The double burden of malnutrition in Vietnamese school-aged children and adolescents: a rapid shift over a decade in Ho Chi Minh City

Reducing the incidence of overweight and obesity by a healthy lifestyle intervention program for schoolchildren in Hanoi, Vietnam: a randomized controlled trial

BACKGROUND

The increasing incidence and prevalence of childhood overweight (OW) and obesity (OB) are major global health challenges. This study aimed to evaluate the effectiveness of a 2-year healthy lifestyle intervention program in reducing the incidence of OW and OB among schoolchildren aged 11-12 years in Vietnam.

METHODS

Study design: Randomized controlled trial.

PARTICIPANTS AND INTERVENTIONS

In total, 733 students participated in this study. Participants were included from four schools in Hanoi based on a random cluster sampling method. Students' health outcomes were assessed at baseline and after 2 years.

MAIN OUTCOMES

The primary outcomes were the incidence of OW and OB, and the secondary outcomes were the prevalence and remission of OW and OB. Generalized estimating equations (GEEs) were used to determine the outcomes and risk factors.

RESULTS

After the intervention, the prevalence of OW decreased by 9.24% in the intervention group and 3.01% in the control group. After adjustment for age and sex, the odds of overweight were 36.7% lower in the intervention group than in the control group (OR = 0.633; 95% CI: 0.434-0.925; P = 0.018). The incidence of OW was 1.31% in the intervention group compared with 5.33% in the control group. After adjustment for age and sex, the odds of incident overweight in the intervention group were 77.4% lower than in the control group (OR = 0.226; 95% CI: 0.063-0.813; P = 0.023). The proportion of patients who achieved OW remission was 41.22% in the intervention group and 28.68% in the control group. After adjustment for age and sex, the odds of OW remission of overweight were 2.219 times greater in the intervention group than in the control group (OR = 2.219; 95% CI: 1.220-4.036; P = 0.009). For most OB-related factors, there were no significant differences between the intervention and control groups.

CONCLUSION

A multicomponent healthy lifestyle intervention was effective in reducing the incidence of OW; however, it had no significant effect on OB among children aged 11-12 years in Hanoi, Vietnam.

TRIAL REGISTRATION

Retrospectively registered number: UMIN000014992, 20/08/2023.

Local anthropometric parameters for assessing double burden of malnutrition in South Asian and Southeast Asian countries: a review and retrospective analysis

The double burden of malnutrition (DBM) is a significant public health issue in South and Southeast Asia (SA and SEA). This study aimed to assess the impact of using local and regional ethnicity-specific anthropometric references versus international references on the prevalence of DBM in these regions.A narrative review of DBM prevalence using local versus international standards was conducted. Additionally, deidentified datasets from India and Indonesia were analyzed to evaluate the effectiveness of different growth standards in identifying DBM. Anthropometric Z-scores were compared, and sensitivity, specificity, and positive predictive value (PPV) were calculated.WHO standards had the lowest specificity for identifying short stature in India and Indonesia. BMI-for-age charts using WHO Growth Reference (2007) had lower sensitivity and higher specificity for metabolic risk. Local references showed lower stunting and higher overweight or obesity prevalence. International standards overestimated stunting and underestimated obesity, leading to misclassification and missed cases of metabolic risk.

Funding

None.

Micronutrient deficiencies and the double burden of malnutrition in Vietnamese female adolescents: a national cross-sectional study in 2020

Background

Vietnam is facing a double burden of malnutrition, with increasing prevalence of overweight coexisting with undernutrition (stunting and/or thinness) and micronutrient deficiencies (MNDs). Although malnutrition during female adolescence leads to poor health outcomes with potential intergenerational effects on offspring, no studies have comprehensively investigated MNDs and nutritional status among contemporary Vietnamese female adolescents.

Methods

Data from 10- to 18-year-old female participants (n = 1471) in the nationally-representative Vietnam General Nutrition Survey 2020 were analysed. Blood nutritional biomarkers, anthropometric measurements, and sociodemographic data were collected, and associations between nutrition status and MNDs were analysed; with anaemia, iron deficiency (ID), iron deficiency anaemia, low serum zinc, low serum retinol, and any MNDs as specified outcomes.

