I. THE COUNTRY’S CURRENT NUTRITION SITUATION
1. Food security and dietary pattern
The most important achievements in the previous period is reduction of hunger in large scale. In the whole country, there are currently 1.4 million households that still suffer from food shortage compared to 3.5 million households in 1992. In 1999, the total food production (paddy equivalent) was 32.8 million tons (reaching the planned objective), and food production was much more diversified.
When comparing the dietary intake between the beginning and the end of the 90's, it is note that prehavesting food shortage with missing meals which requires some kind of food aid has been improved. In the rural delta areas, energy intake is 2062 Kcals per head per day (data of a sentinel survey) compared to 1940 Kcals in 1990. The intake of meat, fats/oil, tofu, sugar and fruits is increased in comparision with 10yrs ago. The percentage of households with low energy intake has been reduced in urban areas and in most rural delta provinces.
However, food insecurity has still experienced in a number of provinces prone to natural disasters. These provinces are located in the Central coast, Central highland and Northern mountainous areas, where a large portion of the country’s population lives. While in the areas of Red River Delta and Mekong Delta, the total cultivated land for staple food production has not increased much and the cultivated surface for agriculture has been narrowed. This will be a great challenge for agricultural development in the coming years. Although agricultural production has been diversified, the country still faces many difficulties such as agricultural products’ processing and preservation, pricing and marketing, etc. Household and community food production has not yet been stable and sustainble.
At the same time, due to the trends of urbanization, advertizing and modernization, food consumption habits and patterns of a large portion of the population are changing.
In general, food security and dietary patterns of the population have clearly improved. However, there are still hidden risk factors in some regions that need more attention. The rate of poor household in the whole country (according to the present classification criteria) has reduced from 20 % (in 1995) to 11 % (in 2000), but this is still considered high.
2. Child and maternal malnutrion.
Child malnutrition prevalence has been remarkably reduced: 51.5% in 1985 and 44.5% in 1995 (a reduction of 0.66% per year). With the National Plan of Action for Nutrition (NPAN) starting in 1995, the rate dropped to 36.7% in 1999 (a reduction of 2 % per year which is considered to be fast as recorgnized by international community). Therefore, approximately 200,000 children have been escaped from malnutrition yearly. In 2000, according to the data of GSO, this rate was 33.1%.
This achievement fast reduction child malnutrition is worth recognized. Severe malnutrition has fallen remarkably (to 0.8%), and most of malnutrition cases in Vietnam are now in mild and moderate forms. However, according to WHO’s classification, a prevalance of child malnutrition of 36.7 % is ranked in the "very high level" world-wide. The prevalance of child malnutrition is varied among ecological regions in the country. It is lowest in Ho Chi Minh City (18,1%) and Hanoi (21%), while in some provinces, it is still above 50%. The region with the lowest prevalance is the South-Eastern area, including HCM city (29.6%); followed by Mekong Delta (32.3%); Red River Delta (33.8%); the Central Coast (39.2%); the North-East (40.9%); the Noth-West (41.6%); the North-Central Coast (39.2%), and the region with the highest rate is Central Highland (49.1%). There is no significant gender difference in malnutrition in Viet nam.
Concerning age groups, children from 6 to 24 months old are the higher risk group for malnutrition than the other age groups. Complementary feeding is usually started at this age. Inappropriate weaning practices could probably be an important factor affecting the nutrition situation.
The causes of child malnutrition are complex, from immediate causes such as inappropriate dieatary intake and high prevalence of preventable diseases, to underlying causes such as the inappropriate care of mothers and children, household food insecurity and inadequate health and sanitation, and to basic causes such as poverty and people’s control of resource they need. The impact of these factors is different among regions. In the Central coast, Central highland and mountainous regions, food insecurity is a prominent cause; while in the other rural areas it is the inadequacies in care (prominently including child care practices). In urban areas, childhood diseases are the possible factor leading to malnutrition in children. It is because in urban areas, food shortage is not a major problem now and child care practices are somewhat better than in rural areas. This scenario calls for different strategies for different regions in different periods. Recent experiences of the International Food Policy Research Institute (IFPRI) show that the educational level of girls and then mothers accounts for up to 43% of child malnutrition, while food security is only responsible for 26%. Therefore, child feeding practices and child care, which much depend on education level of mothers, play a central role in child malnutrition.
