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3 Preface This book has been written to introduce the newly developed Recommended Dietary Allowance (RDA) and Food-Based Dietary Guidelines (FBDG) for school-aged children in Cambodia. Recommended Dietary Allowance (RDA) is a set of recommended amount of energy and nutrient intake per day. RDA for school-aged children in Cambodia (CAM-RDA) was first formulated based on the data analysis of a nationwide food consumption survey conducted in 136 schools in 23 provinces and Phnom Penh. This book elaborates how the recommended amount of energy and 19 types of nutrient for 6 to 17 years old were calculated. The establishment of RDA is the first step to develop FBDG, but it is meant to be used for hospital diet, school meal programs, food fortification and other nutrition-related activities as well. Food-Based Dietary Guidelines (FBDG) for school-aged children in Cambodia consist of seven key messages and its educational materials. They have been developed to bring improvement to nutritional issues identified by the nationwide survey. It is very important that FBDG is disseminated to the public and integrated into the school-based health education to promote healthy eating habits. We hope that RDA and FBDG will be used as a tool to foster healthy growth of school-aged children in Cambodia through integration into health education curriculum. It is also hoped that this book will be used as a reference for nutrition professionals in Cambodia to develop a set of RDA for other age groups in the future. Phnom Penh, 2017 MINISTER OF HEALTH i

4 Acknowledgement We acknowledge Dr. Prak Pisethriangsey, the former director of the Preventive Medicine Department at the Ministry of Health who first generated the enthusiasm among partners to create the first food-based dietary guidelines for Cambodia. Our sincere gratitude goes to Professor Nobuo Yoshiike and Professor Kaoru Kusama from Aomori University of Health and Welfare in Japan, the advisors to the Foundation for International Development/Relief (FIDR), for their professional support and guidance during the process of development. We would also like to express our great appreciation to FIDR for their technical support and the financial assistance provided by Japanese donors through FIDR. We would like to thank all of the respondents, principals and teachers of the 136 schools who participated in the survey. We would not have been able to conduct this analysis without their cooperation. We would like to thank nutrition experts from government ministries and institutions, international organizations and NGOs for their valuable input and suggestions. Most importantly, we would like to thank each member of the FBDG development team, as listed below, for their contribution and commitment to this project. 1. Ms. Koeut Pichenda, MD, MPH, PhD, Deputy Director of Preventive Medicine Department /PMD/MoH 2. Dr. Chhun Loun, Chief of Non-communicable Disease/PMD/MoH 3. Dr. Hok Sirany, Vice Chief of Non-communicable Disease/PMD/MoH 4. Dr. Chea Mary, Deputy Director of National Nutrition Program/MoH 5. Dr. So Chhavyroth, Deputy Director of School Health Department/MoEYS 6. Dr. Say Ung, Director Department, Health, Food Security and Nutrition of Council of Agriculture and Rural Development 7. Dr. Leang Supheap, Staff of National Institute of Public Health 8. Mr. Hou Kroeun, Deputy Country Director of Helen Keller International 9. Dr. Khim Sam Ath, Technical Officer for Non-Communicable Diseases and Health Promotion of World Health Organization 10. Ms. Hanneke Vandyke, Technical Officer of World Food Program 11. Ms. Din Seanglay, Nutrition Programme Assistant of World Food Program Finally, we would like to extend our appreciation to the following supervisors for their continuous support and assistance: H.E Sok Silo, Deputy Secretary General, Council for Agriculture and Rural Development (CARD), Dr. Kol Hero, Director of Preventive Medicine Department (MoH), Dr. Chhay Kimsotheavy, Director of School Health Department (MoEYS), and Dr. Prak Sophonneary, Deputy Director of National Maternal and Child Health Center and Program Manager of the National Nutrition Program. ii

5 Executive Summary Cambodia, like many other developing countries, is beginning to face the threat of emerging obesity and diet-related non-communicable diseases among school-aged children while the country is still struggling with malnutrition. Dietary habits are rapidly changing, especially in urban areas, with the increased access to undesirable nutrient-poor foods that are high in saturated fats, salt and sugar. These changes attribute to the phenomenon of obesity. On the other hand, stunting, underweight and wasting for age are still common in rural areas. To address these problems, the Preventive Medicine Department at the Ministry of Health and the Foundation for International Development/Relief (FIDR) formed a joint initiative to develop Food-Based Dietary Guidelines (FBDG) for school-aged children to promote healthy eating behaviors. Like 17 other countries in Asia and the Pacific who have developed their FBDG, Cambodia should also follow the path to create Food-Based Dietary Guidelines in order to tackle nutritional problems, especially among school-aged children who are the future of the country. The Food and Agriculture Organization of the United Nations (FAO) defines FBDG as providing advice to the general public on foods, food groups and dietary patterns to promote overall health and prevent chronic diseases. So far, Cambodia has not yet established a set of Recommended Dietary Allowances (RDA), therefore formulating RDA was the preliminary step to move on to develop FBDG. In 2014, the relevant departments of the Royal Government of Cambodia, international organizations and non-governmental organizations met together to discuss the development of FBDG for Cambodian school-aged children. A nationwide survey on the nutritional status and dietary intakes of school-aged children was conducted between November 2014 and July More than 2,000 children aged 6 to 17 years old at 136 schools in 23 provinces and in Phnom Penh were surveyed using a dietary assessment method called 24-hour dietary recall *. The overall aim of the survey was to investigate the nutritional status of Cambodian school-aged children by determining the specific nutrient gaps in their diets that can be linked to nutritional problems. The survey revealed that 33% of the students were stunted, 15% were wasted and 35% were underweight. The prevalence of malnutrition amongst school-aged children is estimated to remain high or is even getting worse compared to children under the age of 5 years. More than 50% of the girls in the age group years old were stunted, which leads *24-hour dietary recall will be described in chapter 2 iii

6 to serious negative effects on their health especially during their reproductive age. Also, an important issue to consider is that children who are stunted are at risk of becoming overweight and obese later in life. Malnourished students were more numerous in rural than in urban areas. In rural schools, the prevalence of malnutrition was 36% for stunting, 16% for wasting and 38% for underweight, while the prevalence of malnutrition in urban schools was 20%, 10% and 22% for stunting, wasting and underweight respectively. Students in rural areas depend more on rice as a source of energy and protein than school-aged children in urban areas. Anthropometric data was also collected during the survey to set a reference body weight for the development of Recommended Dietary Allowance for school-aged children in Cambodia (CAM-RDA). Energy and nutrient requirements for 19 types of macro- and micronutrients for boys and girls within 5 age groups were calculated mostly based on the reference body weight. CAM-RDA is the foundation to formulate FBDG. In other words, technical recommendations are transformed into simple messages that are applicable to the target population. FBDG developed in a specific cultural context based on RDA can be useful for nutrition education programs and agriculture planning to bring about positive change in eating habits. The guidelines can also be used as the primary reference for making decisions about nutrition policies. Food-Based Dietary Guidelines (FBDG) for school-aged children in Cambodia Cambodian Food for Healthy Growth has been developed with 7 key messages based on scientific evidence along with a food pyramid a visual display of FBDG. A brochure for primary schools and a booklet for secondary/high schools have been developed to provide further information on what and how much to eat from each food type. The feasibility of the messages and educational materials were tested, revised and finalized in collaboration with the FBDG development team. Key messages: 1. Eat food from all food types with a well-balanced diet* everyday 2. Consume calcium rich-foods such as whole small fish, milk and milk products 3. Eat protein-rich foods such as fish, meat, eggs or beans at least 2 to 3 times a day 4. Eat plenty of fruits and vegetables regularly 5. Eat cereals and starchy foods such as rice, noodles, bread and its alternatives in an adequate amount iv

7 6. Reduce food high in salt, sugar and fat 7. Measure your body weight and height regularly and track your growth * A well-balanced diet is to eat food from all food types in the proper amount and accompanied by physical activities. Once the Cambodian FBDG is established, the next step is to disseminate the information to the target audience and to implement activities. It is recommended that FBDG is integrated into school-based health education curricula. Accompanying materials shall be used for nutrition education as part of the school health education. FBDG can be also used for interventions that promote healthy eating habits among the general public including parents and caretakers. FBDG can be introduced at various institutions, including health centers and hospitals where nutrition information shall be shared with health professionals and patients. The educational materials can be used to educate patients on healthy diets while RDA can also be used for managing and providing hospital meals. The Food-Based Dietary Guidelines shall be monitored and evaluated on a regular basis to identify the relevance and applicability of the messages for the target population. People s lifestyles, eating patterns, and access to food are changing rapidly in the present times. Therefore, their dietary intakes shall be assessed by a wide range of stakeholders in order to ensure that relevant updates to the FBDG and its messages are made regularly. v

