The associations between stunting and wasting at 12 months of age and developmental milestones delays in a cohort of Cambodian children.

Worldwide, over 250 million children under 5 years do not reach their developmental potential due to several causes, including malnutrition. In Cambodia, the prevalence of stunting and wasting among children remains high. This prospective cohort study aimed to assess acquisition of motor and cognitive developmental milestones in early childhood and their associations with stunting and wasting. Children aged from 0 to 24 months were recruited from three provinces in Cambodia and followed up to seven times from March 2016 to June 2019, until their 5 years. Data collection included anthropometry and developmental milestones. Seven motor and seven cognitive milestones were evaluated using the Cambodian Development Milestone Assessment Tool. Associations were assessed with parametric survival models. Hazard ratios (HR) below 1 stood for lower probabilities for achieving developmental milestones. Data were available for 7394 children. At 12 months, the prevalence of stunting and wasting were 23.7% and 9.6% respectively. Both were consistently associated with delays in most motor and cognitive milestones. Stunting was strongly associated with delays in gross motor milestones (HR < 0.85; p < 0.001). Wasting was more strongly associated with delays in fine motor development and most cognitive milestones (HR < 0.75; p < 0.001). Promoting nutritional programs in the first 1000 days to prevent malnutrition is essential to further the optimal growth and motor and cognitive development of Cambodian children.

Stunting Malnutrition Associated with Severe Tooth Decay in Cambodian Toddlers.

BACKGROUND: The persistently high prevalence of undernutrition in Cambodia, in particular stunting or chronic malnutrition, calls for innovative investigation into the risk factors that affect children's growth during critical phases of development. METHODS: Secondary data analysis was performed on a subgroup of children who were present at two time points within the Cambodian Health and Nutrition Monitoring Study (CAHENMS) and who were less than 24 months of age at the nominated baseline. Data consisted of parent interviews on sociodemographic characteristics and feeding practices, and clinical measures for anthropometric measures and dental status. Logistic regression modelling was used to examine the associations between severe dental caries (tooth decay)­as indicated by the Significant Caries Index­and the presence of new cases of stunting malnutrition at follow-up. RESULTS: There were 1595 children who met the inclusion criteria and 1307 (81.9%) were followed after one year. At baseline, 14.4% of the children had severe dental caries, 25.6% presented with stunted growth. 17.6% of the children transitioned from healthy status to a low height-for-age over the observation period. Children with severe dental caries had nearly double the risk (OR = 1.8; CI 1.0-3.0) of making that transition. CONCLUSION: Severe caries experience was associated with poorer childhood growth and, as such, could be an underinvestigated contributor to stunting.

Reducing malnutrition in Cambodia. A modeling exercise to prioritize multisectoral interventions.

Undernutrition is a major contributor to child morbidity and mortality and poses a large burden to the economy, in Cambodia. This study explored factors contributing to child stunting and wasting and their regional inequalities among 1,938 Cambodian children aged 6-23.9 months. Data were drawn from a longitudinal study (year 2017) conducted in six districts of two north-eastern provinces and the capital and used as cross-sectional. Socio-demographic and household characteristics, children's feeding practices during the previous 24 hr, and children's length and weight measurements were collected. Gradient boosting models were used to calculate the contribution of determinants to child undernutrition whereas concentration index was used to assess the impact of those determinants on stunting and wasting inequalities among socioeconomic groups. It was found that low-household wealth could predict 21% to 45% of child stunting and 23% to 36% of wasting across regions. After wealth, source and treatment of drinking water were found the second major predictor for stunting (15%) and wasting (21%). Combining child nutrition and household water, sanitation and hygiene indicators predicted around 30% of child undernutrition, either in the form of stunting or wasting. Mothers' education predicted >30% of stunting in the north-eastern region. Results highlight that a complex interplay of factors contributes to child stunting and wasting. An integrated, intersectoral, equity-focused approach that addresses children's dietary quality, household's water, sanitation and hygiene conditions, mother's education, and poverty is likely to yield the highest impact in achieving further gains in nutritional status among Cambodian children.

Maternal mid-upper arm circumference during pregnancy and linear growth among Cambodian infants during the first months of life.

