Are policies in Vietnam conducive of healthy food environments? Insights from a multi-sectoral policy landscape analysis Even Brice, Truong Thi Thu Trang, Nguyen Thu Duong, Thai Thi Minh Hang, Pham Thi Mai Huong, Bui Thi Viet Anh, Nguyen Tuan Linh, Béné Christophe SHiFT REPORT November 2023 2 The CGIAR Research Initiative on Sustainable Healthy Diets through Food Systems Transformation (SHiFT) combines high-quality nutritional and social science research capacity with development partnerships to generate innovative, robust solutions that contribute to healthier, more sustainable dietary choices and consumption of sustainable healthy diets. We build on CGIAR’s unparalleled track record of agricultural research for development, including ten years of work on food systems and nutrition under the CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), particularly under the research flagship Food Systems for Healthier Diets. To learn more about this Initiative, please visit on.cgiar.org/SHIFT. Suggested citation: Even, B.; Truong Thi, T. T.; Nguyen, T. D; Thai Thi, M. H.; Pham Thi, M. H.; Bui Thi, V. A.; Nguyen, Tuan Linh; Béné, C. 2023. Are policies in Vietnam conducive of healthy food environments? Insights from a multi-sectoral policy landscape analysis. Alliance of Bioversity International and CIAT. Hanoi Vietnam. 92 pages. Photo credit (front cover): Photo by Loifotos from Pexels. https://www.cgiar.org/initiative/sustainable-healthy-diets/ https://www.pexels.com/photo/woman-wearing-gray-jacket-riding-on-canoe-boat-3282516/ 3 Table of contents Abbreviations and acronyms ................................................................................................................. 5 Acknowledgments .................................................................................................................................. 6 About the authors ................................................................................................................................... 6 1. Introduction ......................................................................................................................................... 7 1.1 Why do we need to improve food systems and food environments? ............................................ 7 1.2 Research questions ...................................................................................................................... 7 2. Concepts and methodology ............................................................................................................... 9 2.1 The food environment framework ................................................................................................. 9 2.2 Definitions ................................................................................................................................... 10 2.3 Methods ...................................................................................................................................... 11 2.3.1 Adaptation of the Food Environment Policy Index (Food-EPI) from INFORMAS .............. 11 2.3.2 Data collection.................................................................................................................... 12 2.3.3 Data collation ..................................................................................................................... 12 2.3.4 Preliminary scoring ............................................................................................................. 12 2.3.5 Scoring validation by a panel of experts ............................................................................ 13 3. The food environment in Vietnam at a glance ............................................................................... 13 3.1 Food safety concern vs nutritional quality problems ................................................................... 13 3.2 Mutation of the retail sector towards modern channels .............................................................. 14 3.3 Increasingly aggressive marketing? ............................................................................................ 14 3.4 Cheaper processed food vs more expensive nutritious food ...................................................... 15 3.5 Challenges to ensure food accessibility and availability. ............................................................ 15 4. Results ............................................................................................................................................... 17 4.1 Synthesis .................................................................................................................................... 17 4.1.1 Evidence collation by indicator ........................................................................................... 17 4.1.2 Overview ............................................................................................................................ 19 4.2 Detailed results per food environment domain ........................................................................... 20 4.2.1 Food product properties ..................................................................................................... 20 4.2.2 Food outlet properties ........................................................................................................ 22 4 4.2.3 Food Marketing .................................................................................................................. 24 4.2.4 Food Desirability ................................................................................................................ 26 4.2.5 Food prices and affordability .............................................................................................. 27 4.2.6 Food availability and accessibility ...................................................................................... 28 5. Policy recommendations ................................................................................................................. 30 5.1 Recommendations per domain ................................................................................................... 30 5.2 General recommendations .......................................................................................................... 32 6. References ........................................................................................................................................ 33 7. List of Annexes ................................................................................................................................. 35 Annex 1. Extended definitions .......................................................................................................... 