Strategic directions and nutrition programs for the coming period to reduce stunting among children in Vietnam.

1. Introduction

Malnutrition includes intrauterine growth restriction resulting in low birth weight, underweight (low weight-for-age), stunting (low height-for-age), wasting (low weight-for-height), and manifestations of micronutrient deficiencies. Stunting reflects long-term nutritional deficiencies that affect height and is the most important indicator of nutritional quality. For many years, weight-for-age was commonly used to assess children's nutritional status because measuring height in community settings was more difficult than measuring weight, and height-for-age was believed to depend on genetic factors. However, since the 1970s, many researchers have recognized that height-for-age, alongside weight-for-age, is a valuable indicator for assessing nutritional status and development. Numerous studies in India and several low-income countries have shown that the growth of well-nourished children from higher socioeconomic groups in those countries, in terms of both weight and height, did not differ significantly from that of children in developed countries.

Since 1993, the World Health Organization (WHO) has conducted a large-scale, long-term growth study involving children in six countries with different levels of development and ethnic backgrounds (Brazil, Ghana, Norway, India, Oman and the United States). The results showed that children aged 0–5 years who were exclusively breastfed until six months of age and received appropriate complementary feeding followed similar growth patterns. On this basis, WHO published new child growth standards in 2006 and recommended their uniform application worldwide. Thus, height-for-age has been established as the most important nutritional indicator, with environmental conditions, rather than genetics, being the main determinants of differences in child growth. This also provides the scientific basis for making stunting reduction the most important objective of child malnutrition prevention and control programs.

Maternal and child malnutrition remains a pressing issue in poor and developing countries. WHO has identified 36 countries worldwide with high rates of childhood stunting, including Vietnam. Currently, millions of mothers and children worldwide die each year from nutrition-related causes, while many experience impaired physical and mental development as a result of malnutrition during early childhood. Scientific evidence has shown that malnutrition during the earliest years of life, from the prenatal period to two years of age, can cause irreversible physical and mental consequences that persist into subsequent generations. Malnutrition not only directly affects children's immediate development but also leads to irreversible consequences, including short adult stature, poor educational outcomes, reduced adult work capacity and adverse effects on national income.

2. Current Situation and Consequences of Stunting Among Children in Vietnam

Anthropometric studies of the Vietnamese population during the 20th century showed that over nearly 50 years (1938–1985), there was virtually no improvement in physical stature. Adult height remained almost unchanged, at approximately 160 cm for men and 150 cm for women. This situation was undoubtedly related to the difficult living conditions during and after the war. More recently, several studies have examined and analyzed secular trends in growth among Vietnamese people, including both children and adults. These studies have identified an upward trend in growth, estimated at 1.2 cm per decade for adult men and 1 cm per decade for adult women. Currently, the average height of adult men is approximately 163.7 cm, while that of adult women is 153 cm.

The nutritional status of the Vietnamese population has improved considerably over the past 30 years. Surveys conducted by the National Institute of Nutrition in the early 1980s showed that approximately 51.5% of children under five were underweight, nearly 60% (59.7%) were stunted, around 50% of pregnant women had anemia, and approximately 5,000–7,000 children became blind each year due to vitamin A deficiency.

The results of the 2009 National Nutrition Survey showed that approximately 18.9% of children under five were underweight and 31.9% were stunted. Compared with 1985, the prevalence of childhood malnutrition in Vietnam had decreased by approximately 30%, with an average annual reduction of about 1.5%. Nevertheless, malnutrition rates in Vietnam remained high. According to the 2009 National Nutrition Survey, approximately 1.54 million children under five were underweight, while around 2.59 million were stunted.

Thus, reductions in childhood stunting have occurred alongside improvements in growth among both Vietnamese children and adults. Although children's nutritional status has improved, the Millennium Development Goals and human development targets have not yet been achieved, and the rate of reduction in malnutrition has recently shown signs of slowing.