Stunting prevalence among children under 5 years remains high in Cambodia, affecting about one-third of children. In most low- and middle-income countries, linear growth faltering of young children starts in the womb. The 1,000-days window of opportunity to improve child nutritional status includes pregnancy, as maternal nutritional status is an important determinant of birthweight and child development. In Cambodia, nutritional status of pregnant women is poor, with some studies reporting >20% of pregnant women having a low mid-upper arm circumference (MUAC < 23 cm). Few studies have investigated associations between maternal nutritional status during pregnancy and neonatal growth. Using data from a Cambodian cohort study conducted from 2016 through 2018 in selected districts of Phnom Penh, Kratie, and Ratanakiri provinces, we investigated associations between maternal MUAC during pregnancy as indicator of maternal nutritional status and their offspring linear growth during early life. Multivariate regression models were used to assess the associations between maternal MUAC during the last trimester of pregnancy and infant's length-for-age z-scores during the first 3.5 months of life. Maternal MUAC was significantly associated with infant's length-for-age z-scores (regression coefficient 0.06, 95% CI [0.03, 0.09]). Infants born from mothers with a low MUAC during pregnancy had a 1.6 times higher risk (odds ratio 1.621, 95% CI [0.998, 2.636]) of being stunted during the first 3.5 months of life compared with infants born from mothers with a MUAC >23 cm. This study underlines the importance of optimum maternal MUAC during pregnancy for optimal infant growth. Interventions that aim to tackle stunting in infants should integrate improving maternal MUAC during pregnancy.

Water quality for young children in Cambodia-High contamination at collection and consumption level.

Unsafe drinking water is a leading cause of child morbidity, especially among young children in low-income settings. Safe water consumption requires high-quality water available at its source and at point of use. We examined the quality of drinking water at point of collection and point of use in 796 households in three provinces, in Cambodia. Microbiological testing for coliform and Escherichia coli contamination was conducted for samples collected. Bivariable analysis and multivariable logistic regression were used to examine associations between various factors and the deterioration in water quality (increase in the risk according coliform or E. coli concentration) between point of collection and point of use. Contamination with both coliforms and E. coli was higher at point of use than at point of collection, with contamination at point of collection to account for 76.6% (coliforms) and 46.3% (E. coli). Results suggest that child drinking water represents a considerable pathway for the ingestion of pathogens, in Cambodia. Area of residence, seasonality, type of water source, and water chlorination were associated with coliform concentration between the point of collection and point of use, whereas only seasonality was associated with E. coli contamination (OR = 1.46; 95% CI [1.05, 2.02]). Children living in rural settings were two times more likely to drink water with a deteriorating coliform concentration between the two-time points than children living in urban settings (OR = 2.00; 95% CI [1.22, 3.30]). The increase in coliform and E. coli concentrations between point of collection and point of use indicates that water contamination mostly occurs within the household. Strengthening national legislation on water quality standards and promoting safe water management at the household are needed.

Improving children's nutritional status in Cambodia: Multidimensional poverty and early integrated interventions.

One in three Cambodian children under 5 years of age are stunted. This study adopted a multidimensional approach to understand the influence of a series of contextual factors on the nutritional status of Cambodian children. In this study, we use a multidimensional poverty framework to identify a combination of interventions likely to achieve reductions in child stunting, in Cambodia. We used the UNICEF Multiple Overlapping Deprivation Analysis tool and data from the Cambodia Demographic and Health Survey 2014 to assess children's multidimensional poverty across nutrition, health, early childhood development, water, sanitation, and housing dimensions. We found that 80% of children under age five were deprived in at least two poverty dimensions. Multivariate logistic regression analysis revealed that reducing the likelihood of being deprived in three or more poverty dimensions was associated with a significant reduction of the probability of being stunted, after controlling for potential confounders. The combined probability of nondeprivation in nutrition, sanitation, and health dimensions had the largest effect on reducing the probability of stunting. The results of this study highlight the multiple, intersecting needs of children and their associated explanatory factors. Targeted and integrated cross-sectoral policies that reinforce comprehensive early childhood interventions are needed for improving nutritional status as part of a wider set of child poverty reduction measures in Cambodia.