36 Annex 2: List of indicators ................................................................................................................. 37 Annex 3: List of keywords for each domain ...................................................................................... 39 Annex 4: List of policy documents from which evidence were retrieved ........................................... 41 Annex 5: Evidence collated from policy documents for each indicator. ............................................ 55 1. Food product properties .......................................................................................................... 55 2. Food outlet properties ............................................................................................................. 63 3. Food Marketing ....................................................................................................................... 71 4. Food Desirability ..................................................................................................................... 80 5. Food prices and affordability ................................................................................................... 85 6. Food availability and accessibility ........................................................................................... 88 Annex 6: Considerations for classifying food retail outlets ................................................................ 91 Figures Figure 1: Comparison between the FOOD-EPI food environment domains and our framework .. 11 Figure 2: Proportion of indicators by score. ...................................................................................... 20 Tables Table 1: Number of policy documents tackling indicators pertaining to our food environment domains. ................................................................................................................................................ 17 Table 2: Synthesis of the scores for each indicator .......................................................................... 19 5 Abbreviations and acronyms A4NH Agriculture for Nutrition and Health CIP International Potato Center IFPRI International Food Policy Research Institute INFORMAS International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support IPSARD Institute of Policy and Strategy for Agriculture and Rural Development MOET Ministry of Education and Training MOH Ministry of Health NCD Non-Communicable Disease NIN National Institute of Nutrition PEN Policy Evaluation Network SHIFT Sustainable Healthy Diets through Food System Transformation VAAS Vietnamese Academy of Agricultural Sciences WUR Wageningen University and Research 6 Acknowledgments We express our gratitude to Dr. Dao The Anh, Vice-President of the Vietnamese Academy of Agricultural Sciences (VAAS), Dr. Truong Tuyet Mai, Vice-Director of the National Institute of Nutrition (NIN), and Dr. Tran Cong Thang, Director of the Institute of Policy and Strategy for Agriculture and Rural Development (IPSARD), for their valuable contributions to the review of our findings. Our sincere appreciation also goes out to the members of the panel of experts who played a decisive role in the validation process. Special thanks to the Science Writing Service of the Alliance Bioversity-CIAT (Glenn Hyman, consultant editor) for language editing of this report. Additionally, we would like to express our thanks to Erika Mosquera and Carolina Polo for their efforts in formatting this report. About the authors Brice Even (b.even@cgiar.org) is a Research Team Leader, at the Alliance of Bioversity International and CIAT based in Hanoi, Vietnam. Truong Thi Thu Trang (trangmymy2021@gmail.com) is a director of the Center for Agricultural Policies (CAP) of the Institute of Policy and Strategy for Agriculture and Rural Development (IPSARD). Nguyen Thu Duong (duong.nguyen@cap.gov.vn) is an officer at the Center for Agricultural Policies (CAP) of the Institute of Policy and Strategy for Agriculture and Rural Development (IPSARD). Thai Thi Minh Hang (h.thai@cgiar.org) is a Senior Research Associate, at the Alliance of Bioversity International and CIAT based in Hanoi, Vietnam. Pham Thi Mai Huong (p.huong@cgiar.org) is a Senior Research Associate, at the Alliance of Bioversity International and CIAT based in Hanoi, Vietnam. Bui Thi Viet Anh (anh.bui@cap.gov.vn) Officer at the Center for Agricultural Policies (CAP) of the Institute of Policy and Strategy for Agriculture and Rural Development (IPSARD). Nguyen Tuan Linh (linhnguyentuan1997@gmail.com) Officer at the Center for Agricultural Policies (CAP) of the Institute of Policy and Strategy for Agriculture and Rural Development (IPSARD) Christophe Béné (c.bene@cgiar.org) is a Principal Scientist, at the Alliance of Bioversity International and CIAT based in Wageningen, The Netherlands. mailto:b.even@cgiar.org mailto:trangmymy2021@gmail.com mailto:duong.nguyen@cap.gov.vn mailto:h.thai@cgiar.org mailto:p.huong@cgiar.org mailto:anh.bui@cap.gov.vn mailto:linhnguyentuan1997@gmail.com mailto:c.bene@cgiar.org 7 1. Introduction 1.1 Why do we need to improve food systems and food environments? Current food systems fail to address the triple burden of malnutrition — undernutrition, micronutrient deficiencies, and overnutrition (Popkin, 2019; Béné, 2019; Fanzo, 2020). The Food and Agriculture Organization (FAO) reports that approximately 462 million people worldwide are underweight, while 1.9 billion adults (39%) are overweight or obese. In 2020, globally, 149 million children under the age of five were stunted, 45 million were wasted, and 38.9 million were overweight or obese (FAO, 2021). Many populations have shifted from traditional diets which tend to be locally specific and include coarse grains, pulses, fruits, vegetables, and some meat or fish depending on the season, towards a standardized global diet that is high in animal source proteins, fat, sugar, and processed packaged foods. This dietary shift has occurred over different time scales and in different regions and is also happening in Vietnam (NIN, 2021). In Vietnam, the prevalence of undernourishment decreased from 18% to 11% between 2008 and 2018 (FAO, 2018). Improvements have also been observed in the chronic malnutrition (stunting) of children under the age of five, which has decreased from 32% to 24% between 2007 and 2015 (UNICEF and WHO, 2019). However, the rate of overweight and obesity has been rapidly increasing, especially in urban populations (Viet Nam Ministry of Health, 2021). The World Health Organization (WHO) reported in 2018 that 9.7% of children and adolescents in Vietnam were overweight, as well as 25% of women and 20% of men (WHO, 2018). More recent figures show that the prevalence of overweight and obesity among school-aged children increased from 8.5% in 2010 to 19% in 2020, with urban areas showing a rate of 26.8%, rural areas at 18.3%, and mountainous regions at 6.9% (NIN, 2021). Overweight and obese individuals suffer from increased risk of non-communicable diseases (NCDs), such as type 2 diabetes, cardiovascular diseases, and some types of cancer. Unhealthy eating is largely the result of unhealthy food environments (Hawkes, 2006; HLPE, 2017). Therefore, better knowledge and understanding of food environments is needed to develop interventions that lead to healthy food systems. 