In early 2008, The Lancet (January 2008), one of the world's most prestigious medical journals, published a series of reviews on the prevention and control of childhood malnutrition based on analyses of research evidence. The findings indicated that the "golden window" for effective interventions is the period during pregnancy and the first two years of life. Without early intervention, malnutrition can cause irreversible damage that affects development into adulthood. Among children with stunting, subsequent rapid weight gain can easily lead to obesity and an increased risk of chronic diseases.

Therefore, caring for mothers during pregnancy is particularly important. First, pregnant women need appropriate nutrition, iron and folic acid supplementation to prevent nutritional anemia and fetal neural tube defects, and milk consumption to increase calcium intake. After birth, exclusive breastfeeding until six months of age plays the most important role. Breast milk is an irreplaceable natural source of nutrition. Breast milk, particularly colostrum, contains high levels of antibodies that strengthen children's resistance to disease. Breastfed children develop harmoniously in both weight and height, whereas artificially fed infants are more likely to become obese.

In addition, counseling on appropriate complementary feeding has proven highly effective in reducing stunting rates. For populations experiencing food insecurity, additional food assistance is required. Complementary foods should provide a balance of energy-yielding nutrients and sufficient essential micronutrients (vitamins and minerals), with particular attention to the roles of vitamin A, iron and zinc.

Alongside breastfeeding and appropriate complementary feeding, vitamin A supplementation, food fortification, zinc supplementation for children with diarrhea, and deworming are among the most effective community-based nutrition interventions for reducing mortality and the subsequent burden of diseases associated with malnutrition. Reducing iron-deficiency anemia and iodine deficiency also has implications for intellectual development and future work capacity.

WHO research conducted across multiple countries has shown that when women and children receive optimal care, including adequate nutrition, appropriate infant and young child feeding practices, and effective disease prevention, children in all countries follow similar patterns of linear growth.

Stunting is not simply the result of "chronic malnutrition" but also a consequence of poor maternal nutrition and health, which lead to impaired fetal development, low birth weight and, ultimately, smaller body size as the child grows. In addition, stunting can result from inadequate healthcare and nutrition during the postnatal period.

Therefore, interventions to reduce stunting must address the health and nutritional status of both mothers and children, particularly women during pregnancy and children from the prenatal period until two years of age. Childhood stunting is one of the indicators used to assess the quality of future human resources and is closely associated with each country's socioeconomic development. Investing in stunting prevention and control interventions is a long-term investment that benefits both present and future generations.

3. Strategic Directions for Improving Nutritional Status, Particularly Reducing Stunting Among Children in Vietnam

To reduce stunting and contribute to improving the physical stature of the Vietnamese population, nutrition policy directions are particularly important alongside technical solutions and specific interventions.

Following the International Conference on Nutrition in 1992, the Government of Vietnam approved the National Plan of Action for Nutrition 1995–2000, the country's first policy document outlining its nutritional direction. This was followed by the National Nutrition Strategy for 2001–2010.

The National Nutrition Strategy for 2011–2020 is being finalized and submitted to the Government for approval, with the overall objective:

"By 2020, the diets of the population will have improved in quantity, become more balanced in quality, and ensured food hygiene and safety; efforts to reduce childhood malnutrition, particularly stunting, will be intensified, contributing to improving the physical stature and fitness of Vietnamese people, while effectively controlling overweight and obesity to help reduce nutrition-related chronic noncommunicable diseases."

Several strategic directions for improving nutritional status, particularly reducing stunting, include:

Implement nutrition care using a "life-course approach," with particular attention to women before and during pregnancy to help reduce fetal malnutrition. This is a key component of the intervention strategy. Nutrition care should focus more intensively on adolescent girls and pregnant women, addressing two major issues: micronutrient deficiencies and chronic energy deficiency. Measures include iron and folic acid supplementation, prevention and control of helminth infections, nutrition education, maternal healthcare, and improvements in hygiene and nutritional practices during pregnancy and breastfeeding.

