RESEARCH PROJECT

PREVALENCE AND RISK FACTORS OF OVERWEIGHT AND OBESITY, AND

IDEAL BODY SIZE PERCEPTION, AMONG BREASTFEEDING MOTHERS
BETWEEN 1 AND 2 YEARS AFTER DELIVERY AT GATENGA HEALTH CENTER.

by

Andre MUNYANDAMUTSA
Valens NIYIGABA
Olivier RUKUNDO
Research project submitted in partial fulfillment of the requirement for the award of
bachelor’s degree with honours in
Human Nutrition and Dietetics
in
The Department of Human Nutrition and Dietetics
School of Public Health

University of Rwanda, College of Medicine and Health Sciences

Research project supervisor: Yves Didier UMWUNGERIMWIZA

Kigali, July 2022

DECLARATION
We Andre MUNYANDAMUTSA, Valens NIYIGABA, Olivier RUKUNDO, hereby declare
that this research project entitled “Prevalence and risk factors of overweight and obesity,
and ideal body size perception, among breastfeeding mothers between 1 and 2 years after
delivery at Gatenga health center” is our original study and has no any submission to any
institution for degree award requirements.

Andre MUNYANDAMUTSA signature………………

Valens NIYIGABA signature…………..........

Olivier RUKUNDO signature ……...………..

This research project is submitted with the supervision and approval of:

Mr. Yves Didier UMWUNGERIMWIZA

Signature ………………………………… Date………….……………….

ii
DEDICATION

Dedication of our study goes to Almighty God, beloved parents, families, friends, beloved
colleagues, and all Human Nutrition and Dietetics department staff members.

iii
ACKNOWLEDGEMENT

We thank everyone who participated in this research project. Special thanks go to Mr. Yves
Didier UMWUNGERIMWIZA for his support and guidance during the preparation of this
research project as a supervisor.

We kindly thank all lecturers of human nutrition and dietetics department, your daily advice
was the foundation of this study. We also thank Gatenga health center for their support in this
project.

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ABSTRACT
Background: Healthy and adequate nutrition have benefits on breastfeeding mothers and
overall of their health status. In 2016, 39% of adults aged 18 and above were overweight and
13% were found to be obese as reported by World Health Organization (WHO); and has
adopted a voluntary target to combat with the rise in obesity by 2025. Several factors, have
been reported to influence postpartum weight change.

Objective: Study’s main objective was to carry out assessment of prevalence and risk factors
of overweight and obesity, and ideal body size perception, among breast feeding mothers
between 1 and 2 years after delivery at Gatenga health center.

Methods: 105 breastfeeding mothers were sampled using a cross-sectional study design which
employed both qualitative and quantitative methods.

Results: Overweight and obesity were 26.7% and 20.0% respectively based on BMI, and
central obesity was 50.5%. It was found that 53.3% of mothers wish to be heavier, and 19.0%
wish to be thinner, while 27.6% wish to keep their size. The adequate, and inadequate dietary
diversity were found to be 54.3%, and 45.7% respectively.

Conclusion: The study’s findings indicate a need to improve interventions that are related to
postpartum weight management to halt and prevent health related complications arising from
overweight and obesity.
Key indicators: breast feeding, body size perception, overweight and obesity.

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TABLE OF CONTENTS

DECLARATION .................................................................................................................................... ii
DEDICATION ....................................................................................................................................... iii
ACKNOWLEDGEMENT ..................................................................................................................... iv
ABSTRACT............................................................................................................................................ v
ACRONYMS AND ABBREVIATION .............................................................................................. viii
LIST OF THE TABLES ........................................................................................................................ ix
CHAPTER1: INTRODUCTION ............................................................................................................ 1
1.1. KEY TERMS DEFINITIONS ................................................................................................ 1
1.2. BACKGROUND OF THE STUDY ....................................................................................... 2
1.3. PROBLEM STATEMENT ..................................................................................................... 3
1.4. OBJECTIVES OF THE STUDY ............................................................................................ 3
1.4.1 Main study’s objective .................................................................................................... 3
1.4.2. Specific objectives of the study ...................................................................................... 3
1.5. THE SCOPE OF THE STUDY .............................................................................................. 3
1.6. RESEARCH QUESTIONS..................................................................................................... 4
1.7. STUDY’S SIGNIFICANCE ................................................................................................... 4
1.8. THE STUDY’S STRUCTURE ............................................................................................... 4
CHAPTER 2. LITERATURE REVIEW ................................................................................................ 5
CHAPTER 3: RESEARCH METHODOLOGY .................................................................................... 7
3.1. AREA OF THE STUDY ............................................................................................................. 7
3.2. STUDY’S DESIGN ..................................................................................................................... 7
3.3. THE STUDY POPULATION AND SAMPLE ...................................................................... 7
3.3.1. The study population....................................................................................................... 7
3.3.2. Sampling technique ......................................................................................................... 7
3.4. RESPONDENT’S INCLUSIVE AND EXCLUSIVE CRITERIA OF THE STUDY ............ 8
3.4.1. Respondent’s inclusive criteria ....................................................................................... 8
3.4.2. Respondent’s exclusion criteria ...................................................................................... 8
3.5. DATA COLLECTION METHOD ......................................................................................... 8
3.5.1. Data collection tools........................................................................................................ 8
3.5.2. Pretest.............................................................................................................................. 8
3.5.3. Data collection procedures .............................................................................................. 8
3.5.4. Anthropometric Measurements ....................................................................................... 9
3.5.5. Demographic information ............................................................................................... 9
3.5.6. Dietary diversity.............................................................................................................. 9
3.5.7. Breastfeeding practices and behaviors ............................................................................ 9

