Cascade of Nutrition Outcomes - One Thing Leads To Another!!

The critical thinking involved in Monitoring and Evaluation, the last step in the Nutrition Care
Process, is the identification of indicators and criteria that will provide evidence that the nutrition intervention of the dietitian is effective.

Outcomes can be thought of as occurring in a cascade, each level of outcome leading to outcomes in the next layer, until you reach the ultimate outcome desired.  This may be visualized as shown using the domains of terminology.

For example, let's take a case of a person with Diabetes Mellitus who received both nutrition education related to how to choose foods according to plan and counselling to ensure readiness to change.
Then one short term  indicator of success for this nutrition intervention may be a change in knowledge about optimal food choices and change in readiness to change that could be measured at the end of the nutrition consultation and again at the beginning of the next appointment.  This change in knowledge and beliefs and attitudes would be expected to lead to a change in behavior around food choices, perhaps in adherence with meal planning/food choice guidance and types of food/meals consumed.  That change would then lead to a change in food or nutrient intake, perhaps change in total carbohydrate intake or total energy intake.  This change over time would likely lead to changes in self monitored blood glucose levels and eventually to change in HBA1C.  These changes could then lead to changes in quality of life measures, perhaps health related quality of life scores or disease specific quality of life scores.

Dietitians often look at the biochemical measures or anthropometric measures and overlook the more immediate short term measures that are related to their intervention  or overlook the more global quality of life measures.

If we miss the opportunity to document  immediate short term measures that are specific to our intervention (changes in knowledge, behavior, and dietary intake), we don't really know if the changes in laboratory values are related to our intervention or whether they are coming from other interventions such as medication changes.

While dietitians do not claim full responsibility for changes in biochemical or anthropometric measures, without the immediate short term measures we lack any evidence that we even contributed to the outcomes!!

Bottom line:  Using the cascade of outcomes diagram helps dietitian think of a range of outcomes that demonstrate effectiveness of nutrition interventions and create a logical argument that nutrition interventions are related to positive health outcomes.