Một số định hướng về giải pháp chiến lược và chương trình dinh dưỡng trong thời gian tới nhằm giảm suy dinh dưỡng thấp còi ở trẻ em Việt Nam

1. Problem statement
Malnutrition includes forms of fetal growth retardation leading to low birth weight, underweight (low weight for age), stunting (low height for age), wasting (low weight for height) and manifestations of micronutrient deficiency. Stunting malnutrition is a manifestation of prolonged malnutrition affecting height and is the most important indicator of nutritional quality. For many years, people often use weight for age to assess the nutritional status of children because measuring height in the community is more difficult than weight and it is believed that height for age depends on genetic factors. However, since the 70s of the last century, many authors have recognized that height for age is a valuable indicator to assess nutritional status and development along with weight for age. Many studies in India and some poor countries have shown that the growth of children (both weight and height) of well-nourished children of the upper class in those countries is not significantly different from that of developed countries. Since 1993, the World Health Organization has conducted a large and long-term experimental study on growth of children in 6 countries with different development conditions and races (Brazil, Ghana, Norway, India, Oman and the United States). The results showed that children from 0-5 years old who were exclusively breastfed until 6 months of age and received appropriate complementary foods all had similar growth curves. On that basis, in 2006, WHO announced a new growth standard for children and recommended its application globally. Thus, height for age has been confirmed as the most important nutritional indicator and environmental conditions, not genetics, are the main determinants of growth differences in children. This is also the scientific basis for reducing stunting to become the most important goal of child malnutrition prevention programs.

Malnutrition in mothers and children is a current issue in poor and developing countries. The World Health Organization has determined that there are currently 36 countries in the world with high rates of stunted malnutrition, including our country. Currently, every year in the world, millions of mothers and children die from causes related to nutrition and have physical and mental underdevelopment due to malnutrition from an early age. Scientific evidence has shown that in the first years of life (from the womb to 2 years old), if a child is malnourished, it can leave irreversible physical and mental consequences that can be passed on to the next generation. Malnutrition not only has immediate and direct effects on children's development but also leads to irreversible consequences such as short adult stature, poor academic performance, reduced adult labor capacity and affects national income.

2. Current status and consequences of stunting malnutrition in Vietnamese children

Studies on physical anthropometry of Vietnamese people in the 20th century showed that in nearly 50 years (1938-1985) there were no signs of increase in physical stature, adult height remained almost unchanged: about 160cm for men and 150cm for women. This situation was certainly related to the difficult living conditions during the war and post-war period. Recently, there have been a number of studies and analyses of secular trends and growth in Vietnamese people (both children and adults) and it was determined that there was a trend of increased growth in both children and adults, estimated at 1.2cm/decade in adult men and 1cm/decade in adult women. Currently, the height of adult men is about 163.7cm and that of women is 153cm.

The nutritional status of Vietnamese people has improved significantly over the past 30 years: The results of a survey by the Institute of Nutrition in the early 1980s showed that about 51.5% of children under 5 years old were underweight, nearly 60% (59.7%) of children were stunted, about 50% of pregnant mothers were anemic, and every year about 5,000-7,000 children were blind due to vitamin A deficiency.... The results of the 2009 National Nutrition Survey showed that about 18.9% of children under 5 years old were underweight and about 31.9% were stunted. Compared to 1985, the rate of malnutrition in children in our country decreased by about 30% with an average reduction rate of about 1.5%/year. However, the rate of malnutrition in Vietnam is still high; According to the results of the 2009 general nutrition survey, there were about 1.54 million children under 5 years old with underweight malnutrition and about 2.59 million children with stunting malnutrition. Thus, the reduction of stunting malnutrition in children goes hand in hand with the increase in growth in both children and adults in Vietnam. The nutritional status of children has improved but has not yet achieved the millennium goals as well as the human development index and recently the rate of reduction of malnutrition has tended to slow down.

In early 2008, the Lancet (January 2008), a prestigious medical journal in the world, published a series of reviews on the prevention of child malnutrition based on the analysis of evidence-based research results. The conclusions show that the "golden" time for effective interventions is during pregnancy and the first two years of life. If not intervened early, malnutrition can cause irreversible damage to later development into adulthood. In children with stunted malnutrition, rapid weight gain later can easily lead to obesity and increased risk of chronic diseases. Therefore, taking care of the mother during pregnancy is important. First of all, the mother needs to have a reasonable diet, take iron and folic acid tablets to prevent nutritional anemia and neural tube defects in the fetus, and drink milk to get more calcium. After birth, exclusive breastfeeding until 6 months of age plays the most important role. Breast milk is an irreplaceable natural food source. Breast milk, especially colostrum, contains many antibodies that enhance the child's resistance. Children who are breastfed develop harmoniously in both weight and height, while children who are artificially fed are prone to obesity. In addition, counseling on appropriate complementary feeding has proven to be very effective in reducing the rate of stunting. For those who lack food security, additional food support is needed. Supplementary foods need to balance energy-generating nutrients and provide sufficient micronutrients (vitamins and minerals), with special attention to the role of vitamin A, iron and zinc. Along with breastfeeding and appropriate complementary feeding, supplementary programs, vitamin A and zinc fortification (for children with diarrhea) and deworming are the most effective nutritional interventions in the community to reduce mortality and later disease burden related to malnutrition. Reducing iron deficiency and iodine deficiency anemia affects intellectual development and later working capacity.

