*Corresponding Author:

Dr. Jerome Kotecki,

HSD and Professor of Health Science, Department of Nutrition and Health Science, College of Health, Ball State University, Muncie, IN 47306, USA; Email: jkotecki@bsu.edu

INTRODUCTION

Over two thousand years ago, the ancient Greek physician Hippocrates declared, “Let food be thy medicine and medicine be thy food” emphasizing the power of nutrition in healing and disease prevention [1]. This ancient insight is experiencing renewed emphasis in modern healthcare, as poor diet quality has become a leading global driver of preventable disease and mortality. Current research has elevated the importance of diet quality patterns in overall health to a new level. Notably, the landmark 2019 Global Disease Determinants Study, led by the Institute for Health Metrics and Evaluation, identified poor diet quality as the strongest correlate of global all-cause mortality and disease risk [2]. In response, healthcare organizations and public health initiatives – such as the Food is Medicine initiative – are calling for diet quality to be treated as a central, measurable component of routine clinical care [3, 4].

This growing body of evidence affirms that diet exerts a profound influence on overall health and well-being. Integrating food- and behavior-based interventions into clinical practice is increasingly recognized as essential for the prevention, management, and treatment of diet-related chronic conditions and for promoting health equity [4]. Routine assessment and counseling on diet quality in primary care settings would benefit most individuals, yet such practices remain infrequently implemented. Although clinicians are well positioned to facilitate behavior change, dietary assessment is seldom incorporated into standardized clinical workflows [5].  Most clinicians frequently encounter persistent barriers to the implementation of dietary counseling in routine care, including constrained time and workflow demands, insufficient training in nutrition counseling, ambiguity regarding which dietary behaviors to address, limited confidence, perceptions that nutrition counseling falls outside their professional scope, and the absence of brief, validated, and pragmatic screening tools to facilitate structured clinical dialogue [4, 5].

Diet quality screening assessment tools are a core mechanism to bridge the gap between nutrition science and clinical practice. These tools are designed to help clinicians—especially non-Registered Dietitian Nutritionists (non-RDNs)—efficiently evaluate dietary patterns, initiate patient-centered conversations about behavior change, and tailor brief interventions or referrals to registered dietitian nutritionists (RDNs) when appropriate. Clinical discussion tools like these can provide actionable insights in real-time, support motivational interviewing strategies, and promote continuity of care by documenting and tracking dietary progress across visits. However, despite growing evidence and enthusiasm, diet quality assessment tools that are practical to implement in a clinical setting are lacking [4, 5, 6]. This limits clinicians’ ability to offer meaningful dietary guidance, particularly in high-volume primary care and preventive medicine environments.

To address this gap, our commentary highlights the development and application of the Food Quality Screener (FQS)—a practical, evidence-informed clinical discussion tool that is both understandable and actionable. The FQS has been successfully pilot-tested and integrated into clinical settings with non-RDN clinicians to rapidly screen for diet quality in patients without substantially requiring more time, and advanced education for clinicians [7, 8].  The FQS enables non-RDN clinicians to quickly assess diet quality using a user-friendly, behaviorally grounded format, and serves as a gateway for productive, personalized counseling with their patients that align with preventive care goals.

The Case for the Food Quality Screener

A recent American Heart Association (AHA) study reviewed 15 brief screening assessment tools in terms of their validity, reliability, and usability in clinical settings [6]. While three of the tools, including the Mediterranean Diet Adherence Screener (MEDAS), Starting the Conversation, (STC), and the Rapid Eating Assessment for Participants-Shortened version (REAP-S) reviewed received positive ratings based on their 10 theoretical and practice-based criteria and benchmarks, the authors concluded that there were several limitations for using these tools to assess diet quality among diverse populations. The five theoretical factors included (1) evaluation of total diet quality, (2) test-retest reliability, (3) validity appraised against another dietary assessment method, (4) validity assessed within multiple U.S. adult populations aged 20-75 years, across diverse racial and socioeconomic, and clinical/nonclinical populations, and (5) validity evaluated on the relationship between the diet screener tool score and health biomarkers. The five practice-based factors included (1) a brief tool (takes < 10 min to complete), (2) clinical decision support for immediate guidance or more intensive nutrition or behavioral therapies, (3) sensitive to dietary, behavioral changes over time, (4) an easily completed and administered tool without special knowledge or software, and (5) useful information for chronic disease management (i.e., patients/clients interpretation and understanding of the score and ways to improve their score). Additionally, none of the tools reviewed were informed by behavioral theory or models. Clinicians know it is critical to explain why and how behavioral changes need to be made to their patients. The AHA statement emphasized the urgent need for the development of a rapid dietary assessment screening tool focusing on clinically relevant food groups that meets their theoretical and practice-based criteria along with be grounded in behavioral theory.