Findings

Prevalence of overweight, stunting, and thinness was 27.2%, 14.3%, and 6.9%, respectively. Low serum zinc was common (39.8%), as was ID (13.4%). Bivariate analyses showed that older age (16-18 years old), ethnic minority status, lower wealth index, and inflammation were associated with MNDs. In adjusted logistic regressions, stunting was associated with increased odds ratio and [95% confidence intervals] of low serum retinol (8.92 [2.26, 35.15], p < 0.01), as was thinness (12.25 [3.47, 43.33], p < 0.01). Stunting was also associated with increased odds of having any MND (2.06 [1.31, 3.25], p < 0.01).

Interpretation

More female adolescents were overweight than undernourished in Vietnam in 2020. However, undernutrition, low serum zinc, and ID remain prevalent. Food systems approaches should be considered to stem the stark increase in the double burden of malnutrition in young people living in Vietnam.

Funding

UK BBSRCBB/T008989/1.

Prevalence, determinants, intervention strategies and current gaps in addressing childhood malnutrition in Vietnam: a systematic review

BACKGROUND

Childhood malnutrition in all forms is a major public health issue worldwide. This review systematically examined the prevalence and determinants and identify the potential interventions and current gap in addressing malnutrition including undernutrition, overnutrition and micronutrient deficiencies (MNDs) in Vietnamese children aged 0-18 years old.

METHODS

Embase, Scopus, PubMed, and Web of Science were systematically searched through June 2022 to identify relevant articles published within the past 25 years. Study selection and data extraction were performed by one reviewer and checked for accuracy by the other two reviewers in accordance with PRISMA guideline. Risk of publication bias was assessed using American Dietetic Association Quality Criteria Checklist.

RESULTS

Seventy-two studies that met the inclusion criteria were included. Undernutrition has decreased over time but still 22.4%, 5.2% and 12.2% of children under 5 were stunted, wasted and underweight, respectively. Anaemia, iron, zinc, and vitamin D deficiencies were the more common forms of MNDs, the prevalence varied by age, region, and socioeconomic group. Population-based surveys reported that 11% and 48% of children aged 0-11 years old were iron and vitamin D deficient, respectively. Zinc deficiency affected almost one-quarter of the children and adolescents. Retinol deficiency was of less concern (< 20%). However, more evidence on MNDs prevalence is needed. Overweight and obesity is now on the rise, affecting one-third of school-aged children. The key determinants of undernutrition included living in rural areas, children with low birth weight, and poor socio-economic status, whereas living in urban and affluent areas, having an inactive lifestyle and being a boy were associated with increased risk of overweight and obesity. Nutrition specific intervention studies including supplementation and food fortification consistently showed improvements in anthropometric indices and micronutrient biomarkers. National nutrition-sensitive programmes also provided nutritional benefits for children's growth and eating behaviours, but there is a lack of data on childhood obesity.

CONCLUSION

This finding highlights the need for effective double duty actions to simultaneously address different forms of childhood malnutrition in Vietnam. However, evidence on the potential intervention strategies, especially on MNDs and overnutrition are still limited to inform policy decision, thus future research is warranted.

Dietary patterns and child, parental, and societal factors associated with being overweight and obesity in Vietnamese children living in Ho Chi Minh city

Childhood overweight and obesity are rapidly increasing in urban Vietnam. Dietary patterns are understudied for their association with obesity risk in these children, and it is unclear which parental and societal factors should be targeted in prevention efforts. The study assessed child characteristics, dietary patterns, parental and societal factors for associations with childhood overweight and obesity status in Ho Chi Minh City, Vietnam. A sample of 221 children aged 9-11 years was randomly selected from four Ho Chi Minh City primary schools. Weight, height and waist circumference were measured using standardized methods. Three 24-h dietary recalls were collected from 124 children, which were used to assess dietary patterns using principal component analysis (PCA). Parents completed a questionnaire about child, parental and societal factors. The overall prevalence of obesity was 31.7% and of combined overweight and obesity 59.3%. Three main dietary patterns from 10 food groups were identified by PCA: traditional (grains, vegetables, meat and meat alternatives), discretionary (snacks and sweetened beverages), and industrialized (fast food and processed meat). Children with higher discretionary diet scores had higher odds of being overweight. Being a boy, screen time over 2 h/day, parental underestimation of child weight status, father's obesity, and household income in the lowest quintile were positively associated with childhood obesity. Future intervention programmes in Vietnam need to consider targeting children's unhealthy diets and parental perceptions of child weight status, as well as focusing on upstream approaches that reduce inequities contributing to childhood obesity and concomitant dietary patterns.