Chronic Energy Deficiency (CED) of women of reproductive ages (measured as BMI <18.5) was 38% in 1977 and 32% in a recent survey. CED reflects the caring status of women and is very related to low birth weight of children.
3. Micro-nutrient deficiencies
3.1. Vitamin A deficiency
The most remarkable progress in the last 5 years is the effective implementation of the national program for controlling vitamin A deficiency, as well as the elimination of nutritional blindness, which affected about 5 to 7 thousand children per year in the past. The rate of corneal lesions that lead to blindness has decreased from the level 7 times higher than the WHO’s cut-off point to a level lower than that of public health significance. About 94-97% of children aged 6-36 months in the whole country receives high doses Vitamin A capsules twice a year. At present, however, the prevalence of sub-clinical vitamin A deficiency is still high (11% in children and 50% in lactating mothers). That related to higher morbidity and mortality. The main causes of vitamin A deficiency are lack of Vitamin A rich food and low fat/oils intake.
3.2. Iron deficiency anemia (IDA)
Iron deficiency is a major public health problem in our country. The high vulnerable groups are women of childbearing ages and children (53% of pregnant, 40% of non-pregnant women and 60% of children under 24 months old suffers from IDA). The main cause of this is lack of iron rich foods in the diet, e.g. animal foods. On the other hand, hookworm infection at high prevalence in the country also plays a role. The iron deficiency anemia control program has been carried out with two activities: supplementing women with iron and folic acid tablets and providing them nutrition education together with the prevention of intestinal parasites, especially hookworm. In the program areas, prevalence anemia among women of childbearing age has decreased from more than 50% to 25%. However, the program is implemented in only 1282 out of more than 10,000 communes in the whole country so far.
3.3. Iodine deficiency disorders (IDD)
Iodine deficiency disorders (IDD) are also very widespread in Vietnam. The national program for controlling IDD has reached its objectives set for the year 2000 (based on urinary iodine indicator). However, more than one quarter of school-aged children has goiters (data in 1999). There are geographic/ecological variations in goiters. About 30% of households in the Mekong River Delta suffer from IDD (urinary iodine < 10mcg/dl). A nation-wide program has been implemented to provide iodized salt for the whole population; The universal salt Iodization, has been formulated and incorporated in a Government Decision; 61% of households are now using iodized salt as the result.
So far, the programs for controlling Vitamin A deficiency and IDD have achieved remarkable successes that need to be sustained, and strengthened in the coming years. The results of these programs has been internationally recognized and appreciated. However, because of its late starting, more attention still needs to be paid to the implementation of the program for nutritional anemia control.
4. Maternal and Child Health care
Recent data have shown that during pregnancy, the mean weight gain of rural women is still low: 8 kg (compared to 6 kg in 1985), while in Hanoi women gain 10.6 kg (compared to 8.5 kg in 1985). About 40% of women do not receive prenatal care and weighed. Breast-feeding practice has been remarkably improved. However, there have been only 31.1% of mothers exclusively breast-feeding in the first 4 months and only 20.2% of mothers properly caring their sick children (data in 2000). Although the living standards have improved in general, rural women in particular still experience heavy workloads even during pregnancy and lactating periods. A short prenatal and post natal maternity leave negatively affects breast-feeding and child feeding practices, as well as women’s time allocation for child care.
Child health care activities through the national primary health care program has been remarkably improved. However, the preconditions for health cares such as safe and clean water and latrines, day care centers, are still limited. Kindergartens in rural areas are insufficient and in poor condition (only 9% of children aged 3-36 months have access to kindergartens). Up to now, only about 30% of the rural population have access to clean water supply and 20% to hygienic latrine. Poor sanitation has been negatively affecting children’s health. 70% to 90% of children are suffering from parasite infection. It is conservatively estimated that a child under five gets diarrhea twice a year in average due to an unhygienic environment. This situation is also related to family hygiene practices.
