Managing severe malnutrition: It takes more than calories

Scientists from Imperial and beyond discuss the latest research and developments on the management of severe malnutrition.

How can we better understand and manage malnutrition, a condition responsible for the deaths of some 2.6 million children every year? This pressing question was addressed at the Institute of Global Health Innovation’s latest Global Health Forum on Thursday, where leaders in the field came together to exchange ideas and share their latest evidence.

The researchers based at Imperial and beyond highlighted the intricacies and issues with managing this complex condition, and the scope of the situation at hand.

“Undernutrition is implicated in 45% of child deaths worldwide,” said Professor Kath Maitland, Director of the Centre for African Research and Engagement at Imperial.

“Yet despite its importance it’s often underrepresented as a global health burden, and we still don’t fully understand the factors which contribute to this high mortality.”

Myths around malnutrition

Despite the introduction of feeding regimes to treat severe complicated malnutrition, there has been little change in mortality rates over the last 25 years. Many children will die of a serious condition called refeeding syndrome very early on after treatment has begun. It’s widely believed that this condition causes an abnormal heart rhythm and the heart muscle is shrunken and weak, ultimately leading to death. This has meant that many children have been denied the treatment they need, for example fluid drips to treat dehydration from underlying diarrhoea, due to fears of heart failure.

Prof Maitland introduced her work into this area, and whether refeeding syndrome can disrupt the heart’s normal rhythm. Unexpectedly, her research has shown that while changes in heart rhythm do occur, these will normalise over time and they don’t result in heart failure. 

Alongside having implications for treatment and challenging current management guidelines, this therefore begs the question: what else is going on, and what instead should researchers focus on?

“Nutritional rehabilitation is important, but it’s not the whole story,” said Professor Gary Frost, Chair in Nutrition and Dietetics at the College.

“We argue an organ that’s been terribly ignored is the gut and its role in undernutrition. It undergoes severe changes during this critical time, so is there a way to support it?”

From the microbiome to metabolism

Prof Frost and his group are looking for simple, sustainable ways to ameliorate the impact of malnutrition on gut function through refeeding. Their work focusses on getting complex carbohydrates to where they’re needed most – deep down in the gut’s colon, where they’re fermented and feed non-harmful ‘good’ bacteria and help a healthy microbiome bloom.

They’ve found that supplementing rescue feeds with locally sourced legumes can help carbs reach this critical area and stabilise the gut, but that this alone isn’t enough to boost the microbiome.

The microbiome is also just one piece of the complex puzzle. Dr Douglas Morrison spoke of his research at the University of Glasgow, looking for other ways to measure gut function in malnutrition and whether this information could be used to improve outcomes.

Another major factor is biochemistry, how malnutrition affects different metabolic pathways and which should be targeted by interventions. That’s what Imperial’s Dr Jonathan Swann is revealing through his work. He’s unpicking the biochemical aspects of different stages of malnutrition, to hopefully highlight possible treatment pathways.

From treatment to prevention

These are just some of the important consequences of malnutrition highlighted at the Forum. But what about shifting the focus, to preventing malnutrition from occurring in the first place? That’s what Dr Modou Jobarteh hopes to ultimately help achieve through his Imperial research. With Profs Frost and Maitland and funded by the Gates Foundation, he’s developing and evaluating camera-based systems that can document and analyse food intake in the developing world, to better understand this major driver of malnutrition.

This gives a flavour of the breadth of research into nutrition and global health at Imperial. If you’re interested in finding out more, come along to IGHI’s monthly Global Health Forums and join in the discussion.