Associations between undernutrition and malaria infection: a case–control study from Rwanda

(2025) 24:335 Uwimana et al. Malaria Journal https://doi.org/10.1186/s12936-025-05583-4 Malaria Journal Open Access RESEARCH Associations between undernutrition and malaria infection: a case–control study from Rwanda Aline Uwimana1,2,3, Hélène Alexiou4, Jean d’Amour Mutoni1,5, Annie Robert6, Nadine Rujeni5, Patrice D. Cani1,7,8,9, Jean‑Paul Coutelier5,10, Léon Mutesa11*† and Amandine Everard1,7*† Abstract Background Undernutrition and malaria remain major global public health challenges. The relationship between nutritional status and malaria infection is complex. Better understanding of their association is needed to improve prevention and control of these health conditions. Undernutrition can be assessed by evaluating nutrient intake (macronutrient and micronutrient intake) measured through Food Frequency Questionnaire or by using indicators for chronic undernutrition, including the stunting parameter defined by the World Health Organization as child being too short for age. This study aims to investigate associations between inadequate nutrient intake or indicators for undernutrition and malaria infection. Methods The analysis compares malaria cases diagnosed by a positive blood smear against controls composed of other malaria free people living in the same households with the cases (same household grouping). Data collection was conducted between November 2021 and December 2023 across 9 endemic districts located in all four provinces and Kigali City. Regression models were developed to investigate the association between undernutrition (i.e. inadequate nutrient intake or stunting) and malaria infection. Results Despite numerous nutrition interventions aimed at reducing the burden of undernutrition, the dietary patterns observed in this study remain predominantly imbalanced. The food composition was predominantly made up of starchy staples, accounting for 56.7% of total energy intake. Such foods are typically rich in macronutrients but low in essential micronutrients. The findings revealed a high prevalence of micronutrient deficiency risk, with a reported risk of vitamin A, B2, B12, calcium, zinc, and selenium deficiency between 50 and 80% in the studied population. Regarding stunting, even if the percentage of severe chronic stunting was higher in malaria cases (17%) compared to controls (10,6%), the association between stunting and malaria infection was not statistically significant. After adjusting for covariates, risk of vitamin E deficiency and risk of iron deficiency were positively associated with malaria (aOR = 7.46; 95% CI 4.43–12.58; p < 0.001 and aOR = 1.80; 95% CI 1.11–2.93; p = 0.017, respectively). Conversely, age, sex, and risk of selenium deficiency intake were inversely associated with malaria. Increasing age † Léon Mutesa and Amandine Everard have equally contributed to this work. *Correspondence: Léon Mutesa Amandine Everard Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Uwimana et al. Malaria Journal (2025) 24:335 Page 2 of 13 (aOR = 0.58; 95% CI 0.36–0.95; p < 0.04), female sex (aOR = 0.67; 95% CI 0.46–0.97; p < 0.001), and selenium deficiency (aOR = 0.62; 95% CI 0.43–0.91; p = 0.013) were all linked to lower odds of malaria infection. Conclusions These findings highlight the critical role of nutrient imbalances in influencing malaria infections. Therefore tackling these preventable deficiencies is required through targeted strategies as guided by UNICEF conceptual framework 2020–2030. For instance, improving dietary diversity, regularly monitoring nutritional status, and establishing a comprehensive national food composition database could support such strategies. These approaches will support effective nutrition policies and interventions. Background Undernutrition and malaria remain major global public health concerns, particularly in low- and middle-income countries [1]. Although global undernutrition has declined by 4% over the past decade, it still contributes to half of all deaths in children under five [2–4]. SubSaharan Africa and South Asia bear over 90% of the burden, with East Africa showing particularly high rates of undernutrition [2, 3], ranking above the World Health Organization (WHO) cut-off of > 30% [5, 6]. Undernutrition weakens immunity and increases vulnerability to diseases such as malaria [7–9]. Indicators for chronic undernutrition include the stunting parameter, defined by the WHO as ‘child being too short for age’. In Rwanda, childhood stunting has decreased from 42% in 2000 to 33% in 2020 [10, 11], yet malnutrition is a critical public health issue [9]. Contributing factors to undernutrition include maternal education, household wealth, child age, low birth weight, limited access to health services [9, 12– 14], and food insecurity [15]. Despite agriculture being the main livelihood, food insecurity affects up to 35% of households in some areas, especially in the Western Province [16], due to recurrent flooding and limited dietary diversity [15]. Globally, food security access to safe nutritious food remains a challenge, with over 820 million people affected by food insecurity in 2018 [17, 18]. Climate change, conflict, and economic instability are primary drivers [2, 19, 20]. Food insecurity affects human and planetary health and must be tackle through better food system governance to meet sustainable developments goals [17, 21]. While interventions, such as increasing education, women’s empowerment, and home gardening, have shown some improvements, rural diets remain heavily reliant on nutrient poor staples [22]. In addition to food access, dietary diversity plays a vital role in nutrient adequacy. Micronutrient deficiencies remain widespread, highlighting the need for stronger food policies and diversified agriculture to improve nutrition outcomes [23]. A study found that 81.8% of women in agriculture had low dietary diversity, with 22.1% affected by a (...truncated)