1.2 Research questions At present, food systems do not contribute to healthy diets, fair livelihoods, and sustainable environments in part because of the existence of a range of policy lock-ins and barriers, that prevent or slow the necessary changes. A research team comprised of SHiFT researchers and partners is undertaking policy and political economy research identifying historically contingent governance structures and powerful incumbent actors with an interest in maintaining the system on its current trajectory. The research team identifies key policy lock-ins and barriers and proposes context-specific and evidence-based solutions. The SHiFT country coordination committee design and implement strategies to promote uptake of these solutions in ways that contributes to sustainable healthy diets for all in the Vietnamese food system. As part of this endeavor, SHiFT researchers, in collaboration with the Institute of Policy and Strategy for Agriculture and Rural Development (IPSARD), are conducting a policy landscape analysis focusing on the food environment in Vietnam. For the purpose of this exercise food environment is defined as the physical (food availability, food accessibility, quality, marketing), economic (food affordability, food prices), policy (public regulations) and sociocultural (food desirability, food acceptability, norms and 8 beliefs) surroundings, opportunities and conditions that influence people’s food choices and the subsequent outcomes of these choices (nutritional status, environmental sustainability, socio-economic equity) (adapted from Swinburn, 2016, Caspi et al., 2012, Cobb et al., 2015, Penney et al., 2014, Turner et al., 2018). Reflecting this definition, we categorize food environment-related policies into six domains: 1. Food products properties 2. Food outlet properties 3. Food marketing 4. Food desirability 5. Food prices and affordability 6. Food availability and accessibility A range of drivers have influenced the mutation of the food environment in Vietnam. These include globalization, economic growth, agricultural productivity, and urbanization, associated with changing lifestyles and increasing incomes, driving a demand for more convenient and diverse food options. Government policies also played a key role in shaping the food environment. The Vietnamese government has implemented a series of policies to improve food sovereignty, food security, food safety, and, to a lesser extent, to promote healthy eating. Yet, there is little clarity on how these policies manifest themselves in the different domains of the food environment. The objective of this food environment policy landscape analysis is to explore and clarify how the regulatory framework in Vietnam contributes to or detracts from a healthy food environment in Vietnam. It will be guided by the following research questions: What are the Vietnamese policies and regulations influencing food environments? How does the food environment policy landscape contribute to the adoption of healthy diets? 9 2. Concepts and methodology 2.1 The food environment framework Food environments function as a crucial interface that mediates food acquisition within the broader food system. Depending on the community, the food environments may consist of locally produced and purchased foods, or it may be more global in nature, involving interconnected regional, national, and international markets (Hawkes, 2006). This definition underscores the complex interplay of various factors in shaping individuals' food choices and nutritional outcomes, highlighting the importance of examining the food environment in its entirety. It is also important to recognize and understand the interplay between these drivers and how they interact to shape food environments. For example, economic drivers can influence the availability and affordability of healthy foods, which can in turn affect dietary patterns and health outcomes. Similarly, policy drivers can shape the regulatory frameworks that govern food systems, influencing the availability and accessibility of healthy foods. Understanding these drivers and their interactions is crucial for designing effective policies and interventions to improve food environments and promote healthy diets. Our framework, adapted from Turner et al. (2018), and Downs et al. (2020), includes six policy domains (food product properties, food outlet properties, food marketing, food desirability, food prices and affordability, and food availability and accessibility), as defined below: Domain 1 “Food product properties” concerns the extent to which policies stimulate, propose, develop and/or implement systems (e.g., targets, standards, restrictions) to ensure that food composition is safe (food safety) and healthy (nutritional quality). This domain concerns the extent to which processed food minimize the energy density and the nutrients of concern (salt, saturated fat, trans fat, added sugar). Domain 2 “Food outlet properties” concerns: (i) the extent to which some outlets characteristics (type, density, locations, product placement, etc.) are favored over other types; (ii) the extent to which market regulations (such as those controlling market operations, market planning, and licensing) and urban planning (e.g. infrastructures, land use, etc.) contribute to healthy food retail environments; (iii) the extent to which there are effective food service policies implemented in government and public- funded settings to ensure that food provision encourages healthy food choices; and (iv) the extent to which public policies actively encourage and support private companies to implement similar policies. Domain 3 “Food marketing” concerns: (i) the extent to which policies reduce the impact of promotion of unhealthy foods to consumers — especially children and adolescents — across all media, and (ii) the extent to which policies develop a regulatory system for consumer-oriented labelling on food packaging and menus to enable consumers to easily make informed and healthy food choices, and prevent misleading claims. Domain 4 “Food