Provide childcare from birth, with particular emphasis on the first two years of life, through interventions involving breastfeeding, complementary feeding, vitamin A supplementation, hygiene, prevention of helminth infections, growth monitoring charts that also track height, and improvements in the quality of care for sick children, both at home and in nurseries and kindergartens.

Prioritize resources for areas facing particularly difficult socioeconomic conditions, as well as geographically disadvantaged areas with limited access to healthcare and social services. Investments should include human resource training, equipment, communication materials, nutritional products (food supplementation), and prevention and control of common infectious and parasitic diseases.

Maintain and expand the national malnutrition prevention and control program, placing greater emphasis on household-level care, integrating nutrition interventions into existing hunger eradication and poverty reduction programs, incorporating nutrition programs into the action plans of social organizations, and combining different approaches, including iron fortification of fish sauce, rice, wheat flour and complementary foods. Greater commitment from the State, Party committees at all levels, government departments and mass organizations is also needed to prevent and control malnutrition.

Social mobilization is a particularly important component of nutrition programs in general and stunting prevention and control in particular. Cooperation should be strengthened in all areas with countries in the region and around the world, international organizations, nongovernmental organizations, United Nations agencies and businesses participating in malnutrition prevention and control activities in Vietnam.

Ensure effective implementation monitoring, operational monitoring and evaluation of intervention effectiveness, alongside technical measures and social mobilization approaches.

Proposed Programs and Projects to Implement the Strategy in the Coming Period

1. Nutrition Communication, Education and Human Resource Training Project

Improve public awareness and understanding of appropriate nutrition, with the aim of changing behaviors and promoting healthy lifestyle practices.

Consolidate the nutrition workforce network and strengthen the capacity of personnel working in nutrition across different administrative levels and sectors.

Develop policies and promote intersectoral coordination.

2. Maternal and Child Malnutrition Prevention and Control Project

Prevent and control maternal and child malnutrition, with particular emphasis on preventing stunting and improving the physical stature of the Vietnamese population.

Provide healthcare and appropriate nutritional care for pregnant women.

3. Micronutrient Deficiency Prevention and Control Project

Implement vitamin A supplementation, iron and folic acid supplementation, and food fortification with micronutrients, including fish sauce, rice and wheat flour.

Maintain the project for producing and supplying iodized salt to the entire population.

4. School Nutrition Program

Continue improving the objectives, content and methods of nutrition and physical education for students from preschool through university.

Develop school nutrition models and establish and disseminate school menus appropriate to different geographical regions.

Strengthen the provision of school meals and school milk programs at preschool and primary school levels.

Provide training and professional development for nutrition and dietetics personnel working in school kitchens that prepare meals for students.

5. Overweight and Obesity Control and Nutrition-Related Chronic Noncommunicable Disease Prevention Project

6. Food and Nutrition Security Improvement Program

Promote economic development and household-level food production.

Develop plans to meet nutritional needs during natural disasters and other emergencies.

Research and disseminate postharvest technologies, with particular emphasis on household-scale applications.

7. Food Hygiene and Safety Assurance Program

Strengthen food hygiene and safety quality management capacity, including developing and issuing legal regulations on food hygiene and safety, establishing and consolidating organizational systems, training personnel, and conducting food hygiene and safety inspections.

Enhance information dissemination, education and communication to ensure food hygiene, safety and quality.

Develop networks and strengthen the capacity of food hygiene and safety testing systems.

Establish surveillance systems for food poisoning and foodborne diseases, conduct contamination risk assessments, and ensure the hygiene and safety of street food.

8. Nutrition Surveillance Project

Continue developing and strengthening the capacity of the nutrition surveillance network from central to local levels, with appropriate allocation of responsibilities and sufficient capacity to collect comprehensive, high-quality indicators of nutritional status and food consumption.

These data will be used to monitor and evaluate progress toward the strategy's objectives and to anticipate emerging nutritional problems.