Socio-economic determinants of healthy behaviours among primary schoolchildren and adolescents in Lokossa district of southern Benin

BACKGROUND

There is little information regarding fruit and vegetable (FV) intake and physical activity (PA) among schoolchildren in Benin. In this study we evaluated the differences in breakfast eating, FV consumption and PA according to socio-economic (SE) determinants in primary schoolchildren.

METHODS

A cross-sectional study using a probabilistic sample of 612 students (8-17 y of age) from 26 primary schools was done between December 2018 and January 2019. The association was estimated by logistic regression analyses.

RESULTS

Of all students, 53% were physically inactive, 60% took breakfast <5 d/week, 84% irregularly ate fruits and 68% irregularly ate vegetables. Younger students (8-10 y) take breakfast regularly and older ones (>15 y) were physically more active. The probability of regular breakfast and fruit consumption were significantly higher in children of educated parents (p<0.01 and p<0.001, respectively) compared with children of non-educated parents. Medium SE status was associated with regular breakfast intake, whereas high SE status was associated with higher fruit intake and lower physical activity compared with low SE status (p<0.001). There was no association between breakfast eating, FV intake, PA and the body mass index.

CONCLUSIONS

Findings emphasize the need for interventions to promote healthy eating behaviours in primary schoolchildren and their family environments.

Development and Validation of the Vietnamese Children’s Short Dietary Questionnaire to Evaluate Food Groups Intakes and Dietary Practices among 9–11-Year-Olds Children in Urban Vietnam

This study aims to develop and assess the reproducibility and validity of the Vietnamese Children’s Short Dietary Questionnaire (VCSDQ) in evaluating food groups intakes and dietary practices among school-aged children 9–11 years old in urban Vietnam. A 26-item questionnaire covering frequency intakes of five core food groups, five non-core food groups, five dietary practices over a week, and daily intakes of fruits, vegetables, and water was developed. Children (n = 144) from four primary schools in four areas of Ho Chi Minh City, Vietnam completed the VCSDQ twice, as well as three consecutive 24 h recalls over a week. Intra-class correlation, Spearman correlation, weighted kappa, cross-classification, and Bland–Altman plots were used to evaluate the reproducibility and validity. The direct validity of food groups from VCSDQ against the 24 h recalls was examined using Wilcoxon-test for trend. The VCSDQ had good reproducibility in 12 out of 15 group items; the ICC ranged from 0.33 (grains) to 0.84 (eating while watching screens). This VCSDQ had low relative validity, two items (instant noodles, eating while watching screens) had a moderate to good agreement (k = 0.43, k = 0.84). There was good direct validity in three core-food groups (fruits, vegetables, dairy) and three non-core food groups (sweetened beverages, instant noodles, processed meat). In addition, the VCSDQ can also be used to classify daily intakes of fruits and vegetables from low to high.

Key Informants' Perspectives on Childhood Obesity in Vietnam: A Qualitative Study

Objectives

Vietnam’s post-war globalization, economic development, and urbanization have contributed to a nutrition transition from traditional diets to highly-processed diets, and increased prevalence of childhood overweight and obesity. Our study aims to explore the attitudes and behaviors driving this epidemic.

Methods

This qualitative study focused on the perspectives and practices of Vietnamese parents, schoolteachers and doctors. Semi-structured interviews were conducted with a convenience sample of 12 regarding the historical, social, and cultural influences contributing to childhood overweight and obesity. Audio-recorded interviews were translated and transcribed, then analyzed using modified ground theory to identify themes and representative quotes.

Results

Five themes were identified: (1) Change in diet between generations, (2) Preference for rounder children, (3) Unhealthy feeding practices, (4) Reduced physical activity, and (5) Increasing awareness of childhood obesity. A conceptual map detailed the shift from war-time to post-war economic environment and psycho-social context for raising children to be large, safe and academically-successful.

