Child malnutrition& Adult NCDs-Generating Evidence on mechanistic links in Jamaica, Malawi & Ethiopia to inform future policy/practice (CHANGE study)
Lead Research Organisation:
London School of Hygiene & Tropical Medicine
Department Name: Epidemiology and Population Health
Abstract
Severe malnutrition in early childhood is a major public health concern globally. This has serious consequences:
- Short term: for children to survive: malnutrition in all its forms underlies some 45% of all under 5 child deaths worldwide.
- Long term: for children to thrive: there is increasing realisation that early life malnutrition contributes to the fast-growing global epidemic of non-communicable diseases (NCDs).
As more children now survive episodes of malnutrition in childhood there is increasing need to understand what causes the long term problems. Evidence on this would lead to: improved early treatment of child malnutrition; improved longer term treatment aiming to reduce long term adverse effects.
In this project we have a unique opportunity to explore three groups of children/adults in:
- Jamaica: children suffering from severe malnutrition in the 1980s have been followed up on several occasions already, with scope for further analysis from already collected data.
- Malawi: We recently followed up a group of children admitted for severe malnutrition in 2005/6. We plan to both analyse existing data in more depth: also to possible collect new data in future.
- Ethiopia: Individuals who were young children at the time of the great Ethiopia famine of 1983-85 are about to be followed up in a pilot study. Learning from the above two projects will inform and improve plans for the Ethiopia work.
We aim to understand what are the long term problems following early child malnutrition and why they occur (the 'mechanisms' by which the two problems are linked)
The work proposed in this applicaiton is background towards the above future project. There are two main activities planned
A) Review of exisiting evidence: we will search the scientific literature to better understand what other have found to date re links between early life malnutrition and adult NCDs. Through this we will identify key knowledge gaps to target in future work.
B) Collaborator meeting - we will bring together the teams working on the above three groups of children to: learn from each other and share experiences. Through this better future work will be possible and there is great potential to enhance the overall learning compared to following each group as a stand-alone.
This meeting will be organised in Ethiopia in Autumn 2019: we will invite a number of key experts to make detailed plans for future work.
The Ethiopia/Malawi/UK teams will also visit Jamaica (the most advanced/experienced group) to learn from their experience and thus help plan better future projects in Malawi and Ethiopia.
- Short term: for children to survive: malnutrition in all its forms underlies some 45% of all under 5 child deaths worldwide.
- Long term: for children to thrive: there is increasing realisation that early life malnutrition contributes to the fast-growing global epidemic of non-communicable diseases (NCDs).
As more children now survive episodes of malnutrition in childhood there is increasing need to understand what causes the long term problems. Evidence on this would lead to: improved early treatment of child malnutrition; improved longer term treatment aiming to reduce long term adverse effects.
In this project we have a unique opportunity to explore three groups of children/adults in:
- Jamaica: children suffering from severe malnutrition in the 1980s have been followed up on several occasions already, with scope for further analysis from already collected data.
- Malawi: We recently followed up a group of children admitted for severe malnutrition in 2005/6. We plan to both analyse existing data in more depth: also to possible collect new data in future.
- Ethiopia: Individuals who were young children at the time of the great Ethiopia famine of 1983-85 are about to be followed up in a pilot study. Learning from the above two projects will inform and improve plans for the Ethiopia work.
We aim to understand what are the long term problems following early child malnutrition and why they occur (the 'mechanisms' by which the two problems are linked)
The work proposed in this applicaiton is background towards the above future project. There are two main activities planned
A) Review of exisiting evidence: we will search the scientific literature to better understand what other have found to date re links between early life malnutrition and adult NCDs. Through this we will identify key knowledge gaps to target in future work.
B) Collaborator meeting - we will bring together the teams working on the above three groups of children to: learn from each other and share experiences. Through this better future work will be possible and there is great potential to enhance the overall learning compared to following each group as a stand-alone.
This meeting will be organised in Ethiopia in Autumn 2019: we will invite a number of key experts to make detailed plans for future work.
The Ethiopia/Malawi/UK teams will also visit Jamaica (the most advanced/experienced group) to learn from their experience and thus help plan better future projects in Malawi and Ethiopia.
Technical Summary
Malnutrition is a major global public health problem underlying some 45% of all deaths among children aged under 5 (child u5) worldwide. Severe Acute Malnutrition (SAM) is particularly serious, affecting some 17 million children u5 and causing over 500,000 deaths/year. As well as affecting chances to survive, data also suggests that children's potential to thrive is affected by early life episodes of malnutrition. This has major implications, especially for efforts to tackle the rapidly growing epidemic of NCDs (non-communicable disease).
While intrauterine undernutrition has been linked to later life NCDs, data on the effects of child malnutrition is sparse. Some of the few long-term post-SAM follow-up studies currently that are available show interesting associations between SAM (and related forms of severe malnutrition) in childhood and processes associated with muscle function and growth, including cardiac development, and overall metabolism (especially glucose metabolism) in adulthood. These observations make it plausible that child SAM increases risk of adult NCD - but mechanisms underlying these association are far from understood.
More data matters because:
a) There are many children alive today who suffer from or have suffered from SAM: better understanding their life-course risks is vital for policy, planning and advocacy
b) Understanding SAM>NCD mechanisms could lead to improved treatments for SAM
c) Understanding SAM>NCD mechanisms could also lead to post-SAM treatments to reduce NCD risk.
This study will ultimately provide more data by learning from three unique cohorts:
- Jamaica:
- Malawi:
- Ethiopia
Working with the 3 cohorts together will enable more lesson to be learnt - to inform policy and practice in many other LMIC countries.
The requested grant is towards background literature reivews and collaborator meetings to shape details of future larger studies.