WHO research in many countries shows that if women and children receive optimal care (ie adequate nutrition, adequate child feeding and good disease prevention), children in all countries grow in height similarly. Stunting is not simply the result of “chronic malnutrition” but also the consequence of poor maternal health and nutrition leading to poor fetal development, low birth weight and as a result, small children when they grow up. In addition, stunting is also the consequence of poor health care and nutrition for children in the postnatal period. Therefore, to reduce stunting, interventions need to affect the health and nutrition of both mothers and children, especially mothers during pregnancy and children from the time they are in the womb until they are under 2 years old. Stunting is one of the indicators of human resources for the future and stunting is closely related to the socio-economic development of each country. Investing in stunting prevention interventions is a long-term investment, bringing benefits to the current and future generations.

3. Some orientations for strategic solutions to improve nutritional status, especially reducing stunting in Vietnamese children.

In order to reduce stunting and contribute to improving the stature of Vietnamese people , in addition to technical solutions and specific interventions, the orientations of Nutrition Policy are especially important. After the International Conference on Nutrition in 1992, the Vietnamese Government approved the National Action Plan on Nutrition 1995-2000, which was the first document on nutrition policy in Vietnam, followed by the National Strategy on Nutrition for the period 2001-2010. The National Nutrition Strategy for the 2011-2020 period is being finalized and submitted to the Government for approval with the general goal of "By 2020, people's meals will be improved in quantity, more balanced in quality, ensuring food safety and hygiene; promoting the reduction of child malnutrition, especially stunting, contributing to improving the stature and physical strength of Vietnamese people while effectively controlling overweight and obesity, contributing to limiting chronic non-communicable diseases related to nutrition".

Some orientations for strategic solutions to improve nutritional status, especially reducing stunting:

Implementing nutritional care according to the “life cycle” approach, paying special attention to women before and during pregnancy contributes to reducing fetal malnutrition. This is the key point of the intervention strategy. Nutritional care needs to focus more on adolescent girls and pregnant women with two problems: solving micronutrient deficiencies and chronic energy deficiency. Solutions include iron/folic acid supplementation, worm prevention, nutrition education, maternity care and changing hygiene practices, nutritional practices during pregnancy and breastfeeding.

Implement child care right from birth, focusing on care in the first 2 years with solutions on breastfeeding, complementary foods, vitamin A supplementation, hygiene, worm prevention, monitoring growth charts in both height and improving the quality of care when children are sick, care at home as well as in nurseries and kindergartens.

Prioritize resources for localities with special difficulties in socio-economic development, localities with geographical difficulties, and access to health and social services in terms of investment, including: human resource training, equipment, communication materials, nutritional products (food supplementation) and prevention of common infectious and parasitic diseases.

Maintain and expand the national program to prevent malnutrition, emphasize more on the contents of care for households, integrate into the current poverty reduction program, put the nutrition program into the action programs of social organizations, combine many different approaches (iron fortification in fish sauce, rice, wheat flour, supplementary foods), strengthen the commitment of the state, Party committees at all levels, sectors and organizations to prevent malnutrition.

Social mobilization is a very important content in the general nutrition program and the prevention of stunting in particular. Strengthen cooperation in all aspects with countries in the region and the world, international organizations, non-governmental organizations, United Nations organizations and businesses participating in malnutrition prevention activities in Vietnam.

Implement well the work of monitoring implementation, monitoring activities, and evaluating the effectiveness of interventions in parallel with technical solutions and socialized solutions.

Some project programs to implement the Strategy in the coming period:

1. Project on communication, nutrition education, and human resource training: Raising awareness and understanding of proper nutrition towards changing behaviors and practicing healthy lifestyles; Strengthening the network and enhancing the capacity of nutrition staff at all levels and sectors; Developing policies and inter-sectoral coordination.
2. Project on preventing malnutrition in mothers and children, especially preventing stunting, improving the stature of Vietnamese people; providing health care and proper nutrition for pregnant women.
3. Project on preventing micronutrient deficiencies: Supplementing vitamin A, iron/folic tablets, fortifying foods (fish sauce, rice, flour); maintaining the project on producing and supplying iodized salt for the entire population.
4. School Nutrition Program: continuing to improve the goals, content, and methods of nutrition and physical education for students from preschool to university; Building a school nutrition model, creating and disseminating menus in the school system appropriate to each region; strengthening the organization of school meals/milk in preschools and primary schools; training and fostering nutrition and dietetics staff in school canteens.
 5.  Project on Controlling Overweight - Obesity and Preventing Nutrition-Related Chronic Diseases.
6. Program on Improving Food Security and Nutrition: Developing the economy and creating food sources at households; having a plan to meet nutrition needs in times of natural disasters and catastrophes; researching and disseminating post-harvest technology focusing on household scale.
7. Program on Ensuring Food Safety and Hygiene: Improving the capacity to manage food safety and hygiene quality (developing and promulgating legal documents on food safety and hygiene; building and consolidating the organizational system; training staff; inspecting and inspecting food safety and hygiene); Strengthening information, education and communication work to ensure food safety and hygiene quality; building a network, enhancing the capacity of the food safety and hygiene quality testing system, building a system to monitor poisoning and food-borne diseases, analyzing the risk of contamination; ensuring the safety of street food.
8. Nutrition Monitoring Project: continue to build and improve the capacity of the nutrition monitoring network from central to local levels with appropriate assignment of tasks with the capacity and ability to fully and qualitatively collect indicators on nutritional status and food consumption to monitor and evaluate the implementation of the strategy's objectives and forecast new emerging nutrition issues.