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 3.5.8. Perceived current and desirable body size ...................................................................... 9
3.6. DATA ANALYSIS ............................................................................................................... 10
3.7. LIMITATIONS OF THE STUDY ........................................................................................ 10
3.8. ETHICAL CONSIDERATION ............................................................................................ 10
CHAPTER 4: RESULTS ...................................................................................................................... 12
4.1. RESPONDENTS’S DEMOGRAPHIC CHARACTERISTICS ........................................... 12
4.2. BREASTFEEDING CHARACTERISTICS OF RESPONDENTS ...................................... 12
4.3. OVERWEIGHT AND OBESITY PREVALENCE BASED ON BMI AND WC ............... 12
4.4. DESIRABLE BODY SIZE ................................................................................................... 13
4.5. THE ADEQUATE AND UNADEQUATE DIETARY DIVERSITY ................................. 13
4.6. CROSS TABULATION FOR ASSOCIATION BETWEEN SOCIODEMOGRAPHIC
FACTORS, DIETARY DIVERSITY, BMI AND WC. ................................................................... 14
4.6.1. Cross tabulation for association between sociodemographic factors, dietary diversity
and BMI 15
4.6.2. Cross tabulation for association between sociodemographic factors, dietary diversity
and WC 15
CHAPTER 5: DISCUSSION ................................................................................................................ 17
5.1. OVERWEIGHT AND OBESITY PREVALENCE AMONG BREASTFEEDING MOTHERS
BETWEEN 1 AND 2 YEARS AFTER DELIVERY ....................................................................... 17
5.2. DESIRABLE BODY SIZE ........................................................................................................ 18
5.3. OVERWEIGHT, OBESITY AND SOCIODEMOGRAPHIC FACTORS ............................... 18
5.4. OVERWEIGHT, OBESITY AND DIETARY DIVERSITY .................................................... 18
CHAPTER 6: CONCLUSION AND RECOMMENDATION ............................................................. 20
6.1. CONCLUSION .......................................................................................................................... 20
6.2. RECOMMENDATION ............................................................................................................. 20
6.2.1. Researchers ......................................................................................................................... 20
6.2.2. Ministry of Health (MoH) and Gatenga health center ........................................................ 20
6.2.3. University of Rwanda ......................................................................................................... 20
7. REFERENCES ................................................................................................................................. 21
8. APPENDIX ....................................................................................................................................... 26
8.1. CONSENT FORM IN ENGLISH.............................................................................................. 26
8.2. CONSENT FORM IN KINYARWANDA VERSION.............................................................. 27
8.3. QUESTIONNAIRE ................................................................................................................... 28
8.4. WORK PLAN ............................................................................................................................ 32
8.5. BUDGET ................................................................................................................................... 33

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ACRONYMS AND ABBREVIATION
BMI: Body mass index

BSD: Body Size Dissatisfaction

CMHS: College of Medicine and Health Sciences

CDC: Centers for Diseases Control and Prevention

ECD: Early Child Development

FANTA: Food and Nutrition Technical Assistance

FAO: Food and Agricultural Organization of the United Nations

FRS: Figure Rating Scale

IYCFP: Infants and Young Children Feeding Practices

IRB: Institutional Review Board

MDD-W: Minimum Dietary Diversity for Women

MoH: Ministry of Health

NCDs: Non communicable diseases

PPWR: Postpartum weight retention

RDHS: Rwanda Demographic and Health Survey

SPSS: Statistical Package for Social Science

UN: United Nations

UR: University of Rwanda

USAID: United States Agency for International Development

WC: Waist Circumference

WHO: World Health Organization

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LIST OF THE TABLES
TABLE4.1. Frequency table for respondents’ characteristics……………………….13
Table 4.6.1.1. Cross tabulation for association between sociodemographic factors, dietary
diversity, and BMI………………………………………………………………………14
Table 4.6.2.1. Cross tabulation for association between sociodemographic factors, dietary
diversity, and WC…………………………………………………………………………14

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CHAPTER1: INTRODUCTION
1.1. KEY TERMS DEFINITIONS
Body weight perception: The perception of body weight is a personal evaluation of weight
status either being normal, overweight or obese irrespective of actual body mass index(3).

Dietary diversity: Diversity of diet refers to the consumption of different food groups for a
specified period(4).

Exclusive breastfeeding: It is a period(usually 6 months) in which infant feed on breast milk

only and there is no additional food , water or other fluids except medicines, minerals or
vitamins drops(5)

Minimum Dietary Diversity for Women(MDD-W): It is a population indicator for women

of reproductive age(15-49years) which uses 10 established food groups to evaluate dietary
diversity(6).

Nutrition: It is a process which combines how living beings get and use important substances
for growth, survival and tissues maintenance(7).

Overweight and obesity: they are nutrition status indicators for the excessive fats storage;
BMI of 25 or over indicates overweight while that of 30 or over indicates obesity(8).

Waist circumference: It represents an individual’s abdomen measurement, the evaluation of

waist circumference is obtained by measuring at the narrowest point between hips and rib
cages, and may be used to tract both population and individual’s nutrition/health status(9).

Postpartum weight retention: It is a result of the difference between postpartum weight at

any point and pre-conception weight(10).
1.2. BACKGROUND OF THE STUDY
Proper nutrition has positive impact on breastfeeding mothers and overall mothers’ health
status, and that is why, mothers’ daily intake of micro- and macronutrients should meet all
nutrition requirements. On the other hand, poor nutrition can lead to some nutritional issues
such as overweight or obesity. The global overweight and obesity has been increasing and is
being regarded as a pandemic. The prevalence of overweight globally as indicated by WHO
in 2016 was 39% in adults aged 18 and above while 13% were obese. Women had higher rate
obesity compared to men (15% for women and 11% for men). There are different measures
that are set by WHO to combat with overweight and obesity by 2025. There are different
strategies and measures set to control overweight and obesity within community. Postnatal
period is accompanied with different physiological and anatomical changes to achieve pre-
pregnancy weight, different reproductive parts and other body compositions may return back
to normal early or later postpartum period and have effects on maternal weight status(11).

In most developing countries overweight and obesity is not given public health like an endemic
undernutrition within those countries(1), but in facts it is among public health issue that is
threatening. Lactation has an impact on weight status of mother after deliver due to energy
increase of 500kcal/day, and stored fats use(12).

There are different factors that affect postpartum weight status, they include socio-economic
factors, demographic factors, preconception and pregnancy. WHO recommends to breastfeed
exclusively for six months and to start complementary feeding after that period (12).

About 20% of women keep 5kg or above that was gained during gestation(13). In addition,
being overweight or obese during preconception increase the risk of maternal obesity. Being
overweight or obese is associated with different health threatening issues like diseases which
are not communicable (NCDs). Intention to evaluate weight change after delivery is of
important among breastfeeding mothers. Overweight and obesity assessment mostly use BMI,
but it has limitations as different research say, there is a need to consider other indicator like
waist circumference(13).

Perception regarding to body image refers to thoughts and feelings that are related to
individual’s shape and size(14). Perception accuracy for individual’s body size differs in
women by BMI(15).