While intrauterine undernutrition has been linked to later life NCDs, data on the effects of child malnutrition is sparse. Some of the few long-term post-SAM follow-up studies currently that are available show interesting associations between SAM (and related forms of severe malnutrition) in childhood and processes associated with muscle function and growth, including cardiac development, and overall metabolism (especially glucose metabolism) in adulthood. These observations make it plausible that child SAM increases risk of adult NCD - but mechanisms underlying these association are far from understood.
More data matters because:
a) There are many children alive today who suffer from or have suffered from SAM: better understanding their life-course risks is vital for policy, planning and advocacy
b) Understanding SAM>NCD mechanisms could lead to improved treatments for SAM
c) Understanding SAM>NCD mechanisms could also lead to post-SAM treatments to reduce NCD risk.
This study will ultimately provide more data by learning from three unique cohorts:
- Jamaica:
- Malawi:
- Ethiopia
Working with the 3 cohorts together will enable more lesson to be learnt - to inform policy and practice in many other LMIC countries.
The requested grant is towards background literature reivews and collaborator meetings to shape details of future larger studies.
Planned Impact
The following would benefit from this reasearch
1) Local communities (including vulnerable infants/children and adults with NCD)
--> If any problems (specifically NCDs such as high blood pressure or poor glycaemic control) are identified in study participants at follow-up they will be referred for appropriate medical care, thus directly benefiting their health. We will definitely aim to follow up local communities in Ethiopia. Data is already available from Malawi and Jamaica - depending on outcomes of the investigator meeting further follow-up may be planned.
--> Awareness of NCD and links with early life malnurition will be raised in local communities through our work
--> Vulnerable infants and children would also benefit it (as we anticipate) data from this study ultimately leads to improved treatments for child malnutrition.
2) Policy makers / programme managers
- Highlighting the mechanistic links beween early life severe malnutrition and later life NCD will offer invaluable advocacy materials for policy makers and programme managers working in LMIC/emergency settings.
- Linking the two conditions will provide powerful arguments for greater investment in both preventing and treating early life malnutrition: both an important need in itself, also a way of tackling the growing epidemic of NCDs
3) Scientists & academics
By proving mechanisitc information for researchers to :
- develop better treatments for severe malnutrition.
- develop better post-treatment care packages.
...at-risk individuals and communities will directly benefit.
1) Local communities (including vulnerable infants/children and adults with NCD)
--> If any problems (specifically NCDs such as high blood pressure or poor glycaemic control) are identified in study participants at follow-up they will be referred for appropriate medical care, thus directly benefiting their health. We will definitely aim to follow up local communities in Ethiopia. Data is already available from Malawi and Jamaica - depending on outcomes of the investigator meeting further follow-up may be planned.
--> Awareness of NCD and links with early life malnurition will be raised in local communities through our work
--> Vulnerable infants and children would also benefit it (as we anticipate) data from this study ultimately leads to improved treatments for child malnutrition.
2) Policy makers / programme managers
- Highlighting the mechanistic links beween early life severe malnutrition and later life NCD will offer invaluable advocacy materials for policy makers and programme managers working in LMIC/emergency settings.
- Linking the two conditions will provide powerful arguments for greater investment in both preventing and treating early life malnutrition: both an important need in itself, also a way of tackling the growing epidemic of NCDs
3) Scientists & academics
By proving mechanisitc information for researchers to :
- develop better treatments for severe malnutrition.
- develop better post-treatment care packages.
...at-risk individuals and communities will directly benefit.
Organisations
- London School of Hygiene & Tropical Medicine (Lead Research Organisation)
- Swiss School of Public Health (Collaboration)
- Malawi Epidemiology & Intervention Research Unit (Collaboration)
- University of Jimma (Collaboration)
- University of West Indies (Collaboration)
- UNIVERSITY OF CAMBRIDGE (Collaboration)
- UNIVERSITY OF SOUTHAMPTON (Collaboration)
- University of Malawi (Collaboration)
- University of the West Indies (Project Partner)
- Jimma University (Project Partner)
- Ghent University (Project Partner)
People |
ORCID iD |
| Marko Kerac (Principal Investigator) |
Publications
Gonzales GB
(2020)
Childhood Malnutrition and Association of Lean Mass with Metabolome and Hormone Profile in Later Life.
in Nutrients
Grey K
(2021)
Severe malnutrition or famine exposure in childhood and cardiometabolic non-communicable disease later in life: a systematic review.
in BMJ global health
Bander A
(2022)
Childhood BMI and other measures of body composition as a predictor of cardiometabolic non-communicable diseases in adulthood: a systematic review.
in Public health nutrition
Kirolos A
(2022)
Neurodevelopmental, cognitive, behavioural and mental health impairments following childhood malnutrition: a systematic review.
in BMJ global health
Cheng M
(2023)
Exposure to the 1959-1961 Chinese famine and risk of non-communicable diseases in later life: A life course perspective.
in PLOS global public health
Thompson D
(2023)
Faster rehabilitation weight gain during childhood is associated with risk of non-communicable disease in adult survivors of severe acute malnutrition
in PLOS Global Public Health
Lelijveld N
(2023)
Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi 'ChroSAM' cohort.
in Public health nutrition
Kerac M
(2024)
Long-term and intergenerational impacts of famine: why preventing and treating child malnutrition must be seen as an investment and not a cost.
in The American journal of clinical nutrition
Olga L
(2024)
Weight gain during nutritional rehabilitation post-childhood malnutrition may influence the associations between adulthood desaturases activity and anthro-cardiometabolic risk factors.
in Clinical nutrition (Edinburgh, Scotland)
Kirolos A
(2024)
Long-term outcomes after severe childhood malnutrition in adolescents in Malawi (LOSCM): a prospective observational cohort study.