8 List of Tables and Figures Tables Chapter 2 Table 2-1: Respondent to questionnaire Table 2-2: Demographic characteristics of study participants by age group Table 2-3: Household demographic by region categories Table 2-4: Nutritional status of children by gender, age, and province Table 2-5: Frequency of food consumption by students Table 2-6: Common seasoning consumed Chapter 3 Table 3-1: CAM-RDA for school-aged children Table 3-2: CAM-RDA age group Table 3-3: Reference for BMR calculation Table 3-4: Physical activity level by age Table 3-5: Reference value for EER calculation Table 3-6: Reference value for EAR protein calculation Table 3-7: Reference value for RDA protein calculation Table 3-8: Reference value for calcium calculation Table 3-9: Reference value for iron calculation Table 3-10: Reference value for thiamin (VB1) calculation Table 3-11: Reference value for riboflavin (VB2) calculation Table 3-12: Reference value for niacin (VB3) calculation Table 3-13: Reference value for zinc calculation Table 3-14: Reference value for iodine calculation Table 3-15: Reference value for selenium calculation Table 3-16: Reference value for vitamin A calculation Table 3-17: Reference value for vitamin D calculation Table 3-18: Reference value for vitamin C calculation Table 3-19: Reference value for folate calculation Table 3-20: Reference value for copper calculation Table 3-21: Recommended fat percentage calculated from EER Table 3-22: Reference value for dietary fibre calculation Table 3-23: Reference value for sodium calculation Table 3-24: Reference value for potassium calculation Table 3-25: Reference value for phosphorus calculation vi

9 Chapter 4 Table 4-1: Average of height increase per 10 years (Boys) Table 4-2: Average of height increase per 10 years (Girls) Table 4-3: Average of weight increase per 10 years Chapter 5 Table 5-1: Definition of 6 food types and standard of serving Table 5-2: Energy-based ideal serving size for girls Table 5-3: Energy-based ideal serving size for boys Table 5-4: Ideal menu with serving size Table 5-5: Ideal menu with nutrients data Table 5-6: Summary of the activities during the 1st pilot study Chapter 6 Table 6-1: Suggested monitoring and evaluation plan Figures Chapter 1 Figure 1-1: Roles of RDA and FBDG Chapter 2 Figure 2-1: GIS map of the survey location Figure 2-2: Nutritional status of children by age group Figure 2-3: Typical meal pattern Figure 2-4: Macronutrient distribution (urban vs rural students) Figure 2-5: Macronutrient distribution (boys vs girls) Figure 2-6: Comparison of calcium intake Figure 2-7: Comparison of iron intake Figure 2-8: Comparison of sodium intake Chapter 3 Figure 3-1: Line graph of CAM-RDA reference body weight for boys Figure 3-2: Line graph of CAM-RDA reference body weight for girls vii

10 Chapter 4 Figure 4-1: Distribution of energy intake and EER Figure 4-2: Changes in protein supply in Cambodia, neighboring countries, China, Korea, and Japan ( ) Figure 4-3: Ratio of food groups for protein source Figure 4-3a: Cereals Figure 4-3b: Legumes Figure 4-4: Changes in calcium intake and calcium food group (legumes, fish, meat, eggs, milk and milk products) intakes in Japan Figure 4-5: Changes in milk supply in Cambodia, neighboring countries, China, Korea, and Japan ( ) Figure 4-6: Ratio of food groups for calcium source by age group Figure 4-6a: Condiments Figure 4-6b: Vegetables viii

11 List of Abbreviations BMR CAM-RDA CDHS DG EAR EER FAO FBDG FFQ FIDR GIS IEC materials MoH MoEYS NCDs NPH PAL PMD RDA SEA-RDA WHO Basal Metabolic Rate Cambodian Recommended Dietary Allowance Cambodia Demographic Health Survey Dietary Goal Estimated Average Requirement Estimated Energy Requirement Food and Agriculture Organization of the United Nations Food-Based Dietary Guidelines Food Frequency Questionnaire Foundation for International Development/Relief Geographic Information Systems Information Education and Communication materials Ministry of Health Ministry of Education Youth and Sports Non-communicable Diseases National Pediatric Hospital Physical Activity Level Preventive Medicine Department Recommended Dietary Allowance Southeast Asia Recommended Dietary Allowance World Health Organization ix

12 Table of Contents Preface... i Acknowledgement... ii Executive Summary... iii List of tables and figures... iv List of Abbreviations... ix Chapter 1 Introduction 1.1 Background Definition and purpose of RDA and FBDG Timeline of the process...5 Chapter 2 Nutritional Status and Dietary Intakes of School-aged Children in Cambodia ( ) 2.1 Survey subject Survey subject and Sample size Random selection Respondents and Response Rate Data collection Anthropometric measurements Household questionnaire hour dietary recall method Statistical analysis Results Demographic characteristics Characteristics of households Nutritional Status of students Prevalence of Stunting Prevalence of Wasting and Thinness Prevalence of Underweight Prevalence of Overweight Food Consumption and Nutrient Intakes Food consumption by students Nutrient Intakes by Students Survey Findings...21 Chapter 3 Cambodian Recommended Dietary Allowance (CAM-RDA) 3.1 Cambodian Recommended Dietary Allowance (CAM-RDA)...23 x

13 3.2 Formula to calculate CAM-RDA Energy Protein Calcium Iron Thiamin (Vitamin B1), Riboflavin (Vitamin B2) and Niacin (Vitamin B3) Zinc, Iodine, Selenium, Vitamin A, Vitamin D, Vitamin C, and Folate Copper Fat Dietary fiber Sodium Potassium Phosphorus...41 Chapter 4 Comparison of the survey results and CAM-RDA and recommendations for improvement 4.1 Comparison of dietary intakes and CAM-RDA Recommendations on increasing intakes of some important nutrients Ideal intake goals for protein and calcium Ideal goals for height and weight...48 Chapter 5 The Cambodian Food-Based Dietary Guidelines- Cambodian Food for Healthy Growth 5.1 Seven messages Educational materials for dissemination Poster Brochure Booklet The Pilot Study The First Pilot Study The Second Pilot Study...63 Chapter 6 For the next step 6.1 A handbook for parents and caretakers Training programs and workshops for school teachers Mass media usage Campaigns and promotion activities Application in healthcare institutions Monitoring and evaluation...65 xi

14 References...66 Appendix 1: Member list of Food-Based Dietary Guidelines Development Team Appendix 2-1: The List of 136 Schools...72 Appendix 2-2: Questionnaire-School Children Anthropometry...77 Appendix 2-3: Questionnaire Household...78 Appendix 2-4: Questionnaire for 24 hour recall...83 Appendix 3-1: Dietary intakes and CAM-RDA for Boys Appendix 3-2: Dietary intakes and CAM-RDA for Girls Appendix 3-3: Energy intakes and CAM-RDA...86 Appendix 3-4: Protein intakes and CAM-RDA...86 Appendix 3-5: Calcium intakes and CAM-RDA...87 Appendix 3-6: Iron intakes and CAM-RDA...87 Appendix 3-7: Zinc intakes and CAM-RDA...88 Appendix 3-8: Vitamin A intakes and CAM-RDA...88 Appendix 3-9: Vitamin C intakes and CAM-RDA...89 Appendix 3-10: Thiamin (Vitamin B1) intakes and CAM-RDA...89 Appendix 3-11: Riboflavin (Vitamin B2) intakes and CAM-RDA...90 Appendix 3-12: Niacin (Vitamin B3) intakes and CAM-RDA...90 Appendix 3-13: Copper intakes and CAM-RDA...91 Appendix 3-14: Fat intakes and CAM-RDA...91 Appendix 3-15: Dietary Fibre intakes and CAM-RDA...92 Appendix 3-16: Sodium intakes and CAM-RDA...92 Appendix 3-17: Salt (Sodium Chloride) intakes and CAM-RDA...93 Appendix 3-18: Potassium intakes and CAM-RDA...93 Appendix 3-19: Phosphorus intakes and CAM-RDA...94 xii

15 Chapter 1 Introduction 1.1 Background Cambodia has been struggling with the poor nutritional status of children. According to the Cambodia Demographic Health Survey (CDHS) 2014, 32 percent of children under the age of 5 are stunted, 10 percent are wasted, and 24 percent are underweight. 1) Focusing at the goal of the National Nutrition Strategy ), the Cambodian Government and development agencies have been increasing its efforts to reduce maternal and child morbidity and mortality by improving the nutritional status of women and children. Most of the efforts in nutrition made by the Government and development agencies have been targeting children under the age of 5. However, there seems to be less nutritional interventions for school-aged (6 to 17 years old) children than needed. There is also only limited data available of those age groups. The nutritional status during the primary school period has a significant impact on pubertal development. Raising awareness among caretakers and educating young children to consume an adequate and balanced diet during that important phase is crucial for their proper growth. As the progression of puberty is affected by malnutrition, young children can remain more likely malnourished and lack proper cognitive development in their adolescent life, which will have an effect during their reproductive years. While Cambodia is still struggling with undernutrition, issues of obesity and non-communicable diseases (NCDs), which are partly attributable to improper nutritional intake, are gradually appearing. Other neighboring countries are already facing emerging obesity and NCDs, even among children. Cambodia has achieved rapid economic growth but is also facing changes in people s dietary patterns with many options of nutrient-poor, unbalanced, processed food and sugary beverages. This affects directly today s eating habits of school-aged children, and they are more exposed to the threat of obesity and NCDs. Nutritional interventions to promote healthy eating habits of school-aged children are therefore very important and an urgent task on which the Government and development agencies should work together to protect children from diet-related health problems. These interventions are vital to stop the cycle of passing the negative impact of malnutrition on to the next generation. In that sense, nutritional interventions for school-aged children not only support children s well-being but are also a meaningful investment to increase the productivity and resilience of the population. 1