Adherence to Child Feeding Practices and Child Growth: A Retrospective Cohort Analysis in Cambodia.

Appropriate feeding in the first 1000 days of a child's life is critical for their health and growth. We determined associations between adherence to age-appropriate feeding practices and child growth in Cambodia. Children (n = 1079) were included in the first follow-up (FU) data analyses and followed for 30 months (six FUs). Data were analyzed by generalized linear mixed-effect models. Children who adhered to feeding practices on at least three FUs, with an adequate minimal dietary diversity (MDD), a minimal acceptable diet (MAD), and age-appropriate daily feeding (ADF) were less stunted (14.8%, 12.3%, and 6.4%, respectively) than children who never adhered to these indicators (25.2%, 30.1%, and 24.8%, respectively). A higher adherence to MDD and ADF was associated with a higher height-for-age Z-score (HAZ) (ß: 0.13, 95% CI: 0.01-0.25 and ß: 0.36, 95% CI: 0.22-0.50), while a higher adherence to the MDD and MAD was associated with a higher weight-for-height Z-score (WHZ) (ß: 0.19, 95% CI: 0.08-0.30; and ß: 0.16, 95% CI: 0.05-0.27). A higher adherence to a minimum meal frequency (MMF) was associated with a lower HAZ (ß: -0.99, 95% CI: -1.28--0.70). Our findings showed that to reduce wasting and stunting in Cambodia, interventions should focus on improving both the quality and quantity of food intake of children under two while targeting the whole complementary feeding period.

Age-Appropriate Feeding Practices in Cambodia and the Possible Influence on the Growth of the Children: A Longitudinal Study.

Age-appropriate feeding practice (ADF) during early childhood are vital for optimal nutrition. This longitudinal study determined the effect of selected risk factors and ADF, as described by the National Nutritional Recommendations, on linear and ponderal growth of children below 24 months of age. Weight and length measures were used to calculate z-scores of anthropometric measures by WHO standards. The prevalence of stunting increased from 13.2% to 32.4% over time, while prevalence of wasting remained stable (14.5%). At first visit, 43% of children of all ages complied with ADF criteria, a proportion which decreased to 7.1% in follow-up. The quality of feeding practices for children above 12 months of age was the poorest, where at the last visit, only 6% complied with the criteria for ADF. The linear mixed-effect models found the association between ADF and ponderal growth to be significant (weight-for-height estimate: 0.05 SD). In Cambodia, Ratanakiri province, ADF was the second largest determinant for ponderal growth. We recommend province specific public health actions. For children above 6 months, the quantity of food given needs to be increased, followed by the meal frequency. Mothers' educational level, improved sanitation, and drinking water quality were among strongest predictors of a child's growth.

Child-Sensitive WASH Composite Score and the Nutritional Status in Cambodian Children.

Progress in health has occurred in the past decades in Cambodia, in terms of health service access and interventions, but several indicators, including the prevalence of malnourished children, remain alarming. The causes of undernutrition are often linked to inadequate access to water, sanitation and hygiene services but limited evidence exists on the direct association between poor WASH practices and children's' nutritional statuses. This study investigates the relationship between water, sanitation and hygiene practices, defined as the child-sensitive composite score, and the nutritional status of children under five years old, measured as the weight-for-height z-score, mid-upper arm circumference or height-for-age z-score in six districts of Cambodia. The analysis used data from a longitudinal study, comprising extensive data collection on anthropometry, health, nutrition, WASH, and cognitive development. Chronological trends in wasting and stunting were described cross-sectionally, whereas the effect of WASH practices on the nutritional status of children over up to three consecutive study visits was examined with a linear mixed-effects model. The prevalence of wasting decreased during the study while stunting prevalence increased. A small, but significant, association was found between the WASH child-sensitive composite scores and the wasting child anthropometry indicators: weight-for-height z-score or mid-upper arm circumference. Evidence for an association with height-for-age z-score, detecting stunted children, was found when the independent variable was quantified according to global, but not national, guidelines. This study reinforces discordant existing evidence towards a direct association between WASH practices and children's nutritional status, suggesting the need to align nutrition and WASH programmes.

