history taking allows family physicians to understand a patient's personal nutrition knowledge, choices, habits, goals, barriers, and motivations. Together, the patient and physician can use the information to implement specific and realistic nutrition health goals that align with the U.S. Department of Agriculture (USDA) 2020–2025 Dietary Guidelines for Americans.3

Clinical recommendation Evidence rating Comments
The Rapid Eating Assessment for Participants–Shortened Version, v.2 (REAP-S v.2) can be used to assess nutrient intake in ambulatory patients with omnivorous, vegetarian, and vegan diet patterns.5 C Cross-sectional study of disease-oriented evidence
Physicians should ask about a patient's adherence to diet patterns because adherence is more closely associated with weight loss than the diet pattern itself.16,18,20,23 B Clinical review and meta-analyses of randomized controlled trials looking at weight loss and disease-oriented outcomes
Patients with cardiovascular disease risk factors should be offered or referred to behavioral counseling, including nutrition counseling.30 B Consensus guideline from U.S. Preventive Services Task Force
Physicians should routinely screen athletes for eating disorders.39 C Expert opinion; American Medical Society for Sports Medicine Position Statement–Executive Summary

Among the available brief nutrition and diet screening tools, the Rapid Eating Assessment for Participants–Shortened Version, v.2 (REAP-S v.2) is validated for brief dietary assessment in ambulatory patients compared with three-day dietary recall (Figure 1; printable PDF of Figure 1).5 The original REAP-S (2004) was designed to be completed by a patient before their ambulatory visit, and is validated in patients with omnivorous, vegetarian, and vegan diet patterns compared with dietary recall and measured serum nutrition biomarkers.68 The 21-question REAP-S v.2 was updated for improved administration, scoring assessment, and alignment with the USDA 2020–2025 Dietary Guidelines for Americans.5 Responses to the REAP-S v.2 can be scored quickly within the areas of dietary adequacy, diet pattern, intake of discretionary calories, exercise habits, and motivation for nutrition change.5 The patient's responses to the REAP-S v.2 should provide an immediate assessment of general nutrition health—lower scores suggest poorer nutrition practices, and higher scores suggest healthier nutrition practices—and create context for family physicians as they further elicit a complete nutrition history using the framework proposed in this article.5 To build a shared understanding of the patient's nutrition health, physicians should gather an individualized nutrition history by focusing on four key components: nutrition insight and motivation, dietary intake pattern, metabolic demands and comorbid conditions, and consideration of other supplement or substance use.

Framework for Nutrition History Taking

1. Nutrition insight and motivation: how would you rate your current nutrition health, and what motivations or barriers to nutrition change do you anticipate?

Regardless of whether a patient reports low or high motivation for nutrition change on the REAP-S v.2, a greater understanding of their mental model regarding nutrition and the importance of improving their nutrition health can shape the remainder of the nutrition history taking, as well as any future intervention. Physicians should ask about social and economic barriers to healthy nutrition, including lack of access to fresh foods based on availability or price, limited time to plan or prepare meals cooked at home, family members with varying dietary requirements, food insecurity, minimal cooking and shopping skills, and lack of transportation. When social determinants of health are identified as barriers, physicians should refer patients to available community resources (Table 1).9,10 Physicians can access screening tools and a database of local area supportive services to connect patients with available community nutrition resources through The EveryONE Project ( Physicians can also ask patients about common self-identified barriers to successful long-term nutrition change, including personal motivation, self-efficacy, and self-regulation skills.11

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