in The Lancet. Child & adolescent health
| Description | The main aim of this award was to develop a detailed proposal to explore "Links between nutrition and non-communicable disease (NCD)" in depth/over a longer time period. Already however, through meetings and networking with colleagues in Ethiopia, Jamaica and Malawi, we have made steps towards our ultimate goal of understanding and tackling the links between nutrition and NCDs: Through the background literature review done as part of this project we have confirmed that child malnutrition has negative effects on later life / adult health and disease and increases the risk of non-communicable disease such as heart disease and diabetes. This matters because it makes tackling child malnutrition all the more important: it is not just a child health issue with short term risk of death and disease but it is also relevant for the health and wellbeing of survivors. To effectively tackle the current global epidemic of non-communicable disease (NCD), the global health community must also focus on children and child nutrition in particular. This finding (and sharing it at networking/dissemination activities detailed in the ResearchFish submission) is especially relevant to ODA countries where: - Child malnutrition (undernutrition) is still common - NCDs like heart disease and diabetes are rapidly increasing and are both a current problem / will be a significant future problem. Though our project is focused on Jamaica, Ethiopia and Malawi, the findings of the review take into account all low and middle income countries and are thus widely relevant. |
| Exploitation Route | We have already submitted an application for follow-on work based on the data and discussion arising from this seed award. WE hope the literature review (currently being submitted for publication) will also help others in future. March 2021 Update: Following this successful seed award we were successful in our application for a full award to explore this topic in more detail (this will be separately recorded in future RF submissions). This is a: --> Multi-country (Jamaica, Ethiopia, Malawi) study of 7 different cohorts looking at early life malnutrition and later life cardiometabolic NCD. We have secured funding for a 32 month project to explore this - though we must successfully acheive year 1 objectives to get the full award amount. Our manuscript on "Long term NCD outcomes following child malnutrition" has also recently been accepted for publication by BMJ Global Health - this will be reported in next years' submission as proof has just been sent and we don't yet have a DOI. |
| Sectors | Healthcare |
| Description | Through sharing findings and issues raised during this seed award at meetings aimed at policy-makers/practitioners (e.g. Action Against Hunger "Research 4 Nutrition Meeting) we are already starting to raise wider awareness of the long term consequences of severe malnutrition. This being a very early stage in the project it is too early to assess wider impact of this but we anticipate that it will be relevant to a large number of LMIC settings, not just our target countries Jamaica, Ethiopia, Malawi. As per reporting guidelines: - To ensure meaningful and equal opportunties for people of different genders we have assembled a mixed team of both male and female scientists to work on the project (also scientists at different career stages. - We have not yet started field activities, but plans involve research participants of all genders and include start-up workshops to help local communities/particpants/other stakeholders engage with the work - We do not anticipate and negative consequences on gender equality - In our plans for the full study we will aim to recruit all survivors of severe malnutrition in childhood irrespective of gender and will report outcomes by gender and age. - We have a very diverse research team representing not only different genders but also different professional/personal backgrounds and nationalities. - This being only a seed grant our impacts to date are small - though we have begun engagement activities raising awareness of our research topic (the link between early child undernutrition and later life / adult NCD). We hope that this is an inital step towards influencing future health / nutrition policy and practice. March 2021 Update We are pleased to report that we have been successful in our application for a larger follow-on award under this scheme. This will allow us to pursue the project overall aims in more detail and depth in future. We hope to begin this project this month and will report in full in next year's RF submission March 2023 update We are pleased to report that we are continuing work on our project and evidence of the need and impact from future outputs is that the topic of post malnutrition weight gain was discussed in a recent WHO Guideline Development Group meeting. THe lack of current evidence was highlighted - our work will help provide this evidence in future. |
| First Year Of Impact | 2022 |
| Sector | Healthcare |
| Impact Types | Policy & public services |
| Description | MAMI Global Network (co-chair) |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Contribution to new or improved professional practice |
| Impact | Many organizations are now doing MAMI infant nutrition programme: these are inspired, helped and indirectly supported by us at the MAMI Global Network, including via monthly "implementors' meeting" and by many links and coversations that arise via the group. Several of us are also involved in the WHO Guideline Development Group - infants aged <6m are a key population being considered by WHO in this process. |
| URL | https://www.ennonline.net/ourwork/research/mami |
| Description | Member of WHO GDG (Guideline Development Group) for update of Severe Malnutrition in Children Guidelines Dec 2020, Jan-Dec 2021 (2021 timelines TBC) |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Membership of a guideline committee |
| Description | Member of WHO Guideline Development group for Severe Malnutrition 2021, 2022, 2023 |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Participation in a guidance/advisory committee |
| Impact | Though final guidelines are still not out the process is already influencing the work and thinking of the global experts who are, like myself, part of the WHO Guideline Development Group. Our work has been discussed in the guideline meetings: both MAMI infant malnutrition work and CHANGE project work of weight gain post malnutrition. 2024 update Final WHO guidelines have now been released. Our work has fed into these: - The approach to infants u6m at risk of poor growth and development is very heavily informed on our MAMI care pathway, developed over many years https://www.ennonline.net//mediahub/blog/mami-and-the-new-2023-who-recommendations-on-at-risk-infants-under-6-months - The paucity of evidence around optimal rates of weight gain (and hence what energy rations are optimal) is being addressed by the CHANGE project. |