16 The World Declaration and Plan of Action for Nutrition (1992) calls on that governments, together with other groups, should, on the basis of energy and nutrient recommendations, provide advice to the public by disseminating dietary guidelines relevant for different age groups and lifestyles and appropriate for the country s population. 3) However, as written in a report of the Regional Consultation on Food-Based Dietary Guidelines for countries in the Asia Region 2010 Cambodia does not have a food consumption survey. They also do not have the technical expertise to develop FBDGs 4), nutrient standards and food-based dietary guidelines based on scientific evidence have not yet been established in Cambodia. To respond to such needs, the Preventive Medicine Department of the Ministry of Health and the Foundation for International Development/Relief (FIDR) came together to form an initiative to develop the first Cambodian Recommended Dietary Allowance (CAM-RDA) and to facilitate the development of Food-Based Dietary Guidelines (FBDG) for school-aged children to promote healthy eating behaviors. Like 17 other countries in Asia and the Pacific who have developed their FBDGs, it is time for Cambodia to have its own RDA and FBDG to tackle nutritional issues especially among school-aged children who are the future of the country. In 2014, the relevant departments of the Royal Government of Cambodia, international organizations and non-governmental organizations met together to discuss the development of FBDG for Cambodian school-aged children (see Appendix 1). A nationwide survey was conducted to analyze the situation and the development process was carried out in accordance with the protocols instructed in the joint report Preparation and Use of Food-Based Dietary Guidelines by FAO and WHO. 5) Although it was a big challenge for all of the development team members as it was the first attempt in Cambodia to create a set of RDA and FBDG, the RDA and FBDG for school-aged children have been finally developed. The purpose of this book is to publish the outcomes and to record the three-year development process. 1.2 Definition and purpose of RDA and FBDG What is RDA? Recommended Dietary Allowance (RDA) is the amount of nutrient and energy intake per day considered necessary for maintenance of good health, calculated for males and females of various age. 6) Sufficient scientific evidence is required to establish RDA. In other countries, RDA is used to develop hospital diet or school meal menus and it is supposed to be periodically reviewed and revised. Since 2007, the National Pediatric Hospital (NPH) in Phnom Penh has provided inpatients with a hospital diet based on nutritional calculations. The NPH referred to the RDA of Southeast Asia to 2

17 develop menus as there were no established RDA or nutritional requirements specifically for Cambodians. What is FBDG? Once RDA is established, it should be disseminated to the entire target population. As WHO states, RDA is the foundation for a country to develop Food-Based Dietary Guidelines (FBDG). 7) In other words, FBDG are a means of communicating the message to guide the target population to the recommended nutritional level. FBDG present information that the public can easily understand with a focus on ordinary foods, portion sizes and behaviors. 8) It can be used as a key tool for nutritional education and behavior change by health providers, teachers and others working directly with the public (Figure 1-1). Why food-based? Nutrients should primarily be taken from daily diet, for children as well as other age groups (This does not apply to those under clinical treatments). Supplements and fortified food can only support specific nutrients and they do not ensure the wide range of nutrients necessary for child growth. It is recommended that meals for school-aged children be based on the guidelines demonstrated in this book. Implementers of school meal should also refer to FAO recommendation related to sustainability of such meals. Sustainable diets are protective and respectful of biodiversity and the ecosystem, culturally acceptable, accessible, economically fair and affordable, nutritionally adequate, safe and healthy. 9) 3

18 Figure 1-1: Roles of RDA and FBDG Fortified Food Supplements Meal Program Child well-being with good nutrition Other Health Interventions Hospital Diet, Nutrition Counseling Dietitians Doctors Researchers Public Health Promotion Education in Schools Food-Based Dietary Guidelines As an educational tool Recommended Dietary Allowance Ideal intake of nutrients 4

19 1.3 Timeline of the process 5

20 Chapter 2 Nutritional Status and Dietary Intakes of School-aged Children in Cambodia ( ) The survey was started in November 2014 and completed on July The period of the survey was divided into two rounds with an interval to avoid the holiday season. 1) Round1 was conducted from November 2014 to January 2015: 49 Schools in 6 provinces and Phnom Penh. 2) Round2 was conducted from May to July 2015: 87 Schools in 17 provinces. The objectives of the survey were to: (i) examine the nutritional status of Cambodian school aged children (6-17 years old); and (ii) determine the amount of nutritional intake and eating patterns of such children. The overall aim of the survey was to investigate the nutritional status of Cambodian school-aged children by determining the specific nutrients gaps in their diets that can be linked to nutrition related problems. Based on the results of this survey, the Food Based Dietary Guidelines (FBDG) have been developed and will be promoted in Cambodia for school-aged children. 2.1 Survey subject Survey subject and Sample size The subject of the survey is school aged children: between 6 to 17 years old. ENA for SMART ) was used to calculate its sample size as in the formula down below. Sample size was determined based on the following formula: where n is the required sample size, z is linked to 95% confidence interval (1.96 was used), p is the estimated prevalence of the key variable of interest (25% was adopted considering over and undernutrition), d is the relative desired precision (counted as ±3% which should be sufficient in the most cases in general). To meaningfully interpret Global Acute Malnutrition estimate in the survey, Design Effect DEFF was set as 2. The calculated sample required for the study was 1,743 and taking into account a non-response rate of 20%, the required final sample size was increased to 2,091. 6

21 2.1.2 Random selection The subjects were randomly selected though multi-stage sampling. 1) Primary Sampling Unit (PSU)*: The target schools were randomly selected from all public schools in Cambodia using the Probability Proportionate to Size (PPS) method. The school lists (Appendix 2-1) from the 24 provinces/municipality are obtained from the Education Management Information System (EMIS) office, Department of Planning, Ministry of Education, Youth and Sport (MoEYS). One hundred fifty-four (154) schools (including reserve samples of 19) schools in 21 cities-provinces (except Pailin) were selected for the survey. 2) Secondary Sampling Unit (SSU)*: Students between 6-17 years old, within PSUs were randomly selected using the systematic sampling technique. As a result, 20 students from each elementary school and 12 students from each secondary and high school were respectively selected for the survey. *PSU and SSU are selected by using ENA for SMART Respondents and Response Rate Among students selected by SSU, students over 12 years (n=925) were eligible to answer questionnaires directly to enumerators. For students aged between 6 to 11 years (n=1,095), their caretakers were called to answer the questionnaires for them. Those students who did not meet the criteria of the survey were excluded; the criteria were: 1) Student without physical disability affecting his/her weight or height; 2) Student with normal enrollment age for his/her grade. Altogether students in 136 schools were surveyed: 134 selected schools and 2 reserve sample schools. Response rate was 96.6%. In total, 2,020 samples were collected. Table 2-1: Respondents to questionnaire (n=2,020) 7

22 Figure 2-1: GIS map of the survey location 2.2 Data collection Cross sectional data were collected to assess health status, socio-economic background, food consumption and eating pattern via three methods: 1) anthropometric measurements, 2) household questionnaire, 3) 24-hour dietary recall method. Questionnaires were initially designed in English and translated into Khmer by the survey team and nutrition specialists. The translated questionnaires were tested to assure the appropriateness of the questions ahead of the survey. A pretest of the entire data collection process was conducted in two schools (not selected nor reserved) with 20 students: one school in Phnom Penh and one in Kampong Chhnang province from October 13 to 16, The pretest served to ensure that the questionnaire was fully understood by the enumerators. It also served to test the enumerator behavior while in conducting interviews. The Nutrition Specialist evaluated the results and a final consultation was held with the enumerators. Difficulties with 8

23 the questionnaire that were encountered by the enumerators were discussed and phrasing and/or translation was adjusted accordingly Anthropometric measurements Central weighing and measuring stations were installed in each school selected for the survey. Weight and height of children were measured according to an anthropometric protocol based on the WHO Child Growth Standard Training course 11) on child growth assessment. Children s weights were taken while wearing light clothing and no shoes. Heights and weights were assessed to the nearest 0.5 cm and 0.1 kg respectively. All measures were taken twice and the mean value was used for analysis. (Appendix 2-2) Weight was measured using standardized digital flat scales (TANITA HD-662, Capacity: 150 kg). Height was measured with a stadiometer (SECA 213, measuring range: cm). A pair of enumerators, each consisting of a measurer and an assistant, took all measurements. The data was collected in the record form. (Appendix 2-3) Household questionnaire After providing written consent, caretakers for students aged between 6 and 11 years and students over 12 years old were interviewed in person by enumerators. Depending on the given infrastructure, caretakers were either invited in advance to come to school for interview, or enumerators went to caretakers homes. (Appendix 2-4) If the interviews were conducted centrally in a public place, privacy was assured by keeping an adequate distance between the interviewed respondents such that only enumerators were able to hear the answers hour dietary recall method A 24-hour dietary recall method was used to collect meal intake. A quick dietary record form was used to record food and drinks respondents consumed over the course of one day, where possible. Based on this quick dietary record form, enumerators asked and probed the amount consumed by the respondent using FIDR Picture Book 12). This book shows nine food-groups with pictures of actual portion sizes of 130 sample foods to estimate intake amount Statistical analysis 1) Household data was entered using EPI Data version 3.0 and then exported to the SPSS data editor (IBM SPSS Statistics version 20) and checked for inconsistencies. Flagged values were checked against the paper questionnaires. 9