desirability” concerns the extent to which policies influence individual preferences, tastes, desires, culture, and other food acceptability considerations. It considers how policy increases the desirability for healthy food by improving nutrition knowledge and favoring the promotion of diverse food consumption, such as food groups like legumes, fruits and vegetables. Domain 5 “Food prices and affordability” concerns: (i) the extent to which food pricing policies (e.g., taxes and subsidies) are aligned with health outcomes by helping (poor) consumers to make the healthy food choices the easier and cheaper choices; and (ii) the extent to which policies support / 10 affect food affordability (e.g., purchasing power) for all, including vulnerable groups (e.g., safety nets and social protection, etc.). Domain 6 “Food availability and accessibility” concerns the extent to which policies support and contribute to the availability and accessibility of healthy foods or limit the availability and accessibility of unhealthy foods. 2.2 Definitions Policies are defined as purposeful decisions, plans or actions made by voluntary or authoritative actors in a system designed to create system-level change to achieve specific societal goals directly or indirectly. Within this definition, public policy is a form of government action usually expressed in a law, a regulation, or an order at it reflects an intent of government or its representative entities (Policy Evaluation Network (PEN) Glossary1). Food encompasses edible substances and non-alcoholic beverages, and extends to include breastmilk and its alternatives, thus constituting a comprehensive spectrum of ingestible items. Food Environment encompasses the physical (food availability, food accessibility, quality, marketing), economic (food affordability, food prices), policy (public regulations) and sociocultural (food desirability, food acceptability, norms and beliefs) surroundings, opportunities and conditions that influence people’s food choices and the subsequent outcomes of these choices (nutritional status, environmental sustainability, socio-economic equity). Healthy food2 refers to a variety of nutrient-rich and minimally processed foods that provide essential vitamins, minerals, and other beneficial compounds, while generally being lower in unhealthy components like excessive saturated fats, added sugars, and sodium. Healthy foods support the consumption of a healthy diet in accordance with the WHO guidelines and Vietnam National Institute of Nutrition’s Food Pyramid. Examples of healthy foods include fruits, vegetables, whole grains, lean proteins, nuts, seeds, and legumes. Unhealthy food2 comprises food items characterized by a dearth of essential nutritional constituents and distinguished by their energy-dense nature resulting from extensive processing. Unhealthy food encompasses items such as sugary snacks, carbonated beverages, deep-fried fare like French fries and battered fried chicken, along with heavily processed convenience foods like instant noodles and sugary cereals. These selections are collectively identified as detrimental in light of the stipulations outlined by WHO guidelines and Vietnam National Institute of Nutrition’s Food Pyramid. Nutrients of concern refer to salt (sodium), sugar, trans- and saturated fat. 1 Available from the PEN website: https://www.jpi-pen.eu/ 2 See extended definition in Annex 1 https://www.who.int/news-room/fact-sheets/detail/healthy-diet http://chuyentrang.viendinhduong.vn/FileUpload/Documents/Nam%202021/Cac%20Thap%20DD%20hop%20ly%20cho%20nguoi%20VN-phien%20ban%20Tieng%20Anh.pdf https://www.who.int/news-room/fact-sheets/detail/healthy-diet http://chuyentrang.viendinhduong.vn/FileUpload/Documents/Nam%202021/Cac%20Thap%20DD%20hop%20ly%20cho%20nguoi%20VN-phien%20ban%20Tieng%20Anh.pdf https://www.jpi-pen.eu/ 11 2.3 Methods 2.3.1 Adaptation of the Food Environment Policy Index (Food-EPI) from INFORMAS The Healthy Food Environment Policy Index (Food-EPI) — a tool developed by the International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) — assesses the relevance and strength of policies to create healthy food environments (Swinburn, 2013). It provides a standardized assessment of the extent and comprehensiveness of policies and regulations that promote healthy food environments and reduce the prevalence of obesity and diet related NCDs. It includes a wide range of indicators, each of them related to a specific domain of the food environment, including (as per the Food-EPI terminology): food composition, food marketing, food labelling, food pricing, and food availability. To date, the Food-EPI has been applied in about 50 countries worldwide. The food environment domains used in this study, as outlined in Section 2.1, were adapted from existing food environment frameworks (Turner et al., 2018; Downs et al., 2020), and from the Healthy Food Environment Policy Index (Food-EPI) (Swinburn, 2013). Figure 1 below shows how our food environment framework differs from the domains used in the Food-EPI tool. Figure 1: Comparison between the FOOD-EPI food environment domains and our framework Within each food environment domain, a set of indicators was compiled (see Annex 2), primarily drawn from the indicators of the Food-EPI tool. These indicators were reviewed and reorganized to better fit with our food environment domains. We have also added some indicators, notably to encompass the food safety dimension aimed at preventing microbiological, chemical, or physical contamination and food-borne infection as healthy diets and food environments are not only about nutritional quality and diversity. We cannot ignore the urgent issue of food safety in the emerging economies of the global South, an issue that remains largely neglected in global literature (Ortega and Tschirley, 2017). 12 2.3.2 Data collection We conducted a comprehensive search to identify policy documents that could potentially impact various aspects of the Vietnamese food environment. Our focus was on national-level policies, but we also considered specific sub-national policies that were pertinent to our SHiFT target sites, such as Hanoi. Policies within the following sectors were included: (i) agriculture and food production; (ii) food security and nutrition; (iii) value chains, trade and markets, taxes; (iv) land use and urban planning; (v) climate change, environment, and natural resources. 