| URL | https://app.magicapp.org/#/guideline/noPQkE/section/n32P8W |
| Description | RCPCH International Child Health group meeting |
| Geographic Reach | National |
| Policy Influence Type | Influenced training of practitioners or researchers |
| Impact | This was a guest lecture to the International Child Health group of RCPCH. I talked about malnutrition and included mention of the research work I'm doing with colleagues on severe malnutrition in children. |
| Description | Teaching and training future global health leaders and practitioners at LSHTM |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Influenced training of practitioners or researchers |
| Impact | In my teaching role at LSHTM I have multiple opportunties to teach and train (as well as learn from) our Msc and PhD students - many of whom will go on to be future leaders in global health in their own right. For example, I regularly: - Teach on Malnutrition on the Diploma in Tropical Medicine & Diploma in Tropical Nursing at LSHTM - Lead the organization of the "Nutrition in Emergencies" module - where there's a particuarly key opportunity to influence future leaders (as well as sharing details of the reserach I do in collaboration with various partners globally) - Discuss research-related issues with MSc students on the "Nutrition for Global Health MSc" - of which I am programme director - Discuss research-related issues with student and staff in the MARCH (Maternal, Adolescent, Reproductive and Child Health) Centre - of which I am co-lead for the C(Child) theme - this includes regular seminars and other meetings. MARCH newletters and other media also help disseminate key reserach findings and papers. All these are ongoing - I arrived at LSHTM in Sept 2014 and contibue to build and consolidate teaching/training at the university. |
| URL | https://www.lshtm.ac.uk/aboutus/people/kerac.marko |
| Description | CHild malnutrition & Adult NCD: Generating Evidence on mechanistic links to inform future policy/practice (CHANGE project) |
| Amount | £2,083,590 (GBP) |
| Funding ID | MR/V000802/1 |
| Organisation | Medical Research Council (MRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 03/2021 |
| End | 10/2024 |
| Description | Child malnutrition& Adult NCDs-Generating Evidence on mechanistic links in Jamaica, Malawi & Ethiopia to inform future policy/practice (CHANGE study) |
| Amount | £49,819 (GBP) |
| Funding ID | MR/T008628/1 |
| Organisation | Medical Research Council (MRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 07/2019 |
| End | 01/2020 |
| Description | GCRF Mechanistic Nutrition Links (LMICs) Jan 2020 |
| Amount | £1,994,948 (GBP) |
| Funding ID | MR/V000802/1 |
| Organisation | Medical Research Council (MRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 03/2020 |
| End | 09/2023 |
| Description | MRC GCRF (top up grant - via LSHTM, to supplement and enable new outputs from CHANGE project: enhanced lab outputs project for Malawi ChroSAM cohort) |
| Amount | £25,600 (GBP) |
| Organisation | Medical Research Council (MRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 01/2023 |
| End | 03/2023 |
| Description | MRC GCRF (top up grant - via LSHTM, to supplement and enable new outputs from CHANGE project: quasi-RCT analaysis project) |
| Amount | £83,333 (GBP) |
| Organisation | Medical Research Council (MRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 07/2022 |
| End | 03/2023 |
| Title | A methodology to assess the risk of future non-communicable disease in children treated for severe malnourishment: analysis of a quasi-experimental trial |
| Description | Supported by a top-up grant to our MRC/GCRF CHANGE project, we developed a novel method to assess possible long-term impact of different quantity of nutrition rations. We have presented this at two meetings: - Nutrition & Growth, London, UK March 2023 - European Federation of Nutrition Societies, Belgrade, Serbia, Nov 2023 We are currently working on a manuscript for a peer-review paper. THis will make the tool more widely available to others |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2024 |
| Provided To Others? | No |
| Impact | Too early for this - will report on this next year. |
| Title | CHANGE Cohort 1: Long-term Implications Of Nutrition (LION) dataset |
| Description | LION is an existing prospective cohort of survivors of severe malnutrition in Jamaica which has been followed-up post-discharge after been identified as severely malnourished and treated with specialised feeds. The cohort consist of malnourished children treated in inpatient care (1965-93). Included in the study are children with severe wasting (weight-for-age < 60%) or oedematous malnutrition (weight-for-age 60-80%, plus oedema). NCHS reference. The data comes from a cross-sectional retrospective survey on non-communicable disease (NCD) risk in adult survivors of severe malnutrition in childhood carried out between 2008-2012 at the Tropical Metabolism Research Unit (TMRU), the University of the West Indies (UWI), Jamaica. Adult data include blood pressure, anthropometric measures, body composition data, laboratory test results, and self-reported data relating to medical history, drug history and socioeconomic status. Childhood data include birth weight, and weight, length (height) and mid upper arm circumference (MUAC) measurements taken on admission, during hospitalization and up to 2 years post discharge from hospital. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2022 |
| Provided To Others? | Yes |
| Impact | This has recently been posted and forms the background to one of our CHANGE project analyses |
| URL | https://datacompass.lshtm.ac.uk/id/eprint/2656 |
| Title | CHANGE Cohort 2: Chronic disease outcomes after Severe Acute Malnutrition (ChroSAM). Malawi |
| Description | A dataset containing information collected from a prospective cohort of children originally admitted for treatment of severe acute malnutrition (SAM) in Blantyre, Malawi during 2006 and 2007. It includes health and anthropometric data from admission to care, during treatment, at discharge, at 1 year post-discharge, and at 7-years post-discharge. During original admission to care, data was collected as part of a randomised controlled trial into the effects of pre- and probiotics on treatment recovery - findings were null (trial registry number ISRCTN19364765). At the most recent follow-up in 2013/14, data pertaining to NCD risk were also collected, and data on 1 sibling control and 1 community control (age and sex matched) was also added. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2022 |
| Provided To Others? | Yes |
| Impact | This has just recently been posted and will form the basis of our CHANGE project analysis |
| URL | https://datacompass.lshtm.ac.uk/id/eprint/2657 |