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1.3. PROBLEM STATEMENT
Overweight and obesity has correlation with maternal nutrition intakes, and has impact on
maternal nutrition and health status. In Rwanda, overweight or obesity for women has increased
from 13% to 16.5% in 2000 and 2010 respectively and was high in Kigali city and other urban
areas at rate of 35% and 31.5% respectively (1). Current data on overweight/obesity prevalence
in Rwanda in women of reproductive age(15-49years) is 26%(2). Losing weight acquired
during pregnancy is not observed at the same rate after delivery, some may retain the weight
gained and increase their risk of being overweight or obese. Currently, in Rwanda there are no
data available on obesity and overweight, among breastfeeding mothers between 1 and 2 year
after delivery. Being overweight or obese is a contributor to different health threatening issues
including NCDs among mothers. The aim of determining prevalence and risk factors of
overweight and obesity, and ideal body size perception, among breastfeeding mothers between
1 and 2 years after delivery is significant.
1.4. OBJECTIVES OF THE STUDY
1.4.1 Main study’s objective
The study’s main objective was to determine prevalence and risk factors of overweight and
obesity, and ideal body size perception, among breast feeding mothers between 1 and 2 years
after delivery at Gatenga health center.

1.4.2. Specific objectives of the study

1. To figure out the prevalence of overweight and obesity, among breastfeeding mothers
between 1 and 2 years after delivery.

2. To identify socio and demographic factors that have association with overweight and
obesity, among breastfeeding mothers between 1 and 2 years after delivery.
3. To assess diversity of diet and its association with overweight and obesity, among
breastfeeding mothers between 1 and 2 years after delivery.
4. To assess perceived current and desirable body size perception, among breastfeeding
mothers between 1 and 2 years after delivery.

1.5. THE SCOPE OF THE STUDY

This research was restricted to breastfeeding mothers of children between 1 and 2 years at
Gatenga health center.

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1.6. RESEARCH QUESTIONS
1. What is the percentage of overweight and obesity, among breastfeeding mothers
between 1 and 2 years after delivery at Gatenga health center?
2. What are socio-demographic factors that are related with overweight and obesity,
among breastfeeding mothers between 1 and 2 years after delivery at Gatenga health
center?
3. What is the state of inadequate, and adequate dietary diversity, among breastfeeding
mothers between 1 and 2 years after delivery at Gatenga health center?
4. What is perceived current and desirable body size, among breastfeeding mothers
between 1 and 2 years after delivery at Gatenga health center?

1.7. STUDY’S SIGNIFICANCE

This research reflects what literature talks about breastfeeding practices, diet and weight status
in breastfeeding mothers; where we have referred to different document related to early and
late postpartum weight management for the intention to design intervention(s) to improve
postpartum weight management. We again intensively looked into the reasons why practice of
breastfeeding is related to mothers’ weight state. The study helped us to assess the link between
ideal body size preference and willingness to weight management interventions. This research
will also provide helpful information to both policy makers, and researchers to design
intervention related to breastfeeding mothers. Moreover, the study helped involved students to
gain research experience and to achieve the requirements for our bachelor’s degree.

1.8. THE STUDY’S STRUCTURE

This work comprises of 6 chapters. Chapter one is for introduction part, chapter two is for
review of what literature say, chapter three talks about study methodology, chapter four
indicates study’s results, fifth chapter display discussion while the last chapter has conclusion
and recommendations. The list of references and appendices are also provided at the end of the
six chapters respectively

4
CHAPTER 2. LITERATURE REVIEW
Global overweight and obesity are among nowadays public health issues. Referring to CDC
in 2012, 35.1% female above 20 years of age were obese and 33.9% were overweight. Being
overweight or obese is linked to impaired fertility, cardiovascular disease, antennal and
postnatal complications and other risks contributing to NCDs.(16).

Breastfeeding is expected to contribute to the loss of weight gained and fats stored during
gestation period. Breastfeeding contributes to prevention of weight and fats retention for
women who have proper dietary intakes and practices. One of the study conducted showed
that losing weight among mothers is more for breastfeeding mothers than non-
breastfeeding(17).

Lipsky et al have assessed the pattern of weight among breastfeeding mothers between 1 and
2 years after delivery and they found that 1 in 4 women gained weight more than 2.25kg
during the late postpartum period(18).

Different health issues have link with obesity, the obesity has doubled between 1980 and
2008 and it is becoming public health threat by affecting health status, quality of life and
causing different complications. Gestation period is one of the key factors that contribute to
female weight gain(19).

In Rwanda, overweight/obesity among women prevalence was found to be 13%, 12% and
16% in years of 2000, 2005, and 2010 respectively; the urban areas had high prevalence
compared to rural ones(1).
According to the study conducted based on demographic and health surveys from 1991 to
2014 across 24 countries in Africa trends in overweight and obesity placed Rwanda among
countries where obesity has doubled(20).

The limited use of BMI in assessing fat composition and distribution and anatomical
variations of fats deposit favor the recommendation for use of WC as surrogate measure for
visceral or abdominal fat. In addition, there is an evidence for use of WC in field of
epidemiology to identify individuals with heightened risks for development of cardio-
metabolic diseases(21).

Culture is highly linked with body image and body size perception, from childhood culture
affects body image and body size preferences and the ideal body size preferences are seen

5
across different countries. Overweight or obesity has been regarded as richness in most
African and Arabic countries while among Western people slim body is highly preferred
however, the preference of slim body size has been being preferred in non-Western countries
and that attitude is result of globalization, urbanization and nutrition transition(22).
Increment of overweight and obesity prevalence is of various factors such as socioeconomic
status, lifestyle, food environment and culture. Proposing and enhancing different policies
and actions have been occurring to mitigate overweight and obesity health related threats
such as food laws and regulations, behavior change communication, counseling and
education(23).
The study conducted in the United States showed that: 47% of mothers gained excess weight
during pregnancy and 13-20% did not achieve their preconception weight. They were
weighing additional of 5kg at period between 6 and 18 months after delivery compared to
preconception weight. The retention of weight after delivery termed “ Postpartum Weight
Retention(PPWR) has a significant contribution the obesity’s vicious cycle among women
which contributes to further unhealthy impacts(24).
Different factors affect change in PPWR, they including diet, pregnancy weight gain,
activity level, and preconception weight and breastfeeding duration. Prolonged lactation
may contributes to maternal weight loss due to increased energy needs and use of stored fats
during gestation period(24).
The study carried out on body size perception found that involved participants have
perceived their body size to be heavier than they actually they were. Participants who were
overweight acquired more mean for body size misperception compared to obese ones(15).
Individual’s weight status has impact on body size satisfaction, there is an evidence that size
of the body dissatisfaction has a great association in adoption of behaviors and practices
aiming to control body weight, among women perceiving body size as being obese can
contribute to behavior changes needed for weight control(25).
Self-weight perception and body size satisfaction have contribution to the weight control.
There are number of factors that contribute to body size satisfaction or dissatisfaction such
as age, gender, family, friends, psychological factors and socio-cultural elements, in
addition, people’s dissatisfaction of body size attract them to adopt behaviors for overcoming
the discomfort but literature has proved that the misperception of body size might lower
incentives to practice physical activity(26).

