Nutrition and gut health

This project proposes to develop a passive dietary monitoring system for both adults and children living in Low or Middle Income Countries (LMICs) which does not rely on individual participation to record intake. The system mainly consists of wearable vision sensors, fixed cameras, and a cloud storage server. The aim of the project is to provide a low-cost and robust system for accurate measurement of individuals’ dietary intake. To understand the unique settings in LMICs, this project proposes to conduct a series of studies to identify the specific challenges in dietary monitoring in LMIC settings, such as electricity supply, shared food plates, local recipes, popular ingredients, etc.

 Find out more here.

In the area of nutrition, we have undertaken a programme of prospective studies of severe malnutrition in Kilifi, Kenya and Mbale, Uganda. The scope of work includes comprehensive descriptions of the clinical spectrum and risk factors for poor outcome, pharmacokinetic studies and dose optimisation of the main antibiotics (gentamicin and ciprofloxacin) used for the treatment of concomitant gram-negative bacterial infections. Dr Bernadetter Brent through an MD and Dr Nchafatso Obonyo, through an ISSF fellowship,  have undertaken comprehensive studies of myocardial function in children with severe malnutrition in Kenya and Uganda and examined the response to fluid therapy and re-feeding. In addition, Professor Kathryn Maitland has multiple active collaborations with specialists in nutritional and digestive health at Imperial College (SMIP, MIMBLE and TRACT).

Severe Malnutrition Intestinal Permeability (SMIP) and Modifying Intestinal Integrity And Microbiome in Severe Malnutrition With Legume-Based Feeds [MIMBLE Study]: A Pilot Study

The SMIP study is a collaboration with Professors Holmes and Frost investigating the role of gut-barrier dysfunction and intestinal microbiome in the pathogenesis with severe malnutrition, and whether these contribute to the high rate of treatment failure and adverse clinical outcome.  This has lead to the development of protocol  through and ISSF fellowship to Dr Nuala Calder to examine whether the integrity of the gut epithelial barrier can be supported by short chain fatty acids derived from microbiota fermentation of fermentable carbohydrate using locally-sourced legumes (cowpeas).  

TRansfusion and TReatment of severe Anaemia in African Children: a randomised controlled Trial TRACT (ISRCTN84086586)
In a sub-study of a 4000-child treatment trial of severe anaemia, we will assess the impact of anaemia and undernutrition on gut integrity, appetite regulation and susceptibility to bacterial infection. Undertaking a PhD linked to the TRACT trial  Dr Kevin Walsh, co-supervised by  Professors Holmes, Frost and Maitland combines sequential dietary intake assessment using the multi-pass method at each follow-up visit to estimate macro- and micro- nutrient intake and biomarkers of gut barrier function, gut microbiome, immunity and hormonal appetite control. 

Severe acute malnutrition is one of the major killers of children in many countries, creating a vicious circle of infection and illness. In Africa, children who are hospitalised with severe malnutrition have poor outcomes including death, readmission and relapse. 

Dairy and nut-based formula foods, mostly made in Europe, are a central part of the treatment yet mortality remains stubbornly high despite advances in nutritional and medical support.  

One possible issue is that milk-based formulas do little to improve gut function or stimulate healthy, diverse microbial communities. Children with severe malnutrition have significantly less microbial diversity compared to their well-nourished peers. To enhance gut function, it is crucial to develop feeding strategies that foster the growth of beneficial microbes. 

Professor Kathryn Maitland, Director of Centre of African Research and Engagement, said: "We have conducted a series of studies using a new feed containing legumes – peas or beans - because they provide carbohydrates that feed the 'healthy' bugs, producing chemical molecules which help restore healthy microbial communities and suppress the gut function. 

"We have also finalised the development of a new feed with a local industry partner in Uganda, RECO Limited. The MIMBLE consortium, together with members of the HUNGer consortium, aims to test this feed in a clinical trial in Kenya, Ghana, and Zambia to see if it improves outcomes in children hospitalised with severe malnutrition."

Related publications:  

• Walsh K, Kiosa A, Olupot-Olupot P, et al. Legume-supplemented feed for children hospitalised with severe malnutrition: a phase II trial. British Journal of Nutrition. Published online 2024:1-10. 

• Walsh K, Delamare de la Villenaise de Chenevarin G, McGurk J et al. Development of a legume-enriched feed for treatment of severe acute malnutrition [version 2; peer review: 2 approved]. Wellcome Open Res 2023, 6:206. 