| Title | CHANGE Cohort 3: Assessment of Long-Term Health Consequences of Acute Malnutrition (ACAM). Ethiopia |
| Description | ACAM is an existing prospective cohort of wasting treatment survivors in Ethiopia which has been followed-up post-discharge after been identified as severely malnourished and treated with therapeutic food. Population cohort includes malnourished children treated in outpatient care in 2014-15. Included in the study are children with WLZ |
| Type Of Material | Database/Collection of data |
| Year Produced | 2022 |
| Provided To Others? | Yes |
| Impact | This has just recently been posted and will form the basis of our CHANGE project analysis |
| URL | https://datacompass.lshtm.ac.uk/id/eprint/2658 |
| Title | CHANGE Project (CHild malnutrition & Adult NCD: Generating Evidence on mechanistic links to inform future policy/practice) - main project page |
| Description | This is the main page for our CHANGE project describing overall aims and objectives. As papers come out they will be linked to this. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2022 |
| Provided To Others? | Yes |
| Impact | We are still in process of gathering data but outputs will emerge over the coming years. Already the topic of weight gain after severe malnutrition has been discussed at a WHO Guideline meeting since evidence in this area is lacking: we anticipate that our project will help contribute important evidence to future disucssions/international/national guidelines. 2024 - further outputs will be added and linked to this project page. |
| URL | https://datacompass.lshtm.ac.uk/id/eprint/2655/ |
| Title | ChroSAM database |
| Description | This is data from a follow-up study of an existing cohort of ex-malnourished children aiming to describe long term outcomes following SAM (Severe Acute malnutrition) Data collection is about to be complete so that we will have linked data from: a) Original episode of malnutrition b) A 1- year follow-up study http://www.ncbi.nlm.nih.gov/pubmed/24892281 c) The current follow-up (which is the most detailed to date) The latest variables in the database include: 1) Main outcomes • Alive or dead at 7 years post-SAM • Detailed anthropometric measures, including: o Weight o Height (including standing and sitting height, lower leg length); o Circumferences of head, chest, waist, hip, upper leg and mid-upper arm; From these, measures, appropriate indices will be calculated (height-for-age; weight-for-height; BMI z-scores) 2. Early markers of chronic disease: • Cardiovascular o Blood pressure o Haemoglobin • Respiratory o Oxygen saturation o Lung function assessed by spirometry (Forced vital capacity; Forced expiratory volume in first second; forced expiratory flow 25%-75%) • Physical capacity assessed by shuttle run test (aerobic fitness); hand grip strength • Body composition assessed by bioelectrical impedance and skinfold thickness • Cognitive function o school achievement; o brain MRI (subset of patients only); • Metabolic function assessed by salivary cortisol; and venous blood for HbA1c; fasting blood glucose/glucose tolerance test (subset only); 3. Predictors of favourable or adverse long term outcomes: • Family characteristics (including parental education, employment and family size - again repeated at follow-up to assess changes from original baseline) • Socioeconomic status and household characteristics (repeated at follow-up to assess any changes from original baseline assessment) • Maternal/carer mental health (SRQ questionnaire) • Social support and wellbeing (MPSS - Multidimensional Scale of Perceived Social Support; SWBS - spiritual wellbeing scale; WHO-QoL Bref) • Disability (12 questions screen) |
| Type Of Material | Database/Collection of data |
| Year Produced | 2016 |
| Provided To Others? | No |
| Impact | We are just about to finish data recruitment. The bulk of data will be reported in a PhD which I am supervising. However, we already anticipate that there will be significant "other" data left over for future students and investigators to use to look at related questions about long term outcomes following malnutrition. 2017 update The main paper has now been published. Funding allowing, we hope to continue with further outputs from this database. 2018 update We have published a further paper on lung function following severe malnutrition; have one more paper on cognitive function submitted; are planning further publications over the coming year. 2020 update As well as a MSC summer project based on this database it is one of a number of cohorts which we hope to explore in teh MRC CHANGE study looking at long term outcomes following severe malnutrition. |
| Description | College of Medicine Malawi - Nutrition Projects |
| Organisation | University of Malawi |
| Department | Department of Paediatrics & Child Health |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | I have a long standing relationship with CoM Malawi, since originally working there as a volunteer paediatric registrar/lecturer in 2003-4. The link has both inspired and directly enabled my research career, hosting my PhD in 2005-8 and hosting subsequent links and projects ever since. Since the start of ACF/ACL posts I have maintained close links and have had several UCL MSc students visit Malawi to work on their projects there - all themed around my overall area of research into severe acute malnutrition / infant nutrition. We are currently collaborating on my AMS Clinical Lecturer Starter Grant - COM colleagues are co-authors on work presented at meetings to date and will be co-authors on the future papers arising. |
| Collaborator Contribution | The CoM (Department of Paediatrics in particular) have hosted my UCL MSc students and facilitated access to patients / staff for the the project. Without this the projects would not have been possible. They have also helped with room hire for the community dissemination event which I organized as a key output of my AMS starter grant. |