Guided by these benchmarks, we developed the Food Quality Screener (FQS)—a brief, aesthetically pleasing, score-based, easy-to-interpret tool that guides assessment and counseling, that has been successfully pilot tested with clinicians in a university-based Healthy Lifestyle Center that serves both clinical and community populations (Figure 1). Designed for self-administration, the FQS consists of 11 items on a single double-sided page. The first six items measure food groups with protective health associations (vegetables, fruits, whole grains, nuts and seeds, beans, fish) and the next five items measure (using reverse scoring) adverse health associations (sugary drinks and snacks, processed meats, high sodium foods, and alcohol). The food groups were adapted from the widely used Alternative Healthy Eating Index, a validated metric for predicting chronic disease risk [9]. Responses to these 11 items make up a food quality score. This score is simple to calculate and understand, making it useful for both self-assessment and clinician counseling. One’s food quality score is readily interpretable for patients and clinicians as it is quickly converted “at-a-glance” using a five-level numerical and color-coded classification system (excellent-to-poor) table on the backside. This visual representation and system were designed to allow for dietary habit counseling on any of the specific food groups.

Recognizing time and workflow as major clinical barriers, we prioritized minimal provider and patient burden in the tool’s design. The FQS is quick and easy to administer, taking three minutes or less to complete. Since the FQS can be self-administered, the patient could complete it at home or in the waiting room before seeing the clinician. Our suggested frequency of food group consumption scoring option of “never/rarely”, “sometimes”, and “often/always” provides targeted dietary counseling on specific food groups where the patient can improve, and dietary changes are easily scored allowing the results to be followed over time. Each dietary behavior assessed based on a specific food group consumption has the potential to positively impact health outcomes. As care discussions shift from baseline assessment to long-term goals, the FQS supports an individualized and achievable path to dietary improvement based on six food groups to encourage and five food groups to limit. The tool fosters an ongoing dialogue between clinicians and patients about nutrition using behavioral theory, guiding personalized recommendations and empowering patients to make sustainable dietary changes. For instance, providers may use the FQS to structure goals like healthier grocery shopping or improved meal planning.

An important phase in creating and designing the FQS was to base it on behavioral theory to improve discussions between clinicians and patients. Lifestyle counseling designed for adult learners is most effective when it has a foundation based on a behavior change, as models best explain health-related behaviors [10]. The transtheoretical model (TTM) was selected based on its ‘stages of change’ core construct that classifies based on individuals' readiness to change [11]. The preaction stages of readiness (precontemplation, contemplation, and preparation based on the information provided on the reverse side of the FQS. First, diet quality awareness is gained from a food quality score and the importance of food quality in promoting health and preventing chronic disease may prompt a transition from precontemplation (a healthier behavior is not yet considered) to contemplation (thinking about behavior change) that is introspective in terms of what one eats and drinks and the impact on one’s health. Second, to assess if individuals are in the preparation stage (intending to change behavior) a section on “One change at a time” includes two yes-or-no questions. These questions assess the patient’s readiness to make a small dietary change to their diet in the next month and/or seek professional counseling. Responses to these two questions responses guide the clinician on how best to counsel the patient based on their readiness to welcome counseling and advice. This section awakens the patients’ consciousness and willingness to start a discussion about dietary quality behaviors as a key aspect of preventive medicine, encouraging meaningful behavior change. This provides an opportunity for discussion on small and actionable eating habit changes between patients and providers.  

CLINICAL IMPLICATIONS AND CONCLUSION

This brief commentary was meant to affirm the need to bridge the gap between nutrition science and practice by providing a clinical tool for diet quality screening. We shared a promising example of a clinical tool that would support fruitful patient-provider dialogue about dietary behaviors and behavioral goals. Clinical discussion tools have the potential to enhance the promotion of healthy dietary behaviors between providers and adults who access care. Based on our experience, the FQS is a simple, practical tool that could be integrated into clinical practice by patient providers to rapidly screen diet quality, without markedly demanding more time, or the need for advanced nutrition education and resources. The FQS provides an opportunity for providers in meetings with their patients to easily and accurately assess current dietary behaviors that are clinically relevant, briefly counsel on behavior change strategies for specific food groups, prescribe targets for behavioral change, and refer to other professionals (e.g., RDNs) or programs if needed. The FQS results could be integrated into an electronic health record and followed over time and would be easily available to other clinicians caring for the patient. 

Table 1 outlines six practical and actionable strategies that clinical settings and clinicians can adopt to enhance patient care through the implementation of the FQS. These recommendations are organized to support both implementation and improved patient outcomes. Each proposal supports integration into clinical workflow, promotes personalized nutrition counseling, and advances chronic disease management.

Although further research is warranted to evaluate the implementation of the Food Quality Screener (FQS) across diverse clinical settings, our experience indicates that it is both feasible and practical for use in high-demand healthcare environments. The FQS enables non-RDNs clinicians to quickly identify dietary patterns—specifically food groups that support health or contribute to disease risk—and offers both patients and providers with clear, actionable feedback. This supports informed clinical decision-making and facilitates personalized nutritional counseling within the constraints of routine care. 