The Interaction between Morbidity and Nutritional Status among Children under Five Years Old in Cambodia: A Longitudinal Study.

Even though limited evidence is available, the relationship between morbidity and under-nutrition among children under-five is likely to be a strong two-way association. This study aims to explore this vicious cycle by employing longitudinal data of four periods within a 24 month follow-up, whereby morbidity was captured between two subsequent anthropometric measures. Malnutrition was classified according to z-scores of anthropometric measures and morbidity by number of sick days experienced inbetween. Mixed-effects models were used to assess this relation, where dependency of morbidity and nutritional status were interchanged; models were adjusted for province, age, gender, wealth index score, maternal education level, diet, and Water, Sanitation, and Hygiene indicators. Stunting and wasting prevalences were 29.9% and 8.9%, respectively, where 21.3% of the children hadmultiple anthropometric failures. Children identified as wasted were 35% more likely to experience prolonged illness periods (OR: 1.35, 95% CI: 1.02-1.56). Those experiencing high proportion of sick days were found to be 64% more likely to become stunted (OR: 1.64, 95% CI: 1.18-2.29). This study suggests that the link between wasting and stunting could be partly explained by acute illness, where wasting increases the likelihood of prolonged epiosed of illness, which increases the risk of stunting.

Stunting, Beyond Acute Diarrhoea: Giardia Duodenalis, in Cambodia.

BACKGROUND: The adverse outcomes of malnutrition on the development of a child are well acknowledged as are the broad variety of contextual factors that may impact child nutritional status. Adequate nutrient intake and the adoption of appropriate water, sanitation and hygiene measures are largely documented for their positive influence on health. Improved sanitation and protection from human feces can significantly lower the incidence of diarrhea and environmental enteropathy. However, the impact of excessive exposure to animal feces on child health is less well documented. OBJECTIVES: This study tests the hypothesis that there is a positive association between exposure to animal feces, morbidity and anthropometric outcomes in children under 5 years of age, in Cambodia. It aims to improve insights that can contribute to discerning high-impact policies that promote children can develop to their full potential. METHODS: Data for this study was drawn from the third follow-up round of the MyHealth project cohort study that is conducted in six districts of three Cambodian provinces (Phnom Penh, Kratie and Ratanak Kiri). The analysis included a sample of 639 children under 5 years of age. RESULTS: The presence of livestock and more particularly, pigs near the main household dwelling was found a risk factor associated with Giardia duodenalis infection (23%). Giardia duodenalis infection was found to be a protective factor for acute diarrhea, yet, associated with stunting in the univariate model. CONCLUSIONS: Preventive measures that protect from extensive exposure to animal feces may be most effective to prevent infection with Giardia duodenalis and consequent stunting, thereby improving the potential for a healthy development in young Cambodian children. The results support the need for cross-sector policy measures that reinforce comprehensive early childhood interventions towards improving nutritional status as part of a wider set of child welfare and development measures.

Identification of Acute Malnutrition in Children in Cambodia Requires Both Mid Upper Arm Circumference and Weight-For-Height to Offset Gender Bias of Each Indicator.

Malnutrition remains a serious health problem in Cambodia with over 10% of children less than five years of age suffering from acute malnutrition. In addition to the presence of nutritional edema, two indicators are recommended by the World Health Organization for the diagnosis of acute malnutrition: weight-for-height Z-scores (WHZ; with acute malnutrition defined as WHZ < −2 Z-score) and mid-upper arm circumference (MUAC, with acute malnutrition defined as MUAC < 12.5 cm). Earlier, we showed that WHZ and MUAC identified different subgroups of children with acute malnutrition. To explore factors associated with both indicators of acute malnutrition, we analyzed baseline data from a longitudinal study in three provinces in Cambodia: Phnom Penh (capital, urban environment), Kratie (rural province), and Ratanakiri (hilly, rural province). Data was available for 4381 children below 30 months of age. Malnutrition rates were higher in the two rural provinces than in the capital. Although both MUAC and WHZ showed gender bias, with MUAC identifying more girls, and WHZ identifying more boys with acute malnutrition, the gender effect was strongest for MUAC. The gender bias of MUAC diminished with older age, but remained significant up to 30 months of age. Only using both MUAC and WHZ as indicators resulted in gender neutral identification of acute malnutrition. WHZ alone always identified more children with acute malnutrition than MUAC alone. In Phnom Penh, MUAC alone identified only 11% with acute malnutrition in addition to WHZ. To conclude, both MUAC and WHZ showed gender bias in this cohort of Cambodian children. In Cambodia, implementation of a MUAC-only or a WHZ-only program for the identification of acute malnutrition would be unethical as it will lead to many children remaining undiagnosed.