| Impact | Please see publications list: - Lelijveld et al - Ahmad et al. Other papers are in-progress (two are directly arising from the AMS starter grant: 1) Carers' and health workers' perspectives on Community Management of Acute Malnutrition (CMAM) in infants of less then 6 months: qualitative founding of a formative study from Malawi. (awaiting comments from co-authors; to be submitted to BMC Nutrition Journal) 2) Management of Acute Malnutrition in Infants aged <6 months (MAMI) in Malawi: prevalence and risk factors in an observational study (accepted for presentation at Royal College of Paediatrics Annual Meeting, April 2015. Will be submitted to peer review journal immediately after that) All the above pieces of work are already informing future research discussion / policy-discussions (e.g. in the ENN collaboration to develop assessment / patient management 'tools' for infants <6m). Hence there are already early impacts on policy/health services. 2016 update: This collaboration continues. CoM I hope will be involved in the adolescent study for which I have just been awarded a grant. We also continue collaborating on student projects. 2017 update I remain in contact with colleages at CoM. We are joint investigators on an application to look at body composition in our cohort of ex-malnourished children in Blantyre, Malawi - this is hoped to start later in 2017 (funding allowing) 2019 update - This past year I have not been out to Malawi but did have a MSc student visit over summer 2018 to work on a project looking at nutritional status of surgical patients. 2020 update - another MSc student did her MSc project on Malawi data which we hope to publish together. COM colleagues were also co-applicants on a MRC application (the full version of the CHANGE study). This is a good example of long term outcomes arising from a long established contact. 2024 update - We recently finished co-supervising a Malawi-Liverpool-Wellcome trust PhD focusing on a cohort of children originally treated for malnutrition in Malawi in 2006/7 (I originally recruited these into an RCT for my PhD). This is part of the CHANGE project and we are still collaborating on that (the project has been extended until Oct 2024) |
| Description | Jimma University MAMI Project (funded) & Post-malnutrition follow-up project (seeking funding) |
| Organisation | University of Jimma |
| Country | Ethiopia |
| Sector | Academic/University |
| PI Contribution | I am PI on the $2.5m Eleanor-Crook Foundation funded project on infant malnutrition. It is the culmination and major step forward for the infant nutriton work I've been doing for many years now. Related to but separate from the above project, Jimma are also partners on the MRC CHANGE study. We submitted the main application in Jan 2020 and are awaiting outcomes from a MARCH 2020 panel meeting. |
| Collaborator Contribution | Colleagues at Jimma are leading the research locally in Ethiopia where our study is set. |
| Impact | We have just started the project in Aug 2019 so are in year 1 developing formative work to inform our main RCT planned to start Oct 2020. March 2021 update: - We have completed MAMI project formative work though our main RCT plans have been delayed for a year due to COVID. - We were awared the follow-on larger grant and look forward to continued collaboration on the CHANGE project in 2021/22 (though an overall 3 year project we only have year 1 funding to begin with and need to meet project milestones in order to progress to full 32 month project) March2023 - collaboration still active. Publications and other outputs still in progress March 2024 update: - Following a 1 year no-cost extension to the CHANGE project, this collaboration is still active and working towards project aim/objectives. |
| Start Year | 2019 |
| Description | Partnership with Cambridge University on CHANGE Project Child malnutrition & Adult NCDs: Generating new Evidence on mechanistic links to inform future policy and practice (CHANGE project) |
| Organisation | University of Cambridge |
| Department | Institute of Metabolic Science (IMS) |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | Following a seed award in Sept 2019 - Jan 2020 we successfully applied for a 32 month MRC project to explore long term outcomes post severe malnutrition in more detail. We have to deliver on year 1 milestones for the project to proceed - these focus on profiling the cohorts and ensuring detailed plans for follow-up work. I am PI on the project and led both the writing of the seed award and also the main award. |
| Collaborator Contribution | Cambridge (Dr Albert Koulman - Wellcome-MRC Institute of Metabolic Science) are our key lab partner in the CHANGE project and will lead on lipidomic work |
| Impact | The main project is due to start this month, March 2021. Overall aims and objective are as below: THE AIM: To optimise severe malnutrition treatment programmes by better understanding the mechanisms linking infant/child undernutrition to longer-term (adult) NCD OBJECTIVES: 1. To understand how post-malnutrition weight gain (PMWG) affects risks of cardiometabolic NCD a. How does the timing of an episode of malnutrition influence this risk? b. How does severity of malnutrition influence this risk? c. How do different patient management approaches influence this risk? 2. To develop biomarkers for predicting NCD risk in survivors of child malnutrition by: a. Describing the biochemical characteristics of malnutrition survivors, differentiating those with/without NCD. b. Describing the biochemical profiles of different patterns of PMWG c. Identifying biomarkers common to different patterns of PMWG and NCD risk in survivors March2023 - collaboration still active. Publications and other outputs still in progress March 2024 update: - Following a 1 year no-cost extension to the CHANGE project, this collaboration is still active and working towards project aim/objectives. |
| Start Year | 2020 |
| Description | Partnership with MEIRU (Malawi Epidemiology & Intervention Research Unit) - CHANGE Project Child malnutrition & Adult NCDs: Generating new Evidence on mechanistic links to inform future policy and practice (CHANGE project) |
| Organisation | Malawi Epidemiology & Intervention Research Unit |
| Country | United Kingdom |
| Sector | Learned Society |
| PI Contribution | Following a seed award in Sept 2019 - Jan 2020 we successfully applied for a 32 month MRC project to explore long term outcomes post severe malnutrition in more detail. We have to deliver on year 1 milestones for the project to proceed - these focus on profiling the cohorts and ensuring detailed plans for follow-up work. I am PI on the project and led both the writing of the seed award and also the main award. |
| Collaborator Contribution | MEIRU are one of our 3 key partners and will collect data from two cohorts: - A cohort of children from 2003-4 (the "MEIRU 1000" cohort) who were small/undernourished then and who we will follow-up now in their teens to look for early signs of NCD - A birth cohort |
| Impact | The main project is due to start this month, March 2021. Overall aims and objective are as below: THE AIM: To optimise severe malnutrition treatment programmes by better understanding the mechanisms linking infant/child undernutrition to longer-term (adult) NCD OBJECTIVES: 1. To understand how post-malnutrition weight gain (PMWG) affects risks of cardiometabolic NCD a. How does the timing of an episode of malnutrition influence this risk? b. How does severity of malnutrition influence this risk? c. How do different patient management approaches influence this risk? 2. To develop biomarkers for predicting NCD risk in survivors of child malnutrition by: a. Describing the biochemical characteristics of malnutrition survivors, differentiating those with/without NCD. b. Describing the biochemical profiles of different patterns of PMWG c. Identifying biomarkers common to different patterns of PMWG and NCD risk in survivors March2023 - collaboration still active. Publications and other outputs still in progress March 2024 update: - Following a 1 year no-cost extension to the CHANGE project, this collaboration is still active and working towards project aim/objectives. |
