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

Diabetes prevalence in Malawi, at 5.5%, is comparable to high-income countries (HIC) in Europe, despite a relatively low prevalence of obesity and physical inactivity. Approximately 40% of Malawians with diabetes have 'normal' BMIs. We hypothesised that a combination of sub-optimal nutrition in utero and/or childhood and high levels of exposure to infection which together contribute to low muscle mass and strength are likely to contribute to a different diabetes risk phenotype in Malawians compared to those in HIC. Thus interventions, focused on weight loss and increased physical activity, which have been effective at preventing diabetes in HIC may not be effective in Malawi and a shift towards nutritional interventions focused on increasing muscle mass & strength and reducing inflammation was likely a more effective approach. Our long-term aim was therefore to develop and implement effective and pragmatic large-scale nutritional interventions optimized to prevent diabetes in Malawians at elevated diabetes risk. The overall aim of this project was to undertake key initial steps to facilitate the development of such interventions. Our first objective was 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. To achieve this we recruited 50 participants (25 from rural and 25 from urban areas) with pre-diabetes and an equivalent number of age- and sex- matched healthy participants (25 rural and 25 urban) and make measurements of dietary intake, body composition, grip strength, physical activity levels, cardiometabolic risk profile (glucose, HbA1c, lipids, insulin, blood pressure), gut microbiota and inflammatory markers (detailed below). This enabled detailed characterization of the Malawian 'pre-diabetes' phenotype and identification of aspects of dietary intake which could potentially be altered in nutritional interventions to reduce diabetes risk. Our second aim was 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 risk of developing diabetes. To achieve this we undertook secondary analysis of existing interview, focus group and observational qualitative data collected by MEIRU during studies investigating salt intake and diabetes medication adherence in Malawi [NHRSC protocol ~1425], and supplemented this with primary data collection (via focus groups) to explore nutritional and physical activity (exercise) practices and understandings of diabetes in urban and rural communities in Malawi, and considered which nutritional and physical activity practices might be amenable to changes likely to reduce risk of developing diabetes.

NHSRC number: 18/01/1951