Diets and Feeding Practices during the First 1000 Days Window in the Phnom Penh and North Eastern Districts of Cambodia.

Although several health and development indicators have improved significantly in Cambodia, inadequate breastfeeding and inappropriate complementary feeding practices leave many children at high risk of malnutrition during the early stages of life. In 2014, the prevalence of wasting and stunting among Cambodian children under 5 were 10% and 32%, respectively. Thus, a strong focus on improving feeding practices within the first 1000 days window to reduce child malnutrition prevalence in Cambodia is needed. This cross-sectional study assessed the current feeding practices among of women of reproductive age, pregnant women, lactating women and children less than 24 months living in six districts from Phnom Penh and two rural provinces in the North East of Cambodia. The nutritional status of pregnant women was poor, with 21.4% having a Middle Upper arm circumference below 23 cm. While breastfeeding was predominant within the first 6 months of age in every district, feeding practices of pregnant women and children were a concern, as >70% of the children were not meeting the minimum acceptable diet, and most of the women did not improve their diet during pregnancy. Inadequate nutrition during the first 1000 days is highly prevalent in Cambodia. A comprehensive national Mother, Infant and Young Child Nutrition strategy needs to be developed and operationalized to improve feeding practices of Cambodian women and children.

The unfinished health agenda: Neonatal mortality in Cambodia.

BACKGROUND: Reduction of neonatal and under-five mortality rates remains a primary target in the achievement of universal health goals, as evident in renewed investments of Sustainable Development Goals. Various studies attribute declines in mortality to the combined effects of improvements in health care practices and changes in socio-economic factors. Since the early nineties, Cambodia has managed to evolve from a country devastated by war to a nation soon to enter the group of middle income countries. Cambodia's development efforts are reflected in some remarkable health outcomes such as a significant decline in child mortality rates and the early achievement of related Millennium Development Goals. An achievement acknowledged through the inclusion of Cambodia as one of the ten fast-track countries in the Partnership for Maternal, Newborn and Child Health. This study aims to highlight findings from the field so to provide evidence for future programming and policy efforts. It will be argued that to foster further advances in health, Cambodia will need to keep neonatal survival and health high on the agenda and tackle exacerbating inequities that arise from a pluralistic health system with considerable regional differences and socio-economic disparities. METHODS/FINDINGS: Data was drawn from Demographic Health Surveys (2000, 2005, 2010, 2014). Information on a series of demographic and socio-economic household characteristics and on child anthropometry, feeding practices and child health were collected from nationally representative samples. To reach the required sample size, live-births that occurred over the past 10 years before the date of the interview were included. Demographic variables included: gender of the child, living area (urban or rural; four ecological regions (constructed by merging provinces and the capital), mother's age at birth (<20, 20-35, 35+), birth interval (long, short) and birth order (1st, 2-3, 4-6, 7+). Socio-economic variables included: mother education level (none, primary, secondary+) and household wealth (asset-based index). Data on antenatal care, tetanus injection and skilled assistance at birth were used for the mother's last child. Between 2000 and 2014, Cambodia achieved a considerable reduction in neonatal mortality (46% reduction rate). By 2014, gender inequities became almost non-existent (for all measures of equality); inequity related to mother's education decreased for all time periods; improvements were observed for differences in neonatal mortality by preceding birth interval; and a reduction in neonatal mortality rates could be noted among all the regional subgroups. Inequities increased between mothers who had limited antenatal care and those who received more than four antenatal care visits. In most scale indicators, the Slope Index of Inequality and Relative Index of Inequality estimates for all four rounds of the survey suggest inequity exacerbated in deprived communities. Also, wealth and residence (urban/rural divide) continued to be major determinants in neonatal mortality rates and related inequity trends. CONCLUSION: Analysis highlighted some of the complex patterns and determinants of neonatal mortality, in Cambodia. There has been a considerable decline in neonatal mortality which echoes global trends. Our analysis reveals that despite these advances, additional socio-economic and demographic characteristics considerably affected neonatal mortality rates and its inequities. There continue to be pockets of vulnerable groups that are lagging behind. This analysis highlights the determinants along the urban-rural and rich-poor divides in neonatal mortality inequities and how these affect access to and utilization of quality basic health services. This calls for future policy and programming efforts to be deliberate in their equity approach. Quality improvements in health services and targeted interventions for specific socio-economic groups will be required to further accelerate progress in reducing neonatal mortality and address Cambodia's pressing unfinished agenda in health.