| Start Year | 2020 |
| Description | Partnership with Southampton University - CHANGE Project Child malnutrition & Adult NCDs: Generating new Evidence on mechanistic links to inform future policy and practice (CHANGE project) |
| Organisation | University of Southampton |
| Department | Human development and health |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | Following a seed award in Sept 2019 - Jan 2020 we successfully applied for a 32 month MRC project to explore long term outcomes post severe malnutrition in more detail. We have to deliver on year 1 milestones for the project to proceed - these focus on profiling the cohorts and ensuring detailed plans for follow-up work. I am PI on the project and led both the writing of the seed award and also the main award. |
| Collaborator Contribution | Southampton (Prof Jon Swan) are our key lab partner and will lead on metabolomic aspects of this work |
| Impact | The main project is due to start this month, March 2021. Overall aims and objective are as below: THE AIM: To optimise severe malnutrition treatment programmes by better understanding the mechanisms linking infant/child undernutrition to longer-term (adult) NCD OBJECTIVES: 1. To understand how post-malnutrition weight gain (PMWG) affects risks of cardiometabolic NCD a. How does the timing of an episode of malnutrition influence this risk? b. How does severity of malnutrition influence this risk? c. How do different patient management approaches influence this risk? 2. To develop biomarkers for predicting NCD risk in survivors of child malnutrition by: a. Describing the biochemical characteristics of malnutrition survivors, differentiating those with/without NCD. b. Describing the biochemical profiles of different patterns of PMWG c. Identifying biomarkers common to different patterns of PMWG and NCD risk in survivors March2023 - collaboration still active. Publications and other outputs still in progress March 2024 update: - Following a 1 year no-cost extension to the CHANGE project, this collaboration is still active and working towards project aim/objectives. |
| Start Year | 2020 |
| Description | Partnership with UWI Tropical Metabolism Research Unit (TMRU) on application to study links between child malnutrition and adult NCD |
| Organisation | University of West Indies |
| Department | Tropical Metabolism Research Institute |
| Country | Jamaica |
| Sector | Academic/University |
| PI Contribution | Together with TMRU, Jimma University and MEIRU Malawi we applied to and obtained seed funding to develop a project to explore links between early child malnutrition and later life NCD. I am PI on the project and had a research assistant lead on a background systematic review / contribute to grant-writing. |
| Collaborator Contribution | TMRU colleauges made key scientific contributions to multiple aspects of this project: - The original concept - Co-authors on the systematic review - Co-authors of the full grant application - Hosted a research planning meeting in Jamaica in November |
| Impact | We submitted a full application to MRC in Jan 2020 and are awaiting results. Irrespective of what happens with that we hope that the collaboration can continue. March 2021 update: - We were awared the follow-on larger grant and look forward to continued collaboration on the CHANGE project in 2021/22 (though an overall 3 year project we only have year 1 funding to begin with and need to meet project milestones in order to progress to full 32 month project) March2023 - collaboration still active. Publications and other outputs still in progress March 2024 update: - Following a 1 year no-cost extension to the CHANGE project, this collaboration is still active and working towards project aim/objectives. |
| Start Year | 2019 |
| Description | Swiss School of Public Health / University of Lausanne - China famine study |
| Organisation | Swiss School of Public Health |
| Country | Switzerland |
| Sector | Academic/University |
| PI Contribution | Following a PhD student event at which I was external speaker, I was invited to join the author group on a paper describing non-communicable disease outcomes. This was recently published. and contributes to our overall CHANGE project theme of work looking at child malnutrition/adult NCD links |
| Collaborator Contribution | Our partners here led the analysis and writing on the main paper. I inputted as a co-author. More recently, we discussed the possibility of a follow-on paper - this will potentially happen later in 2024. |
| Impact | We have together published one paper and one editorial 1) Exposure to the 1959-1961 Chinese famine and risk of non-communicable diseases in later life: A life course perspective. Cheng M, Sommet N, Kerac M, Jopp DS, Spini D. PLOS Glob Public Health. 2023 Aug 16;3(8):e0002161. doi: 10.1371/journal.pgph.0002161. eCollection 2023. PMID: 37585364 2) Long-term and intergenerational impacts of famine: why preventing and treating child malnutrition must be seen as an investment and not a cost. Kerac M, Cheng M. Am J Clin Nutr. 2024 Feb;119(2):239-240. doi: 10.1016/j.ajcnut.2023.12.001. Epub 2023 Dec 29. PMID: 38309820 Both these feed into societal/policy/public services impact regarding highlighting the importance of long-term sequelae of severe malnutrition. |
| Start Year | 2022 |
| Description | ACF (Action Contre la Faim) Research for Nutrition conference |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | The International Scientific Research for Nutrition Conference #R4NUT, organised by Action Contre la Faim, is a major meeting place to bring to light the latest research findings and topics related to undernutrition. It brings together internationally renowned field experts and researchers for a two-day exchange of knowledge and critical perspectives on the prevention, diagnosis and treatment of undernutrition. Based on field experiences, research projects, strategic guidelines or nutrition & health policies and programs, all the evidence generated is discussed during the conference. It will contribute to strengthening the knowledge and capacity of professionals involved in the fight against undernutrition. Action Contre la Faim recognizes the importance of harnessing local solutions in the fight against nutritional insecurity. It encourages operational, participatory, accountable, innovative and transformative research. At this meeting I was part of a session focusing on long term outcomes from severe malnutrition and with two junior colleagues presented on our CHANGE project work. This led to a good discussion and again focused people's attention on this often neglected part of malnutrition care. We hope that this information and change of focus will in future lead to more programmes/policies focusing on these long-term risks. |
