Right now Vietnam is straddling two different worlds: at either end of this long and narrow country you have two powerhouse cities while a smattering of smaller cities follow suit. Although Hanoi and Ho Chi Minh City get the lion’s share of the press, they make up just 25 percent of the country’s overall population. The vast majority live in rural landscapes, where life is completely different.
The realities of these two landscapes—rural towns and metropolises—differ in all aspects, from infrastructure to education to food and diet. While the former two examples affect the quality of life, the latter affects the length of it.
As Dr. Nguyen Thi Dan Thanh, a nutritionist at Victoria Healthcare and lecturer at the Medical University wrote to me in an email, “Community-wise, Vietnam currently is in a nutrition transition period, which is characterised by the existence of both the nutrition problems in advanced and advancing economies. On the one hand, malnutrition remains an issue; on the other, obesity and lifestyle-related problems have increased rapidly, which puts weight on government policy.”
She concluded, “All in all, more and more people are facing some kind of nutrition-related problems, but the sad thing is that it is hard to find an appropriate resource to help them.”
The Vietnamese Paradox
Nutrition-based health problems and non-communicable diseases are wreaking havoc on the population of Vietnam, a curious problem for a country with a deep-seated pride and love for its traditionally healthy cuisine.
Commonly lauded as one of the most healthy cuisines in the world, nutritional experts are quick to list the many benefits of a purely Vietnamese diet. Antoine Yvon, a former nutritionist at Centre Medical International, wrote in a former issue of #iAMHCMC that “[a]s a professional, I have seen that dishes and ingredients used in Vietnamese cuisine can cover all the dietary needs on protein, lipids, carbohydrates, vitamins and minerals because there is a great natural diversity of agricultural products.” He goes on to conclude that “It is this diversity and variety that are the foundations of a healthy and balanced lifestyle.”
The common example is usually a bowl of pho. Here you have everything you need for a balanced diet: fats, proteins, starches and, of course, plenty of vegetables.
Simple yet complex, fresh yet slow-cooked, there’s no wonder many Vietnamese people don’t stray from their national cuisine. However, this might be part of the problem.
Phil Kelly, a fitness specialist, took time out to meet—ironically, at Tous Les Jours, one of the many Western-style quick-fix cafes doing well in Ho Chi Minh City in recent years.
“There’s a big difference between what’s traditional [Vietnamese food] and what it’s turned into,” he tells me.
“Now, with modern-day cooking and flavour enhancement they’re adding more oils, more sugar… If you go back to basic eating, they never had that. It was actually very healthy.”
Antoine Yvon mirrored this view, calling the problem “a Vietnamese paradox”: while Vietnamese food might be based on vegetables and healthy cooking techniques, the onset of chemically enhanced flavour profiles and industrialised cooking methods have rendered it anything but.
Building a Foundation
“Nutrition is the foundation for everything that we do,” Phil Kelly says simply. “You can be very, very healthy and not exercise. If you exercise and don’t have your nutrition and lifestyle right, you can be unhealthy.”
Kelly describes the basic tenets of nutrition and its part in health: our bodies are in a continual process of rejuvenation. Our cells grow and die, renewing our skin and cellular tissue—the cells of our bones, for example, completely regenerate every 10 years.
However, the strength of the cells, and therefore the strength of our bodies and health, depends primarily on the food we use to fuel the process.
Antoine Yvon says that 40 percent of cancers in Vietnam are linked to food consumption, caused mainly by processed foods, bad eating habits and the presence of pesticides and chemicals.
Professor Hoang Dinh Chau, the director of the Hung Viet Cancer Hospital, says that in Vietnam more people die from cancer caused by unsafe food than from smoking, a shocking statistic when you consider that over 45 percent of men in Vietnam smoke habitually.
Cancer is just one example. Other non-communicable diseases caused by poor diet include cardiovascular diseases, diabetes and chronic pulmonary diseases; it’s estimated that 7 out of 10 deaths in Vietnam are caused by cancer or one of these chronic diseases.
Getting Bigger Faster
The decline of nutrition standards, and the adverse effects that come with it, is nothing new to Vietnam, or even the world. Case in point: obesity.
A well-publicised study published in The New England Journal of Medicine last July found that worldwide, 2.2 billion people are considered overweight. Unsurprisingly, the US was found to have the greatest number of obese adults (79.4 million people, almost a quarter of the population), while Vietnam and Bangladesh were tied for last—8.1 million people in Vietnam were overweight, less than two percent of the adult population.
While these results are undoubtedly good—especially for a country ranked seventh-to-last in terms of daily physical exercise, according to a global survey put out by Stanford University—the rising rate of obesity is cause for alarm.
The obesity numbers have risen steadily in recent years, although the exact statistics depend on which studies you read. A recent study by the University of Washington has shown a 6.8 percent obesity rate in Vietnamese children aged 2 to 19 (to put this in context, the US’s current rate is 28.5 percent), while a survey by Vietnam’s National Institute of Nutrition has listed the childhood obesity rate in urban cities to be as high as 40 percent in major cities, an increase of almost 10 times from a decade ago.
While it can’t be called a fully fledged epidemic at the moment, Antoine Yvon points out that the number of Vietnamese children under five years old with weight problems has doubled in the past four years, and the rate of obese grade-schoolers in Ho Chi Minh City tripled from 2002 to 2009.
The municipal administration of HCMC aims to keep the rate of overweight and obese children under five years of age at less than 12 percent by 2020; as of yet, no public campaigns have been pursued.
East vs. West?
