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

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 sub-saharan 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.

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).

The aims of the current proposal are:
1) To increase understanding of the links between nutritional intake and status, and the physical, metabolic and inflammatory phenotype in Malawian adults at increased risk of diabetes in relation to the Malawian general population and populations in other regions of the world.

2) To explore nutritional practices and understandings of diabetes in urban and rural communities in Malawi, and consider which nutritional practices might be amenable to changes likely to reduce the risk of developing diabetes.

3) To form and work with a network of key stakeholders to (i) develop potential theory(ies) of change, (ii) identify possible mechanisms of delivery, and (iii) develop a strategic plan to achieve sustainable implementation of effective nutritional diabetes prevention intervention(s) across Malawi.

Achieving these aims will have clear impact and we have detailed firstly who will benefit from this research and secondly how they will benefit from this research.

a) Who will benefit from this research?
The current research will be of benefit to academics; local, national and international policy makers and non-governmental organisations; health professionals, the food industry and the public

b) How will they benefit from this research?
Academics: The current proposal will be of benefit to academics working in the pathogenesis and treatment of diabetes as the study findings will enhance our knowledge of the nutritional phenotype of Malawian adults at risk of diabetes and also identify areas of nutrition amenable to intervention. There will also be career development benefits to the two early career scientists working on this project, and this will help build capacity for research in the field in Malawi.

Local, national and international policy makers and NGOs: The current proposal will provide early indicative data to indicate where public health policies in diabetes prevention may need to be changed. Future research, to confirm the effectiveness of the interventions, will be able to confirm where changes to policies may (or may not) need to be made.

Health professionals: A wide variety of health professionals working in nutrition and the treatment/prevention of diabetes will benefit via an increase in our understanding of the pathogenesis of diabetes in Malawi, information key for effective treatment and prevention.

Food industry: The current study will indicate aspects of nutrition that may need to be changed and are amenable to change which can reduce incidence of diabetes and associated complications. Such information will be important in such companies future strategies.

Public: The public will benefit from an increase in understanding of the importance of nutrition in diabetes risk in Malawi. The current project is also the first step in the development of an intervention, which can reduce the incidence of diabetes in Malawi and thus the associated health burden and increase quality of life.