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CHAPTER 3: RESEARCH METHODOLOGY
This part of the work has description for study methodology. It has different sections
including area of the study, study design, recruited population, study sample, data collection
method, analysis done, limitation of the study, and ethical consideration.
3.1. AREA OF THE STUDY
This study was carried out at Gatenga health center, which is located in Kigali city, Kicukiro
district, Gatenga sector. Gatenga sector has four cells, 48,640 population (23,613 female
and 25,027 male), and area of 12.44 km² and 3,910/km² population density(27). Gatenga
Health Center which is under catchment area of Masaka hospital was our data collection site.
We chose this health center because it is located in Kigali city where RDHS 2019-20
indicated that Kigali city has the highest percentage of overweight and obesity among
women of reproductive age in Rwanda with prevalence of 43%(2).
3.2. STUDY’S DESIGN
The study was conducted as a descriptive cross-sectional study, which used both quantitative
and qualitative data. The questionnaire was adapted from the guidelines provided by WHO
to assess overweight, and obesity(28), WHO guidelines used in assessing IYCF
practice(29), FAO’s guidelines in assessing MDD-W(6), and FRS adapted from Stunkard
body size perception assessment guidelines(30). In addition, questionnaire was used to
collect data on mothers’ demography, anthropometry, healthy and desirable body size
perception, breastfeeding and dietary diversity.
3.3. THE STUDY POPULATION AND SAMPLE
3.3.1. The study population
The study’s intended population were breastfeeding mothers between 1 and 2 years after
delivery attending Gatenga health center.

3.3.2. Sampling technique

The sample of the study were breastfeeding mothers between 1 and 2 years after delivery
who attended Gatenga Health Center services during period of our study, from 21st
December, 2021 to 24th January, 2022. During that period we have collected data on 105
breastfeeding mothers between 1 and 2 years after delivery. In addition, convenience
sampling strategy was used during the time of the research.

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3.4. RESPONDENT’S INCLUSIVE AND EXCLUSIVE CRITERIA OF THE STUDY
3.4.1. Respondent’s inclusive criteria
Inclusive criteria for this study focused on breastfeeding mothers between 1 and 2 years
after delivery at Gatenga health center who voluntarily accepted participation in the study.
3.4.2. Respondent’s exclusion criteria
Being excluded from the study focused on the mothers who did not matcth criteria that
include: breastfeeding mothers between 1 and 2 years after delivery, and voluntary
participation in the study were excluded.
3.5. DATA COLLECTION METHOD
Data were obtained from breastfeeding mothers between 1 and 2 years after delivery. The
questionnaire used has different sections including demographic section, anthropometric
section, diet diversity section, breastfeeding practices and behavior section, and body size
perception section.
3.5.1. Data collection tools
Tools used during data collection include an electronic scale, pens, stadiometer, and tape
measure. The questionnaire was adapted from the guidelines provided by WHO to assess
overweight, and obesity(28), WHO guidelines used in assessing IYCF practice(29), FAO
and USAID’s FANTA guidelines in assessing MDD-W(6), and FRS adapted from Stunkard
body size perception assessment guidelines(30).
3.5.2. Pretest
To assess the structure and strength our questionnaire we pretested it before conducting the
study in order to check and evaluate its clarity and accuracy. We made efforts in correcting
unclear questions and also we reviewed the structure and order of questions to avoid errors
in data collection and further entry, analysis, and interpretation. The questionnaire was
administered to 5 breastfeeding mothers between 1 and 2 years after delivery who attended
different services offered at Gatenga health center. After pretesting, identified corrections
were made before conducting the actual study.

3.5.3. Data collection procedures

Primary quantitative, and qualitative data were obtained to meet the study’s purpose of
getting information on the prevalence and risk factors of overweight and obesity, and ideal
body size perception, among breastfeeding mothers between 1 and 2 years after delivery
attending Gatenga health center. Gatenga health center was our site of data collection.
Respondents were given information about the research conducted and they were asked to
sign informed consent form. Following a signed informed consent, mothers who accepted

8
to take a participation in the study voluntarily; questionnaire was used to collect data on
them.

3.5.4. Anthropometric Measurements

The nearest of 0.1kg of accuracy was used to record measured mother’s weight, to measure
weight the study employed use of electronic scale named “seca”. Mothers were requested to
step on scale, they were measured without shoes and empty pockets; possibly with minimum
clothing. Stadiometer was employed to measure mother’s height with consideration of
nearest of 0.1cm as an accuracy, while waist circumference (WC) was obtained using a tape
measure with the same accuracy as that used to measure height. Body Mass Index(BMI) was
obtained by dividing weight in kg by squared height in metre, while WC was obtained by
measuring circumference at the widest girth(31).
3.5.5. Demographic information
Socio and demographic data that are related to mothers were obtained using study’s
questionnaire. Questionnaire focused on mothers’ information on mother’s education, age,
location, and wealth categories (Ubudehe categories). Child’s age was obtained from child’s
growth chart information, while mother was requested to present her identification card or
asked about her demographic information.
3.5.6. Dietary diversity
In the questionnaire, information on adequate, and inadequate dietary diversity among
breastfeeding mothers between 1 and 2 years after delivery attending Gatenga health center
were obtained using a population indicator in assessing dietary diversity among women of
reproductive age(MDD-W) by using qualitative 24hours dietary recall(6).
3.5.7. Breastfeeding practices and behaviors
The questionnaire was also addressing how often, how long and the way mothers breastfeed
their babies, based on WHO guidelines on breastfeeding(29).
3.5.8. Perceived current and desirable body size
To obtain data on mothers’ perceived current and desirable body size the study has used a
Stunkard Figure Rating Scale (FRS) (32). It has nine female or male drawn figures of
increasing body size used to evaluate individual’s body size perception(33). Mothers were
asked two questions; the first one was asking a mother to rate her current body size while
the second question was asking her to state her ideal body size she desires; a dissatisfaction
of body size was noted by obtaining the discrepancy(34).

