Journal of Epidemiology and Global Healthhttps://doi.org/10.1007/s44197-022-00053-5

RESEARCH ARTICLE

Prevalence of Metabolic Syndrome and Its Components in Urban
Cambodia: A Cross‑Sectional Study
Miharu Tamaoki1 · Ikumi Honda1 · Keisuke Nakanishi1 · Sophathya Cheam2 · Manabu Okawada2 ·Hisataka Sakakibara3
Received: 11 April 2022 / Accepted: 30 July 2022
© The Author(s) 2022

Abstract
Background The incidence of noncommunicable diseases, such as cardiovascular diseases and diabetes mellitus, is increasing in Cambodia. Urbanization and lifestyle changes due to rapid economic development have affected the components ofmetabolic syndrome (MetS). This study aimed to determine the prevalence of MetS, MetS components, and health statusamong Cambodians living in urban areas.
Methods This cross-sectional study enrolled adult Cambodians (age ≥ 20 years) who underwent a health checkup at aJapanese hospital in Phnom Penh. MetS was defined based on the harmonized diagnostic definition from the joint interim
statement.
Results Among the 6090 (3174 men and 2916 women) participants who were enrolled in the study, the prevalence of MetS
was 60.1% in men and 52.4% in women. The prevalence of elevated blood pressure was 73.2% in men and 65.3% in women,
and was the highest MetS component in both men and women. In contrast, the lowest prevalence rates were observed for
abdominal obesity (44.8%) in men and for high triglyceride levels (33.5%) in women. The MetS group showed a significantly
higher proportion of patients with hypertension, diabetes, dyslipidemia, and obesity compared with the non-MetS group.
Conclusion The high prevalence of MetS in this study was attributed to urbanization, as in economically developed countries.
It is necessary to explore the lifestyle habits of Cambodians that contribute to MetS and to develop preventive measures toreduce the incidence and prevalence of MetS.
Keywords Metabolic syndrome · Cambodia · Urbanization · Noncommunicable diseases

1 BackgroundThe number of noncommunicable diseases (NCDs),
such as cardiovascular diseases, stroke, and type 2 diabetes, is increasing remarkably in Cambodia, which is an* Ikumi Honda
ihonda@met.nagoya-u.ac.jp
Miharu Tamaoki
tamaoki.miharu.j4@s.mail.nagoya-u.ac.jp

economically developing country [1, 2]. Over the past few
decades, increasing proportions of deaths caused in Cambodia have shifted from communicable to NCDs. Cardiovascular diseases were the leading cause of death in 2016,accounting for 24% of all deaths, and NCDs accounted for1

Department of Integrated Health Sciences, Graduate Schoolof Medicine, Nagoya University, 1‑1‑20 Daiko‑Minami,
Higashi‑ku, Nagoya, Aichi 461‑8673, Japan2

Department of Pediatric, Sunrise Japan Hospital Phnom
Penh, No177E, Kola Lourn Street (the Bay Road), Group2,
Phurn2, Sangkat Chroy Changvar Khan Chroy Changvar,
Phnom Penh, Cambodia

3

School of Nursing, Ichinomiya Kenshin College, 5‑4‑1
Jougan‑dori, Ichinomiya, Aichi 491‑0063, Japan

Keisuke Nakanishinakanishi@met.nagoya-u.ac.jp
Sophathya Cheam
cheam.sophathya@sunrise-hs.com
Manabu Okawada
okawada.manabu@sunrise-hs.com
Hisataka Sakakibara
h.sakakibara.t@ikc.ac.jp

13

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Journal of Epidemiology and Global Health