5. Food hygiene and safety
In February 1999, the Vietnamese Food Administration was founded at the MOH. Every April, the authorities launch a "food safety month" (April 15 to May 15). However, there have been still difficulties in food safety. The system to manage food quality and safety by HACCP (Hazard Analysis and Critical Control Point) and GMP (Goods Manufacture Product) in food production, processing, handling and preservation stage has only possibly been implemented in small scale.
There is still lack of hygienic conditions and knowledge/understanding in food preparation. This leads to food contamination, especially ready-to-eat food. In many localities, food poisoning still occurs. According to a source from the Ministry of Health, 327 out-breaks, which affected 7576 persons, resulted in 72 deaths were reported in 1999. Causes of these food poisoning cases are 50% with microbial agents, 11% with chemical related, 6% with natural poisons, and 34% with unknown causes. Up to 60% of street food samples are found contaminated with microbial agents.
In addition, food regulations have not been completed yet, and the awareness/understanding of both food producers and consumers on food safety is still not satisfactory. Laws/regulations on food safety must be strengthened and different sectors have to collaborate in their enforcement.
6. Non-communicable nutrition-related chronic diseases.
There were evidences on increasing incidence of nutrition-related chronic diseases, e.g. obesity, cardiovascular disease, diabetes and cancer in some recent years. The role of appropriate dietary intake is proved to be a key determinant in these diseases.
Overweight and obesity have been increasing: prevalence was 2.5% for children 4-5 years old in HCMC in 1995 and 1% in Hanoi in 1996; for 6-11 year olds, the prevalence was 4% in Hanoi and 12% in HCMC. For adults (in Hanoi), the prevalence figures were 15% for men and 19% for women.
The prevalence of diabetes is currently 1% in Hanoi; 2.5% in HCMC and 1% in Hue. Its prevalence has been related with the growing modern lifestyles in cities. The data in hospital showed that number of diabetes including non-insulin dependent type (type 2) has been increasing.
Cardiovascular disease is also rapidly increasing. Overweight, measured as increased body mass index (BMI), especially in people over 60 years of age, has clearly been associated with increased cardiovascular disease. The prevalence of strokes in Hanoi in 1994 was over three times higher than that in 1989. The prevalence of myocardial infarction is six times higher than in 1960s.
Cancer: Over 35% of all cancers have been found diet-related and particularly associated with high fat intake, nitrites and contaminants (e.g. pesticides) in the diet, and with food additives (e.g. colors and preservatives).
II. THE FIRST NATIONAL PLAN OF ACTION FOR NUTRITION 1996 - 2000: IMPLEMENTATION AND RESULTS.
The NPAN is a multi-sectoral plan in which the NIN has been assigned as the focal point, under the guidance of the MOH. There are 7 sub-committees responsible to follow-up and implement 7 prioritized content areas. At the same time, these 7 sub-committees have also directly implemented several pilot activities for gaining valuable experience and lessons. Each of the prioritized measures such as PEM, IDD, and HFS (household food security) has received funds from the government in order to reach the specified objectives. Local fund mobilization and international agencies' support have covered other activities’ expenditure. The focal point of NPAN proved to be successful in setting up a nutrition information system, in carrying out education and communication activities, social mobilization and training of multi-sectoral staff at different levels, thus accelerating implementation of the NPAN activities.
Evaluation of the NPAN's objectives.
- Through the NPAN, the importance of nutrition has been more recognized and draws more attention from the society at large. Nutrition knowledge and desirable practices of the population have been improved.
- In 2000, malnutrition prevalence of children <5 years was 33.1%. Despite the expected objective of getting malnutrition prevalence below 30%, the reduction rate has been quite fast (2% per year).
