Menu ENN Search

Chronic disease outcomes after SAM in Malawian children (ChroSAM): A cohort study

Summary of research*

Location: Malawi

What we know: Little is known about the long-term health effects of survivors of severe acute malnutrition (SAM), particularly risk of non-communicable diseases (NCDs) in later life.

What this article adds: A cohort of Malawian SAM-survivor children were followed up seven years after inpatient SAM treatment and compared with sibling and community controls. Seven years post-treatment, nearly one-third of discharged cases had died and another 15% were lost to follow-up. SAM survivors had lower height-for-age (HAZ) compared with controls, although with evidence of catch-up growth. Associated functional impairments were found, such as poorer physical strength, poorer physical capacity, and lower school achievement, compared to controls. Results suggest that SAM has long-term adverse effects (patterns of growth associated with future NCDs), but with potential for rehabilitation (evidence of catch-up growth and largely preserved lung and cardiometabolic functions). Recommendations for future follow-ups include establishing the effects of puberty and later dietary or social transitions.

Extensive research links nutrition in early life with adult health and non-communicable diseases (NCDs), a field of research known as developmental origins of health and disease (DOHaD). Most evidence for DOHaD describes associations between in utero or very early postnatal exposures and adult NCD risk. However, it is biologically plausible that early life events such as severe acute malnutrition (SAM) during late infancy or early childhood, and the rapid catch-up growth that occurs during and after treatment, could have long-term health implications.

The chronic disease outcomes after SAM in Malawian children (ChroSAM) study followed up children seven years after they had received SAM inpatient treatment. Researchers investigated the effects of SAM on growth, body composition, functional outcomes and risk factors for NCDs.

Study overview

The original prospective cohort comprised 1,024 patients admitted for SAM treatment at Queen Elizabeth Hospital in Blantyre, Malawi, during a nine-month period (July 2006 to March 2007). All patients were treated with initial inpatient stabilisation using therapeutic milk, followed by nutritional rehabilitation with ready-to-use therapeutic food (RUTF) at home. The median age at admission was 24 months. The ChroSAM study group was made up of 320 surviving children from the original cohort, identified from a one-year post-discharge follow-up study (n=477). For comparison, the researchers aimed to recruit one sibling control (the sibling closest in age to the case child) and one community control (a child of the same sex and close in age living in the same community) per child in the case group. Children who had been treated for SAM were not eligible as controls.

The study’s outcomes of interest included: anthropometry, body composition, lung function, physical capacity (measured as handgrip strength, step test and physical activity), school achievement and blood markers of NCD risk. Multivariate linear regression was used to compare all outcomes, adjusted for age, sex, HIV status and socioeconomic status, as well as puberty in the body composition regression model. Data collectors were not blinded to the case or control status of the children. With 320 cases, 217 sibling controls and 184 community controls, the authors calculated that the study was adequately powered (at least 90% to detect a Z score difference of 0.5 between the cases and controls based on reference data for growth and lung function outcome). The sample size was considered adequate for all outcomes except physical activity (steps per day), which was underpowered.


Of the 1,024 children originally admitted, 238 (23%) died during treatment. At one-year follow-up, 24% of children were known to have died (192/786 of those discharged); an additional 117 were lost to follow-up. Of 398 children traced seven years post-discharge, 46 (11.5%) had died. Thus, of 786 children discharged from SAM treatment, nearly one-third (30%) were known to have died seven years later and another 15% were lost to follow-up. (See Figure 1.)

Figure 1: Recruitment of the case group1

Key findings show:

Most of the other NCD risk factors assessed (such as lipid profle and glucose tolerance) were not significantly different between cases and controls, except for diastolic blood pressure, which was higher for cases than for sibling controls (adjusted diference 1·91 mm Hg, p=0·03). Amongst cases, 28% were confirmed HIV-positive (compared to 4% in sibling controls and 3% in community controls).

