Reason for a Stunting Reduction Strategy
The nutritional status of people in Viet Nam has improved considerably in the last twenty years thanks to improvements in income, food security, fertility reductions, health advances and the high political commitment to nutrition. However even these improvements are not as good as expected compared to GDP or the Human Development Index and there has been a ‘slow down’ in the rate of reduction in recent years. As a result, the prevalence of undernutrition remains unacceptably high in Viet Nam and continues to contribute to health, social and economic inequalities. A recent estimate suggests that globally maternal and child undernutrition is responsible for about 35% of child deaths and 11% of the global burden of disease. In addition, poor nutrition can constrain social and economic development through reduced educational achievement of children and reduced productivity of adults. In light of the consequences of undernutrition and the scale of the problem, a new and accelerated approach for addressing undernutrition is needed in Viet Nam. As the next National Nutrition Strategy (2011-2020) is currently being developed, now is the time to further increase the priority given to nutrition and improve the effectiveness and cost-effectiveness of the approach.
As in other countries, the prevalence of underweight (weight for age) of young children has been used as the main indicator for the nutritional situation in Viet Nam. However there are several reasons to address and monitor instead the prevalence of stunting, as a more accurate and meaningful indicator.
The 2008 nutrition surveillance data indicate that more than 30% of children in Viet Nam are too short for their age, ie. they are stunted. Stunting in young children is not caused by genetic factors. A WHO multi-country study found that if women and children received optimal care (eg. adequate nutrition, no smoking, optimal infant and young chid feeding and prevention and treatment of illness), all children in the six study countries grew as tall as each other. It is also now known that stunting is not a result of “chronic under nutrition” as once thought. Rather stunting is caused by poor maternal health and nutrition leading to inadequate growth of the foetus during pregnancy and low birth weight and pre-programming of the child to remain small. In addition stunting is the result of poor child health and child care after birth. The implication is that to reduce stunting, interventions that address both maternal and child health and nutrition, will be needed.
Poor fetal growth or stunting in the first two years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income and decreased offspring birthweight such that stunting at 2 years is a strong indicator of future human capital. As such stunting is closely related to the social and economic development of a country. Prevention of stunting is thus a long-term investment that will benefit the present generation and their children.
Stunting starts in utero during pregnancy and continues until the child is about 24 months old. This is thus the ‘window of opportunity’ for preventing stunting: from conception, through pregnancy until the child is 24 months old. Interventions after this are too late and may contribute to chronic disease in later life – children who are undernourished in the first two years of life and who put on weight rapidly later in childhood and adolescence are at high risk of chronic diseases related to nutrition in adulthood.
Stunting in Viet Nam has been reduced significantly, in a similar way as underweight. However analysis of the annual rate of reduction over the last 20 years indicates that the rate of reduction for stunting has been declining since the 1995-2000 period. In the most recent period the average annual rate of reduction was only 0.9 compared to a rate of 1.3 for underweight. In addition, disparities in stunting prevalence between provinces are greater than for underweight.
Stunting Reduction Interventions
In 2008 the results of an analysis of interventions that affected maternal and child undernutrition and nutrition-related outcomes were published. The review found that interventions to reduce stunting, micronutrient deficiencies and child deaths are available and that if implemented at large scale in the 36 countries which are home to 90% of stunted children would reduce stunting at 36 months by 36%, mortality between birth and 36 months by about 25% and disability-adjusted-life-years associated with these conditions by about 25%. Specifically, the analysis identified 13 interventions with sufficient evidence for implementation in all 36 countries with 90% of stunted children plus 11 interventions for implementation in specific situational contexts (ie, food insecure, high malaria or high hookworm infection). The analysis also identified common nutrition interventions for which they found “insufficient or variable evidence of effectiveness” and some for which “evidence showed little or no effect”. This stunting reduction strategy will be based on implementing a package of these proven interventions and reducing investment in or discontinuing those with no, insufficient or variable evidence of effectiveness.
At present, Viet Nam is achieving high coverage of just two of the thirteen effective interventions for all countries; vitamin A supplementation for young children and universal salt iodization. Several other interventions are being implemented but (i) with apparent poor impact eg. Breastfeeding counseling; although this is happening breastfeeding practices have not improved in the last 10 years, or (ii) with insufficient coverage eg. Iron folate supplementation for pregnant women is government policy but no central level government resources are allocated to this and no data is available on current coverage. On the other hand significant financial and human resources are being invested in some of the interventions with poorer evidence of impact. Hence this strategy will aim to (i) increase implementation and coverage of the proven interventions, (ii) improve the way some interventions are being implemented, and hence their effectiveness, and (iii) reduce investment in some existing interventions which do not have proven effectiveness. The stunting reduction strategy will also significantly increase the number and scale of interventions for maternal nutrition, in recognition that approximately half of stunting is caused by maternal malnutrition.
An optimal package of interventions was developed for Viet Nam that includes all of the thirteen ‘proven effective for all countries’ interventions except for two for which there is little global programmatic experience. It also includes some of the eleven ‘specific situational context’ interventions, specifically those intended to address anaemia and worm infestation, both of which are prevalent in Viet Nam. The optimal package is shown below; the interventions in orange are those for ‘specific situational contests.’ The same list is shown in the table on the next page with notes on current implementation of each intervention and a brief overview of what will be done to increase coverage or improve the quality of the service in the final column. In addition, in Annex I, technical notes are provided on each intervention explaining why it was included in the package, what is the evidence of effectiveness and more detail on how the intervention will be implemented under the Stunting Reduction Strategy.