9
3.6. DATA ANALYSIS
Data were checked manually for missing and unclarified information. Coded data were
entered in Microsoft Excel then were analyzed using IBM SPSS version 21. The descriptive
aspects of the findings were obtained using IBM SPSS, cross tabulation was done with aim
of determining socio-demographic factors, and dietary diversity association with overweight
and obesity, and Chi square test was employed to see if there is any association. The
established formula for the test is written as χ2 = ∑ (Oi – Ei) 2/Ei, where Oi = observed value
(actual value) and Ei = expected value. The considered P values for a significant association
are those below 0.05 and variables with this P value were sent to logistic regression for
identifying the nature of association(35).

For assessing nutrition status of mothers; the World Health Organization established cutoffs
were used to make BMI and WC classifications(28): underweight was considered when
BMI<18.5, a BMI of 18.5 -24.9 was classified as normal, a BMI of 25-29.9 was classified
as overweight while a BMI OF 30 and over was classified as being obese. While for WC for
female it is normal if WC<80cm, while WC>=80cm is considered as having central obesity.
The population’s indicator among women of reproductive age; MDD-W was considered to
evaluate diet quality (adequate, inadequate dietary diversity) among breastfeeding mothers
between 1 and 2 years after delivery. The adequate dietary diversity was considered only if
at least five predetermined food groups were consumed while below five food groups was
classified as inadequate; for each category percentage of inadequate, and adequate dietary
diversity was calculated regarding number of participants (6). Moreover, a Body Size
Dissatisfaction (BSD) variable was created to analyze perceived current and desirable body
size, the variable was obtained by subtracting perceived current body size from ideal body
size both scored on Figure Rating Scare (FRS). The indication of wishing to be thinner is a
BSD score of <1 A , the indication of wishing to be heavier is a BSD score >1 while a BSD
score of zero was considered as body size satisfaction(30).

3.7. LIMITATIONS OF THE STUDY

The study has not received any financial support from any institution to be done, and in
effect, this led to limited time of data collection and hence we reached a small sample size.
In addition, having a small sample size may limits generalization to the population.

3.8.ETHICAL CONSIDERATION
To conduct our study we have requested, and obtained ethical clearance from University of
Rwanda Institutional Review Board (IRB). In our study participation was voluntarily agree,
10
participant signed an informed consent form and had full right to withdraw from the study
at any stage of the study. Confidentiality was kept and maintained about participant’s
information. Participant presenting with nutrition or other health issue during the period of
our study was referred to Gatenga health center authorities for further management.

11
CHAPTER 4: RESULTS
Results chapter displays different findings from the study with respect of the established
study objectives. This section contains results about demographic, breastfeeding, nutrition
status based on body mass index, and waist circumference, dietary diversity, desirable body
size, and cross tabulations results to identify association between overweight and obesity and
sociodemographic factors and dietary diversity. Moreover, this chapter displays different
tables from analysis of the data of the study.

4.1. RESPONDENTS’S DEMOGRAPHIC CHARACTERISTICS

During our study we collected data on 105 breastfeeding mothers of children between 1 and
2 years old in Gagetnga sector. As shown in the Table 4.1, the respondents were from
different Ubudehe category, and they have different level of education, having children
between 12 and 24 months. The minimum mother’s age is 18 years, while the maximum is
49 years. On the side of the children the minimum child’s age is 12 months, while the
maximum mother’s age is 24 months. The description of respondents based on education
level shows that 4.8% are not educated, 41.9% have primary education, 47.6% have
secondary education, and 5.7% are graduate. The description of respondents based on
Ubudehe category shows that 37.1% are from first category, 33.3% are from second
category, and 29.5% are from third category.

4.2. BREASTFEEDING CHARACTERISTICS OF RESPONDENTS

Description of respondents ’breastfeeding characteristics provided in the table 4.1, based on
if they have practiced exclusive breastfeeding, 6.7% have not practiced exclusive
breastfeeding, and 93.3% have practiced exclusive breastfeeding. For continued
breastfeeding is 100%.

For the frequency of breastfeeding, mothers were classified as follow 2 to 4, 4 to 6, and

above 6, based on times they breastfeed daily, and the percentage rate is 17.1%, 29.5% and
53.3% respectively. Furthermore, for duration of breastfeeding, 61.0%, 24.8%, and 14.3%
of the respondents breastfeed between 5 to 10 minutes, 10 to 15minutes, and above 15
minutes respectively per each breastfeed.
4.3. OVERWEIGHT AND OBESITY PREVALENCE BASED ON BMI AND WC
As table 4.1 is displaying, based on classification of BMI, among 105 respondents, 5.7%
were found to be underweight, 47.6% were normal, while 26.7% were overweight and 20.0%

12
were obese. In addition, based on classification of waist circumference in assessing central
obesity, 49.5% were normal, 50.5% were obese.

4.4. DESIRABLE BODY SIZE

Among 105 respondents, 53.3% wish to be heavier, and 19.0% wish to be thinner than they
actually are, while 27.6% want to keep their size.
4.5. THE ADEQUATE AND UNADEQUATE DIETARY DIVERSITY
The adequate and inadequate dietary diversity were evaluated using MDD-W by employing
a qualitative 24hours recall. The adequate dietary diversity was awarded to a mother who
consumed at least 5 food groups from established 10 food, while the consumption of food
groups below 5 was considered as inadequate(6). The adequate, and inadequate dietary
diversity among breastfeeding mothers between 1 and 2 years after delivery in Gatenga
sector is 54.3%, and 45.7% respectively.