The authors identified a number of limitations to their research, including:


The results from the study suggest that SAM has long-term adverse effects, especially with regard to mortality, growth and body composition. SAM survivors continue to have signi?cantly more stunting than their siblings and other children in their community at seven years’ post-discharge from inpatient nutritional treatment. Associated functional impairments include poorer physical strength, poorer physical capacity, and lower school achievement than controls.

Despite greater stunting among cases, sitting height was similar to controls, suggesting that torso growth had been preserved while limb growth was compromised. Other outcomes such as head circumference were also similar in all groups, while lung function and HbA1c were close to normal when compared with children of African-American origin in all groups. This suggests that survivors of SAM might have undergone so-called brain-sparing or thrifty growth, whereby the growth of vital organs has been preserved at the cost of less vital growth.

Large sitting-to-standing height ratio, short limb length, lower peripheral mass, and larger waist-to-hip ratio have all been associated with NCDs in adulthood. The pattern of lower lean mass and preservation of fat mass seen in children in the case group is similar to that seen in children born with low birthweight (LBW). This is an important predictor of physical work capacity in later life. The combination of reduced lean mass and greater stunting compared with controls might explain the de?ciencies in physical function and strength seen in the SAM survivors. Weaker handgrip is also associated with lower bone mass, impaired cell membrane potential, and reduced muscle function, as well as all-cause early mortality, risk of malnutrition and risk of NCDs.

However, SAM survivors did show signs of growth recovery, with gain in HAZ increasing at a steeper rate in cases who were catching up to their sibling controls. The evidence for catch-up growth, as well as the apparent preservation of vital organs, suggests the potential for recovery following SAM. Yet case study children remain relatively small (compared with global population for this age), and organ damage might only become apparent when exposed to weight gain and unhealthy lifestyles (as seen in studies of LBW). SAM survivors may face potentially greater NCD risks due to changes in dietary trends in many African countries.

This study found high in-treatment and post-discharge mortality amongst children treated for SAM. The study period preceded the establishment of community-based management of acute malnutrition (CMAM) in Malawi with associated earlier detection of SAM and outpatient care options.

In conclusion, the study suggests that SAM has long-term adverse effects, with survivors showing patterns of ‘thrifty growth’ associated with future NCDs. Evidence for catch-up growth and preservation of vital organs suggests potential for rehabilitation, but future follow-ups need to focus on how to optimise recovery and minimise any long-term adverse outcomes.


*Lelijveld, Natasha, Andrew Seal, Jonathan C Wells, Jane Kirkby, Charles Opondo, Emmanuel Chimwezi, James Bunn, et al. 2016. “Chronic Disease Outcomes after Severe Acute Malnutrition in Malawian Children (ChroSAM): A Cohort Study.” The Lancet Global Health 4 (9) (September 14): e654–e662. doi:10.1016/S2214-109X(16)30133-4.

1 Flow diagram showing recruitment, starting with original recruitment in 2006 for the PRONUT study, followed by one-year follow up in the FuSAM study, and the present follow-up (ChroSAM).


More like this

FEX: Follow-up of post-discharge growth and mortality after treatment for SAM in Malawi

Summary of research1 Location: Malawi What we know: There are limited data on long term outcomes following discharge from SAM treatment; what exists is largely pre-HIV....

FEX: Long-term outcomes for children with disability and severe acute malnutrition in Malawi

View this article as a pdf Research snapshot1 Despite broad understanding that severe acute malnutrition (SAM) and disability can cause and influence one another, there is...

FEX: Impact of maternal mental health on recovery from severe acute malnutrition in Malawi

View this article as a pdf MSc summer project1 By Mphatso Nancy Chisala Mphatso Chisala is a medic by profession with an interest in the prevention and treatment of child...

FEX: Severe malnutrition in infants under six months old: outcomes and risk factors in Bangladesh

Summary of research1 Location: Bangladesh What we know: The World Health Organization (WHO) recommends that infants under six months with uncomplicated severe acute...

en-net: Impact of acute undernutrition on stunting

Can anyone point me in the direction of any research on the links between acute and chronic undernutrition? I'm looking at the extent to which a failure to prevent acute...