64% of all deaths [3]. While treating patients with infectious diseases, such as tuberculosis, diarrhea, and HIV, it
has become essential to deal with NCDs.
Metabolic syndrome (MetS) constitutes a combinationof risk factors, such as elevated blood pressure (BP), dyslipidemia, hyperglycemia, and obesity, and confers a highrisk for NCDs. Globally, the most common metabolic risk
factors for mortality are elevated BP, followed by overweight
and obesity, and elevated blood glucose levels [4]. A study
published in 2010 examined the risk factors for NCDs in
Cambodia and reported the prevalence of overweight andobesity as 15.4% and 1.9%, respectively, which was higher
in women, whereas that of hypertension and diabetes were
11.2% and 2.9%, respectively, and were significantly higher
in urban areas than in rural areas [5]. Wagner et al. reported
a higher prevalence of diabetes and obesity in the urban
areas of Cambodia [6]. One of the main reasons for the highprevalence of metabolic risk factors in urban areas is thechange in the living environment due to urbanization, whichis caused by economic development [7]. Yevgeniy et al.
examined data from 173 countries and found that urbanization contributed to increased body mass index (BMI) andcholesterol levels, with a more pronounced association in
low- and middle-income countries [7]. A study conductedby Maude et al. in Malaysia showed that urbanization has an
impact on obesity, cholesterol levels, and hypertension [8].
In low- and middle-income countries, including Cambodia, health systems have not yet been developed to matchthe rapid economic growth. Medical expenses are self-paid,
and there are no facilities to provide advanced medical care.
Despite an increase in the middle-class and upper-class populations due to economic development, the financial burden
is huge among those affected by NCDs. In addition, myocardial infarction and stroke require advanced medical care
and are direct liabilities for death if untreated. As the numberof people with risk factors for NCDs is high in urban areas,
it is expected that the number of people with MetS, which
confers multiple risk factors, will be high in urban areas.
However, there are no reports on MetS in Cambodia. In thisstudy, we examined the prevalence of MetS among Cambodians living in urban areas, which is predicted to be high,and identified the actual conditions of the target population
who require intervention.

2 Methods
2.1 Data Source and Study Population
In this cross-sectional study, we used data from healthcheckups conducted at a Japanese private hospital, a collaborative research facility, with permission from the facility.
The private hospital of this study center is located in Phnom

13

Penh, the capital of Cambodia, and aims to provide quality
medical care that conforms to Japanese standards. The hospital targets the middle-class and upper-class populations
and specializes in neurosurgery, gastrointestinal surgery, andinternal medicine. Most patients are from Phnom Penh or
the surrounding area. According to the general population
census of Cambodia 2019, Phnom Penh city and adjacentareas were categorized as urban areas [9]. An urban area wasdefined for this census by the National Institute of Statistics
based on population size, population density, and workers
in agriculture. The population of urban Cambodia in 2019was 6.14 million, representing 39.4% of the total population, whereas that of Phnom Penh was approximately a halfmillion, or 8% of the total urban Cambodian population.
The participants were Cambodian citizens aged ≥ 20 years
who underwent health checkups at our facility between January 2017 and December 2019. Those with complete healthcheckup data required for this study were included in theanalysis. Individuals with any physical symptoms at the timeof the health checkup were excluded.

2.2 Anthropometric and Biochemical
Measurements
Participants were instructed to consume no food or energy
drinks after 9 pm, the night before visiting the hospital. We
used data from electronic medical records, including blood
test results [triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDLC), fasting blood glucose (FBG)], systolic and diastolic BP,
waist circumference (WC), and body mass index [BMI: bodyweight {kg}/height {m}2]). These measurements were performed by professional medical staff. After at least 5 min ofrest, BP was measured on the upper arm using an automatic
medical sphygmomanometer (ES-H55, Terumo Corporation,
Tokyo, Japan). WC diameter is the diameter of the umbilicalheight measured while standing and during light exhalation.
Blood tests were performed using an automated chemistry
analyzer (Siemens Dimension EXL 200, Siemens Healthcare, Erlangen, Germany) at the hospital.

2.3 Definition of Metabolic Syndrome
MetS was defined based on the harmonized diagnostic
definition from the joint interim statement [10]. MetS
was diagnosed when three of the following five symptoms
were observed: (1) abdominal obesity (WC ≥ 90 cm in men
and ≥ 80 cm in women), (2) elevated TG levels (≥ 150 mg/dL), or on treatment for dyslipidemia. (3) Decreased
HDL-C levels (< 40 mg/dL in men, < 50 mg/dL in women,
or ongoing treatment for dyslipidemia), (4) elevated BP(≥ 130 mmHg systolic BP, ≥ 85 mmHg diastolic BP), or
treatment for previously diagnosed hypertension, and (5)Journal of Epidemiology and Global Healthelevated FBG level (≥ 100 mg/dL) or treatment for previously diagnosed type 2 diabetes.

3 Results

2.4 Statistical Analyses

A total of 6090 (3174 [52.1%] men and 2916 [47.9%]
women) participants were included in the study The statistical analysis for the characteristics of these participants ispresented in Table 1.