2.3.3 Data collation Policy documents were analyzed using the Provalis Suite, a text-analytics software suite that combines qualitative data analysis, content analysis, and text mining to extract insights from textual data. We employed WordStat9 and QDA miner within this suite. To ensure focused data collation, a set of keywords (provided in Annex 3) was established for each domain. These keywords guided the retrieval of relevant text segments from the policy documents, forming the basis for subsequent analysis. The retrieved segments were compiled into a structured spreadsheet, which facilitated the categorization of the Vietnamese government's actions in relation to each indicator. Additionally, these relevant segments were consolidated into an evidence report, presenting a coherent summary of the government's actions for each indicator. The evidence report was used for the subsequent steps. 2.3.4 Preliminary scoring A preliminary analysis was conducted by our research team using a 5-level scoring system to assign provisional scores to each indicator. The scoring criteria were as follows: Score Scoring criteria A The existing policy documents consist of a comprehensive framework that acknowledges the significance and necessity of addressing the indicator/issue; and provide full comprehensive guidance and specific measures on how to approach it; and include a focus on the implementation and enforcement of these policies, including clarifying the roles and responsibilities of the entities involved in policy implementation. B The existing policy documents acknowledge the significance and necessity of addressing the indicator/issue; and provide guidance and specific measures on how to approach it; however, they do not comprehensively address all the dimensions related to the indicator/issue (i.e., there are still some gaps); and/or lack of a focus on the implementation and enforcement of these policies. C The existing policy documents acknowledge the significance and necessity of addressing the indicator/issue; however, there are no documents that provide guidance and specific measures on how to address it. D The existing policy documents do not acknowledge the significance and necessity of addressing the indicator/issue. E Policies in place are likely to have detrimental / counterproductive outcomes and hinder the achievement of the indicator. 13 2.3.5 Scoring validation by a panel of experts A panel of 18 experts reviewed and validated the scoring in September 2023. The panel was comprised of scholars, professionals, and representatives from scientific associations, civil society, and governmental organizations. They specialized in various fields, such as agriculture, health, nutrition, and trade. Involving researchers and practitioners aimed to ensure a well-rounded, multidisciplinary approach. 3. The food environment in Vietnam at a glance Food preferences and dietary habits of Vietnamese consumers, particularly those living in urban areas, are shifting along with the rapid transformation of the food environment. Household diets are shifting from traditional plant-based diets — involving locally produced coarse grains, pulses, fruits and vegetables and meat — towards standardized global diets (Wertheim-Heck and Raneri, 2020). Processed foods including packaged food, ultra-processed food, fast food, and sugar sweetened beverages are consumed more frequently. Though Vietnam has a rich supply of fruits and vegetables, an increase in consumption is only recorded for fruits while the consumption of vegetables is declining (Harris et al., 2020). There is also a rapid increase in meat consumption being driven in part by an increased availability of meat, but also positive social connotations attached to meat as a symbol of development and progress, alongside increased prevalence of eating out and the meat-intensification of traditional meals (Hansen, 2018). This shift in the Vietnamese dietary pattern is concerning, as it leans, with an increased uptake of animal proteins, ultra-processed food, and sugar-sweetened beverages, towards unhealthy food choices. It is driven by a wide range of factors, including the increased availability and affordability of certain food items, significant lifestyle changes and the adoption of foreign-influenced eating practices and dishes, the evolution of the food retail sector, adaptations to the food safety situations, etc. that we intend to briefly explain below. 3.1 Food safety concern vs nutritional quality problems Ensuring access to safe food is of critical concern for public health in Vietnam. The country has made significant efforts to improve food safety standards in recent years, with the government implementing various measures to ensure that food products meet national and international safety requirements. This includes the establishment of a multi-sectoral National Steering Committee on Food Safety and Hygiene, which oversees the implementation of food safety policies and regulations. Additionally, Vietnam has also strengthened its food safety inspection systems and has increased public awareness campaigns on the importance of safe food practices. However, despite these efforts, food safety remains a concern for most consumers. While it is less of a concern among consumers, access to and consumption of nutritious foods is also of concern from a public health perspective. Vietnam has made significant progress in reducing undernutrition and stunting among children; however, the prevalence of micronutrient deficiencies remains high, particularly for iron, zinc, and vitamin A. In addition, overweight and obesity are becoming increasingly common, especially among urban population. These trends suggest that the food environment in Vietnam is failing to deliver healthy outcomes for all consumers. There is a need for policies and interventions to promote healthier food choices and improve diet quality. 14 3.2 Mutation of the retail sector towards modern channels As in many other low- and middle-income countries (LMIC Vietnam's food retail sector is experiencing modernization, with the development of modern retail channels such as supermarkets and chain convenience stores (Traill, 2006; Reardon, 2011; Rupa et al. 2019). Although formal traditional wet markets and informal food vendors remain the most important sources of fresh food for Vietnamese consumers, supermarkets, convenience stores, and fast-food chains are developing fast, especially in urban areas., supermarkets, convenience stores, and fast-food chains are developing fast, especially in urban areas. This constitutes significant changes of the food environments, especially in urban settings, with notable implications for nutrition and social equity. The development of modern food retail channels jeopardizes access to fresh, healthy, and nutritious foods for poor consumers. Several studies in developing countries have shown that the modernization of food retail is positively associated with an increased consumption of energy dense and processed food, often considered unhealthy (Asfaw, 2008; Hawkes, 2008; Kelly et al., 2014; Rischke et al., 2015; Toiba et al., 2015; Demmler et al., 2018). In Vietnam, modern food retail channels (in particular convenience store chains) are offering a food assortment that is often dominated by ultra-processed foods, rather than fresh products, and contribute to their increased availability and market penetration (Huynh et al.et al. 2021). It will likely have implications for dietary quality and health outcomes and may contribute to the rising prevalence of obesity and non-communicable diseases (NCDs) in Vietnam (Harris et al.et al., 2020). Another recent study showed that lower availability and density of traditional food markets are susceptible to cause welfare loss for poorer households who cannot choose to substitute modern markets for traditional markets that have become distant due, in-part, to government market transformation policies (Nguyen-Anh, 2021). Furthermore, while the government promotes the development of modern channels, such as supermarkets and convenience store chains, to enhance food safety, the wet markets, which play a central role in sourcing fresh food products, receive limited support for upgrading and development (Wertheim-Heck & Raneri, 2020). This poses the risk of marginalizing informal groups active in these traditional markets, thereby impacting inclusion and social equity. Overall, the rapid urbanization and food retail mutations have modified the modalities of physical access to food, creating new challenges, and possibly putting the accessibility to fresh and healthy foods at risk. The urban population also faces risks of limited access to fresh markets, which may lead to a shift towards a diet dominated by ultra-processed foods. 3.3 Increasingly aggressive marketing? Marketing and advertising play a crucial role in shaping consumers' food environment. In Vietnam, the marketing of ultra-processed food and sweetened beverages can easily reach a large urban and rural population, including youth, through major media channels (Pham and Worsley, 2016; Wertheim-Heck and Raneri, 2020). Yet, understanding of nutritional content and food labelling remains limited for most consumers in Vietnam (Huynh et al., 2021), which further exacerbates the issue. Moreover, popular culture has led the younger generation to develop a taste for unhealthy food (Wertheim-Heck and Raneri, 2020). Pester power mechanisms resulting partly from this aggressive marketing, have also contributed to the penetration of western and fast-food into households (Wertheim-Heck and Raneri, 2020). 15 3.4 Cheaper processed food vs more expensive nutritious food Vietnamese spend a large proportion of their income on food, on average 43%, according to Harris et al. (2020). Another study suggests that urban, peri-urban, and rural populations in Vietnam spend 52%, 44%, and 54% of their total expenditures, respectively, on food (Huynh et al., 2021). Over the past two decades, the price of most food items in Vietnam has been unstable, with significant increases observed in the price of many food items (Harris et al., 2020; GSO, 2022). While higher food prices may benefit some rural households who are net producers, they are likely to have a significant impact on net buyers. Many of the poor, especially rural smallholders with limited household budgets for food purchasing, are actually net buyers of food, making them vulnerable to food prices increases, and exacerbating their food insecurity (Harris et al., 2020). High and unstable prices also further exacerbate food insecurity of poor urban dwellers (Vu and Glewwe, 2011; Gibson and Kim, 2013a). An increase in the price of staple foods is also associated with less healthy diets that are higher in fat and carbohydrates and lower in protein and micronutrients (Cuong, 2007; Nguyen T.T., 2018). In rural areas, low-quality processed foods such as biscuits, cakes, and ice cream are becoming increasingly popular due to their low cost, while fresh meat products are becoming less affordable due to their high price (Nguyen T., 2021). Sugar and sweets' price decreased, while the price for other fresh foods, especially pork, has increased (Nguyen-Anh, 2021). The consumption of unhealthy sweetened non-alcoholic beverages is significantly associated with these price variations, negatively impacting individuals' diets (Nguyen T.T., 2018; Nguyen-Anh, 2021). Low-income consumers in Vietnam are less likely to afford safe food products, such as certified rice, which are sold at high prices (Nguyen H.D. et al., 2021). Similarly, only better-off urban Vietnamese consumers are willing to pay higher prices for meat products from supermarkets due to quality differences (JICA, 2013). Food price stabilization measures face challenges, particularly in traditional markets in suburban areas and industrial zones, including high transportation costs and unstable selling spaces. Food products under price-stabilized programs are often available at higher prices than similar products sold in traditional markets, making it difficult for rural and poor consumers to access them (Binh, 2018). 3.5 Challenges to ensure food accessibility and availability. The accessibility and availability of ultra-processed foods are on the rise in both rural and urban areas of Vietnam, likely contributing to the dietary shift. In recent years, the availability (and consumption) of oil, fats, sweets, sweetened beverages, and processed and ultra-processed food, specifically targeting the young generation, has drastically increased (Harris et al., 2020). For example, the consumption of sugar-sweetened beverages in Vietnam has experienced a significant increase over the past 15 years; according to data from the Ministry of Health (MOH, 2021), the proportion of Vietnamese individuals consuming sugar-sweetened beverages has multiplied by seven between 2002 and 2017. This trend is particularly concerning among children, as highlighted by the WHO (2019), which reports that 33% of children in Vietnam consume sugar-sweetened beverages at least once daily. Overall, rural people are highly dependent on locally grown products (Huynh et al., 2021). They have less access to diverse food due to the limited number of food outlets compared to urban areas, especially in mountainous areas. Physical and transportation constraints further exacerbate this issue, with poorly maintained roads and dangerous conditions during the rainy season. Although wet markets exist in rural districts, they are often difficult to reach, and some categories of food products may be 16 less available, with seasonal availability of fruits and vegetables playing a critical role (Huynh et al., 2021). In urban and peri-urban areas, access to various types of