Conclusions for Practice

We found that globalization, urbanization and economic development—in the context of historical, social and cultural attitudes—may contribute to increasing child obesity in Vietnam. Obesity prevention through public health and educational institutions should involve policies and programs for healthy eating and exercise, tailored to address parental figures’ concerns.

Prevalence and associated factors of overweight and obesity among primary school children: a cross-sectional study in Thanhhoa City, Vietnam

OBJECTIVE

To determine the prevalence and associated factors of overweight and obesity among primary school children (6-11 years old) in Thanhhoa city in 2021.

DESIGN

Cross-sectional study.

SETTING

Seven primary schools in Thanhhoa city, Vietnam.

PARTICIPANTS

782 children (and their parents).

PRIMARY AND SECONDARY OUTCOME MEASURES

Two-stage cluster random sampling was used for selecting children and data were collected from January to February 2021. A self-administrated questionnaire was designed for children and their parents. Children's height and weight were measured and body mass index (BMI)-for-age z-scores were computed using the WHO Anthro software V.1.0.4. Data were analysed using R software V.4.1.2. The associations between potential factors and childhood overweight/obesity were analysed through univariate and multivariate logistic regression analyses. Variables were selected using the Bayesian Model Averaging method.

RESULTS

The prevalence of overweight/obesity among primary school children in Thanhhoa city was 35.93% (overweight 21.61% and obesity 14.32%). The proportion of overweight girls was nearly equal to that of boys (20.78% and 22.52%, respectively, p=0.6152) while the proportion of boys with obesity was four times as many as that of girls (23.86% and 5.62%, respectively, p<0.0001). Child's sex was the factor significantly associated with childhood overweight/obesity. Boys had double the risk of being overweight/obese than girls (adjusted OR: aOR=2.48, p<0.0001). Other potential factors which may be associated with childhood overweight/obesity included mode of transport to school, the people living with the child, mother's occupation, father's education, eating confectionery, the total time of doing sports, and sedentary activities.

CONCLUSION

One in every three primary school children in Thanhhoa city were either overweight or obese. Parents, teachers and policy-makers can implement interventions in the aforementioned factors to reduce the rate of childhood obesity. In forthcoming years, longitudinal studies should be conducted to determine the causal relationships between potential factors and childhood overweight/obesity.

Lifetime impact of being underweight or overweight/obese during childhood in Vietnam

BACKGROUND

There is limited evidence about lifetime burden of child malnutrition. This study aimed to estimate the lifetime impact of being underweight or overweight/obese during childhood in Vietnam.

METHODS

We developed a life table model in combination with a Markov model for Vietnamese children aged 5-19 years and simulated until they reached 75 years of age or died using published data. The starting year was 2019 and the model estimated number of deaths, years of life lived and quality-adjusted life years (QALY) with an annual discount rate of 3%. We performed scenario, one-way, and probabilistic sensitivity analyses to assess the impact of uncertainties in input parameters.

RESULTS

The model estimated 9.68 million deaths (6.44 million men and 3.24 million women), 622 million years of life lived (317 million men and 305 million women), and 601 million QALYs (308 million men and 293 million women). Scenario analyses showed that the reduction in either underweight or overweight/obesity alone, and reduction in both underweight and overweight/obesity resulted in fewer deaths, more years of life lived and more QALYs gained. In the scenario where everyone was a healthy weight, the model estimated 577,267 fewer deaths (6.0% less), 2 million more years of life lived (0.3% more), and 3 million QALYs gained (0.6% more) over base-case results which represents current situation in Vietnam.

CONCLUSIONS

Our results suggest that addressing underweight and overweight/obesity will contribute to reducing deaths and increasing years of life lived and QALYs. Policies and interventions in alignment with Sustainable Development Goals to address underweight and overweight/obesity are necessary to achieve health for all.