24 If necessary, study participants were approached to verify the result. 2) Anthropometric data was entered in WHO Anthro Plus 13) and analyzed. 3) Nutrient analysis was performed using FIDR Nutrition Calculation Database ) Statistical analysis was performed using IBM SPSS statistics version Results Demographic characteristics During the study period 2,020 children in 136 schools in 23 provinces and Phnom Penh of Cambodia were surveyed. The age range of students was 6 years old as minimum to 17 years old as maximum. The mean age of students was 12.1 years old with the median age being 12 years old. In five age groups as defined in ASEAN Food Composition Tables ) for school-aged children, the age group years old was the largest group (33.2%), and 47.5% of boys and 52.5% of girls were involved in this study. All provinces were divided into four regions as follows: Plain: Phnom Penh, Kandal, Kampong Cham, Tbmong Khmum, Svay Rieng, Prey Veng, Takeo Tonle Sap: Kampong Thom, Siem Reap, Battambang, Pursat, Kampong Chhnang, Banteay Meanchey, Oddar Meanchey, Pailin Coastal: Sihanoukville, Kampot, Kep, Koh Kong Plateau and Mountain: Kampong Speu, Stung Treng, Ratanak Kiri, Mondul Kiri, Kratie, Preah Vihear As shown in Table 2-2, 19.9% of students live in urban areas while 80.1% live in rural areas. The largest number of students live in plain areas (45.5%), which includes Phnom Penh, Kandal, Kampong Cham, Svay Rieng, Prey Veng, and Takeo. Second to the plains, 34.1% live in Tonle Sap area. 10

25 Table 2-2: Demographic characteristics of study participants by age groups *P-value of <0.001 indicates statistically significant level Characteristics of households Summary of household demographic by region categories is shown in table 2-3. While a half of students answered, the rest asked their caretakers to answer the questionnaire. Median age of caretakers was 31, in which difference by regions was observed (p<0.001). Most of the caretakers relationship to children was mother (74.9%) followed by grandmother (12.8%). About one fifth of respondents owned the poor ID card (21.4%). With regards to the type of poor ID card, proportions of level 1 and 2 were nearly the same (Table 2-3). It was also found that overall, 16.9% of people experienced food deficit, which is not different regionally. (Not shown in table) However, the proportion of respondents experienced food deficit was significantly higher in rural areas compared to urban areas (Rural; 18.2%, Urban; 11.9%, respectively; p = 0.003). 11

26 Table 2-3: Household demographic by region categories *P-value of <0.001 indicates statistically significant level 2.4 Nutritional Status of students The nutritional status of study participants by age, gender, and province is shown in Table 2-4. It shows that the mean (Z-score) of all indicators (height-for-age, weight-forheight, and weight-for-age) resulted negative values, which means the participants nutritional status is below the average of the WHO standard 15). 12

27 2.4.1 Prevalence of Stunting Students whose height-for-age is below minus two standard deviation (<-2SD) compared to WHO child growth standard are considered stunted, and are short for their age. Stunting is the outcome of failure to receive adequate nutrition over an extended time 16). Recurrent or chronic illness also may contribute to the effect. Thirty-three percent (33.2%) of students were short for their age. The rate of stunting, which includes severe stunting (<-3SD,) for boys (36.8%) was higher than that of girls (30.0%). By age group in total, age group years showed the highest rate of stunting (43.0%) (Table 2-4). By comparison with sex, age group for boys showed the highest, while age group years showed the highest for girls (Figure 2-1). The prevalence of stunting was higher among rural students (36.4%) than among urban students (20.4%). The highest rate of stunting (53.3%) was found in Kep province (Table2-4) Prevalence of Wasting and Thinness Students whose weight-for-height is lower than negative 2 standard deviation (<-2SD) compared to WHO child growth standard are considered wasted or thin. Wasting represents the failure to receive adequate nutrition in the period immediately before the survey, and typically is the result of recent illness, especially diarrhea, or the effect of a rapid deterioration in food supplies 17). The survey found that fifteen percent (15.0%) of students were wasted at the time of the survey. The rate of stunting for boys (16.7%) was higher than girls (13.4%). By age group, age group years showed the highest rate of wasting (19.4%) (Figure 2-1). The prevalence of wasting in rural area was 16.1% while 10.4% was in urban area. The highest rate of wasting (23.3%) was found in Kep (Table 2-4). The prevalence of thinness or sever thinness (BMI-for-age) was 15.0% in total, and the highest was among years old boys (25.0%) and years old girls (21.0%). 13

28 Figure 2-2: Nutritional status of children by age group *Underweight (Weight for Age) does not include students over 11 years old Prevalence of Underweight Students whose weight-for-age is lower than 2 standard deviation (<-2SD) compared to WHO child growth standard are considered as underweight. The measurement is reflecting the effects of both acute and chronic under nutrition. However, the score of weight-for-age in WHO Anthro Plus is only available up to 10 years old thus students older than 10 years old were not analyzed in this study. Around thirty-five percent (35.1%) of children was underweight. The prevalence of underweight among boys and girls was almost the same, 35.3% for boys and 35.1% for girls (Table 2-4). The prevalence of underweight was higher among rural (22.1%) than urban students (38.1%). The highest rate of underweight (75.0%) is found in Stung Treng province (Table 2-4) Prevalence of Overweight Students whose weight-for-height is greater than 2 standard deviations compared to WHO growth standard are considered overweight. Overweight and obese children are more likely to stay obese into adulthood and more likely to develop NCDs at a younger age 18). 14

29 The data showed that 3.2% of students in total were overweight. The prevalence of overweight is higher among urban (2.1%) than rural students (0.1%) and highest among children aged 6 (2.8%). Although, in the majority of provinces students are not overweight, Phnom Penh and Siem Reap stand out with 3.7% and 1.2% prevalence of overweight among students, respectively. Table 2-4: Nutritional status of children by gender, age, and province 15

30 2.5 Food Consumption and Nutrient Intakes Food consumption by students Frequency of consumption of selected food groups by students is summarized in Table 2-5. Fruits: The result showed that 86.7% of students ate fruit at least one day a week. Among those, the most common answer (23.7%) was 2 days per week (Table 2-5). Vegetables: Almost all students (95.9 %) ate vegetable at least one day a week. Among those, the most common answer (31.1%) was 7 days per week (Table 2-5). Meat: Animal meat was found to be consumed by 91.3% of students at least one day per week. Among those, the most common answer (22.3%) was 3 days per week (Table 2-5). Fish/poultry or seafood: Fish/poultry or seafood was found to be consumed by almost all students (99.3%) at least one day per week. As fish is widely available in Cambodia, 30.0% of students consumed 7 days per week (Table 2-5). Milk/Soy milk: In Cambodia, it is not common to consume fresh milk as it is produced in very few amount domestically and not everyone has access to it due to its availability and price. However, around a half (45.9%) of students did drink milk or soymilk at least one day a week. The most common answer (11.6%) was 2 days in a week (Table 2-5). Further, 6.5% of students answered that they consumed unsweetened whole milk while 7.9% of students consumed sweetened whole milk. (Data not shown here) Junk food consumption: The majority of students (86.6%) consumed junk food at least one day a week. The most common answer (21.9%) was 7 days per week (Table 2-5). Soft drink consumption: The majority of students (84.3%) consumed soft drink which contain a lot of sugar at least one day per week. The most common answer (18.4%) was 2 days per week (Table 2-5). 16

31 Table 2-5: Frequency of food consumption by students (n=2,020) Typical meal composition: The type of meal pattern was questioned to identify the typical meal composition. The most common type of meal seemed to be composed of rice with soup or sweetened stew (41%) followed by rice with soup and deep-fried/grilled dish (32%) (Figure 2-3). Figure 2-3: Typical meal pattern Common seasoning: The common seasonings consumed were salt (99.5%), oil/fat (98.6%) and MSG/ Rosdee/Knorr (99.4%) (Table 2-6). 17

32 Table 2-6: Common seasoning consumed Nutrient Intakes by Students Energy: In comparison between urban and rural area, the average amount of stdents total energy intake per day was higher in urban area (1,636 kcal) than that of rural area (1,591kcal) (Figure 2-4). As the amount of energy intake between urban and rural areas differs, the composition of energy intake was also different. As Figure 2-4 shows, the students in rural area were more dependent on carbohydrate as the source of energy than those in urban. On the other hand, the students in urban area consumed more fat than in rural area. Protein: In comparison between urban and rural area, the result showed that the students in urban area consumed more protein (48.3g) in average than students in rural area (43.9g). Further, boys consumed 47.7g of protein in average and 42.2g for girls, but in terms of energy contribution, both were not so much different from each other (Figure 2-4, 2-5). Fat: Like protein, more fat was consumed by urban students (17.7% from total energy) than students in rural (14.4% from total energy) in average. In comparison between genders, fat intake was 14.4% for boys and 15.6% for girls in average, and girls fat consumption was contributing more to their total energy intake than that of boys (Figure 2-4, 2-5). 18