| Year(s) Of Engagement Activity | 2023 |
| URL | https://research-for-nutrition-conference.org/ |
| Description | ANH (Agriculture, Nutrition & Health) Academy, Malawi, 2023 |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | The ANH Academy Week is a series of annual events that bring together the community of researchers, practitioners and policymakers working at the intersection of agriculture, food systems, nutrition, and health. The objective of the ANH Academy Week is to foster knowledge exchange, innovation and learning around interdisciplinary ANH research. The ANH Academy Week format may consist of one or two of these interlinked components: Learning Labs - a series of training workshops in interdisciplinary skills and knowledge for agriculture, nutrition and health research and practice; (explore all previous labs here) Research Conference - an abstract-driven symposium featuring oral presentations, poster sessions and keynote speeches, as well as plenary round tables, side events and working group discussions. At this 2023 ANH academy work I co-led a "learning lab" on severe malnutrtion and shared details and latest results from the MRC CHANGE project. This helped focus audience attention (and hopefully future programme/policy directions) on the importance of considering not just short-term outcomes from malnutrition but long-term outcomes too. |
| Year(s) Of Engagement Activity | 2023 |
| URL | https://www.anh-academy.org/academy-week/2023 |
| Description | Action Against Hunger "Research for Nutrition" conference, Nov 2019 |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | This was a meeting linking researchers with practitioners / funders and others working in nutrition. The aim was to encouage dialogue and sharing of evidence. As well as chairing a session on infant malnutrition I also enabled a number of ex-MSc students to attend and present their summer project research. This included a systematic review on long term outcomes following malnutrition which is directly related to the CHANGE project |
| Year(s) Of Engagement Activity | 2019 |
| Description | LSHTM Open day |
| Form Of Engagement Activity | Participation in an open day or visit at my research institution |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Postgraduate students |
| Results and Impact | This was LSHTM wide open day. Students mainly came to learn about our MSc courses (including the Nutrition MSc I'm programme Director of). But in process they also learn about LSHTM research and our nutrition research. |
| Year(s) Of Engagement Activity | 2020 |
| Description | MARCH summer projects launch event |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Postgraduate students |
| Results and Impact | As part of LSHTM MARCH centre activites we held a Christmas party / summer project launch event. This involved linking current MSc students with potential projects /supervisors. This is a win/win: - Researchers get linked to a student who can support their research - Students get a policy/practice relevant project to work on. I also included work on my projects in the project list: both MAMI projects and long term follow-up projects. |
| Year(s) Of Engagement Activity | 2019 |
| Description | New Scientist interview - Starvation-resistant cave fish |
| Form Of Engagement Activity | A magazine, newsletter or online publication |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Public/other audiences |
| Results and Impact | In March 2024 I was interviewed by a New Scientist jounralist about an article they were publishing on starvation-resistant cave fish (which authors were arguing might lead to improved future treatments for malnutrition) I took the opportunity to share wider information about severe malnutrition globally and also highlighted MRC-GRCF CHANGE project work on longer-term outcomes following severe malnutrition. |
| Year(s) Of Engagement Activity | 2024 |
| URL | https://www.newscientist.com/article/2421466-blind-cave-fish-offers-lessons-in-how-to-survive-starva... |
| Description | Rank Prize meeting on Severe Undernutrition |
| 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 | I was invited as a guest speaker to a RANK PRIZE symposium organized by Imperial College London. This was a meeting of about ~20 professionals and policy makers working in severe malnutrition. THe meetings are usually reported on the RANK website. DIscussions were had about possible future links and collaborations after sharing of ideas at the meeting. |
| Year(s) Of Engagement Activity | 2023 |
| URL | https://www.rankprize.org/symposia/ |
| Description | STRONGER foundation talk |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Supporters |
| Results and Impact | I was invited speaker to a STRONGER Foundations talk, speaking to core team and other funders who are part of coalition about my research and it's impact / what it might mean for future funding efforts. Though too early to say I planned this talk to influence future funding efforts and approach to work by funders (including reflection on why longer term investments are so important) |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://stronger-foundations.org/ |
| Description | Teaching on LSHTM courses: Diploma in Tropical Medicine; Diploma in Tropical Nursing; Nutrition in Emergencies Module |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Postgraduate students |
| Results and Impact | I regularly teach on severe malnutrition on the above three courses at LSHTM. All talks are informed by / include descriptions of research I'm also engaged with and a key aim (from my perspective) is to broaden awareness of the research - and in turn to imporve policy/practice in the field of severe malnutrition. THis happen because: - Some students go directly to research in this area (e.g. via summer project with myself; via projects with others) - Many of our students will go onto be leading policy-makers/practitioners in their own right. All the above begins with change in views/knowledge - as evidenced by positive feedback I get. |
| Year(s) Of Engagement Activity | 2019,2020,2021,2022,2023 |
| Description | Wageningen University Study visit - Feb 2020 |
| Form Of Engagement Activity | Participation in an open day or visit at my research institution |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Undergraduate students |
| Results and Impact | As part of a study tour of a number of UK Universities, a group of undergrad / postgrad students from Wageningen University, Netherlands visited LSHTM for an afternoon. I was among a number of staff who shared short summaries of the research we're doing. No direct impact in short term but was helpful to broaden awareness of the research we're doing. |
| Year(s) Of Engagement Activity | 2020 |