Schmall, Alexandria

School of Public Health - International Health (Human Nutrition)


In Cambodia, over 30% of children are stunted and 14% of women are underweight, with the highest burden among low-income, subsistence farming families1. Due to suboptimal agricultural practices and seasonal food shortages, food insecurity is high and dietary diversity is low.2 Though women perform most household and agricultural tasks, they have little influence over household food expenditures and other purchases, which can negatively affect household nutritional status.2 While women-centered, nutrition-sensitive agriculture interventions have proven to be successful at increasing household food security and dietary diversity in Cambodia, there is little evidence about how these programs have affected women’s time use, home-garden productivity or fruit and vegetable intake among women and children.3,8 To address these questions, I will partner with an international NGO, Helen Keller International, to quantitatively evaluate how their Enhanced Homestead Food Production model influences these outcomes.

How has your research experience shaped/changed your perspectives on global health?

My primary research interest is the prevention of child stunting and the promotion of optimal nutrition within the first 1,000 days of life. I have developed a background in this area through supporting nutrition-specific (e.g. promotion of exclusive breastfeeding and timely initiation of optimal complementary feeding) and nutrition-sensitive interventions (e.g. home gardens and livestock raising, and promotion of optimal WASH and nutrition practices through SBCC) in eleven countries in Latin America and Eastern Africa over the past six years.

During my MSPH practicum research within Helen Keller International in Cambodia, I learned about another area of critical importance for child nutrition-- gender. In many settings, women’s status and empowerment within the household, community and society has a significant influence on child nutritional status. A recent literature review reported that women with higher empowerment and greater involvement in household decision-making have healthier children and are happier and healthier themselves. Several other studies have demonstrated that when women are in control of use of household financial resources, they purchase food for their children, and invest in their education and other needs. Further, within agricultural communities, when women have more involvement in the agricultural production process and control over use of income from agricultural activities, diets and nutritional status of themselves and their children are positively impacted. Our research on the evaluation of a women-centered, nutrition-sensitive agriculture intervention, touched on some of the same themes. Programmatic research conducted by IFPRI in Cambodia a few years earlier found women’s empowerment, as measured by the Women’s Empowerment in Agriculture Index, was associated with aspects of improved diets among women and their children in rural Cambodia.

Improving women’s status is important to achieving improved global health and nutrition outcomes. From a systems perspective, addressing and improving women’s status contributes to an enabling environment for nutrition. More nutrition programs should incorporate a women’s empowerment component due to the potential intersectional benefits on health and nutrition outcomes among women and their children.

Through many conversations with expert colleagues, I also learned about the potential challenges associated with improving gender equity and women’s empowerment in different settings. Depending on the country and context, addressing women’s status and supporting empowerment can be very difficult due to culture, longstanding traditions and gender norms. One of colleague described the goal of women’s empowerment as not only to improve women’s status within their own home, but changing and improving relationships between women and men to be more equitable, respectful and empowered at the household, community and societal level. My research experience in Cambodia provided the opportunity for me to study the critical influence of women’s empowerment on child nutrition, an area that I plan to continue to research in the future. Further, I will remain an advocate for women’s empowerment and gender equity because a woman’s health, happiness and wellbeing are important for her an autonomous human being first, in addition to considerations for their children.

Photo: HKI Beneficiary Farm

What lessons did you learn about the field of global health?

During my practicum, I learned a lot about the near universality of the nutrition transition. The nutrition transition is the movement away from a diet composed of traditional foods, towards one that includes more highly processed, high-fat and high-sugar foods that are associated the ‘Western diet.’ The nutrition transition is occurring rapidly in many countries around the world and is associated with the epidemiologic transition, which is the shift in primary disease burden from infectious diseases towards chronic (and often, diet-related) diseases like cardiovascular disease, hypertension, obesity and diabetes mellitus. These transitions are driven by globalization, urbanization, economic development, technological advances within the workforce, are linked to some positive outcomes including improving economies and increased disposable income for communities and populations.

In countries from Thailand to Tanzania, highly processed foods and drinks are more available, affordable, and people are consuming a lot more of them. Multinational food and beverage corporations have capitalized on these ‘new markets,’ and colorful, attractive advertisements for the junk foods are everywhere, from densely populate urban settlements to remote, rural communities. In addition, fresh fruits and vegetables can be difficult to access and are often more expensive than the junk foods.