Table 1  Characteristics of participants
N = 6090

Men
N = 3174

Women
N = 2916

Age (years)
BMI
Waist circumference (cm)Triglycerides (mg/dL)
HDL cholesterol (mg/dL)
LDL cholesterol (mg/dL)
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Fasting blood glucose (mg/dL)
HbA1c (%)

46.9 ± 14.5
25.4 ± 3.6
88.5 ± 10.1
149 (103–223)
41.9 ± 10.6
128.5 ± 35.1
128.6 ± 16.3
84.5 ± 11.1
110.1 ± 33.4
5.8 ± 0.98

49.3 ± 15.7
23.9 ± 3.9
80.3 ± 10.7
110 (75–167)
49.3 ± 12.9
125.4 ± 35.7
122.2 ± 19.2
77.8 ± 11.3
103.8 ± 27.6
5.8 ± 0.96

Data are presented as means ± standard deviations or medians (interquartile ranges)
BMI body mass index, HDL-cholesterol high-density lipoprotein cholesterol, LDL-cholesterol low-density lipoprotein cholesterol
Table 2  Prevalence of MetS and
MetS components
Metabolic syndrome
Abdominal obesity
Hypertriglyceridemia
Low HDL cholesterol
Elevated blood pressure
Elevated fasting blood glucose

3.2 Prevalence of MetS
The prevalence of MetS was 60.1% in men and 52.4% in
women, and the most common component of MetS waselevated BP in people of both sexes: 73.2% in men and
65.3% in women. The second most common symptom was
hyperglycemia in men (66.1%) and low HDL-C in women(56.4%). In contrast, abdominal obesity for men and hypertriglyceridemia for women were the least common in 44.8%
and 33.5%, respectively (Table 2).
The age-stratified prevalence of MetS showed that 54.0%
of men in their 30 s had MetS. Among women in their 40 s,
more than half (53.5%) had MetS. The prevalence of MetS
increased with age for both men and women, with men having a significantly higher prevalence of MetS from their 20
to 40 s; however, women had a significantly higher prevalence in their 70 s (Fig. 1).

Prevalence of MetS (%)

Analyses were conducted separately for men and women,
and the descriptive statistics of the participants are presented in Table 1. The Chi-square test was used to compare
differences between men and women in each age group.
Age-adjusted bivariate analyses were performed to compare the prevalence of MetS and MetS components in men
and women and to compare the prevalence of hypertension, diabetes, and dyslipidemia between the MetS andnon-MetS groups. IBM SPSS Statistics for Windows ver.
28 (IBM, Armonk, NY, USA) was used for statistical analysis, and the significance level was set at 5% (two-tailedtest).

3.1 Characteristics of Participants

100
80

*

60
40

*

p=0.192

p=0.0.971

*
Men

*

Women

20
0

20-29 30-39 40-49 50-59 60-69 ≥70
Age (yr)Fig. 1  Prevalence of metabolic syndrome (MetS) by age (%)

Men (N = 3174)% (95% CI)

Women (N = 2917)% (95% CI)

p value*

60.1 (58.4–61.8)
44.8 (43.1–46.6)
52.3 (50.6–54.1)
48.6 (46.8–50.3)
73.2 (71.6–74.7)
66.1 (64.5–67.8)

52.4 (50.6–54.2)
53.9 (52.1–55.7)
33.5 (31.8–35.2)
56.4 (54.6–58.2)
65.3 (63.5–67.0)
53.3 (51.4–55.0)< 0.001< 0.001< 0.001< 0.001< 0.001< 0.001*Age-adjusted p value

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Journal of Epidemiology and Global Health

Figure 2 shows the percentage of the number of components of MetS by age group. More than 90% of both men andwomen in their 40 s or older had at least one component of
MetS. Approximately 20% of men in all age groups had two
MetS components. The proportion of women with three ormore MetS components increased with age.

Fig. 2  Number of metabolic
syndrome components and percentage prevalence by age

Figure 3 shows the prevalence of MetS components by
age group. In men, elevated BP was the most common
symptom in all age groups, followed by hyperglycemia. In
women, except for those in their 20 s and 50 s, elevated BP
was the most common symptom. In addition, abdominal
obesity rises sharply in their 20 s and the highest prevalence was observed in the 50 s.

