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. The Global Challenges Research Fund (GCRF) supports cutting-edge research to address challenges faced by developing countries. The fund addresses the UN sustainable development goals. It aims to maximise the impact of research and innovation to improve lives and opportunity in the developing world.