77151 Nutrition at a GLANCE Cambodia The Costs of Undernutrition Annually, Cambodia loses over US$134 million • Over one-third of child deaths are due to under- nutrition, mostly from increased severity of dis- in GDP to vitamin and mineral deficiencies.3,4 ease.2 Scaling up core micronutrient interventions would • Children who are undernourished between con- cost less than US$6 million per year. ception and age two are at high risk for impaired (See Technical Notes for more information) cognitive development, which adversely affects the country’s productivity and growth. Approximate • The economic costs of undernutrition include Key Actions to Return on direct costs such as the increased burden on the Address Malnutrition: Investment(%):12 health care system, and indirect costs of lost pro- Improve infant and young child 1400 ductivity. feeding through effective education • Childhood anemia alone is associated with a and counseling services. 2.5% drop in adult wages.5 Country Context Invest in vitamin A Supplementation. 1700 HDI ranking: 137th out of 182 Where Does Cambodia Stand? Achieve universal salt iodization. 3000 countries1 • 42% of children under the age of five are stunted, Fortify commonly consumed foods 800 28% are underweight, and 9% are wasted.2 with iron. Life expectancy: 61 years 2 • 14% of infants are born with a low birth weight.2 Ensure an adequate supply of zinc 1370 Lifetime risk of maternal death: • 1 in 5 women are considered too thin and 4 in supplements for the treatment of 1 in 482 5 women are considered too short, increasing diarrhea. Under-five mortality rate: health risks during pregnancy to both the mother and child.6 90 per 1,000 live births2 Undernutrition is not just a problem of poverty. As Global ranking of stunting Cambodia has achieved high rates of vitamin A Figure 2 shows, children are undernourished in almost prevalence: 28th highest out of supplementation: 88% of children 6–59 months of one-fifth of even the richest households. This is not an 136 countries2 age receive the recommended two doses of vitamin issue of food access, but of caring practices and disease. A approximately six months apart.2 As seen in Figure 1, Cambodia performs worse Figure 2  Undernutrition Affects All Wealth Quintiles – than members from the same region and income Technical Notes group. Compared to income peers in Africa, such Poor Infant Feeding Practices and Disease are Major Causes Stunting is low height for age. as Uganda and Ghana, stunting rates in Cambodia are more severe. Richest 17.9 Underweight is low weight for age. Fourth 35.3 Wasting is low weight for height. Figure 1  Cambodia has Higher Rates of Stunting than its Neighbors and Income Peers Middle 36.3 Current stunting, underweight, and wasting estimates are based on comparison of the 60 Second 41.8 Prevalence of Stunting Among most recent survey data with the WHO Child 50 Nepal Children Under 5 (%) Growth Standards, released in 2006. They Myanmar Poorest 46.8 Cambodia are not directly comparable to the wealth 40 Vietnam Indonesia Uganda 0 10 20 30 40 50 quintile data shown in Figure 2, which are 30 Phillippines Ghana Prevalence of Stunting Among Children Under 5 (%) calculated according to the previously-used Togo Mongolia NCHS/WHO reference population. 20 China Source: DHS 2005 (figures based on NCHS/WHO reference population). 10 Low birth weight is a birth weight less than 2500g. 0 0 1000 2000 3000 Most of the irreversible damage The methodology for calculating nationwide GNI per capita (US$2008) due to malnutrition in Cambodia costs of vitamin and mineral deficiencies, and interventions included in the cost Source: Stunting rates were obtained from the WHO Global Database on Child happens during gestation and in Growth and Malnutrition (figures based on WHO child growth standards). GNI of scaling up, can be found at: data were obtained from the World Bank’s World Development Indicators. the first 24 months of life.7 www.worldbank.org/nutrition/profiles Solutions to Primary Causes of Undernutrition CAMBODIA Poor Infant Feeding Practices High Disease Burden Limited Access to Nutritious Food • 35% of all newborns receive breast milk within • Undernourished children have an increased risk of • One in four households is food insecure.8 one hour of birth.2 falling sick and greater severity of disease. • Achieving food security means ensuring quality and • Two-thirds (66%) of infants under six months are • Undernourished children who fall sick are much continuity of food access, in addition to quantity, for exclusively breastfed.2 more likely to die from illness than well-nourished all household members. • During the important transition period to a mix of