Age (Yr)

Men
≥70

17%

28%

25%

60-69

19%

25%

28%

50-59

16%

40-49

15%

30-39

27%

20-29

4%
0%

25%

9%

15%

25%

10%

20%

30%

7% 2%

20%

27%

18%

11% 0%

20%

26%

24%

11%

19%

10%

19%

13%

21%

50%

60%

3%
7%

18%
32%

40%

2%

14%

70%

80%

90%

100%

14%

3%
0%

Women
≥70

27%

Age (Yr)

60-69

29%
28%

21%

50-59

15%

40-49

11%

30-39 3%11%

20-29 1%4%

8%

0%

10%

26%
24%

25%
20%

24%

29%

50%

40%
4

3

2

Prevalence (%)

Men
100

90

90

80

80

70

70

60

60

50

50

40

40

30

30

20

20

10

10
30-39

Abdominal obesity

40-49

50-59

13

60-69

Elevated tryglycerides

Fig. 3  Prevalence of metabolic components by age

70%

80%

100%

90%

0

Women

100

20-29

8%

27%

60%
1

3%

15%

34%

5

0

14%
25%

26%
30%

10% 2%
10%

22%

22%

17%

20%

16%

25%

≥70

0

20-29

Decreased HDL-C

30-39

40-49

50-59

Elavated Blood Pressure

60-69

≥70

Age (yr)

Elevated FBG

Journal of Epidemiology and Global Health3.3 Proportion of Patients with Hypertension,
Diabetes, and Dyslipidemia and the UntreatedRate
Significantly more participants with MetS had hypertension,
diabetes, or dyslipidemia than non-MetS participants. However, even among non-MetS participants, around 20% of themen had hypertension and dyslipidemia (Table 3).
Table 4 shows the proportions of participants with hypertension, diabetes, and dyslipidemia and the proportion of
those that are untreated. Dyslipidemia was the most common
type of untreated condition, accounting for 94.2% of men
and 93.5% of women (Table 4).

Table 4  Prevalence of hypertension, diabetes, and dyslipidemia andthe rate of untreated participants
N (%)

Hypertensiona
1146
b
472
Diabetes
2036
Dyslipidemiac
Untreated ­participantsd­Hypertensiona
528
209­Diabetesb
1917­Dyslipidemiac

Women(N = 2917)(36.1)(15.3)(64.1)

679
363
1161

(23.3)(12.8)(39.8)(46.1)(44.3)(94.2)

271
135
1085

(39.9)(37.2)(93.5)aHypertension: systolic blood pressure ≥ 140 mmHg or diastolicblood pressure ≥ 90 mmHgbc

4 Discussion

Men (N = 3174)

Diabetes: HbA1c ≥ 6.5% or fasting blood glucose ≥ 126 mg/dL

Dyslipidemia: total glyceride ≥ 150 mg/dL or HDL cholesterol < 40 mg/dL

To the best of our knowledge, this study is the first to identify the prevalence of MetS among Cambodians living inurban areas. The prevalence of Mets was high in urban areas,
at 60.1% in men and 52.4% in women, indicating that manyurban Cambodians are at high risk for NCDs.
The prevalence of MetS in this study was comparable
to that reported in previous studies of urban areas in othercountries: 31.3% in South Korea [11], 14.39% in China [12],23.1% in Thailand [13], 28.4% in Indonesia [14], 34.8% in
Sri Lanka [15], and 42.5% in Malaysia [16]. These countries
are categorized as lower-middle and upper-middle-income
countries with rapidly developing economies. Urbanization
has been considered one of the reasons for the high prevalence of MetS in these countries, and its high prevalence inCambodia may also be a result of urbanization.
The change in prevalence by age group differed between
sexes. Overall, the prevalence was higher in men, although
this trend was reversed in those belonging to older age
groups. The prevalence of MetS in men exceeded 50%
among those in their 30 s and continued to increase gradually thereafter. In recent years, it has been recognized thatthe prevalence of MetS is increasing among young people
and has been a focus of research. Cambodia is no exceptiond

The denominator is the number of people included in prevalence

to this. This suggests a need for preventive measures startingat a young age [17, 18]. The prevalence of MetS in women
increased dramatically from 31.1% in their 30 s to 53.5%
in their 40 s. A Taiwanese study investigating the differences between men and women based on their developmentof MetS, found a higher prevalence among men until their
50 s and a higher prevalence among women after their 50 s
[19]. A systematic review by Vera et al. reported that theprevalence of MetS was higher in younger men and higher
in women with increasing obesity [20]. Other studies havealso shown that menopause, which occurs in women in their
40 s and 50 s, is strongly associated with increased MetS
[21–23]. Our results showed that the prevalence was significantly higher in men until their 40 s and significantly higher
in women in their 70 s and that there was no significant
difference between men and women in their 50 s and 60 s.
These results, which are consistent with those of previous
studies, suggest that the factors associated with differencesin the prevalence of MetS by age group in urban Cambodian
men and women are not specific to Cambodia, but are largely
due to physical factors related to aging.