food outlets, such as informal street markets and formal open markets, is significantly higher, with short average distances between them. Residents of urban areas have greater access to local wet markets, as well as supermarkets that offer a wide variety of processed, packaged, and fresh foods. Most urban consumers are disconnected from the production sites and mostly purchase their food from food outlets, while in peri-urban areas, local farmers still produce 40% of all food consumed (Huynh et al., 2021). The number of street food stalls offering ready-to-eat foods and beverages has also increased from 1991 to 2020 (Hiemstra, 2016). Nevertheless, the urbanization process in Vietnam may pose significant challenges to food accessibility for some consumers, particularly those with limited mobility, such as the poor and elderly. Fresh food products may become less accessible in new modern urban neighborhoods due to the suppression of wet and informal wet markets in some areas. Overall, rural and urban areas face different specific issues related to accessibility and availability. Rural areas face challenges related to physical availability and transportation constraints, limited access to diverse food, and seasonal availability of some products. In contrast, urban and peri-urban areas have better access to food outlets and a wider variety of food products, although accessibility issues may arise for some consumers, particularly those with limited mobility. 17 4. Results 4.1 Synthesis 4.1.1 Evidence collation by indicator During the data collation phase (from December 2022 to May 2023), the research team gathered and screened 857 policies. Relevant content, in relation to the food environment domains defined above, was retrieved from 232 valid relevant policy documents (see Annex 4 and 5). Table 1 below shows the number of documents covering the different food environment domains. Table 1: Number of policy documents tackling indicators pertaining to our food environment domains. Domain Number of policy documents3 Law Resolution Decree Decision Circular and others #1: Food product properties 162 12 25 33 92 #2: Food outlet properties 29 1 2 21 5 #3: Food marketing 28 5 1 9 8 5 #4: Food desirability 30 1 2 24 3 #5: Food prices and affordability 21 4 4 3 9 1 #6: Food availability and accessibility 16 1 1 13 1 Note 1: in addition, 741 documents pertaining to food safety standards and regulations (Domain 1: Food Product Properties) were retrieved from a “food safety database” developed by Food Safety for Development Project (SAFEGRO). These documents were not analyzed individually, but their existence was taken into account when scoring the indicators related to food safety. Note 2: Some documents contained relevant content for more than one domain. Law: is a type of mandatory legal document with the highest legal value (after the Constitution), promulgated by the National Assembly to regulate basic issues. Law documents help specify the provisions of the Constitution for each specialized industry and field. Resolution: a type of legal document, often used to decide on basic issues after being discussed and passed by a majority vote, expressing the opinion or intention of party agencies or organizations on a certain issue. Resolutions are usually in the form of documents of the National Assembly, the National Assembly Standing Committee, the Government, the Council of Judges of the Supreme People's Court, the People's Council, the People's Committees at all levels or of an agency, certain organization. Decree: A type of legal document issued by the Government and used to guide laws or regulate arising matters that have not yet been regulated by any laws or ordinances. In addition, the Decree issued by the Government also stipulates the rights and obligations of the people according to the Constitution and Law. 18 Decision: A form of legal document, including legal normative documents and legal application documents issued by competent agencies and organizations. A Decision can be a legal document used to promulgate specific measures and regulations to implement the Party and State's guidelines and policies. At the same time, a Decision can also be a legal document management of a specific organization to promulgate specific content related to individuals and specific tasks of that organization. Directive: An administrative document developed to express measures to direct, manage, and handle the affairs of organizations and agencies such as Ministries, Ministerial-level agencies, Government agencies, and the People's Committee people at all levels in the process of implementing state guidelines, policies, and laws. Circular: A document that explains and guides the implementation of state documents issued and under the management of a specific sector. Joint Circular: A document jointly issued by multiple relevant ministries, such as those pertaining to food safety management or food labeling. Plan: A document issued by an agency, organization or individual have the authority to develop the content of work to be performed in a certain period of time to achieve a certain purpose. Technical Regulations (QCVN): Regulations defining the limits of technical characteristics and management requirements that products, goods, services, processes, the environment, and other objects in socio-economic activities must adhere to. These regulations are established to ensure safety, hygiene, and human health; protect animals, plants, and the environment; and safeguard national interests, security, consumer interests, and other essential requirements. Technical regulations are formally promulgated in writing by a competent state agency and are mandatory for application. Technical Standards (TCVN): Regulations outlining technical characteristics and management requirements used as a standard for classifying and appraising products, goods, services, processes, the environment, and other objects in socio-economic activities. The purpose of these standards is to enhance the quality and effectiveness of these objects. Technical standards are published in written form by an organization and are intended for voluntary application. Note: Legal documents of a similar nature issued by different entities may exhibit variations in terms of scale and the extent of planning and implementation 19 4.1.2 Overview Table 2: Synthesis of the scores for each indicator Domains and indicators Score D – Very low C - Low B – Medium A - High Domain 1: Food product properties IND1.1.1 Food safety law together with technical regulations IND1.1.2 Framework regulating food safety control management IND1.1.3 Strategy for information, education and communication on food safety issues IND1.2.1 Food composition