33 Carbohydrate: All students consumed well amount of carbohydrate. When its intakes were compared in the macronutrient distribution chart, only a slight difference was observed between boys and girls (Figure 2-5). However, it seemed that students in rural area were relying more on carbohydrate, rice in this case, as the main source of their energy (Figure 2-4). Figure 2-4: Macronutrient distribution (urban vs rural students) Figure 2-5: Macronutrient distribution (boys vs girls) Calcium: In comparison between the area and gender, Figure 2-6 shows that average amounts of total calcium intake were similar. It was observed that fish-related foods largely contributed to calcium intake for both students in urban and rural areas. The students in urban area were more likely to consume calcium from milk and dairy 19

34 products, while the students in rural took more calcium from the food group of condiments and spices, which refers to fish paste in this case. Figure 2-6: Comparison of calcium intake Iron: In comparison between urban and rural area, the average amount of total Iron intake was different as urban students consumed more than rural students. When compared between gender, boys consumed more iron than girls (Figure 2-7). Figure 2-7: Comparison of iron intake 20

35 Sodium: As for sodium intake, there were not much difference between genders. In comparison between urban and rural area, however, it showed a clear difference in the average amount of sodium intake, and urban students consumed more sodium (2,251mg) than rural students (1,840mg) (Figure 2-8). Figure 2-8: Comparison of sodium intake 2.6 Survey Findings The survey found that 33.2% of the students were stunted, 15.0% was wasted and 35.1% was underweight. The prevalence of malnutrition among school-aged children (6-17 years old) is estimated to remain still high or is even worsen compared to children under 5 years old. The 2014 Cambodia Demographic and Health Survey 19) provides data for the prevalence of malnutrition among children under 5 years old: 32.4% of these children were stunted, 9.6% was wasted and 23.9% was underweight. In the students of age group years old, stunted (43.0%) was found the most. Wasted (19.4%) appeared the most in the age group of years old and underweight (54.4%) was noticed the most in the age group of 10 years old. In gender comparison, the girls of the age group years old should be highlighted. More than 50.0% of the girls in the group were stunted, which leads to serious negative effects on their health especially during reproductive age. Girls with stunting are reported to experience slow secondly growth (puberty) and tend to give birth to an underweight baby. Also, an important issue to consider is that children who are stunted are at risk of becoming overweight and obese later in life. Looking at adult overweight and increasing non-communicable diseases in Cambodia 20), the high prevalence of stunting among children is worrisome. 21

36 The students were found more malnourished in rural area compared to urban area. In rural schools, a prevalence of malnutrition was 36.4% for stunting, 16.1% for wasting and 38.1% for underweight. While the prevalence of malnutrition in urban school was 20.4%, 10.4% and 22.1% for stunting, wasting and underweight respectively. Poverty and food shortage surely wield influence on malnutrition status of students. The mean scores for stunting (height for age: HAZ) among students from those households that possessed ID poor cards was worse (-1.85) than students from normal households (-1.50). In addition, the mean of HAZ for the students from households that experienced food shortage more than one month in the previous year was worse (-1.92) than students from households not experienced (-1.51). In the survey, some key findings on dietary intake of students should be emphasized. In comparison between urban and rural area, the students in rural area are more dependent on rice as a source of energy than those in urban. On the other hand, the students in urban area consume more foods which contain fat and protein and various kinds of foods than in rural area. The prevalence can be reduced by improving nutrient intakes of school-aged children through increase of awareness regarding their quality of diet. Children and caretakers of these children should be educated about the importance of balanced diet. Consumption of protein and calcium rich food products such as milk, legumes, animal meat and whole small fish etc., should be promoted and increased. Further recommendations and suggestions are made in later chapter. 22

37 Chapter 3 Cambodian Recommended Dietary Allowance (CAM-RDA) Recommended Dietary Allowance (RDA) refers to the level of intake of energy and dietary components which, on the basis of current scientific knowledge, are considered adequate for the maintenance of health and well-being of nearly all healthy persons in the population. RDA provides the levels of nutrient intake that almost all individuals (97% to 98%) should consume to avoid the risk of deficiency and can reduce the risk for development of non-communicable diseases (NCDs) in a target population 21). 3.1 Cambodian Recommended Dietary Allowance (CAM-RDA) Cambodian Recommended Dietary Allowance (CAM-RDA) for school-aged children was developed for the first time in Cambodia through data collection from a nation-wide survey among school-aged children in 2014 and Energy and nutrient requirements for 19 types of macro- and micronutrients for boys and girls within 5 age groups were calculated based on the reference body weight of Cambodian school-aged children. The RDA energy and nutrient requirements are used to formulate food-based dietary guidelines (FBDG) that are applicable to the target populations. FBDG developed in a specific cultural context based on RDA can be useful for nutrition education programs and agriculture planning to bring about positive change in eating habits. It can also be used as the primary reference for making decisions about nutrition policies. Moreover, RDA is used as a basis for food labeling of nutrition facts to indicate nutritional values of a food or food product. It is hoped that this newly developed CAM-RDA is not only the foundation for formulating the FBDG, but that is also to serves as a starting point for the government when developing nutrition policy, planning, and education programs. 23

38 Table 3-1: CAM-RDA for school-aged children * 4, 5 years old and 18 years old were excluded from the data collection. ** EAR (Estimated Average Requirement) is the intake level for a nutrient at which the needs of 50 percent of the population will be met 22). *** Fat percentage from total energy ****Sodium chloride Note that the figures are rounded for the final CAM-RDA. The actual quatitative amounts are showed in the colored column in the following pages. 24

39 3.2 Formula to calculate CAM-RDA Table 3-1: CAM-RDA for school-aged children All energy and nutrient requirements were calculated based on each age group. Students ages were divided into five groups in accordance with the SEA (Southeast Asian)-RDA table. However, while the school age in Cambodia is 6 to 17 years, other ages like 4 or 18 years remained in the table in parentheses as a reference. The classification of CAM-RDA age groups was set as shown in (Table 3-2). Reference body weights used for Cambodian school-aged children were set at the mid-point between the median of the survey data and the SEA-RDA. Figure 3-1: Line graph of CAM-RDA reference body weight of boys 25

40 Figure 3-2: Line graph of CAM-RDA reference body weight of girls Energy The estimated energy requirement (EER) is the amount of food energy needed to balance energy expenditure in order to maintain body size, body composition and a level of necessary and desirable physical activity, consistent with long term good health 23). EER for each age group and sex was calculated based on the BMR predictive equations 24) along with level of physical activity. The data of the real target group of Cambodian children from the survey were also used for the calculation. EER= BMR x PAL +Energy deposition In which: Note: Energy deposition = Weight gain per year x 1000/365 x Energy density Basal Metabolic Rate (BMR) is defined as the lowest rate of energy exchange in the body that is related to the organization of bodily functions and the production of body heat. Technically, it is defined as the rate of energy expenditure of a fasted and fully-rested individual in a thermoneutral environment. It can also simply be defined as the minimal rate of energy expenditure compatible with life. The following equations 26

41 were used to estimate BMR by using reference body weigh in Kg 25). Table 3-3: Reference for BMR predictive equations W = Reference body weight PAL (Physical Activity Level) Japanese table of PAL were used to calculated estimated energy requirement 26) Table 3-4: Physical activity level by age (for both boys and girls) Table 3-5: Reference value for EER calculation * 0.00 is set for the calculation as there is no data from the survey 27

42 3.2.2 Protein The estimated average requirement (EAR) is key to calculating RDA. For protein, EAR was calculated using the formula below: EAR = (Protein deposition/ Conversion for utilization for growthx100 + Maintenance requirement / Efficiency of conversion from dietary proteinx100)x RBW In which: Protein deposition = weight gain x 1000/365 x body protein mass/100/rbw Conversion for utilization for growth = 40% Maintenance requirement= 0.67 Efficiency of conversion from dietary protein = 70-85% RBW = CAM reference BW (Cambodia reference body weight) Table 3-6: Reference value for EAR Protein calculation The above calculated EAR is used to determine the RDA for protein by using the following equation. Twelve point five percent was assumed to be the inter-individual variation of the requirement 27). RDA (g) = EAR x Coefficient of variation Coefficient of variation =

43 Table3-7: Reference value for RDA Protein calculation Calcium Only 1% of calcium is found in blood, extracellular fluid, muscle and other tissue, where it plays an important role in mediating vascular contraction and vasodilatation, muscle contraction, nerve transmission and glandular secretion. The other 99% is found in bone and teeth 28). To meet the recommended value of calcium, the estimated average requirement is multiplied by the coefficient of variation. EAR = (Bone mineral accretion + Urinary Excretion + Loss through skin)/apparent calcium absorption The above calculated EAR is used to determine the RDA for calcium by using the following equation. 10% was assumed to be the inter-individual variation of the requirement 29). RDA=EAR x Coefficient of variation Coefficient of variation =