Tensions and coalitions: A new trade agreement affects the policy space for nutrition in Vietnam

Global trade has shaped food systems over centuries, but modern trade agreements are hastening these changes and making them more complex, with implications for public health and nutrition transition. This study aimed to understand the impact of the 2018 Comprehensive and Progressive Agreement for Trans-Pacific Partnership (CPTPP) on the policy space for public health nutrition in Vietnam. We conducted comparative document review and key informant interviews, and our analysis drew on a framework of policy space and the theory of advocacy coalitions. We identified 10 CPTPP sections with potential public health nutrition implications; and 50 Vietnamese policies relevant to nutrition having one or more tensions with one or more CPTPP sections. A majority of policy tensions were in sections of the CPTPP relating to technical barriers to trade and government procurement; most tensions related to protecting policy-making from vested interests. Different groups of policy actors hold different beliefs and interests on these issues, and therefore promote different framings and policy approaches. We identified two advocacy coalitions working very separately on issues affecting nutrition policy space: a trade coalition holding the policy position that free trade improves nutrition by default; and a nutrition coalition holding the policy position that nutrition should be explicitly considered in trade policy. The policy space for nutrition in Vietnam has important potential constraints through written policy, and the trade and nutrition coalitions will need to interact more regularly and constructively in order to foresee where these tensions will arise in practice, and create plans for their mitigation. This study adds to global evidence of free trade agreement impacts on nutrition policy space, and we extend previous work by explaining these actor groupings in the policy space through the theory of advocacy coalitions.

Double burden of malnutrition in ethnic minority school-aged children living in mountainous areas of Vietnam and its association with nutritional behavior

BACKGROUND/OBJECTIVES

Although children of ethnic minority groups are experiencing a transition from a predominance of undernutrition to overnutrition, there is little evidence of a dual-malnutrition burden. Therefore, this study examined the double burden of malnutrition among school-aged ethnic minority children living in mountainous areas and its association with their diets.

SUBJECTS/METHODS

A cross-sectional study was conducted from September 2019 to March 2020 in 3 mountainous areas of Northern Vietnam among 1,556 ethnic minority school-aged children. The prevalence of under-nutrition (stunting and thinness) and over-nutrition (overweight and obesity) were measured using the WHO 2006 child growth standards (height-for-age and BMI-for-age Z-score). Nutritional practices were evaluated by the frequency of food consumption based on a 4-level scale.

RESULTS

The percentage of children with stunting and thinness were 14.0% and 5.4%, respectively, while the figure for overweight/obesity was 9.4%. The factors positively associated with stunting were living in a family with more than 2 children or being Muong/other ethnicities compared to the Tay ethnicity. Children who consumed fish/shrimps/crabs or milk weekly/daily were less likely to be undernourished compared to those who never consumed these foods. By contrast, children who never consumed foods rich in vitamin A precursors and vitamin A and fruit or consumed daily snacks/junk food were more likely to be overweight/obese.

CONCLUSIONS

Undernutrition remains a common issue among school-aged children and adolescents of ethnic minority groups, while over-nutrition exists simultaneously. Public health nutrition programs promoting adequate diets and positive lifestyle changes related to nutrition are essential to tackle the double burden of malnutrition among ethnic minority children.

Intraindividual Double Burden of Malnutrition in Chinese Children and Adolescents Aged 6-17 Years: Evidence from the China Health and Nutrition Survey 2015

Studies on the intraindividual double burden of malnutrition (DBM) among Chinese children and adolescents were lacking. This study aimed to analyze the prevalence of intraindividual DBM defined as the coexistence of overweight/obesity and dietary micronutrient intake insufficiency and investigate dietary micronutrient intake in Chinese children and adolescents. Using data from the 2015 China Health and Nutrition Survey (CHNS), 1555 children and adolescents aged 6 to 17 years were selected as the subjects. We referred to China Food Composition to calculate the intakes of 11 selected dietary micronutrients from diet data collected by consecutive three days of 24 h recalls combined with household weighing of seasonings. We used the Chinese estimated average requirement (EARs) as a cutoff to define the dietary micronutrients deficiency, and applied the body-mass-index-for-age Z-scores (BAZ) of World Health Organization (WHO) child growth standards to define the category of body weight. Among the subjects in present study, the prevalence of overweight and obesity was 15.43% and 11.06%, respectively, and 26.24% of the subjects had undergone intraindividual DBM. The results suggest that the prevalence of intraindividual DBM and dietary micronutrients deficiency in Chinese children and adolescents is high.