• Calder N, Walsh K, Olupot-Olupot P, Ssenyondo T, Muhindo R, Mpoya A, Brignardello J, Wang X, McKay E, Morrison D, Holmes E, Frost G, Maitland K. Modifying gut integrity and microbiome in children with severe acute malnutrition using legume-based feeds (MIMBLE): A pilot trial. Cell Rep Med. 2021 May 18;2(5):100280. 

Partnership For Child Development  (PCD), formed in 1992, works to improve the education, health and nutrition of school-age children in low- and middle- income countries. 

Read more about this work

We did prospective studies of severe malnutrition in Kilifi, Kenya and Mbale, Uganda. These  included comprehensive descriptions of the clinical spectrum and risk factors for poor outcomes, pharmacokinetic studies to inform and optimise the dose of the main antibiotics (gentamicin [1] and ciprofloxacin [2]) used for the treatment of gram-negative bacterial infections.

Myocardial Function

Dr Bernadette Brent through an MD and Dr Nchafatso Obonyo, through an ISSF fellowship,  did comprehensive studies of myocardial (heart) function in children with severe malnutrition in Kenya and Uganda and examined the response to fluid therapy and re-feeding. [3]: They found that the heart function in severe malaria is well preserved and that the positive response to rehydration is the same as it would be in a well-nourished child. This counter to what has been widely considered by nutrition experts and guidelines recommending to avoid intravenous fluids should be reviewed. This work underpinned the need for a clinical trial investigating rehydration strategies (see GASTROSAM). 

Rehydration guidelines for severe malnutrition: evidence review  

The current guidelines for rehydration of children with severe malnutrition recommend oral rehydration. The guidelinesare exceptionally conservative and differ substantially from what is recommended for well-nourished children. Management focuses on the exclusive use of oral rehydration using low-sodium oral rehydration solutions (ORS) called Rehydration Solution for Malnutrition (ReSoMal). 

The guidelines are based on expert opinion rather rather data from clinical trials, and follow concern that children are at risk of cardiac failure, and fluid and sodium overload. Our 2017 narrative review of the recommendations for management of severe and moderate dehydration found  that for severe dehydration, two were randomised controlled trials, two were observational cohort studies, and one incorporated assessment of heart function and blood flow. There was no evidence of fluid overload or other fluid-related adverse events, including children managed on more liberal rehydration protocols [4]. In 2026, following the results of the GASTROSAM trial  we conducted a formal systematic review and metanalysis of intravenous rehydration (IVR) compared to oral rehydration (OR), involving 484 participants with severe malnutrition and dehydration. We  found the estimated effect of using IVR versus OR in children with SAM with severe dehydration ranges from a 54% relative reduction to a 10% relative increase in the risk of death, with IVR resulting in fewer adverse events [5]. The intravenous approacghes to rehydration were not harmful and therefore guidelines should be revied in light of this 

For oral rehydration we found two trials evaluating ReSoMal (comparing this to standard oral rehydration solutions (ORS) recommended by the WHO for non-malnourished children, both demonstrated similar efficacy. Both studies reported significantly more episodes of low sodium concentration (hyponatremia) by 24 hours in the ReSoMal arm than the WHO old or standard WHO low osmolarity [6].

The GASTROSAM trial also examined optimal ORS which was published in 2026 [7].

1. Seaton C, Ignas J, Muchohi S, Kokwaro G, Maitland K, Thomson AH. Population pharmacokinetics of a single daily intramuscular dose of gentamicin in children with severe malnutrition. The Journal of antimicrobial chemotherapy 2007; 59(4): 681-9.
2. Thuo N, Ungphakorn W, Karisa J, et al. Dosing regimens of oral ciprofloxacin for children with severe malnutrition: a population pharmacokinetic study with Monte Carlo simulation. The Journal of antimicrobial chemotherapy 2011; 66(10): 2336-45.
3. Brent B, Obonyo N, Akech S, et al. Assessment of Myocardial Function in Kenyan Children With Severe, Acute Malnutrition: The Cardiac Physiology in Malnutrition (CAPMAL) Study. JAMA Netw Open 2019; 2(3): e191054.
4. Houston KA, Gibb JG, Maitland K. Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review. Wellcome Open Res 2017; 2(65): 65.
5. Dewez JE, Sunyoto T, Mogaka C, et al. Intravenous rehydration in children with severe malnutrition: a systematic review and meta-analysis. medRxiv 2025: 2025.08. 18.25333854.
6. Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017; 2: 66.
7. Maitland K, Sainna H, Connon R, et al. Oral rehydration for severe malnutrition in children with moderate and severe dehydration (GASTROSAM): a phase 2, open-label, superiority randomised controlled trial. Lancet Child Adolesc Health 2026; 10(5): 319-29.