44 Table 3-8: Reference value for Calcium calculation Iron Most girls reach puberty at an earlier age than boys and they generally start their first menstrual cycle around the age of 10. The RDA was calculated in two recommendations. One is for non-period days and another is for period days (Table 3-9). 30

45 Table 3-9: Reference value for Iron calculation * Extrapolation: W 0 =68.6kg, X 0 =0.96mg/day ** 6-9 yrs: (volume of hemoglobin of higher age group -volume of hemoglobin the target age group) x 3.39mg/(median age of the higher age group median of the target age group)/365days; 10-17yrs: c x (h+d) x g x 0.075L x 3.39/365 *** 6-14yrs= 20%; >15yrs= 10% 31

46 3.2.5 Thiamin (Vitamin B1), Riboflavin (Vitamin B2) and Niacin (Vitamin B3) Following upon the estimated energy requirement (EER) calculated for Cambodian children, the amount of required Vitamin B1, B2, and B3 were calculated based on the EER of CAM-RDA. X= X 0 x EER of CAM-RDA/ EER 0 X = new RDA for the target population X 0 = value existing in the reference (SEA-RDA) EER 0 = EER existing in the reference (SEA-RDA) Thiamine (Vitamin B1) was calculated as below (Table 3-10): Table 3-10: Reference value for Thiamin (VB1) calculation Riboflavin (Vitamin B2) was calculated as below (Table 3-11): Table 3-11: Reference value for Riboflavin (VB2) calculation 32

47 Niacin (Vitamin B3) was calculated as below (Table 3-12): Table 3-12: Reference value for Niacin (VB3) calculation Zinc, Iodine, Selenium, Vitamin A, Vitamin D, Vitamin C, and Folate Another basic rule to extrapolate RDA values is based on the reference body weight of the target group and the reference value of the existing reference, where an exponent of 0.75 is adopted to estimate the ratio of body surface area proportional to the requirement of the selected nutrients. Nutrient and body weight references from SEA were used to calculated Zinc, Iodine, Selenium, Vitamin A, Vitamin D, Vitamin C and Folate. X=X 0 (W/W 0 ) 0.75 X = new RDA for the target population X 0 = values in the existing reference (SEA-RDA) W = CAM reference BW W 0 = reference BW used in the existing reference (SEA-RDA) 33

48 Zinc was calculated as below (Table 3-13): Table 3-13: Reference value for zinc calculation Iodine was calculated as below (Table 3-14): Table 3-14: Reference value for iodine calculation 34

49 Selenium was calculated as below (Table 3-15): Table 3-15: Reference value for selenium calculation Vitamin A was calculated as below (Table 3-16): Table 3-16: Reference value for Vitamin A calculation 35

50 Vitamin D was calculated as below (Table 3-17): Table 3-17: Reference value for Vitamin D calculation Vitamin C was calculated as below (Table 3-18): Table 3-18: Reference value for Vitamin C calculation 36

51 Folate was calculated as below (Table 3-19): Table 3-19: Reference value for Folate calculation Copper Copper was calculated using the same formula as the other micronutrients, but with a different reference (Table 3-20). The Japanese reference was used for X 0 and W 0. Fifteen percent was assumed to be the inter-individual variation of the requirement 35). RDA (g) = EAR x Coefficient of variation Coefficient of variation= 1.3 Table 3-20: Reference value for copper calculation 37

52 3.2.8 Fat The Japanese reference was used to determine the percentage of the recommended fat intake. The percentages vary from 20-30% based on the level of activity. To calculate the amount of fat intake, we used the estimated energy requirement of each age group and selected the activity level (Table 3-21). A median of 25% is recommended to avoid both chronic energy deficiency and obesity. Table 3-21: Recommended Fat percentage calculated from EER Dietary Fibre Dietary Fibre was calculated by using the data from the survey combined with Japanese reference values. The new Dietary Goal (DGx) was derived from the equation below: DGx= 18.9 x (RBW of our data/57.8) 0.75 The above figure 18.9g is the intermediate value of a and b, which is set as a tentative goal to be achieved by considering very low actual intake levels in the target population. a: Median of DF intake in Japanese adult (over 18 years) (13.7g/day) 36). b: Observed risk decrease in heart attack mortality (24g/day) 37) = the average body weight of Japanese adult DG x = Tentative goal aimed to prevent life-style related disease e.g. coronary heart disease, stroke and cancer 38). 38

53 Table 3-22: Reference value for Dietary Fibre calculation Sodium A reduction in sodium intake to <2 g/day sodium (5 g/day salt) is recommended by WHO to reduce the risk of high blood pressure, cardiovascular disease, stroke and coronary heart disease in adults. Not only for adults, but WHO also recommends a reduction in sodium intake to control blood pressure in children. The recommended maximum level of intake of 2 g/day sodium in adults should be adjusted for children based on the energy requirements of children 39). DGx = [5.0 x (EERx/ EER 0 ) + Ix] / 2 DGx = tentative dietary goal for preventing life-style related diseases 5.0 = Suggested maximum level of intake for sodium chloride (salt) in gram by WHO for adult EERx = EER for CAM-RDA EER 0 = EER for years old for SEA-RDA Ix = Median of sodium chloride (salt) intake in CAM data In this formula, the intermediate values between the true recommended level (=5g) adjusted for EER and the actual intake levels are calculated as a tentative and achievable goal in the real settings of the target population. 39

54 Table 3-23: Reference value for sodium calculation Potassium An increase in potassium intake from dietary sources is suggested by WHO in order to reduce blood pressure, the risk of cardiovascular disease, stroke and coronary heart disease in adults. WHO also suggests an increase in potassium intake from dietary sources to control blood pressure in children. The recommended potassium intake of at least 90 mmol/day (3,510mg/day) should be adjusted downward for children, based on the energy requirements of children relative to those of adults 40). DGx = [3,510 x (EERx/EER 0 ) + Ix] / 2 In which: DGx = tentative dietary goal for preventing life-style related diseases 3,510 = recommended potassium intake in mg by WHO for adults EERx = EER for CAM-RDA EER 0 = EER for years old for SEA-RDA Ix = median of potassium intake in CAM data 40

55 Table 3-24: Reference value for potassium calculation Phosphorus The adult requirements for phosphorus are based on studies of serum inorganic phosphorus concentration. The EAR, and hence the RDA, for healthy adolescents aged 9 through 18 years is based on a factorial approach and is higher than the adult value. This is because this age range is one of intensive growth, with growth rate, absorption efficiency, and normal values of inorganic phosphorus in the extracellular fluid changing during this time 41). CAM-RDA Phosphorus= (DRI US & Canada + Ix)/2 In which: DRI US & Canada= the DRI value of -US and the RDA value of Canada Ix = Median of Phosphorus intake in CAM data Table 3-25: Reference value for phosphorus calculation 41

56 Chapter 4 Comparison of the survey results and CAM-RDA and Recommendations for improvement This chapter intends to discern the gap between the actual nutritional status and dietary intakes revealed by the nationwide survey and the nutritional objectives (RDA) as well as to introduce recommendations aiming to improve the nutritional status of school-aged children. The recommendations are derived from the gap analysis with relevant data from other Asian countries. It is hoped that this will serve as useful information for policy-makers when developing a nutrition policy for children and adolescents. 4.1 Comparison of dietary intakes and CAM-RDA From the survey results introduced in Chapter 2, the mean of students intake of energy and fifteen nutrients such as protein, calcium, iron, thiamin (VB1), riboflavin (VB2), niacin (VB3), zinc, vitamin A, vitamin C, copper, fat, dietary fiber, sodium/salt (sodium chloride), potassium, phosphorus along with CAM-RDA are shown by gender and age group (Appendix 3-1 to 3-19). In summary, the majority of students surveyed were found not meeting the CAM-RDA for most nutrients. The total average of energy intake is 1,600 ± 595 kcal (mean ± SD). When energy intake is compared with EER of CAM-RDA, all groups except 6 yearold boys are not within the appropriate range of EER (Figure 4-1). There is a slight difference between girls (54%) and boys (61%) who are getting enough protein. 6 year-old boys (91%) were getting sufficient protein (Appendix 3-4). The total intake of calcium was 396 ± 246mg (mean±sd). It is the most needed among year-old boys (only 6% meet the EAR of CAM-RDA), followed by year-old boys and year-old girls (in both age groups only 10% meet the EAR of CAM-RDA). Overall, only 14% of students met the EAR of CAM-RDA for calcium (Appendix 3-5). Iron intake was the lowest among year-old girls (31% meet EAR of CAM-RDA) and the highest among year-old boys (82% meet EAR of CAM-RDA) (Appendix 3-6). None of the students surveyed met the RDA for zinc (Appendix 3-7). A majority of children did not meet the CAM-RDA for vitamins A, C, B1 and B2. For vitamin A, only 21% of boys and 18% of girls met the recommended dietary intake and it was lowest among 6 year-old boys (only 6% meet CAM-RDA). For vitamin C, only 41% of boys and 44% of girls met the RDA. Only 14% of boys and 13% of girls consumed the recommended amount of thiamin or vitamin B1. Similarly, 18% of boys and 20% of girls met the RDA for riboflavin or vitamin B2, the lowest consumption was seen among year old boys (8%). For niacin or vitamin B3, the lowest percentage of students who consumed adequate amounts is among year old boys (7%) and 42