13
Table 4.1. Frequency table for respondents’ characteristics
Background characteristics Frequency Percentage (%)
Education level Not educated 5 4.8
Primary 44 41.9
Secondary 50 47.6
Graduate 6 5.7
Ubudehe category First category 39 37.1
Second category 35 33.3
Third category 31 29.5
Mothers’ age categories (18 to 28) years 53 50.5
(29 to 39) years 40 38.1
(40 to 49 years) 12 11.4
Children’s age categories (12 to 18) months 65 61.9
(19 to 24) months 40 38.1
Exclusive breastfeeding Yes 98 93.3
No 7 6.7
Continued breastfeeding Yes 105 100
Frequency of breastfeeding From 2 to 4 per day 18 17.1
From 4 to 6 per day 31 29.5
Above 6 per day 56 53.3
Duration of breastfeeding (5-10) minutes 64 61
(10-15) minutes 26 24.8
Above 15 minutes 15 14.3
Classification of body mass Underweight 6 5.7
index (BMI) Normal 50 47.6
Overweight 28 26.7
Obese 21 20
Nutrition status based on Waist Normal 52 49.5
circumference Central obesity 53 50.5
Desirable body size based on Wish to be heavier 56 53.3
body size dissatisfaction Wish to be thinner 20 19
Wish to keep their 29 27.6
size
Dietary diversity status Inadequate dietary 48 45.7
diversity
Adequate dietary 57 54.3
diversity
Source: Primary data collected in 2021-2022
4.6.CROSS TABULATION FOR ASSOCIATION BETWEEN
SOCIODEMOGRAPHIC FACTORS, DIETARY DIVERSITY, BMI AND
WC.
This section focus on use of cross tabulation in identifying association between
sociodemographic factors, dietary diversity, BMI and WC.

14
 4.6.1. Cross tabulation for association between sociodemographic factors, dietary
diversity and BMI
The table 4.6.1.1 shows that the p value for association between education level, ubudehe
categories, mothers’ age categories, and dietary diversity is 0.570, 0.570, 0.078, and 0.003
respectively. To test association a Chi square test was employed; 95% was taken as
confidence interval and P value was considered as significance when less than 5%, based on
mentioned results there is significance association between dietary diversity BMI.

Table 4.6.1.1. Cross tabulation for association between socio-demographic factors,

dietary diversity and BMI.
Background Number of Percent of Numbe Percent P-value
characteristics overweight overweigh r of of obese
t (%) obese (%)
Crosstab for Not educated 0 0 2 1.9 0.570
association Primary 11 10.5 5 4.8
between Secondary 15 14.3 14 13.3
education level Graduate 2 1.9 0 0
and BMI
Crosstab for First category 10 9.5 5 4.8 0.570
association Second 8 7.6 10 9.5
between category
ubudehe Third category 10 9.5 6 5.7
categories and
BMI
Crosstab for (18 to 28)years 15 14.3 6 5.7 0.078
association (29 to 39)years 11 10.5 14 13.3
between (40 to 49)years 2 1.9 1 1.0
mothers’ age
categories and
BMI
Crosstab for Inadequate 12 11.4 3 2.9 0.003
association dietary
between dietary diversity
diversity and Adequate 16 15.2 18 17.1
BMI dietary
diversity
Source: Primary data collected in 2021-2022
4.6.2. Cross tabulation for association between sociodemographic factors, dietary
diversity and WC
The table 4.6.2.1 shows that the p value for association between education level, ubudehe
categories, mothers’ age categories, and dietary diversity is 0.831, 0.858, 0.007, and 0.015
respectively. To test association also a Chi square test was employed; 95% was taken as
confidence interval and P value was considered as significance when less than 5%, based on

15
mentioned results there is significance association between dietary diversity, mothers’ age
categories and WC.

Table 4.6.2.1. Cross tabulation for association between sociodemographic factors,

dietary diversity, and WC
Background Number of Percent of Numbe Percent P-value
characteristics normal normal r of of
(%) central central
obese obese
(%)
Crosstab for Not educated 2 1.9 3 2.9 0.831
association Primary 24 22.9 20 19
between Secondary 23 21.9 27 25.7
education level Graduate 3 2.9 3 2.9
and WC
Crosstab for First category 20 19 19 18.1 0.858
association Second 16 15.2 19 18.1
between category
ubudehe Third category 16 15.2 15 14.3
categories and
WC
Crosstab for (18 to 28)years 33 31.4 20 19.0 0.007
association (29 to 39)years 12 11.4 28 26.7
between (40 to 49)years 7 6.7 5 4.8
mothers’ age
categories and
WC
Crosstab for
Inadequate 30 28.6 18 17.1 0.015
association dietary
between dietary diversity
diversity and WC Adequate 22 21 35 33.3
dietary
diversity
Source: Primary data collected in 2021-2022

16
CHAPTER 5: DISCUSSION
This section is comprised of discussions about research findings based on the results found
in the assessment of overweight and obesity prevalence and risk factors, and ideal body size
perception, among breastfeeding mothers between 1 and 2 years after delivery done at
Gatenga health center to respond to research questions and to meet specific objectives of this
study.

5.1. OVERWEIGHT AND OBESITY PREVALENCE AMONG BREASTFEEDING

MOTHERS BETWEEN 1 AND 2 YEARS AFTER DELIVERY
Overweight and obesity prevalence among breastfeeding mothers between 1 and 2 years
after delivery at Gatenga health center was found to be 26.7% and 20.0% respectively based
on BMI, while 47.6% and 5.7% were normal and underweight respectively.

Overweight and obesity prevalence among breastfeeding mothers between 1 and 2 years
after delivery in Gatenga sector which is 46.7%, which is higher compared to overweight
and obesity prevalence of 42% among women of reproductive age in Rwanda(2). Study’s
overweight and obesity prevalence found is lower to the one found among women of
reproductive age in Dar es Salaam, Tanzania in study conducted in 2018-2019 which was
50.4%(37), but it is higher than the overweight and obesity prevalence among women of
reproductive age in Kenya which was 29.6% in 2014 health survey data analyzed in
2018(38).

Based on WC to assess central obesity, central obesity prevalence was found to be 50.5%
while 49.5% of mothers have normal WC. The findings of the study on central obesity is
higher than in that found in the study conducted in 2018 among Iranian women on
socioeconomic factors that are related to excessive weight and abdominal obesity and found
prevalence of 34.6% of central obesity(39).
It is also higher than that found in the study conducted in 2020 on prevalence and risk factors
associated with general and central obesity in both urban and rural women of Bangladesh
which found the central obesity to be 49%(40). The occurrence of some non-communicable
diseases has relationship with overweight and obesity such diseases or conditions include
diabetes, hypertension, cancers, stroke and other systemic diseases(41). Therefore, we call
for respective stakeholders, and policy makers to reinforce plans on appropriate interventions
that will improve management and prevention of health related complications and threats
that may arise from being overweight or obese.

