Could Diet Be Another Vital Sign in the Electronic Health Record?

Neha Pathak, MD

November 11, 2022

Dr Kristi Artz

For almost 20 years, Kristi Artz, MD, witnessed the staggering toll of diet-related disease on the patients in her emergency room (ER).

Every day, Artz's ER became ground zero for patients with the most severe chronic disease complications. Some presented with strokes, others required limb amputations from uncontrolled diabetes, all were people she hoped to save. Ultimately, Artz tells Medscape Medical News, she just "felt like I was putting a band-aid on the problem."

Artz decided to change course and pursue further training in therapeutic lifestyle interventions and culinary medicine to focus on health promotion and chronic disease reduction and remission.

When she had the opportunity to help start a lifestyle and culinary medicine program in Michigan, Artz jumped at it. She recognized the critical need to help patients assess and improve diet quality as a fundamental step to better health.

Artz is now medical director of such a program within a large integrated health system in Michigan. She and her team were early adopters of a digital platform, Diet ID, which enabled them to standardize and track diet like other vital signs, directly into the electronic health record (EHR).

The recent integration of the Diet ID platform within the Epic EHR system in the United States means that more than 300 million patients nationwide could be poised for information about diet quality collected and tracked just like blood pressure, heart rate, and other vital signs.

Now that Diet ID is available within Epic's App Market, individual health systems can choose to add Diet ID's dietary screening tool into their standard workflow.

Health system leader Dexter Shurney, MD, MBA, MPH, finds the integration of a digital tool such as Diet ID with Epic, an EHR with extensive reach, a promising advance.

Shurney — who has no affiliation with Diet ID — notes that the integration has the potential to make nutrition assessment a part of the regular clinic visit on a large scale. He also said that this is one of the first tools to be able to make diet a vital sign feasible.

"I think that the technology can actually help patients realize that, you know, this might be just as important to my health as my blood pressure. It starts to change the conversation for both the patient and the doctor," says Shurney, who is chief health equity, diversity, inclusion officer and Adventist Health president, Blue Zones Well-Being Institute.

What Constitutes a High-Quality Diet?

Poor quality diets, now the leading cause of premature death in the United States, take the lives of more than 500,000 Americans every year, usually through complications from chronic disease. Globally, around 11 million deaths can be attributed to bad food choices. In the US alone, six out of 10 adults live with one or more diet-related chronic diseases, and the costs to the US healthcare system continue to balloon, with $1.42 trillion/year attributed to obesity-related illnesses.

Among many patients, however, confusion still reigns when it comes to what constitutes a healthy diet. Artz suggests that overblown hype around the latest fad weight loss diets, or the perennial question of whether or not individual foods are healthy such as eggs, obscure the robust consensus around the basic scaffolding of a healthy diet.

Whether it's the Mediterranean diet, Dietary Approaches to Stop Hypertension (DASH), or other similar eating patterns, advisory committee recommendations in the Dietary Guidelines for Americans conclude that a healthy diet is made up of higher quantities of vegetables, fruits, whole grains, low-fat or nonfat dairy, seafood, legumes, and nuts.

On the flip side, a high-quality diet is lower in red and processed meat, sugar-sweetened foods and drinks, refined grains, and processed foods.

As it stands, Americans do a very poor job of eating high-quality diets. The federal government's Center for Nutrition Policy and Promotion uses the Healthy Eating Index (HEI) to see how well people adhere to the Dietary Guidelines for Americans. A score of 100 suggests ideal alignment, but the average American diet tallies to a score of just 58 out of 100.

This tracks with the 2022 annual report released by the American Heart Association (AHA), in conjunction with the National Institutes of Health, which found that less than 10% of American adults eat the recommended amount of fruits and vegetables and less than 10% of adults met guidelines of ≥ 3 servings per day of whole grains.

Health Professional Role in Nutrition Assessment and Counseling

Given the high cost to health and massive healthcare spending from poor nutrition, a growing chorus of experts is calling for routine diet-quality assessments during all patient encounters. In a 2020 scientific statement, the AHA endorsed the addition of diet-quality screening tools in patient EHRs.

Despite these calls to expand nutrition screening, many health professionals are often stymied by an array of barriers. From time constraints, concerns about lack of training in nutrition counseling, and difficulty administering dietary assessments, healthcare professionals may not have the bandwidth to add another task to busy clinic workflows.  

"I think we all recognize, and the evidence suggests, that there's a lot of recall bias with 24-hour dietary recall, and food logs are incredibly tedious and time-consuming, both for the patient as well as the clinician to interpret. So, there are clear time barriers to being able to evaluate diet quality with a patient in a short amount of time in clinical encounters," Artz told Medscape Medical News.

Physician, CEO, and Founder of Diet ID David Katz, MD, believes this is where Diet ID has the potential to create a revolution in medicine by incorporating nutrition in the EHR as a critical vital sign.

"Our goal is to make Diet ID's diet assessment and quality score available as key data points in the EHR," Katz said in a statement provided to Medscape Medical News. "The availability of Diet ID in Epic advances the mission to make diet quality the vital sign it clearly deserves to be."

Diet as a Vital Sign

Artz agrees that the Diet ID digital platform integrated in the EHR set her innovative clinic up for success.

"We began really from day one of seeing patients in our medical practice. Just like we would check their blood pressure and other vital signs. We would be checking their diet quality as a vital sign as well and using that to help inform their clinical care."

As she explains, the digital platform allows for an image-based visual diagnosis of diet quality. Patients — even those with low health literacy or English as a second language, for example — are sent a link prior to the appointment where visual images of a variety of foods are depicted so patients can click through and select the best approximation to their diet.

The collection generally takes patients less than a minute or so and provides a numeric score in the EHR, which can be tracked as the patient's dietary vital sign.

The tool is based on the validated HEI and scores patients from 1 to 100 on diet quality. This score is also converted to a decile score between 1 and 10, making it easier for patients to objectively see where they stand and how their diet quality might shift over time.

Artz was further impressed by the specificity of recommendations from the platform based on an individual patient's diet quality.

"It gives very actionable information that can be viewed in real-time with the patient and very food-focused recommendations," for example, "of how a patient might increase their fiber intake to better control their diabetes. Or how to decrease their saturated fat intake to better manage their hyperlipidemia or cardiovascular disease," says Artz.

She cautions that, like all tools, it is critical to think about how the dietary vital sign is incorporated into clinic flow.

"I think when clinicians are looking to implement a tool like Diet ID, it may sound great and solve potentially a lot of problems but if you don't know how to implement it within a clinical workflow it either becomes a tool that you don't use or it becomes a burden to the team," says Artz.

As an early adopter with several years of experience using the tool, Artz consults on best practices with other health systems that are interested in implementing the Diet ID platform into their workflow.

Game-Changing Conversations

Shurney points out that simply putting the diet "vital sign" on the same footing as other vital signs at every visit may change the conversation in the exam room between patients and health professionals.

"Because so much of what we do really hinges on how people eat, if you have a tool that within a couple of minutes, can do a dietary assessment that normally would take an hour perhaps, that's kind of a game-changer," he tells Medscape Medical News.

Artz is senior director, Health System Integrations at Diet ID, which is a contract position.  Shurney has reported no relevant financial relationships.  

Neha Pathak, MD, is Chief Physician Editor, WebMD. She reports on lifestyle medicine and the impact of the environment and climate change on health. You can follow her on Twitter: @NehapathakMD

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