In the Cambodian context, sugary drinks (e.g. sweet coffees, teas and soft drinks) and fried foods (fried, instant noodles, hotdog-style processed meats, and fried chicken) are among the most popular- especially among young people. These foods and drinks are cheap and easier to prepare compared to healthier, more traditional food options, such as a fish amok, a traditional coconut fish stew, or other meat and vegetable stir-fries and slow-cooked soups. Other than their affordability, the main reason for their popularity…the high-sugar, high-salt, high-fat foods taste very good.

As people consume more of these food and drinks, risk of overweight, obesity, cardiovascular disease, hypertension, certain cancers and other diet-related diseases rises, and population burden of diet-related disease increases. This is on-going in Cambodia, as rates of obesity and diabetes have been increasing rapidly in recent years. At present, over 20% of adults are overweight or obese, and 43% of deaths are attributable to chronic diseases including cardiovascular disease, cancers and diabetes. Nearly 50% of children consume one or more soft drinks per day. At the same time, there remains a large burden of undernutrition, including high prevalence of child stunting (34%) and wasting (~10%) and widespread micronutrient deficiencies among women and children. The coexistence of high burden of over and undernutrition is known as double burden of malnutrition, which can add additional pressure to an already stressed health system. 

Individual freedom of choice is important and empowering, and increased disposable income is a great thing. People should be able choose the types of foods they want to eat. However, it is important to support communities to choose to eat healthfully. In order to support communities to do so, we need to ask and address some difficult questions. Why are junk foods cheaper and more accessible than fresh fruits and vegetables? How can we increase access, affordability and preference for fresh fruits, vegetables? Why are multinational food and beverage companies able to flood markets with these highly-processed foods and drinks while national rates of diet-related disease continue to increase? How can we work together with communities to promote healthy lifestyles, including increased physical activity and diets rich in fresh fruits, vegetables and lean proteins?

In Cambodia, progress is being made to encourage healthy lifestyles. Many schools are including nutrition education as part of curriculum, exercise clubs are increasingly popular, there is a 10% tax on non-alcoholic beverages including soft drinks, and communities are increasingly aware of and interested ‘healthy eating’, including promotion of traditional foods. While great progress is being made, there is more to do to support communities to adopt healthy lifestyles. My practicum experience in Cambodia influenced me to think about creative and effective ways to support these efforts through my work as a public health nutritionist.

Photo: Fish amok- traditional Cambodian fish stew

What would you tell a student who was considering applying for a similar experience?

If a student was interested in applying to a similar practicum experience, I would first encourage them to do a self-assessment of their goals for their practicum, skillset and personal preferences. When working abroad, it is important to have a skillset that matches up with the organization’s work agenda in order to be able to work most effectively. It is important to assess your personal goals as well: what do you want to get out of your practicum experience? Are you looking to work in an urban or rural area? Do you want to collect primary data, support with intervention design or evaluation, work on policy, research or programs, hone your quantitative or qualitative skills- or both? Having personal and professional goals can help make your practicum work best for you, while also helping to advance the work of the organization you are matched with. Reach out to people at the organization you’re interested in and ask questions- about the work you would do, work and communication style, your colleagues, work and office culture- it is important to assess your ‘fit’ with the organization, and let them get to know you a bit, before deciding to work there. I would also suggest that the student evaluate their personal environmental preferences. Working abroad is often quite different than working in the US. It is important to be open-minded, kind, respectful, flexible and perseverant when working in different countries and cultures. While working abroad, you will be forced to get out of your comfort zone, and your lifestyle might (temporarily) change. That said, get to know your colleagues- local and international. Most are kind, and they want to get to know you and show you around. Eat at local restaurants (they have the best food!) and visit local markets, you learn a lot about local culture through eating and shopping with people. Experience the country and learn the history. Practice the local language- even if you can only speak a little, people appreciate it and it shows that you care enough to try. Finally, do your best work and make the most out of your opportunity!

Photo: Nutrition transition in Phnom Penh


August 2022




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