Correction: Greffeuille, V.; et al. Persistent Inequalities in Child Undernutrition in Cambodia from 2000 Until Today. Nutrients 2016, 8, 297.

We would like to submit the following as a correction to our recently published paper [1] because of the use of the wrong cut-off for overweight.[...].

The High Prevalence of Anemia in Cambodian Children and Women Cannot Be Satisfactorily Explained by Nutritional Deficiencies or Hemoglobin Disorders.

BACKGROUND: Anemia is highly prevalent in Cambodian women and children, but data on causes of anemia are scarce. We performed a national micronutrient survey in children and women that was linked to the Cambodian Demographic Health Survey 2014 (CDHS-2014) to assess the prevalence of micronutrient deficiency, hemoglobin disorders and intestinal parasite infection. METHODS: One-sixth of households from the CDHS-2014 were selected for a follow-up visit for the micronutrient survey. Households were visited from two weeks to two months after the CDHS-2014 visit. Data on micronutrient status were available for 1512 subjects (792 children and 720 women). RESULTS: Anemia was found in 43% of the women and 53% of the children. Hemoglobin disorders affected >50% of the population, with Hemoglobin-E the most prevalent disorder. Deficiencies of iron (ferritin < 15 g/L), vitamin A (retinol-binding-protein (RBP) < 0.70 mol/L) or vitamin B12 (<150 pmol/L) were not prevalent in the women (<5% for all), whereas 17.8% of the women had low concentrations of folic acid (<10 nmol/L). In the children, the prevalence of iron, vitamin A, vitamin B12 or folic acid deficiency was <10%. Zinc deficiency, hookworm infection and hemoglobinopathy were significantly associated with anemia in children, whereas in the women none of the factors was significantly associated with anemia. Iron deficiency anemia (IDA) was more prevalent in children <2 years, but in older children and women, the prevalence of IDA was <5%. The most prevalent, preventable causes of anemia were hookworm infection and zinc and folic acid deficiency. Over 40% of the anemia was not caused by nutritional factors. CONCLUSION: The very high prevalence of anemia in Cambodian women and children cannot be explained solely by micronutrient deficiencies and hemoglobin disorders. Micronutrient interventions to improve anemia prevalence are likely to have limited impact in the Cambodian setting. The focus of current interventions to reduce the high prevalence of anemia in children and women should be broadened to include zinc and folic acid as well as effective anti-hookworm measures.

High Prevalence of Vitamin D Deficiency in Cambodian Women: A Common Deficiency in a Sunny Country.

