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The Dual Burden of Malnutrition – Trials of Improved Practice Methodology Utilized in Rwanda

Poor nutrition continues to cause nearly half of deaths in children under five, while low- and middle-income countries now witness a simultaneous rise in childhood overweight and obesity – increasing at a rate 30% faster than in richer nations.[i] The co-existence of under and overweight is widely known as the double or dual burden of malnutrition.[ii] According to WHO, in 2014,

Most of the world's population live in countries where overweight and obesity kills more people than underweight; Worldwide obesity has more than doubled since 1980;

In 2014, more than 1.9 billion adults, 18 years and older, were overweight. Of these, over 600 million were obese; 39% of adults aged 18 years and over were overweight in 2014, and 13% were obese. [iii]

Globally, the greatest increase of overweight children under 5 years of age was found in low- and middle-income countries.[iv] In Africa, countries are grappling with the extremes of both underweight caused by limited access and availability of nutritious foods (for multiple reasons) as well as overweight caused by changed diet, introduction of an increased amount of processed foods and sedentary lifestyle etc. For example, Rwanda experienced one of the largest increases in overweight children among sub-Saharan African countries from 1990-2012.[v] The prevalence of overweight children under 5 years of age in Rwanda in 2014-15 was 7.7%, while the prevalence of underweight was 9.3%.[vi]

Attempting to understand and address dual-burden requires further investigation. As such, in 2016, Research Triangle Institute (RTI) partnered with Three Stones and the Ministry of Health’s implementation arm, the Rwanda Biomedical Center (RBC), to better understand the problem in Rwanda.


...this research will benefit Rwanda and the global community at large by contributing new knowledge about how under- and overweight infants and young children are being fed in Rwanda and how families are willing to change feeding practices... – RTI International


Dual burden study in Rwanda

The study, “Using Trials of Improved Practices to Test Strategies for More Optimal Nutrition in Underweight and Overweight Children in Rwanda,” funded and led by RTI, began in December 2016 and included 4 months of research fieldwork in rural and urban locations in Rwanda. Three Stones was selected to provide in country support to secure approvals for the study, develop contextualized tools for research, collect data from the field, and contribute to the analysis and dissemination of results of the study. Additional insights and valuable context was provided by co-investigators from RBC.

Data Collection

Three Stones led a 12-person field team composed of university-trained nurses. In accordance with the research methodology and protocols, we screened approximately 1,500 participants, purposely identifying under- and overweight children who were within a 6-59-month-old category using the WHO standard weight for height ratios. This phase was challenging both in identifying overweight children in rural areas and attending to common misperceptions that bigger babies are naturally healthier. Finally, after the screening, 136 children were successfully recruited for enrollment in the study. Overweight children were oversampled as less information is available on their diet and physical activity, whereas the underweight category is well established based on previous nationwide studies conducted in Rwanda.

Three Stones, Utilizing the Trials of Improved Practice

The research approach consisted of three separate visits to each of the chosen households. Approximately half of the children were from the urban area of Kigali City and the other half were from the rural areas of Rulindo and Gasabo districts in the Northern Province. Over the three visits to each household, the Three Stones research team was responsible for gathering a full description of household demographics as well as an understanding of the situation of each household. During the second visit, researchers provided recommendations of “doable actions” which caregivers of the children could easily undertake to improve the health and nutrition of the child in their care. The third visit, which occurred at least a week after the second visit, provided caregivers with an opportunity to give feedback on which recommendations they were able to follow and what worked and what needed to be altered. Three Stones’ researchers carefully recorded feedback from caregivers at each household in order to develop an understanding of barriers and facilitate better nutritional outcomes for overweight and underweight children.


25 key recommendations/ strategies applicable to caregivers of both overweight and underweight children emerged from the fieldwork. These findings provide guidance for future interventions for implementers and donors who want to provide nutritional messaging to caregivers of young children. RTI is finalizing the findings.


On January 30th 2018, a dissemination meeting was held in Kigali organized by Three Stones, RTI and RBC. The meeting provided a forum to share and highlight the methodology and data collection approach and initial findings. After a lively panel discussion, an interactive brainstorming session was facilitated to develop recommendations for next steps and consider program and policy priorities. In attendance were representatives from UNICEF, USAID, WHO, Swiss Development Agency, SUN Alliance, and several INGO and local organizations. Participants provided excellent feedback which will be incorporated in future publications and possible interventions.




[iv] World Health Organization (WHO), Report of the commission on ending childhood obesity, 2016, Geneva, Switzerland: WHO Document Production Services.

[v] Tzioumis, E., et al., Prevalence and trends in the childhood dual burden of malnutrition in low- and middle-income countries, 1990-2012. Public Health Nutr, 2016: p. Feb 24:1-14 [epub ahead of print].

[vi] National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda], and ICF International, Rwanda demographic and health survey 2014-15. 2015, Rockville, MD, USA: NISR, MOH, and ICF International.

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