57 girls (7%) (Appendix 3-8 to 3-12). The percentage of students who met the dietary goal (DG) for fat is low overall (19%) but is higher among girls (22%) than boys (16%) (Appendix 3-13). While the percentage of students who consumed within the dietary goal for sodium (49%) and sodium chloride (49%) seems relatively high, a closer look reveals that the other 50% consumed either more than enough or not enough sodium (Appendix 3-15, 3-16). For potassium, only 2% of students met the DG of CAM-RDA. 17% met the DG for phosphorus, while 9% met the DG for copper, with only slight differences between girls and boys (Appendix 3-18, 3-19). Considering the importance of the sodium-potassium ratio to prevent hypertension, the current data is worrisome. Far too few children consumed an adequate amount of potassium, but too much sodium. It would be ideal to grasp habitual intakes measured by survey of multiple days to compare them with values of CAM-RDA for more strict assessment. The demonstrated results from a single-day survey could be different from the habitual intakes, therefore, it should be carefully interpreted. Figure 4-1: Distribution of energy intake and EER 43

58 4.2 Recommendations on increasing intakes of some important nutrients Ideal intake goals for protein and calcium Adolescents require more nutrients compared to the needs of younger children as they enter puberty and experience many physical changes including growth spurts, sexual maturity, bone mineralization, and body composition changes. The survey results indicated that both boys and girls for aged and who met or exceeded the standard (or within the standard range) were low. Proteins and calcium are especially important during puberty and its ideal intake goal values are suggested below. Protein Figure 4-2 shows that protein supply among Asian countries increased significantly in the past 25 years, with a range from 4-15 g of increase in a decade (except Japan). While more protein is being consumed in these countries than in the past, increasing protein intake by 5-10g (from the current 45g to 50-55g) in next 10 years may be both ideal and feasible (Figure 4-2). Figure 4-2: Changes in protein supply in Cambodia, neighboring countries, China, Korea and Japan ( ) Change of average protein supply per 10 years ( ) g/capita/day Japan: -4g Korea: 6g China: 15g Vietnam: 15g Myanmar: 15g Laos: 9g Thailand: 4g 44

59 As demonstrated by the survey, students protein intake mostly relied on cereal 36.8%, (82% of which is from rice, 6% from wheat noodle, and 5% from bread), followed by fish (20.7%), meat (16.6%), eggs (4.9%) and legumes (4.9%, 40% of which is from mung bean and 25% from soybean milk) (Figure 4-3). This indicates that students consumed protein mostly from rice. However, this may need to be shifted to protein-rich foods, such as fish, meat, or eggs. The food portion equivalent to 6g of protein is about 30g of meat or fish, 1 egg, or 60g of legumes. When expressed in serving size, the average intake for protein-rich food (fish, meat, beans and eggs) is around 3 servings at the time of the survey, but should be increased by 1-2 servings, for a total of 4-5 servings. Figure 4-3: Ratio of food groups for protein source [Figure 4-3a: Cereals] [Figure 4-3b: Legumes] 45

60 Calcium According to statistics for Japan, calcium intake among the intake among Japanese almost doubled over 30 years (from 300mg in 1949 to 548mg in 1979). This is mostly due to milk and milk products consumption, which increased from 4g to 113g over the same time period (Figure 4-4). Figure 4-5 shows the milk supply in Cambodia and neighboring countries for the past 20 years. Countries such as Vietnam, Thailand, and Myanmar increased their milk supply by double over the two decades. In Cambodia, milk supply remains low (Figure 4-5), along with milk and milk product consumption. However, this trend may change in future as these milk products can be an ideal source of calcium. In order to achieve the increases seen elsewhere in the region, intake would need to be increased by 50 to 100mg over the next 10 years (from the average of 396mg of current calcium intake to mg). From the survey results, students intake of calcium mostly relied on the condiments which accounted for 27.6% of calcium consumption (from this, 84% is coming from fish and shrimp paste, and 12% is from fish sauce), followed by cereals (13.9%), fish (12.7%), and vegetables (9.2%, mainly coming from leafy vegetables of 61%) (Figure 4-6). When converted into serving size, only about 0.3 servings were consumed from the calcium-rich foods. This should be increased to 2-3 servings. The food portion equivalent to 1 serving (100mg) of calcium is 100ml for milk, 40g for whole small fish, 60g of tofu, and 50g for amaranth (leafy green vegetables). Figure 4-4: Changes in calcium intake and calcium food group (Legumes, fish, meat, eggs, milk and milk products) intakes in Japan Source: Ministry of Health, Labour and Welfare, Japan: National nutrition survey 46

61 Figure 4-5: Changes in milk supply in Cambodia, Neighboring countries, China, Korea and Japan ( ) Source: FAO. FAOSTAT. Food Balance Sheets Figure 4-6: Ratio of food groups for calcium source by age group 6 years old 7-9 years old years old years old year old 47

62 [Figure 4-6a: Condiments] [Figure 4-6b: Vegetables] Ideal goals for height and weight As shown by anthropometric results in earlier chapter, it is important to observe the physique of students at 6-17 years of age. Reducing the number of students who are underweight, stunted, and thin can be an optimal goal for their overall health and growth. Setting ideal goals for weight and height within the next 10 years is recommended using examples from other Asian countries. In Asia, the children s average height and weight increased over the past few decades. For instance, boys height increases ranged from 0.9 cm (Thailand) to 4.7 cm (Korea), and their weight increases ranged from 0.8 kg (Japan) to 5.3 kg (Korea) on average over years 42)-48) (Table 4-1, 4-2). Likewise, girls height increased 0.6 cm (Thailand) to 3.9 cm (Korea), and gained 0.8 kg (Japan) to 3.7 kg (Korea) on average over 10 years 47),48). Taking into consideration the above data, weight increase of 1-3 kg and height increase of 1-4 cm from the current mean or median may be an ideal goal over the next 10 years (Table 4-3). Table 4-1: Average of height increase per 10 years (Boys) 48

63 Table 4-2: Average of height increase per 10 years (Girls) Table 4-3: Average of weight increase per 10 years Boys Girls 49

64 Chapter 5 The Cambodian Food-Based Dietary Guidelines -Cambodian Food for Healthy Growth- As presented in Chapter 3, the CAM-RDA for school-aged children has been calculated based on the dietary intakes and nutritional status found through the nationwide survey conducted in In order to promote nutritional recommendations generated through the CAM-RDA to the public, this information needs to be translated into Food-Based Dietary Guidelines (FBDG) that comprise simple messages on healthy eating along with the food pyramid and other Information Education and Communication (IEC) materials that give guidance on specific foods and amount to be eaten each day from each food type. These guidelines and accompanying IEC materials can be used as tools for nutrition education in schools as well as for interventions that promote healthy eating habits among the general public including caretakers of children. 5.1 Seven messages The following 7 key messages were first drafted based on the scientific rationale from the survey. The wording of the messages and its statement were evaluated by the FBDG development team to ensure that they are appropriate for school-aged children. They were revised taking into account feedback from other interested parties and finalized by the FBDG development team after pilot testing. 1. Eat food from all food types with a well-balanced diet* everyday 2. Consume calcium rich-food such as whole small fish, milk and milk products 3. Eat protein-rich foods such as fish, meat, eggs or beans at least 2 to 3 times a day 4. Eat plenty of fruits and vegetables regularly 5. Eat cereal and starchy food such as rice, noodles, bread and its alternatives in an adequate amount 6. Reduce food high in salt, sugar and fat 7. Measure your body weight and height regularly and track your growth * Balanced diet is to eat food from all food types in proper amount and fit with physical activity 49) 50

65 5.2 Educational materials for dissemination IEC materials play a very important role in drawing the attention of the target population to the guidelines and communicating its substance effectively. The Camboidan Food-Based Dietary Guidlines have been translated into the following 4 kinds of IEC materials. 51

66 5.2.1 Poster Target: All school-aged children and the general public Content: The food items were selected from the top 50 most commonly consumed items reported by respondents during the nationwide survey in Young Cambodian artists drew all of the food items in the pyramid. The shape of pyramid was inspired by Angkor Wat Temple. The pyramid Cambodian Food for Healthy Growth is designed to show the recommended proportion of food types to be consumed; ie., low consumption at the top and higher consumption at the base of the pyramid. The food types are (1) cereals and starchy foods as main source of carbohydrate, (2) fruits and (3) vegetables as important sources of vitamins and minerals, (4) whole small fish, small dried shrimp, milk and milk products as the main source of calcium and (5) meat, fish, eggs, and beans as main sources of protein and (6) fat and condiments such as oil, animal fat, salt and sugar. Examples of food types in the food pyramid: i. Cereals and starchy foods: rice, yellow noodle, white noodle, bread, corn, and potato. ii. Vegetables: morning glory, cucumber, carrot, tomato, spinach, pumpkin, wax gourd, bean sprout and snake gourd. iii. Fruits: banana, pineapple, water-melon, mango, papaya, orange, sapodilla, jack fruit and guava. iv. Protein-rich foods: fish, chicken, meat, eggs, snail, crab and beans. v. Calcium-rich foods: whole small fish, small dried shrimp, tofu, milk and milk products. vi. Salt, sugar, fat and oil: oil and pork fat, salt and sugar. 7 key messages are introduced on both sides of the pyramid expressing the connection between food types and messages by color. 52