17
5.2. DESIRABLE BODY SIZE
The study found that 53.3%wish to be heavier, 19.0% wish to be thinner, while 27.6% wish
to keep their size. The study’s findings are different from body size perception and
dissatisfaction among adults in Poland which found that 8.9% wish to be heavier, 65.7%
wish to be thinner, and 25.4% perceived to keep their size(42). Moreover, study’s findings
are different from that conducted at University of Sharjah in United Arab Emirates, on
dissatisfaction of body shape and behaviors that are related to weight status among university
students; which found 19.1% wish to keep their size, 23.4% wish to be heavier, and 57.5%
wish to be thinner(30). Differences in body size perception across different studies may be
due to different factors either being biological or non-biological factors.
Different weight management programs targeting breastfeeding mothers should look at the
individual’s information and awareness of her shape/size of the body and its acceptance.
Combination of individual’s size and acceptance with other weight management programs
such as diet, physical activity, food habits and healthy eating can improve weight
management efficacy.

5.3. OVERWEIGHT, OBESITY AND SOCIODEMOGRAPHIC FACTORS

This research was carried out with one of the specific objectives aiming to determine socio-
demographic factors that have association with overweight and obesity. The identification
of the socio-demographic association with overweight and obesity among breastfeeding
mothers between 1 to 2 years after delivery at Gatenga health center employed use of Chi
square test and confidence interval of 95% and P value has significance if lower than 5%(24).
However, the study found no significant association between education level, ubudehe
categories, mothers’ age categories, and BMI. Only significance association was found
between mothers’ age categories and WC, while other considered sociodemographic factors
in the study have no significance association with WC.

5.4. OVERWEIGHT, OBESITY AND DIETARY DIVERSITY

Adequate, and inadequate dietary diversity among breastfeeding mothers between 1 and 2
years after delivery at Gatenga health center is 54.3%, and 45.7% respectively.

The adequate MDD-W obtained(54.3%) is higher than the finding of the study conducted in
Ethiopia where 44% of lactating mothers have adequate MDD-W(43). Which is also
relatively higher to that of findings among women of reproductive age in Kolkata, India
which was 46.2%(44). Moreover, the study’s finding is high in comparison to the findings
obtained in Kenya where 19.8% of women of reproductive age had achieved adequate

18
dietary diversity (45). The differences in achieving adequate dietary diversity among women
of reproductive age are of different perspectives. The research has found a significance
association between dietary diversity and overweight and obesity. The result of mothers
with inadequate dietary diversity at Gatenga health center may reflect inadequate availability
and access of food at household level.

19
CHAPTER 6: CONCLUSION AND RECOMMENDATION
6.1. CONCLUSION
To sum up, overweight and obesity prevalence, among breastfeeding mothers between 1 and
2 years after delivery at Gatenga health center is 26.7% and 20.0% respectively based on
BMI, and the prevalence of central obesity is 50.5%. It was found that 53.3% of mothers
wish to be heavier, and 19.0% wish to be thinner, while 27.6% wish to keep their size. The
adequate, and inadequate dietary diversity among breastfeeding mothers between 1 and 2
years after delivery at Gatenga health center is 54.3%, and 45.7% respectively. The study
failed to identify a significance association between overweight and obesity and
sociodemographic factors, but the study has identified a significant association between
mothers’ age categories and waist circumference, dietary diversity, and overweight and
obesity, among breastfeeding mothers between 1 and 2 years after delivery at Gatenga health
center. Referring to the study results, therefore, we call for respective stakeholders, and
policy makers to reinforce plans and interventions that can improve management and
prevention of health problems that are associated with overweight and obesity.
6.2. RECOMMENDATION
6.2.1. Researchers
This research is the first to be carried in Rwanda on on prevalence and risk factors of
overweight and obesity, and ideal body size perception, among breastfeeding mothers
between 1 and 2 years after delivery there are no available data on it. Therefore, we
recommend researchers to work on this topic in order to have a bigger image on the topic.
In addition, for population generalization other researchers are encouraged to conduct bigger
researches with large sample size.

6.2.2. Ministry of Health (MoH) and Gatenga health center

Ministry of health as policy maker need to reinforce and evaluate different programs that are
related to maternal nutrition, in order to promote and sustain behavior change regarding
overweight and obesity management. Gatenga health center has to improve implementation
and monitoring of maternal nutrition services based on individuals.

6.2.3. University of Rwanda

Conducting research project needs to be funded, in order to get better and accurate results.
So, UR should build a sustainable system to finance undergraduate projects. The university
needs also to improve digitalized data collection tools and make them readily available to
the students.

20
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8. APPENDIX
8.1. CONSENT FORM IN ENGLISH
Happy morning/happy afternoon, we, Andre MUNYANDAMUTSA, Valens NIYIGABA,
Olivier RUKUNDO, students from University of Rwanda(UR), college of medicine and
health sciences(CMHS), school of public health, department of Human Nutrition and
Dietetics, in final year. We are carrying out a study on prevalence and risk factors of
overweight and obesity, and ideal body size perception, among breastfeeding mothers
between 1 and 2 years after delivery in Gatenga sector. The finding of research will help us to
obtain Bachelor of Science with honor in human nutrition and dietetics.

That is why we humbly request you to participate in the research, and your participation is
completely voluntary, interviewers are allowed to stop or skip any of questions and
confirmation for your willingness to have a participation needs you to sign an informed
consent form and it will be proof for being the part of research and you have full right to take
off your participation at any stage of this research in case you are not willing to move with
study’s procedures. The research will take about 15 minutes. In addition, we keep your
information private and confidential; they are not going to be shared or be revealed by
external party.

The purpose of this study is not aiming to create any evaluation or criticism on you, we ask
you to be feel open to any response and do not hesitate to give your answers honestly;
answers do not reflect any weakness of yours.

Certificate of consent

After more explanation concerning this research and its purpose. Do you agree to participate
voluntary as there is no risk will come from the research?

If yes…Continue and if no….. Stop research

Participant name……………...

Participant telephone………...

Date ……...

Signature ……...