We conclude this commentary by returning to its conceptual foundation and offering a reframed interpretation of Hippocrates' timeless statement with a modern refinement. By adding a single word—“quality”—to the phrase “Let food be thy medicine and medicine be thy food,” we underscore a vital distinction: not all food possesses equal therapeutic potential. The revised quote, “Let quality food be thy medicine and medicine be thy quality food,” reinforces the idea that it is the quality of food—nutrient-dense, minimally processed, whole foods—that holds the greatest promise for promoting well-being and preventing disease.

REFERENCES

1. Witkamp, R. F., (2018). Let food be thy medicine . . . when possible, European Journal of Pharmacology, 836, 102-14.

2. GBD 2017 Diet Collaborators, Afshin, A., Sur, P. J., Fay, K. A., Cornaby, L., Ferrara, G., Salama, J. S.,… Murray, C. J. L. (2019). Health effects of dietary risks in 195 countries, 1990-2017: A systematic analysis for the global burden of disease study 2017. Lancet, 393(10184), 1958-1972.

3. Reddy, K. R., Aggarwai, M., Freeman, A. M. (2024). Food is medicine: The time is now. The American Journal of Medicine. 137:1180-1183.

4. Vadiveloo, M. K., Throndike, A. N., Lichtenstein, A. H., (2023). Integrating diet quality into routine clinical care: The time is now, Journal of the American Heart Association, 12:e028583.

5. Kahan, S., & Manson, J. (2017). Nutrition counseling in clinical practice: How clinicians can do better, Journal of the American Medical Association, 318(12), 1101-1102.

6. Vadiveloo, M., Lichtenstein, A., Anderson, C., Aspry, K., Foraker, R., Griggs, S., … Thorndike, A. (2020). Rapid diet assessment screening tools for cardiovascular disease risk reduction across healthcare settings: A scientific statement from the American Heart Association. Circulation: Cardiovascular Quality and Outcomes, 13(9).

7. Kotecki, J., Greene, M., Khubchandani, J., Kandiah, J. (2021). A brief dietary screening and counseling tool for health educators, American Journal of Health Education, 52(3):111-116.

8. Kotecki, J., Greene, M., Jones, M. (2021). Utilizing health literacy measures to assess a food quality screener for understandability and actionability. American Journal of Health Education, 52(6):392-401.

9. Chiuve, S. E., Fung, T. T., Rimm, E. B., Hu, F. B., McCullough, M. L., Wang, M. J., Stampler, M.J., & Willett, W. C. (2012). Alternative dietary indices both strongly predict risk of chronic disease, The Journal of Nutrition, 142(6), 1009-1018.

10. Davis, R., Campbell, R., Hildon, Z, Hobbs, L., Michie, S. (2014). Theories of behaviour and behaviour change across the social and behavioural sciences: A scoping review. Health Psychology Review, 9(3):323-344.

11. Prochaska, J. O., Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1):38-48.

PEER REVIEW

Not commissioned. Externally peer reviewed.

1. Witkamp, R. F., (2018). Let food be thy medicine . . . when possible, European Journal of Pharmacology, 836, 102-14.

2. GBD 2017 Diet Collaborators, Afshin, A., Sur, P. J., Fay, K. A., Cornaby, L., Ferrara, G., Salama, J. S.,… Murray, C. J. L. (2019). Health effects of dietary risks in 195 countries, 1990-2017: A systematic analysis for the global burden of disease study 2017. Lancet, 393(10184), 1958-1972.

3. Reddy, K. R., Aggarwai, M., Freeman, A. M. (2024). Food is medicine: The time is now. The American Journal of Medicine. 137:1180-1183.

4. Vadiveloo, M. K., Throndike, A. N., Lichtenstein, A. H., (2023). Integrating diet quality into routine clinical care: The time is now, Journal of the American Heart Association, 12:e028583.

5. Kahan, S., & Manson, J. (2017). Nutrition counseling in clinical practice: How clinicians can do better, Journal of the American Medical Association, 318(12), 1101-1102.

6. Vadiveloo, M., Lichtenstein, A., Anderson, C., Aspry, K., Foraker, R., Griggs, S., … Thorndike, A. (2020). Rapid diet assessment screening tools for cardiovascular disease risk reduction across healthcare settings: A scientific statement from the American Heart Association. Circulation: Cardiovascular Quality and Outcomes, 13(9).

7. Kotecki, J., Greene, M., Khubchandani, J., Kandiah, J. (2021). A brief dietary screening and counseling tool for health educators, American Journal of Health Education, 52(3):111-116.

8. Kotecki, J., Greene, M., Jones, M. (2021). Utilizing health literacy measures to assess a food quality screener for understandability and actionability. American Journal of Health Education, 52(6):392-401.

9. Chiuve, S. E., Fung, T. T., Rimm, E. B., Hu, F. B., McCullough, M. L., Wang, M. J., Stampler, M.J., & Willett, W. C. (2012). Alternative dietary indices both strongly predict risk of chronic disease, The Journal of Nutrition, 142(6), 1009-1018.

10. Davis, R., Campbell, R., Hildon, Z, Hobbs, L., Michie, S. (2014). Theories of behaviour and behaviour change across the social and behavioural sciences: A scoping review. Health Psychology Review, 9(3):323-344.

11. Prochaska, J. O., Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1):38-48.