67 5.2.2 Brochure Target: Primary school students Content: The main information is derived from the food pyramid with additional short statement about the 7 key messages. The short statement is to support each key message in order for children to understand the rationale behind the recommendations. The short statement: Message 1: Eat food from all food types with a well-balanced* diet everyday: Eating food from different food types every day is to support your health and growth. Message 2: Consume calcium-rich food such as whole small fish, milk and milk products: Calcium is important to maintain healthy teeth and bones. Message 3: Eat protein-rich food such as fish, meat, eggs or beans at least 2 to 3 times a day: Protein-rich foods will help you build a strong body and muscles. Message 4: Eat plenty of fruits and vegetables regularly: Eating vegetables and fruits can help you prevent illness. Message 5: Eat cereals and starchy foods such as rice, noodles, bread and its alternatives in an adequate amount: The body needs to maintain a constant supply of energy. Providing energy is the major function of cereals and starchy foods. Message 6: Reduce food high in salt, sugar and fat: Try to limit sweetened drinks. You can choose to stay healthy through selecting foods that are low in fat, salt and sugar. Message 7: Measure your body weight and height regularly and track your growth: Knowing your body weight and height can help you manage healthy growth. The ideal body weight and height for each age group are also introduced for boys and girls. 53

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69 5.2.3 Booklet Target: Secondary and high school students (13-17 years old) Content: The below contents were selected taking into consideration the target age group that will soon be responsible for their own food choices and will soon reach their reproductive years. 1. Food pyramid Food pyramid is introduced with illustration of food item and in which type each belongs to. 2. Serving size information How much do we need to eat from each food type? In order for an individual to understand how much to eat from each food type, it is important to provide guidance on serving sizes. The information was prepared for both boys and girls from years old or more, based on three of energy requirement levels from CAM- RDA. Students will be able to identify their required energy consumption by their age and their physical activity levels indicated alongside the table. However, this may need to be explained by school teachers or caretakers for better understanding. In addition, a standard serving size for each food type needs to be introduced along with the serving size guide 50 ). So far, only selected food items have been listed in the table, but the food list can be updated as necessary. ( () () () () () () () () 55

70 Table 5-1: Definition of 6 food types and standard of serving Table 5-2: Energy-based ideal serving size for girls 56

71 Table 5-3: Energy-based ideal serving size for boys 3. Ideal Menus To better illustrate the phrase good variety, well-balanced diet, an ideal menu for a day (breakfast, lunch, dinner, and snack) was created in the next page. Each menu was calculated for energy and nutrients using FIDR Nutrition Calculation Database, created based on ASEAN Food Composition Table 51) and was converted into serving sizes for each food type. 57

72 Table 5-4: Ideal menu with serving size 58

73 Table 5-5: Ideal menu with nutrients data 4. Basic nutrients It is important to provide the basic information of essential nutrients such as carbohydrates, protein, fat, vitamins and minerals. Some of their major functions are introduced so that students are able to learn and reflect on choosing better foods. 5. Malnutrition Students are able to learn more about how under and over nutrition affect their health. Particular information on sugar, salt, vitamin A and calcium as well as information related to non-communicable diseases (NCDs) are provided. 6. FBDG messages and explanations: The 7 key messages are mentioned and followed by explanation in order for the students to understand the reason of such recommendations. 59

74 Message1: Eat food from all food types with a well-balanced diet everyday Our body cannot synthesize nutrients on its own -- or not to an adequate amount -- and must be provided by the diet. Eating a variety of food ensures you ll get all the nutrients you need. Choose food items from all the different food types to get the most nutrients. Message 2: Consume calcium-rich food such as whole small fish, milk and milk products We need to consume a certain amount of calcium to build and maintain strong bones and teeth. When we don t get enough calcium for our body s needs, it is taken from our bones, which can lead to bone loss, low bone density and even broken bones. Calcium also facilitates a healthy communication between the brain and various parts of the body. Calcium can also be found in leafy green vegetables. Message 3: Eat protein-rich food such as fish, meat, eggs or beans at least 2 to 3 times a day Protein is an essential nutrient found in animal products (meat, fish, and eggs), nuts, and beans. Our cells and organs, our muscles, and even our bones could not hold together without the help of protein. Message 4: Eat plenty of fruits and vegetables regularly Vegetables and fruits contain important vitamins, minerals and fiber. Scientific research shows that if you regularly eat lots of fruits and vegetables, you can lower risk of developing diseases or health problems. Message 5: Eat cereals and starchy foods such as rice, noodle, bread and its alternatives in an adequate amount Cereals and starchy foods rice, noodle, bread, potato, corn, and so on are rich in carbohydrates. Carbohydrate is the preferred energy source for most of the body s functions, especially brain. Eating cereals and starchy foods should be in conjunction with daily physical exercise to maintain ideal weight and health. Message 6: Reduce food high in fat, salt, and sugar Many health problems are linked to poor eating habits. Many people eat too much saturated fat (especially animal fat), added salt (fish sauce and salty condiments) and added sugar (sugary beverages). Reducing these by small amounts can make us healthier by helping us manage our weight and reducing our risk of diseases. Message 7: Measure your body weight and height regularly and track your growth It is important to know your body weight. Being overweight or underweight can increase your risk for serious diseases and health conditions. Try to measure your weight on a regular basis to control and manage your healthy body. 60

75 7. Meal Planning After introducing basic nutrients and issues related to under and over nutrition, students will learn how to plan their own meals with healthy food choices. Examples of recommended daily eating habit and overall patterns for a healthier diet are introduced by providing several options applicable to both urban and rural populations. 8. Recipe A recipe is introduced based on traditional Cambodian dishes. These will encourage students to appreciate the Cambodian food culture that consists of variety of vegetables, meat, fish, tropical fruits and rice as the main staple food for Cambodians. They are rich in nutrient and well-balanced food. Nutrition facts and cooking instructions are also illustrated. 9. Review checklist Students can review their current own eating habits and reflect with what they learned throughout the booklet. 5.3 The Pilot Study The purpose of the pilot study was to assess practicality, comprehensibility and cultural acceptability of the developed FBDG. IEC materials, including a food pyramid poster as well as brochures were also shown to target audiences in order to get feedback for revision The First Pilot Study The first-pilot study was conducted in two rounds in 6 provinces: Takeo, Kep, Kampong. Speu, Kampong. Cham, Siem Reap and Preach Vihear. Eight schools (4 primary and 4 secondary schools) were selected in the four regions: Tonle Sap, Plateau and Mountain, Plain and Costal. The respondents were students, caretakers and teachers, totaling 365 (round 1) and 345 (round 2). Three tools were developed and tested: (1) questionnaire and (2) quiz for students to assess their knowledge and FIDR staff explaining the food pyramid to Grade 4 students and their parents at Sbov Primary School in Kep understanding of nutrition education and (3) feedback from teachers to seek their recommendations on IEC and teaching materials (see Appendix 4 for the list of the schools). 61

76 Table 5-6: Summary of the activities of the 1 st pilot study Result Students: Primary and secondary school students were willing to learn the nutrition topics. They seemed to understand the importance and the relationship between nutrition and health. However, it is difficult to change their eating habits due to the environment at school and at home. Caretakers: Most of caretakers said they had not paid much attention to what their children should eat. After the session, they understood the importance of nutrition, especially for their children s healthy growth and they showed their willingness to prepare meals from a variety of food for their family. This pilot study was useful for learning the areas that should be revised or modified within the IEC materials. The key messages were mostly accepted by students, teachers and caretakers. Some revisions were made by the FBDG development team based on the feedback from the pilot study. The FBDG development team member from the School Heath Department of MoEYS joined to evaluate the pilot study at Mrum Khang Tboung Secondary School in Kg. Speu 62

77 5.3.2 The Second Pilot Study The second-pilot study was conducted at 2 schools (primary school and secondary school) in Kampong Chhnang and 2 schools (primary school and high school) in Phnom Penh in July 2017 in order to ensure that the target audience understood the revised IEC materials. The pilot study was conducted in focus-group discussions to collect qualitative information. A total of 37 students and 5 teachers participated in the discussions. The design and wording were discussed again within the FBDG development team for future adjustment based on the feedback from the students. Students finding weight and height on the brochure Svay Chrom Primary School, Kg. Chhnang The concept of the serving size is explained to the students Sovannaphumi High School, Phnom Penh Students checking food items in the food pyramid Sovannaphumi primary shcool, Phnom Penh High school student from Sovannapumi School clarifies the serving of Tofu. 63