26
8.2. CONSENT FORM IN KINYARWANDA VERSION
Muraho! amazina yacu ni, Andre MUNYANDAMUTSA, Valens NIYIGABA, Olivier
RUKUNDO turi abanyeshuri ba kaminuza y’uRwanda, kaminuza y’ubuvuzi nubumenyi mu
by’ubuzima, ishuri ry’ubuzima rusange, ishami ry’imirire n’imboneza mirire mu mwaka wa
nyuma. Turi gukora ubushakashatsi tureba ingano n’isano hagati y’ibitera umubyibuho
n’umubyibuho ukabije mu babyeyi bafite abana bonsa hagati y’umwaka umwe n’imyaka
ibiri mu murenge wa Gatenga. Ibizagerwaho muri ubu bushakashatsi bizadufasha kurangiza
amasomo y’akaminuza mu mirire yabantu n’imboneza mirire.

Niyo mpamvu tubasabye ngo mutwemerere kuba mwagira uruhare muri ubu bushakashatsi.
Kandi kugira icyo usubiza ni kubushake bwanyu, kandi ushobara guhitamo kureka kugira
uruhare muri ubu bushakashatsi igihe icyaricyo cyose cangwa gusubiza ibibazo byose
ntabwo ari itegeko, kugirango ugire uruhare muri ubu bushakashatsi ni uko ubanza kwemera
no gusinya amasezerano y’ubufatanye natwe, kandi ushobora guhagarika kugira uruhare
muri ubu bushakashatsi igihe cyaricyo cyose ntabisobanuro ubanje gutanga. Ibibazo
k’ubushakashatsi bimara iminota itarenze 15 kandi tubijeje ko amakuru yose muduha
azagirirwa ibanga ntabwo azigera ashyirwa k’umugaragaro.

Intego nyamukuru y’ubu bushakashatsi ntabwo ari ukugusuzuma cyangwa kukunegura,

ntukumve ko uhatirwa gutanga igisubizo cyihariye kandi ntukagire isoni niba utazi igisubizo
cy’ikibazo. Ntabwo dutegereje ko utanga igisubizo cyihariye; turashaka ko usubiza ibibazo
mubyukuri, ukatubwira ibyo uzi, n’uko ubyumva.

Nyuma y;ibisobanuro byerekeye ibu bushakashatsi hamwe n’intego yabwo uremera kugira
uruhare muri ubu bushakashatsi?

Yego…… Oya…... niba ari yego komeza ugire uruhare m’ubushakashatsi, niba ari Oya
hagarika kugira uruhare m’ubushakashatsi.

Amazina………...

Nimero ya telephone……………

Itariki…………………...

Umukono………………………….

27
8.3. QUESTIONNAIRE

1. Demographic assessment section

Mother names…………………………………………………………

Mother’s age child age

Sector………………………………………………………………….

Cell……………………………………………………………………

Village…………………………………………………………………

Level of education: 1. not educated 2. Primary 3. Secondary 4. Graduate

Ubudehe category

2. Anthropometric measurements section

Mother’s weight in………….kg

Mother’s height in…………….m

Mother’s BMI………………….

Mother’s waist circumference in……..cm

3. Breastfeeding patterns and behaviors section

Exclusive breastfeeding till 6 months: 1. Yes 2. No

Continued breastfeeding: 1. Yes 2. No

Frequency of breastfeeding: 1. 2-4 2. 4-6 3. Above 6

Duration of breastfeeding: 1. (5-10) min 2. (10-15) min 3. Above 15min

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 4. Dietary assessment section
4.1. Assessing dietary diversity using a population indicator; Minimum Dietary
Diversity for Women of reproductive age(MDD-W) by employing 24hours
dietary recall (4)

At this time I would like get information by giving a description of everything you have
consumed (food and beverages) for yesterday, mention every food or drink either
consumed at home or out. Do not forget to recall food/drinks you have consumed during
meal preparation, all snacks and fruits.

We may start with first drink/food you consumed yesterday.

1. Had you anything to consume as you woke? If yes, what? Anything else?

2. Did you have any food or drink later in the morning? If yes, what? Anything else?

3. Have you taken any food or drink at mid-day? If yes, what? Anything else?

4. Did you take any food/drink during afternoon? If yes, what? Anything else?

5. Did you have any food/drink in the evening? If yes, what? Anything else?

6. Anything else did you consume in the evening before bed time? If yes, what?
Anything else?

PREDETERMINED FOOD Food item consumed YES/NO

GROUPS YES=1,
NO=0
1. Grain, roots and tubers

2. Pulses

3. Nuts and seeds

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 4. Dairy

5. Meat, poultry and fish

6. Eggs

7. Dark leafy greens and

vegetables

8. Other vitamin A rich

fruits and vegetables

9. Other vegetables

10. Other fruits

 Scores
 Note: dietary diversity is considered when there is a minimum score of 5 food groups

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  Achieved dietary diversity: YES NO
4.2. Level of physical activity 1. Sedentary 2. Moderate 3. Vigorous
5. Ideal body size perception section
1. Based on the image (regarding female section) below which body size matches with
your body size?

(Pick only one number). Number picked corresponding BMI

2. Based on the image (regarding female section) below which body size would you
like to have?

(Pick only one number). Number picked corresponding BMI

Fig. Body figure-scale(14). BMI classes based on WHO recommendations(36).

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8.4. WORK PLAN

Number Activity Time to complete Number of

assigned persons
1 Research proposal preparation 300days 3
and submission
2 Ethical clearance 1 day 3
3 Proposal submission 1day 3
4 Pretesting 1day 3
5 Data collection 20 days 3
6 Data coding and entry 5 days 3
7 Data analysis 3 days 3
8 Report writing 4 days 3
9 Report presentation 1 day 3
10 Report submission 1day 3

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8.5. BUDGET

No Task People’s Days Cost per Total cost in

number unit in Rwf
Rwf
1 Preparation of 3 300 5000 1500000
research proposal and
submission
2 Ethical clearance and 3 1 5000 15000
permission to do
research
3 Pretesting the 3 1 7000 21000
questionnaire
4 Transport during data 3 20 2000 120000
collection
5 Communication 3 20 1000 60000
6 Accommodation 3 20 5000 300000
7 Restaurant 3 20 2000 120000
8 Data coding and entry 3 5 5000 75000
9 Data analysis 3 3 5000 45000
10 Report preparation 3 4 5000 60000

Items Number of Cost per Total cost

items unit
11 Questionnaires 107 250 26750
12 Pens 3 150 450
13 Note books 3 500 1500
Total 2,344,700 Rwf

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