Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Epidemiology and Biostatistics


Campbell, M. Karen

2nd Supervisor

Stranges, Saverio

Joint Supervisor


There is only sparse research in Sub-Saharan Africa (SSA) that focuses on the double burden of malnutrition (DBM) among the most vulnerable population including women and infants. Therefore, the objectives of this thesis were (1) to describe the current state of knowledge regarding the DBM among preschool children and women of reproductive age in low- and middle-income countries, (2) to determine the patterns and predictors of the household level DBM in mother-child dyads in SSA, and (3) To determine the patterns and predictors of the individual level DBM among women of reproductive age in SSA. A scoping review and thematic analysis of the literature was done to examine the first objective. Theoretically- driven secondary data analyses from Cameroon, Nigeria, Rwanda, and Zimbabwe were performed to explore the second and third objectives. Data were obtained from the Demographic and Health Survey program. Our scoping review revealed existence of varied phenotypes operationally defining DBM, most of which used anthropometric measures as indicators for nutrition status. The following themes emerged as plausible mechanisms for DBM development: nutrition transition, breastfeeding, diet behaviour, biological mechanism, and statistical artifact. Data analyses for objective 2 indicated that the prevalence of household DBM ranged from 7.6–7.8%. Predictors for higher odds of DBM across all the countries were increasing child and mother’s ages, male child, maternal short stature, higher parity, short interpregnancy interval whereas those for lower odds were higher mother’s education and breastfeeding. Parity and age at first birth were found to mediate the relationship between mother’s education and DBM. Finally, objective 3 findings revealed that the prevalence of individual level DBM ranged from 3.1% (Rwanda) to 16.5% (Nigeria). Predictors for higher odds of DBM were age, higher parity, lower age at first birth, short stature, being married/formerly married, being a Christian or Muslim, higher education, higher household wealth, higher neighbourhood wealth. Parity and household wealth were found to be key mediators in the association between neighborhood variables and DBM. This thesis reveals that DBM may represent the current and possibly future nutrition burden in SSA and it requires creative ways to address the challenge it portends.

Summary for Lay Audience

The double burden of malnutrition (DBM) is a term used to describe the coexistence of different forms of undernutrition (e.g., underweight and stunting) alongside overnutrition (e.g., overweight and obesity). This coexistence can occur at the population, household, or the individual levels. Though no one is spared from the effects of DBM, certain population sub-groups such as women of reproductive age (15-49 years) and preschool children (5 years and below) are among the most vulnerable groups. Despite its recognition by the World Health Organization as a serious public health issue in developing countries, little research has been conducted in Sub-Saharan Africa among the aforementioned populations. This research therefore was designed to address this gap by first scrutinizing the current literature with the aim of understanding the cause(s) of DBM and drivers that shape its occurrence in the population. Additionally, we conducted analyses from survey data from four countries (Cameroon, Nigeria, Rwanda, and Zimbabwe) with an aim of determining the relationship between common socio-demographic factors and DBM:- assessed at the household (mother and child pairs) and individual levels (women). Findings from our literature review showed that there is no consistency in how DBM is defined. Furthermore, our review showed that, depending on how it is defined, there are various ways that can lead to the occurrence of DBM. This includes substantial changes in diet, diet behavior, breastfeeding practices, biology, and extraneous interpretation of data. Our data analyses revealed that all the countries had similar proportions of household DBM averaging at 7.6%. However, when assessed at the individual level, the proportion of women who had DBM ranged from 3.1% (Rwanda) to 16.5% (Nigeria). DBM was likely to occur in households and individuals with the following characteristics: older age for both the mother and the preschool child, households with boys, many children and mothers who had short birth spacing and those gave birth in adolescence and higher household wealth. Households were protected from DBM if mothers had higher education and regularly breastfed. This thesis shows that DBM is an emerging public health concern in SSA and action is required to address it.

Available for download on Thursday, May 01, 2025