The changes in health, especially in urban and increasingly modernised areas, seem to point to a widespread shift in the way Vietnamese people feed themselves and their families. This has roughly correlated with Vietnam’s entry into the World Trade Organisation in 2007.
Has the influx of Westernised food products spurred the changes?
Jake Pulkrabek, a barbecue specialist who owns Jake’s American BBQ in District 1, said that although Western food is now more prevalent in Vietnam, that doesn’t necessarily mean that Vietnamese people are flocking to it.
Pulkrabek’s business model emphasises American authenticity, and for him that starts with the ingredients.
“When you’re trying to make something as authentic as possible, you have to use a lot of imported ingredients. So that always brings up the price a bit more than the local cuisine, which makes it a little more challenging for the locals to come and try it.”
Hitting the right price points is important in a country still in the throes of development, where the average annual income per capita is below US$2,000 in HCMC. Even fast food, considered a cheap food option in Western countries, is a spendy splurge in Vietnam.
Although around 85 percent of Pulkrabek’s clientele are expats or foreigners on business trips, he has noticed a loyal following among Viet Kieus—Vietnamese people who have spent time or grown up abroad, many of whom are heading back to Vietnam.
With a more diverse palate and a taste for Western cuisines, Viet Kieus act as a bridge between the two culinary worlds, aided by a growing middle-class income that allows for a dinner out.
Dr. Thanh from Victoria Healthcare considers the issue from all angles. “As a specialist in nutrition, I do welcome the wide introduction of foreign foods in Vietnam,” she writes. “I can understand the worried views, however, from my opinion, food is a pleasure, and having the opportunity to try different foods is a blessing; why do we have to reject it? Eating right does not mean we have to starve until death.
It means we have to be smart and put everything on our plate with a sense of control.”
Worse Before it Gets Better
Rather than throwing the baby out with the bathwater, experts have been looking at individual factors in the shifting food landscape, above all: portion size, sugar consumption and an increased use of processed ingredients.
Phil Kelly is adamant that portion size plays a big role. “With a rising economy and additional [spending money], people are going out and enjoying more food. It’s treating yourself.” Kelly has observed that Vietnamese eaters are generally controlled, but he sees voracious appetites in children especially, encouraged by parents who might not understand the adverse ramifications of too much food.
On a cultural level, Kelly also worries about the ubiquitous use of sugar in modern Vietnamese cooking, a culinary trend especially prevalent in the South. Studies have shown that diabetes rates have grown particularly in the Mekong Delta region. Kelly recalls that when he moved to Ho Chi Minh City five years ago, “when [I] asked for no sugar, it was quite an issue to really explain it.” Today he sees more knowledge of the health defects of sugar, though the use of it in cooking is still strong.
Above all, Dr. Thanh worries most about sugar consumption in young people today. She writes that on the weekend, it’s common to see young people clutching a sugary milk tea. This, combined with “the habit of using sugar in almost every recipe, especially nuoc mam,” is cause for concern.
The government is also taking note of excess sugar consumption and has proposed an additional tax on imported soft drinks—a controversial proposition that has garnered plenty of criticism from advocates of free trade.
The tax would join the ranks of neighbouring countries like Cambodia (10 percent tax) and Thailand (20 to 25 percent tax), although nothing has yet been mandated.
When asked about the issue, Jake Pulkrabek sees similarities in America: “In America, we’re getting to the point where everything we eat is out of a box or a bottle.”
As convenience stores like Circle K, Family Mart and recently 7-11 have taken hold in the FMCG market, chances are the situation will get worse before it gets better.
Education Is Key
As Vietnam modernises and the middle class continues to grow, consumer spending has outpaced public education and awareness of health and nutrition.
Many people agreed that the general perception of health and the body is limited, leaving the market open for global food distributors whose sales in Western countries have stagnated.
“The whole snacking phenomenon came about when food companies were searching for new markets,” Phil Kelly notes. “It wasn’t that we needed to snack. Highly advertised packaged snacks came into existence for a purpose… When was the last time you saw a TV advert for broccoli?”
Dr. Thanh describes her own journey towards becoming one of Ho Chi Minh City’s first Vietnamese nutrition specialists when she saw the adverse effects of some foods:
“I came to the conclusion that nutrition is one of the most [serious] problems for patients, but at that time we were not taught nutrition at school. That was the reason I chose to join a newly established nutrition department in my university.”
Today Dr. Thanh is pioneering nutrition education with the help of Victoria Healthcare. She heads up a program called MyPlate, which counsels Vietnamese women about healthier cooking options.
And just as Vietnamese people who have spent time abroad come back with altered palates, they also come back with new information and outlooks about food in general. Cindy Kawak, General Manager of Propaganda Bistro, has noticed a shift: “They come back with different knowledge, with different views of health and the world. And they share it.” Kawak describes her experience becoming vegetarian, and seeing the curiosity of her staff. “Now some of them want to go that way too. They see that it’s not killing me, but in fact quite the contrary.”
Small shifts are perceptible on the business side of things as well: a recent Nielsen’s Consumer Confidence Index report for Vietnam has determined that 34 percent of Vietnamese consumers list health as a number one concern; Nguyen Van Viet, the chair of the Vietnam Beverage Association, has reported a trend away from sugary drinks and towards juice drinks or drinks with reduced sugar.
But a clear top-down educational structure has yet to be developed. At the moment, most people in Vietnam gain knowledge through their own efforts, rather than at school or through media campaigns. As food-related disease rates inch higher, can knowledge be gained before the damage is irreversible?