Development of nutritional strategies for diabetes prevention in Malawian adults at high diabetes risk

Lead Research Organisation: University of Glasgow

Abstract

Low- and middle-income countries, such as Malawi, are currently faced with disparate nutritional challenges such as childhood and adult malnutrition alongside increasing levels of obesity. On top of this, people in Malawi (and wider subsaharan Africa (SSA)) are exposed to repeated infections and inflammation. Together these contribute to the rising levels
of non-communicable diseases, such as diabetes, in these countries. Rates of death from diabetes in SSA are 5 times higher than in high-income countries, and the disease is placing substantial burdens of fragile health systems. It also has important economic consequences as it largely affects working age adults. It is therefore important to develop strategies to prevent diabetes in Malawi and wider SSA. What is also becoming clear is that people who get diabetes in Malawi are very
different from White Europeans in high-income countries. For example, whereas in high-income countries people who get diabetes are likely to be obese (BMI over 30 kg/m2) and inactive, in Malawi over 90% of the population meet physical activity guidelines and are often normal weight. This discrepancy may be explained by differences in nutrition, particularly
in early life, and infection burden which come together to cause a low level of muscle mass and strength in people from Malawi. Indeed muscle size and strength are lower in people in Malawi compared to high income countries such as the UK and United States: this is important, as low muscle mass and strength have been shown to increase the risk of diabetes.
A detailed exploration of nutritional habits, body composition and inflammation burden in people at risk of diabetes in Malawi is currently lacking. Such data are needed before we can develop appropriate interventions to prevent diabetes in this population. In high-income countries lifestyle interventions are focused on weight loss (via decreasing food intake) and increases in physical activity, which are unlikely to be effective in Malawi where people are already very active and normal
weight. It may be the case, therefore, that nutritional strategies such as increasing protein intake or altering the diet to help reduce inflammation may be more effective in Malawi. Indeed some preliminary data has shown protein intake to be generally very low in Malawi. In this proposal we will carry out detailed measurements of nutritional intake, body
composition and infection burden in people in Malawi at risk of diabetes and compare these to a healthy Malawian population and with available data from databases in other African countries and high-income countries (e.g. United Kingdom and United States). This will allow us to identify where best to target interventions, e.g. at increasing muscle mass
via increases in protein intake. Following this, in the same population, we will explore normal nutritional practices and knowledge of diabetes with an aim to identify areas where beneficial intervention may be possible. Thirdly, we will form a network of people and organisations who will be key in facilitating any developed intervention. Together these will allow us
to develop potential theories of change for new nutritional interventions to reduce diabetes risk in Malawi. This work will lead to the future development of new nutritional approaches to prevent diabetes in the Malawian population focused on increasing muscle mass and reducing inflammation.

Technical Summary

In Malawi (and wider SSA) diabetes is exerting an increasing public health burden, with age-standardised death rates 5 times higher than high-income countries (HIC). This risks overburdening fragile health systems and has important economic consequences. The Malawian diabetes phenotype differs from that seen in HIC, occurring at lower BMI and high despite high physical activity (PA). Thus standard diabetes prevention interventions of weight loss and increased PA are unlikely to be effective. It is vital to develop effective diabetes prevention strategies for the Malawian context. Low muscle mass/strength and chronic inflammation are both strongly linked to increased risk of diabetes, and are likely important contributors to diabetes risk in Malawi, where muscle mass/strength are low and exposure to infection/inflammation is high.
Thus nutritional strategies to increase muscle mass and reduce systemic inflammation, by increasing protein intake and reducing the inflammatory potential of the diet, may be effective for diabetes prevention in Malawi. Our long-term aim is to develop and implement effective and pragmatic large-scale nutritional interventions to prevent diabetes in Malawi. The current proposal will adopt the 6SQuID approach to begin developing new nutritional diabetes prevention intervention(s) as follows: 1) assessing links between nutritional intake/status, and physical/metabolic/inflammatory phenotype in Malawian adults at high diabetes risk; 2) assessing nutritional practices and diabetes knowledge in Malawian adults at high diabetes risk to identify areas amenable to change; 3) working with a key stakeholder network to develop potential theories of changes and identify how nutritional interventions may be delivered in Malawi. In future proposals we will finalise intervention development and test feasibility, acceptability, short-term effectiveness; before ultimately undertake robust, long term evaluations of the most promising intervention(s).

Publications

10 25 50
 
Description University of Glasgow / MEIRU / LUANAR / Malawi College of Medicine 
Organisation Lilongwe University of Agriculture & Natural Resources
Country Malawi 
Sector Academic/University 
PI Contribution The present award is a collaborative award between the University of Glasgow, Malawi Epidemiology & Intervention Research Unit (MEIRU), Lilongwe University of Agriculture & Natural Resources (LUANAR), and College of Medicine in Malawi. The intellectual input into the study has come from all four organizations. The University of Glasgow's contributions include protocol design, staff training, some aspects of data collection, data analysis and interpretation.
Collaborator Contribution The Malawian partners' (MEIRU. LUARNAR, Malawi College of Medicine) contributions include protocol design, staff training, most of the data collection, sample analysis, data analysis and interpretation.
Impact Data collection for this study is still ongoing. An initial stakeholder meeting on "Development of Diabetes Strategies in Malawi" was held at Crossroads Hotel, Lilongwe, Malawi on 12th April 2018 at the start of this project. It included attendees from Diabetes Association of Malawi, Kamuzu Central Hospital (Malawi), Kilimanjaro Christian Medical Centre (Tanzania), Kilimanjaro Clinical Research Unit (Tanzania), Queen Elizabeth Central Hospital (Malawi), Malawi Ministry of Health, MEIRU and University of Glasgow. This consultation meeting enabled stakeholders to discuss challenges and strategize on solutions and opportunities to tackle Diabetes in the country, and ultimately in the region. The objectives of the meeting were to understand the stakeholder's perspectives on: 1. The general public knowledge of Diabetes. 2. The status of diet and physical activity in the region. 3. Delivery of key messages and activities around Diabetes. 4. Who else needs to be involved in the project?
Start Year 2018
 