- The objective to reduce micro-nutrient deficiencies (vitamin A, iron, and iodine) has been reached at national scale for vitamin A and IDD control programs up to the year 2000. The iron deficiency control program reached its objective in 1282 communes covered by the program.
- The objective to reduce the percentage of households with average energy intake of below 1800 Kcal per capita partially succeeded (it fell from 22% to 15%), but did not reach the planned objective of falling below 10% by 2000.
The NPAN 96-2000 is really the government's policy with key strategies on nutrition improvement in the whole country. For this reason, it got much international support in the implementation of a number of the activities carried out by seven sub-committees in the framework of the NPAN have addressed basic, underlying and immediate causes of malnutrition. Thanks to the NPAN, much attention has been paid to nutrition objectives, and many of them have been incorporated into socio-economic development plan of local governments.
III. CONSTRAINTS
- The prevalence of malnutrition is still high. Food security is not ensured in disadvantaged areas; KAPs on nutrition care are limited; meanwhile IEC activities do not reach the household level and do not have impact on the whole society. Moreover, changing food habits is not easy.
- The society’s awareness about the important role of nutrition, as well as its responsibility to nutrition improvement is insufficient.
- The implementation of solutions is often not well coordinated and not always appropriate for different geographical settings. Trained staff is insufficient to implement nutrition activities at community level.
- There are limited in the budget from the Government to invest in nutrition activities and mobilization of resources from community for the same activities is not well developed.
- Intersectoral collaboration is not working adequately and sufficiently. There is insufficient as policy supportive. Many coordination and integration activities have been implemented in vertical manner with little horizontal. The NPAN has not yet reached all localities; making local authorities understands and takes responsibility for effective implementation of nutrition activities.
- There is not enough attention being paid to nutrition problems of groups with special needs, e.g. vulnerable age groups, occupation categories, etc., as well as to dietary therapy in hospital.
IV. CHALLENGES
- Economic growth: In 1999, the growth of GDP was 4.5%. The increasing tendency of GDP growth has been observed, but not stable. The number of households under poverty line is still high. Jobless may emerge in the coming years.
- Food insecurity continues to threaten many high-risk areas, usually due to natural disasters, affecting food production and environment.
- The population growth rate is still high; It is estimated that Vietnam’s total population will be 85 millions in 2005 and about 93 millions in 2010.
- The infrastructure to ensure quality of health and nutrition care, such as safe water supply, kindergartens, household sanitation, environmental conditions, food safety, cultivation habits, health care network, etc. does not meet the people’s demand. It is also recognized that communities' understanding and perception of the “care” concept are limited.
- There are some undesirable habits/practices, which affect maternal and child feeding practices in a number of localities. In urban areas, over-nutrition and non- communicable nutrition-related chronic diseases are increasing.
- Concerning the NPAN implementation network, it is recognized that there is insufficiency of qualified nutrition staff.
- Budgetary allocation is limited. There are approximately 1 million newborns every year; requiring more investment in nutrition care.
V. SOCIO-ECONOMIC IMPACT
According to the World Bank, in Vietnam malnutrition could reduce the annual GDP growth by 2.4%, if simply based on physical work capacity. In terms of the metal retardation due to lack of nutrition care in early childhood period and treatment expenditures. It is estimated that PEM, IDD and Nutritional Anemia lower GDP by 0.3%, 1% and 1.1% , respectively.
Cost - Effectiveness Analysis
Investment in nutrition has high economic returns. An investment of 1 billion Dong in the PEM control program yields benefits of 8.56 billion to the economy; the same amount invested in the nutritional anemia control yields 5.38 billion Dong (WB calculation for Vietnam). Addition to this, investment in nutrition not only yields economic benefit, but also it is an effective investment to reduce the mortality due to malnutrition. Poverty alleviation helps reduce malnutrition. Control of malnutrition will, in turn, actively reduce poverty.
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Full text: National Nutrition Strategy period 2001-2010
Full text: Decision of the Prime Minister on the ratification of the National nutrition strategy 2001-2010