children. • Dietary diversity is essential for food security. breast milk and solid foods between 6–9 months • Parasitic infestation diverts nutrients from the body Solution: Involve multiple sectors including agricul- of age, 18% of infants are not fed appropriately and can cause blood loss and anemia. ture, education, transport, gender, the food industry, with both breast milk and other foods.2 Solution: Prevent and treat childhood infection and health and other sectors, to ensure that diverse, nutri- • Only 49% of children 6–23 months of age receive other disease. Hand-washing, deworming, zinc sup- tious diets are available and accessible to all house- appropriate feeding in terms of minimum times, plements during and after diarrhea, and continued hold members. This includes making sure that moth- dietary diversity, and breast milk or milk product.6 feeding during illness are important. ers adopt appropriate infant and young child feeding Solution: Support women and their families to behaviors. practice optimal breastfeeding and ensure timely and adequate complementary feeding. Breast milk fulfills all nutritional needs of infants up to six months of age, boosts their immunity, and reduces exposure to infections. References Vitamin and Mineral Deficiencies Cause foods are effective strategies to improve the iron status of these vulnerable subgroups. 1. UNDP. 2009. Human Development Report. Hidden Hunger • Zinc: 44% of the population is at risk for insuffi- 2. UNICEF. 2009. State of the World’s Children. Although they may not be visible to the naked eye, 3. UNICEF and the Micronutrient Initiative. cient zinc intake.12 Zinc supplementation during 2004. Vitamin and Mineral Deficiency: A vitamin and mineral deficiencies impact well-being diarrheal episodes can reduce morbidity by more Global Progress Report. in Cambodia, as indicated in Figure 3. 4. World Bank. 2009. World Development than 40%.13 Indicators (Database). Figure 3  High Rates of Vitamin A and Iron Deficiency 5. Horton S. and Ross J. The Economics of Iron Deficiency. Food Policy. 2003;28:517–5. Contribute to Lost Lives and Diminished Productivity World Bank Nutrition Related Activities in 6. McGuire J.S. et al. (forthcoming). 70 Cambodia Opportunities to Protect and Enhance Projects: Through the nutrition component of the Nutrition in the East Asia and Pacific Region. 60 World Bank. Second Health Sector Support Project, the World 50 Prevalence (%) 7. UNICEF. 2009. Tracking Progress on Child Bank is supporting (a) exclusive breastfeeding for 40 and Maternal Nutrition. infants 0–6 months; (b) timely and adequate com- 8. FAO. 2009. The State of Food Insecurity in 30 plementary foods for children from six months to the World: Economic Crises – Impacts and 20 Lessons Learned. two years of age with continued breastfeeding un- 10 9. WHO. 2009. Global Prevalence of Vitamin A til two years of age and promotion of an adequate 0 Deficiency in Populations at Risk 1995–2005. Preschool Children Pregnant Women diet for women of reproductive age, particularly WHO Global Database on Vitamin A Deficiency. Vitamin A Deficiency Anemia pregnant women; (c) appropriate care of sick and 10. WHO. 2008. Worldwide Prevalence of Anemia 1993–2005: WHO Global Database on Anemia. malnourished children; (d) provision of iron-folic Source: 2000 data from the WHO Global Database on Child Growth and Mal- 11. Horton S. et al. 2009 Scaling Up Nutrition: nutrition acid supplements for women and children; (e) pro- What will it Cost? vision of vitamin A for women and children; and 12. Micronutrient Initiative. 2009. Investing in the • Vitamin A: About one-fifth of preschool aged Future: A United Call to Action on Vitamin (f) availability of iodized salt for all members of the and Mineral Deficiencies. children and pregnant women are deficient in household. 13. Bhandari N., et al. 2008. Effectiveness of vitamin A.9 Zinc Supplementation Plus Oral Rehydration • Iron: About two-thirds of preschool aged chil- Addressing undernutrition is cost Salts Compared With Oral Rehydration Salts dren and pregnant women have anemia.10 Ap- Alone as a Treatment for Acute Diarrhea in a effective: Costs of core micronutrient Primary Care Setting: A Cluster Randomized proximately half of these cases are due to dietary Trial. Pediatrics 121;e1279–e1285. iron deficiency. Iron-folic acid supplementation interventions are as low as of pregnant women, deworming, provision of US$0.05–3.60 per person annually. multiple micronutrient supplements to infants Returns on investment are as high and young children, and fortification of staple as 8–30 times the costs.11 THE WORLD BANK Produced with support from the Japan Trust Fund for Scaling Up Nutrition