Description University of Glasgow / MEIRU / LUANAR / Malawi College of Medicine 
Organisation Malawi Epidemiology & Intervention Research Unit
Country United Kingdom 
Sector Learned Society 
PI Contribution The present award is a collaborative award between the University of Glasgow, Malawi Epidemiology & Intervention Research Unit (MEIRU), Lilongwe University of Agriculture & Natural Resources (LUANAR), and College of Medicine in Malawi. The intellectual input into the study has come from all four organizations. The University of Glasgow's contributions include protocol design, staff training, some aspects of data collection, data analysis and interpretation.
Collaborator Contribution The Malawian partners' (MEIRU. LUARNAR, Malawi College of Medicine) contributions include protocol design, staff training, most of the data collection, sample analysis, data analysis and interpretation.
Impact Data collection for this study is still ongoing. An initial stakeholder meeting on "Development of Diabetes Strategies in Malawi" was held at Crossroads Hotel, Lilongwe, Malawi on 12th April 2018 at the start of this project. It included attendees from Diabetes Association of Malawi, Kamuzu Central Hospital (Malawi), Kilimanjaro Christian Medical Centre (Tanzania), Kilimanjaro Clinical Research Unit (Tanzania), Queen Elizabeth Central Hospital (Malawi), Malawi Ministry of Health, MEIRU and University of Glasgow. This consultation meeting enabled stakeholders to discuss challenges and strategize on solutions and opportunities to tackle Diabetes in the country, and ultimately in the region. The objectives of the meeting were to understand the stakeholder's perspectives on: 1. The general public knowledge of Diabetes. 2. The status of diet and physical activity in the region. 3. Delivery of key messages and activities around Diabetes. 4. Who else needs to be involved in the project?
Start Year 2018
 
Description University of Glasgow / MEIRU / LUANAR / Malawi College of Medicine 
Organisation University of Malawi
Department College of Medicine
Country Malawi 
Sector Academic/University 
PI Contribution The present award is a collaborative award between the University of Glasgow, Malawi Epidemiology & Intervention Research Unit (MEIRU), Lilongwe University of Agriculture & Natural Resources (LUANAR), and College of Medicine in Malawi. The intellectual input into the study has come from all four organizations. The University of Glasgow's contributions include protocol design, staff training, some aspects of data collection, data analysis and interpretation.
Collaborator Contribution The Malawian partners' (MEIRU. LUARNAR, Malawi College of Medicine) contributions include protocol design, staff training, most of the data collection, sample analysis, data analysis and interpretation.
Impact Data collection for this study is still ongoing. An initial stakeholder meeting on "Development of Diabetes Strategies in Malawi" was held at Crossroads Hotel, Lilongwe, Malawi on 12th April 2018 at the start of this project. It included attendees from Diabetes Association of Malawi, Kamuzu Central Hospital (Malawi), Kilimanjaro Christian Medical Centre (Tanzania), Kilimanjaro Clinical Research Unit (Tanzania), Queen Elizabeth Central Hospital (Malawi), Malawi Ministry of Health, MEIRU and University of Glasgow. This consultation meeting enabled stakeholders to discuss challenges and strategize on solutions and opportunities to tackle Diabetes in the country, and ultimately in the region. The objectives of the meeting were to understand the stakeholder's perspectives on: 1. The general public knowledge of Diabetes. 2. The status of diet and physical activity in the region. 3. Delivery of key messages and activities around Diabetes. 4. Who else needs to be involved in the project?
Start Year 2018
 
Description Development of Diabetes Strategies in Malawi: Stakeholder Meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact An initial stakeholder meeting on "Development of Diabetes Strategies in Malawi" was held at Crossroads Hotel, Lilongwe, Malawi on 12th April 2018 at the start of this project. It included 25 attendees from Diabetes Association of Malawi, Kamuzu Central Hospital (Malawi), Kilimanjaro Christian Medical Centre (Tanzania), Kilimanjaro Clinical Research Unit (Tanzania), Queen Elizabeth Central Hospital (Malawi), Malawi Ministry of Health, MEIRU and University of Glasgow. This consultation meeting enabled stakeholders to discuss challenges and strategize on solutions and opportunities to tackle Diabetes in the country, and ultimately in the region. The objectives of the meeting were to understand the stakeholder's perspectives on: 1. The general public knowledge of Diabetes. 2. The status of diet and physical activity in the region. 3. Delivery of key messages and activities around Diabetes. 4. Who else needs to be involved in the project?
Year(s) Of Engagement Activity 2018