Early childhood factors associated with obesity at age 8 in Vietnamese children: The Young Lives Cohort Study

Background

Over recent decades, Vietnam has experienced rapid economic growth, a nutrition transition from the traditional diet to highly-processed and calorie-dense foods and beverages, and an increasing prevalence of childhood overweight/obesity (ow/ob). The goal of this study is to describe the patterns of ow/ob in a longitudinal sample of Vietnamese children from ages 1 to 8, and the sociodemographic and behavioral factors associated with ow/ob at age 8.

Methods

This study is a secondary data analysis of a geographically-representative, longitudinal cohort of 1961 Vietnamese children from the Young Lives Cohort Study from 2002 to 2009. Thirty-one communities were selected with oversampling in rural communities, and children age 1 were recruited from each community using simple random sampling. Surveys of families and measurements of children were collected at child ages 1, 5, and 8. Our specified outcome measure was childhood ow/ob at age 8, defined by the World Health Organization’s thresholds for body-mass-index (BMI) for age Z-scores. Associations between early and concurrent socio-behavioral factors, childhood nutrition and physical activity variables were analyzed using STATA 15. Bivariate and multivariable analyses were completed utilizing logistic regression models.

Results

The prevalence of ow/ob increased from 1.1% in both sexes at age 1 to 7% in females and 13% in males at age 8. Bivariate analyses show greater likelihood of ow/ob at age 8 was significantly associated with early life sociodemographic factors (at age 1), male sex (OR = 2.2, 1.6–3.1), higher wealth (OR = 1.1–1.4), and urban residence (OR = 4.3, 3–6). In adjusted analyses, ow/ob at age 8 was associated with early nutrition practices at age 5, including frequent consumption of powdered milk (OR = 2.8, 1.6–4.6), honey/sugar (OR = 2.7, 1.8–4.1), prepared restaurant/fast foods (OR = 4.6, 2.6–8.2), and packaged sweets (OR = 3.4, 2.3–4.9). In addition, breastfeeding for 6 months or longer was protective against obesity at age 8 (OR = 0.3, 0.1–0.9).

Conclusions

We found that increased consumption of powdered milk, honey/sugar, packaged sweets, and prepared restaurants/fast foods are associated with childhood ow/ob. In contrast, breastfeeding for 6 months or longer was protective against childhood ow/ob. These findings suggest that public health programs and campaigns aimed to prevent childhood ow/ob in Vietnam should target early feeding practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10292-z.

Nutrition transition in Vietnam: changing food supply, food prices, household expenditure, diet and nutrition outcomes

While literature has noted the presence of a nutrition transition in terms of changing nutrition outcomes in Vietnam, very limited evidence linking changes in upstream food system factors to downstream diet and nutrition changes exists. Combining available data from different sources and analyzing it through a conceptual food systems framework, our study examines different pathways of nutrition transition through food supply, food prices, household food expenditures, diets, and nutrition outcomes in Vietnam. Our findings show that while Vietnam is at the start of its nutrition transition, change is happening rapidly. Undernutrition is falling, obesity is rising, and nutrition-related chronic diseases account for a significant burden of diseases and death. In terms of changes in healthful foods, the supply of vegetables and fruits is plentiful, and expenditure on vegetables remains consistent and small. Notably however, vegetable consumption has dropped, and increasing meat and milk consumption have been double-edged swords for nutrition. In terms of foods associated with the negative sides of the nutrition transition, the availability of sweets and sweetened beverages has risen in recent years, with oils and fats rising less. The expenditure share on food eaten away from home, in many contexts a marker for less healthful diets, has increased over time. While these changes are typical of a nutrition transition, Vietnam is also somewhat of an outlier in some respects: wet markets and daily fresh food purchases continue to dominate food purchasing behaviour, and food eaten away from home means a different thing in a country renowned for its diverse and healthy street food and roadside restaurant culture. While this study brings together important data on the food system drivers of a nutrition transition in Vietnam, it cannot link each of these issues into a standard statistical model of change due to data gaps at different levels, calling for data collection improvement in future diet and food systems research. Vietnamese health policy explicitly acknowledges nutrition transition issues, with targets for obesity reduction. This work on the food system drivers of the nutrition transition points to the need to further adapt policy in other sectors beyond health, however. At the same time as making nutrient-rich foods more accessible, nutrient-poor or ultra-processed foods need to be made less accessible and desirable if additional income is to contribute to a healthy diet in limiting Vietnam’s emerging nutrition transition.