FEX: Promoting linear growth when treating child wasting

View this article as a pdf This article discusses the state of evidence surrounding the treatment of wasted and stunted children considering current challenges and possible...

en-net: Do we need to reconsider the CMAM admission and discharge criteria?; an analysis of CMAM data in South Sudan

You can find the paper through the link below and is also attached. please help share with...

FEX: Kenya and Malawi: Intestinal disturbances and mortality in complex malnutrition cases

View this article as a pdf Lisez cet article en français ici This is a summary of the following paper: Wen B, Farooqui A, Bourden C et al. (2023) Intestinal...

FEX: Ghana: Sustained growth effects of early lipid-based nutrient supplements

This is a summary of the following paper: Bentil H, Adu-Afarwuah S, Prado E et al. (2023) Sustained effects of small-quantity lipid-based nutrient supplements provided during...

FEX: The link between foetal and childhood nutrition and adult non-communicable disease: lessons from birth cohort studies in India

View this article as a pdf Research summary1 Location: India What we know: Non-communicable diseases (NCDs) are rising in prevalence globally and they particularly affect...

FEX: Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali

Summary of research1 Location: Mali What we know: Community-led total sanitation (CLTS) is being scaled up, but there is limited evidence on child health impacts. What this...

FEX: Concerns that The Lancet double-burden series may undermine moderate wasting treatment

View this article as a pdf By Mark Manary, Donna Wegner, D Taylor Hendrixson, Rebecca Roediger, Meghan Callaghan Mark Manary is one of the world's foremost experts in...

en-net: Malnutrition & Disability, indicator and age

We are planning a cross sectional survey (with nested case-control study with 2 controls: sibling+neighbour) looking at malnutrition & disability. I am wondering if there is...

FEX: Tackling the double burden of malnutrition in low and middle-income countries: response of the international community

Research By Alexandra Rutishauser-Perera Alexandra Rutishauser-Perera is a Humanitarian Nutrition Adviser with Save the Children. She has ten years of experience of public...

FEX: Research Snapshots

The following provides a short summary of each of these important research studies. A fuller summary of each can be found online at Inpatient management...

FEX: Defining and treating “high-risk” moderate acute malnutrition using expanded admission criteria (Hi-MAM Study): A cluster-randomised controlled trial protocol

View this article as a pdf By Natasha Lelijveld, David Taylor Hendrixson, Claire Godbout, Alyssa Los, Jukka M Leppänen, Aminata Koroma and Mark Manary Natasha Lelijveld...

FEX: Risk factors associated with severe acute malnutrition in infants under six months in India: a cross sectional analysis

By Susan Thurstans Susan is a registered nurse and midwife with over 12 years' experience in maternal and child health and nutrition programmes in both development and...

FEX: Does nutritional supplementation for two weeks prevent malnutrition in ill children?

Summary of research1 Location: DRC, Uganda and Nigeria What we know: Ill children are at increased risk of malnutrition due to the infection-malnutrition cycle. What this...

FEX: Prevalence, clinical predictors, and outcome of hypocalcaemia in severely malnourished children in urban Bangladesh

Summary of review1 Location: Bangladesh What we know: Severely malnourished children are depleted in electrolytes. Therapeutic milks contain calcium, however there is no WHO...

FEX: Inflammation and moderate acute malnutrition in children: A cross-sectional study in Burkina Faso

Summary of conference abstract1 Presented at the ACF research conference, November 9, 2016. Published research: B Cichon, F Fabiansen, CW Yaméogo, MJH Rytter, C Ritz, A...


Reference this page

Lelijveld, Natasha, Andrew Seal, Jonathan C Wells, Jane Kirkby, Charles Opondo, Emmanuel Chimwezi, James Bunn, et al. (). Chronic disease outcomes after SAM in Malawian children (ChroSAM): A cohort study. Field Exchange 53, November 2016. p17.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.