The whole development process is summarized in Figure 1. As only engaged experts were involved in this multistage consensus process on an entirely voluntary basis, ethical approval was deemed unnecessary.
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The levels illustrate different modes of action: Level 1 dark green : Central etiologic mechanisms; Level 2 light green : Factors in this level directly lead to one of the three mechanisms in Level 1 e. Three DoMAP levels around malnutrition in the center were defined, which illustrate different modes of action in the development of malnutrition.
The innermost level, surrounding malnutrition, consists of the three central mechanisms leading to malnutrition: low intake, high requirements, and impaired bioavailability of energy and nutrients Level 1, dark green. The middle level Level 2, light green consists of factors which may directly lead to one or more of these central mechanisms, for example, swallowing problems may directly cause low intake, or diarrhea may directly impair bioavailability.
The outermost level Level 3, yellow contains factors that may indirectly lead to one or more of the three central mechanisms through one or more of the direct factors in the light green triangle, for example, stroke may cause low intake, however not directly but via one or more factors in Level 2, for example, via dysphagia or difficulties with eating, or gastrointestinal disease may lead to impaired bioavailability through diarrhea.
Low education was moved from the outermost level to the surrounding space, and poverty from the middle to the outermost level. Furthermore, general explanations for the four levels were added to facilitate the understanding of the model see Figure 2. All modifications mentioned above were sent out for approval in the second Delphi round. In this ballot about suggested changes, four of the responding 20 persons completely agreed to all suggested changes. All modifications resulting from the feedback rounds are documented in Supplementary Table S1.
Finally, 18 direct factors in the middle level and 27 indirect factors in the outermost level were included in the model Figure 2. The DoMAP model was developed to illustrate the multitude of potential causes and the mechanisms underlying the development of malnutrition. It highlights not only the great number and diversity of factors involved but also their relation to malnutrition and potential modes of action.
The tip of the model does not indicate a specific hierarchy and should not be misunderstood as such. Factors in the upper part about the top two thirds of the model relate to low intake, they account by far for the largest share. Factors in the lower left and right area relate to reduced bioavailability and high requirements respectively and are less numerous. The model consists of several levels to illustrate different modes of action of different factors. In our model, factors in Level 2 are suggested to be direct causes assuming that these factors will always lead to malnutrition if they persist and no countermeasures are taken, for example, chewing problems will lead to low intake and consequently malnutrition unless an intervention, for example, oral care or modification of food texture, is conducted.
Thus, Level 2 factors are assumed as having superior importance, and health professionals should always be particularly alert and should immediately take action when one of these factors is present. Factors from Level 3 do not necessarily lead to malnutrition but may cause one or more factors in Level 2 and thus trigger indirectly one or more of the three central mechanisms in the first triangle. The position of a variable in a specific level is not always unambiguous and was also discussed in the live meetings and Delphi rounds, as variables may be interrelated and different pathways to malnutrition are plausible, for example, a specific medication may cause dry mouth—both variables are in Level 3—leading to chewing and swallowing problems Level 2.
Furthermore, the classification of factors according to their mode of action and the need of arrows to indicate specific pathways was thoroughly debated. Finally, it was decided to omit such a classification and also arrows for reasons of clarity and simplicity, as an indirect factor outermost level may impact malnutrition through several direct factors middle level. Also, interrelations between factors are assumed, which may presumably not be completely covered. Regarding selection and number of determinants, a comprehensive but at the same time lucid approach was followed with a main focus on personal factors, which were thought to be most relevant.
The selection of variables out of more than potential determinants derived from literature van der Pols-Vijlbrief et al. It is mainly based on the opinion of the participating experts, who have not always been in agreement, and may be subject of further discussions. In summary, there is no claim for completeness or objectivity, as by far not all factors discussed in the literature could be considered for reasons of clarity, and opinions about in- or exclusion may differ.
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The model is based on scientific knowledge and clinical experience of a multiprofessional, international group of renowned experts in the field of geriatric nutrition who contributed to its development. It is not evidence-based—as originally intended—as it quickly turned out that scientific evidence about determinants of malnutrition is overall limited and conflicting, and is often based on cross-sectional studies where reverse causation bias is present. Thus, the model is primarily theory-based, and related scientific evidence needs comprehensive separate elaboration in a next step.
To further develop DoMAP into an evidence-based model, longitudinal studies are needed to identify potential determinants of incident malnutrition to exclude reverse causation. The causality of the association between these determinants and incident malnutrition would need to be subsequently confirmed in intervention studies by studying whether elimination or treatment of the determinant in older persons would indeed lower the risk of developing malnutrition.
It is a clear strength of DoMAP that it highlights the diversity of factors affecting malnutrition as well as potential causative mechanisms. It includes frequent and relevant problems which might respond to interventions—either elimination or compensation—and is thus suitable for clinical practice as well as for scientific purposes. It may be used by health care professionals to check and highlight combinations of potential causes of malnutrition in individual patients as basis for intervention.
Limitations of the model are that the many and potentially overlapping pathways are not visible and that interrelations between factors are not addressed. Some factors might be placed in different levels, and scientific evidence and strength of the associations are not reflected. Moreover, the model was developed by a limited group of experts, which may have facilitated consensus-finding on one hand and excluded opinions and ideas of colleagues who were not involved on the other hand.
The model is however intended as a starting point and base for further discussions and developments. It may be modified in the future based on further discussions with additional experts, according to emerging scientific evidence as well as experiences from practical use. Scientific evidence type and strength of association , prevalence, or modifiability may be indicated in the future by different colors or symbols. The model may be adapted for different health care settings considering setting-specific risk factors, and generation of intervention concepts is conceivable based on the model.
Thus, also more or less simplified or complex versions may be developed. Posting the model on the Internet in an interactive manner may facilitate future exchange and further development. Within the scope of the European MaNuEL knowledge hub, the DoMAP model was developed and consented by an international, multiprofessional group of experts to illustrate potential causes of malnutrition and potential causative mechanisms.
This model of determinants of malnutrition in aged persons may contribute to a common understanding about the multitude of factors and different pathways involved in the etiology of malnutrition. It may serve as an important basis for future research, for example, to substantiate the assumed relevance of the factors considered or to develop preventive strategies for malnutrition in older persons.
After further validation, it may also be helpful in clinical routine to check potential causes of malnutrition in individual patients and identify persons at increased risk of malnutrition and may serve as basis for appropriate interventions. This work was further supported by the BANSS foundation who enabled a two-day live meeting of the experts without any obligation. The funders were not involved in the development of the model at any time. Supplemental Material: Supplemental material for this article is available online.
National Center for Biotechnology Information , U. Journal List Gerontol Geriatr Med v. Gerontol Geriatr Med. Published online Jun Lorenzo M. Author information Article notes Copyright and License information Disclaimer. Email: ed. This article has been cited by other articles in PMC.
Abstract In older persons, the origin of malnutrition is often multifactorial with a multitude of factors involved. Keywords: older persons, malnutrition, determinants, etiology, model.
Open in a separate window. Figure 1. Figure 2. DoMAP model. Discussion The DoMAP model was developed to illustrate the multitude of potential causes and the mechanisms underlying the development of malnutrition. Conclusions and Implications Within the scope of the European MaNuEL knowledge hub, the DoMAP model was developed and consented by an international, multiprofessional group of experts to illustrate potential causes of malnutrition and potential causative mechanisms.
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