Recent studies have shown that in spite of being generally close to the equator; vitamin D deficiency is common in South East Asian countries. In order to quantify micronutrient status for women and children in Cambodia; a nationally-representative survey was conducted in 2014 linked to the Cambodian Demographic Health Survey. The countrywide median of 25(OH)D was, respectively, 64.9 and 91.1 nmol/L for mothers and children. Based on The Endocrine Society cutoffs (>50<75 nmol/L = insufficiency; ≤50 nmol/L = deficiency); 64.6% of mothers and 34.8% of their children had plasma vitamin D concentrations indicating insufficiency or deficiency. For deficiency alone, 29% of the mothers were found to be vitamin D deficient, but only 13.4% of children. Children who live in urban areas had a 43% higher rate of vitamin D insufficiency versus those who live in rural areas (OR; 1.434; 95% CI: 1.007; 2.041). However, such differences were not observed in their mothers. The high prevalence of vitamin D deficiency is likely in part due to lifestyle choices, including sun avoidance, increasingly predominant indoor work, and covered transport. These survey findings support the need for a broader national Cambodian study incorporating testing of adult men, adolescents and the elderly, and encompassing other parameters such as skeletal health. However, the data presented in this study already show significant deficiencies which need to be addressed and we discuss the benefit of establishing nationally-mandated food fortification programs to enhance the intake of vitamin D.

The Economic Burden of Malnutrition in Pregnant Women and Children under 5 Years of Age in Cambodia.

Malnutrition is locked in a vicious cycle of increased mortality, poor health, impaired cognitive development, slow physical growth, reduced learning capacity, inferior performance, and ultimately lower adult work performance and productivity. The consensus of global scientific evidence indicates that lowering the rates of malnutrition will be an indispensable component of any successful program to raise the quality of human capital and resources. This study used a "consequence model" to apply the coefficient risk-deficit on economic losses, established in the global scientific literature, to Cambodian health, demographic, and economic data to develop a national estimate of the value of economic losses due to malnutrition. The impact of the indicators of malnutrition analyzed represent a burden to the national economy of Cambodia estimated at 266 million USD annually (1.7% of GDP). Stunting is reducing the Cambodian economic output by more than 120 million USD, and iodine deficiency disorders alone by 57 million USD. This economic burden is too high in view of Cambodia's efforts to drive economic development. The government should rapidly expand a range of low-cost effective nutrition interventions to break the current cycle of increased mortality, poor health and ultimately lower work performance, productivity, and earnings.

Persistent Inequalities in Child Undernutrition in Cambodia from 2000 until Today.

The study assessed the trends of nutritional status of children under age five in Cambodia over four DHS surveys from 2000 to 2014 and the contribution of socioeconomic and demographic factors to its changes. Undernutrition was a public health problem in all surveys. Despite consistent improvement over the years, stunting still affected 32.5% of children in 2014. Wasting prevalence did not improve since 2005 and affected 9.6% of children under five in 2014. Low wealth and mother education; and rural residence contributed to undernutrition. In 2014; wealth status was the main socioeconomic factor associated with undernutrition and the nutritional status of children was strongly related to that of their mothers. Anemia prevalence was high and after a decrease between 2000 and 2005 remained at 45%. The prevalence of overweight was less than 10% and did not change over the years despite an increasing trend in the richest households of urban areas. Persistent inequalities in child undernutrition call for action, giving priority to the most vulnerable households to ensure availability and access to nutrient-rich foods for women and children through nutrition-sensitive and nutrition-specific programs. The recent increase of overweight in the richest populations must also be considered in Cambodian health policies.

Low Urinary Iodine Concentration among Mothers and Children in Cambodia.

A 2014 national assessment of salt iodization coverage in Cambodia found that 62% of samples were non-iodized, suggesting a significant decline in daily iodine intakes. The Cambodian Micronutrient Survey conducted in 2014 (CMNS-2014) permitted obtaining national data on urinary iodine concentrations (UIC) to assess iodine status and whether iodized salt use had an impact. Urine samples were collected from mothers (n = 736) and children (n = 950). The median UIC was 63 µg/L and 72 µg/L in mothers and children respectively. More than 60% of mothers and their children had a UIC < 100 µg/L, thereby indicating a serious public health problem. Iodine status was significantly lower among mothers and children living in rural areas, belonging to the poorest socioeconomic category, or living in a household not using iodized salt. The limited enforcement of the legislation for iodized salt has resulted in a major decrease in the prevalence of iodized salt, which in turn has compromised iodine status in Cambodia. It is essential for the government to enhance enforcement of the iodized salt legislation, and implement short term strategies, such as iodine supplementation, to prevent an increase of severe complications due to iodine deficiency in the Cambodian population.