Table 3  Prevalence of hypertension, diabetes, and dyslipidemia in the MetS or non-MetS groups
N (%)

Hypertensiona
Diabetesb
Dyslipidemiac

Men (N = 3174)

p value*

MetS (N = 1907)

Non-MetS (N = 1267)

891 (77.7)
415 (87.9)
1633 (80.2)

255 (22.3)
57 (12.1)
403 (19.8)< 0.001< 0.001< 0.001

Women (N = 2917)

p value*

MetS (N = 1528)

Non-MetS (1388)

536 (78.9)
338 (93.1)
979 (84.3)

255 (22.3)
25 (6.9)
182 (15.7)< 0.001< 0.001< 0.001*Age-adjusted p valueabcHypertension: systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg
Diabetes: HbA1c ≥ 6.5% or fasting blood glucose ≥ 126 mg/dL
Dyslipidemia: total glyceride ≥ 150 mg/dL or HDL cholesterol < 40 mg/dL

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Journal of Epidemiology and Global Health

Focusing on the components of MetS revealed that theydiffer according to sex and age. According to the change in
the number of components by sex, approximately 20% of
men always had two MetS components at all age groups.
However, the number of those with 0 or 1 component
gradually decreased. Since three components constitute
MetS, 20% of men can be interpreted as always having
MetS risk; therefore, to avoid attaining MetS is important.
Among women, the number of those with 0 to 2 components
decreased steadily with age, indicating that the number of
MetS components is steadily increasing with age.
The result of focusing on the details of MetS components showed that both men and women of all ages had ahigh prevalence of elevated BP. Elevated FBG level was thesecond most prevalent MetS component among men. Some
components showed an increase in prevalence, while others
showed a decrease. In contrast, the second most prevalent
component for women was low HDL-C in their 30 s and
40 s, and abdominal obesity after their 50 s. The increasein the prevalence of abdominal obesity was the fastest until
the 50 s. Although the prevalence was the second lowest
before the 50 s, after the 50 s, it became a major factor for
MetS, followed by elevated BP. The prevalence of all components continued to increase until after their 70 s. Previous
studies have also shown differences in MetS components
between men and women [24–26]. For example, in the
United States, elevated BP was the most common factor inmen and abdominal obesity in women [25]. Another study
showed that, in Nigeria, women had a higher prevalenceof elevated BP than men [26]. Thus, the main components
differ by country as well. The difference in the prevalenceof the components by age group implies that the target components to be approached for prevention may vary by sex
and age. Different preventive interventions by avoiding any
single metabolic risk factor depending on sex and age, may
be key to preventing an increase in the incidence of MetS.
The results of a comparison of the proportion of hypertension, diabetes, and dyslipidemia between participants
with and without MetS showed that significantly higher
proportions of participants with MetS had hypertension,
diabetes, and dyslipidemia. Our study suggests that MetS
leads to a higher proportion of abnormal values, in the urban
areas of Cambodia. In the non-MetS group, 20% of men had
hypertension and 30% had dyslipidemia. MetS is a high-riskfactor for NCDs; however, this does not imply that NCDs do
not occur in the non-MetS group. This suggests that preventive interventions are necessary not only for those with MetS
but also for those without MetS in urban areas.
The present study’s results for the prevalence of hypertension and diabetes and dyslipidemia were similar or higher
than the prevalence of hypertension (34.7%) and diabetes(9.6%) in urban Cambodia in 2012, which was reported by
Wagner et al. in 2018 [6]. Moreover, the prevalence was13higher than the prevalence of hypertension (29.7%) and diabetes under treatment (5.6%) in urban Cambodia reported by
the STEPS survey in 2010 [5]. Urbanization in Cambodia
has spread rapidly, more than doubling from 19.5% in 2009
to 39.5% in 2019 [9]. In particular, Phnom Penh and its suburbs have been developed and are growing rapidly. Previous
studies have shown an association between the degree ofurbanization and risk factors for NCDs [27]. The increasing
trend in the prevalence of hypertension and diabetes in urban
Cambodia, based on the results of this study and previous
studies, suggests that although the study participants werefrom a single institution, the results represent urban results
and reflect the progression of urbanization.
Furthermore, by determining the proportion of untreatedpeople with hypertension, diabetes, and dyslipidemia,
we found that more than 40% of men and 30% of womenwith hypertension and diabetes were untreated, and morethan 90% of people of both sexes with dyslipidemia wereuntreated. The STEPS survey reported an untreated hypertension rate of 72.2% in Urban Cambodia and that 37.2%
and 71.2% of urban participants had never had their BP andblood glucose levels measured, respectively, although thepercentages were lower than in the rural areas [5]. Thus,
untreated rates may be similarly high for diabetes and dyslipidemia, although these were not reported in the STEPS
survey. Another report on untreated rates reported a highuntreated rate similar to that in Cambodia, as 42.3% of urban
participants in India aged ≥ 45 years had undiagnosed hypertension [28]. Moreover, data reported from China indicatethat 49.0% and 25.2% of the participants were unaware of
their hypertension and were untreated, respectively, and thatfactors associated with untreated hypertension included age
and education level [29]. The relatively low untreated ratein this study, compared with that in the STEPS survey in2010, is attributable to a greater concern of the participants
about their health than the general urban population, which
may have led to a higher proportion of our participants
being diagnosed and treated. Health checkups are common
in developed countries in the primary prevention of disease.
However, health checkups are not common and widespreadin Cambodia and in other developing countries. Thus, a highuntreated rate and unawareness of disease could lead to theunintentional development and progression of NCDs. Furthermore, the high untreated rate in developing countries
may contribute to the increase in NCDs unless preventive
measures are implemented. This study identified a large
number of untreated participants in Cambodia who needtreatment, suggesting the necessity for early intervention.
The strength of this study is that it presents the prevalence of MetS and its components in an urban area ofCambodia for the first time. However, there is a possibility of sampling bias because the participants were from asingle institution, and health checkups are not common inJournal of Epidemiology and Global HealthCambodia; therefore, it is likely that these population has
health concerns or are relatively interested in health. Thus,
the results of this study have a limitation in representing
urban Cambodia as a whole. However, the results show thereal-world prevalence of NCDs in urban Cambodia that isstrongly affected by urbanization, and this study provides
an important indication of the need for MetS prevention.

5 Conclusion
The prevalence of MetS among Cambodians living inurban areas is 60.1% in men and 52.4% in women. Thishigh prevalence is attributable to the influence of urbanization, similar to that in economically developed countries. The prevalence of MetS and its components differedaccording to sex and age. Our study provides valuable
information for Cambodia, where no reports of MetS havebeen presented yet. Further studies are needed to explore
the factors necessary for prevention and develop preventive measures for early intervention.
Acknowledgements This work was financially supported by JST
SPRING, Grant number JPMJSP2125. The author MT would like totake this opportunity to thank the “Interdisciplinary Frontier NextGeneration Researcher Program of the Tokai Higher Education andResearch System.
Author Contributions MT designed the study, analyzed the data, wrote
the manuscript, and edited the final manuscript for publication. KN
provided advice for the design of the study and comments for writing
the manuscript. SC and MO contributed to the documentation andprocedures required for the ethical review in Cambodia and to the datacollection. HS interpreted and critically revised the manuscript. IH
supervised the whole study and edited the final manuscript for publication. All authors read and approved the final manuscript.
Funding This study received no external funding.
Availability of Data and Materials The datasets generated during and/or
analyzed during the current study are available from the corresponding
author on reasonable request.

Declarations
Conflict of interest The authors declare that they have no conflicts ofinterest.
Ethics approval and consent to participate This study was approved by
the Ethical Review Committee of the Cambodian Ministry of Health(200NECHR), the ethical Committee of Sunrise Japan hospital Phnom
Penh (20-002), and the Ethical Review Committee of the Department of Health, Nagoya University (20-109). Consent forms were notobtained because this study used existing data, and the data were analyzed anonymously. Instead of consent forms, an opt-out agreement
was provided by Sunrise Japan hospital Phnom Penh for the use ofexisting data in this study.

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provide a link to the Creative Commons licence, and indicate if changes
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