standards for processed foods – SALT IND1.2.1 Food composition standards for processed foods – SUGAR IND1.2.1 Food composition standards for processed foods – TRANS FAT IND1.2.2 Food composition standards for food service outlets – SALT IND1.2.2 Food composition standards for food service outlets – SUGAR IND1.2.2 Food composition standards for food service outlets – TRANS FAT Domain 2: Food outlet properties and food provision IND2.1.1 Standards to define and identify healthy/unhealthy food retailers IND2.1.2 Policies to encourage the development and modernization of healthy food retail IND2.1.3 Policies to restrict the development of unhealthy food retailers IND2.2.1 Policies in schools to promote healthy food choices IND2.2.2 Policies in other public sector settings to promote healthy food choices IND2.2.3 Procurement standards in public sector settings to promote healthy food choices. IND2.2.4 Support and training system (schools and other public sector organizations) IND2.2.5 Support and training system (private sector) Domain 3: Food marketing IND3.1.1 Restricting unhealthy food promotion on broadcast and social media IND3.1.2 Restricting unhealthy food promotion to children on broadcast and social media IND3.1.3 Restricting unhealthy foods promotion to children in settings children gather IND3.1.4 Restricting unhealthy foods promotion to children on food packages. IND3.1.5 Restrict marketing of breast milk substitutes IND3.2.1 Ingredient lists and nutrient declarations on the labels of all packaged foods. IND3.2.2 Regulatory systems for health and nutrition claims IND3.2.3 Front-of-pack labelling IND3.2.4 Menu boards labelling Domain 4: Food desirability IND4.1.1 Food based dietary guidelines IND4.1.2 National communication campaign and nutrition awareness activities Domain 5: Food prices and affordability IND5.1.1 Reducing taxes on healthy foods IND5.1.2 Increasing taxes on unhealthy foods IND5.2.1 Food subsidies to favour healthy foods Domain 6: Food availability and accessibility IND6.1.1 Promote the availability healthy foods in-store IND6.1.2 Encourage the promotion of healthy foods in food service outlets IND6.2.1 Zoning laws for unhealthy food outlets IND6.2.2 Zoning laws for healthy food outlets N = 15 11 4 5 20 Table 2 presents the synthesis of scores for each Food-EPI indicator, encompassing a total of 35 indicators representing our domains and subdomains. Notably, 43% (n = 15) of these indicators were not acknowledged in any of the policy documents identified, while 31% (n = 11) displayed a low level of implementation. Additionally, 12% (n = 4) exhibited a medium level of implementation, and 14% (n = 5) demonstrated a high level of implementation. Policies pertaining to areas such as food safety, restrictions on the marketing of breast milk substitutes, food-based dietary guidelines, and the reduction of taxes on healthy foods have received (very) strong evaluations. In contrast, policies linked to food nutritional quality, support and restriction of certain types of food outlets, limitations on advertising unhealthy foods to children via media and packaging, food subsidies favoring healthy foods, and the promotion of healthy food availability in stores and food service outlets are assessed as very weak or even non-existent. Figure 2: Proportion of indicators by score. 4.2 Detailed results per food environment domain 4.2.1 Food product properties 4.2.1.1 Food safety Indicators Justification Final score IND1.1.1 Food laws and regulations have been established for ensuring food safety Vietnam is equipped with a modern food safety law and technical regulations encompassing production, handling, storage, and preparation of food. Food safety standards and guidelines have been established. The roles and responsibilities of the relevant authorities involved in ensuring food safety are clear. We identified 384 policy documents related to technical regulations (cf. FS database), focusing on food safety assurance conditions for food production and trading, food safety assurance conditions for import and export, as well as standards settings. A 14% 12% 31% 43% High score Medium score Low score Very low score 21 IND1.1.2 A food control management system has been established for ensuring food safety Beyond the assignment of responsibilities for state management of food safety, we identified 552 policy documents related to food safety control management, such as food safety inspection, food safety examination and supervision, food sampling, testing, and analysis, integrated risk management, prevention and remedy of food safety incidents, traceability, recall and disposal of unsafe foods, and regulations on penalties for food safety violations. However, specialized food safety inspection regulations have only been developed at the provincial or city levels and are not yet developed for lower levels. The pilot program at the district and ward level has ended and is not maintained. B IND1.1.3 A strategy and plan have been developed for information, education, communication, and training on food safety Many existing policies contain communication programs and plans on food safety. There are also specific regulations on objectives, implementation plans, and specific assignment of responsibility for communication on food safety to relevant agencies. Yet, there is no specific guidance on education and especially training on food safety for food system stakeholders. B In response to the recurring food safety crises in Vietnam, the government has implemented a series of structural solutions, among which the establishment of a national food control system stands out. The enactment of the Food Safety Law in 2010 signaled a paradigm shift towards contemporary principles of administration. The law created decentralized public agencies, the establishment of standards, and the implementation of food safety controls. Despite these concerted efforts, however, the effectiveness of control activities is still hampered by persistent challenges. Specifically, the enforcement of food safety regulations currently lacks sufficient strength, necessitating immediate and sustained improvements in this area (Pham, 2020; World Bank, 2017). 4.2.1.2 Food nutritional quality Indicators Justification Final score IND1.2.1 Food composition targets/standards/restrictions have been established in industrially processed foods - SALT The issue of high salt content in processed food is acknowledged. There are targets set to reduce salt consumption and to have 30% of businesses implement salt reduction measures. However, there are no standards specifying the maximum salt content of processed food, and there is no clarity regarding who is controlling salt content in processed food. The maximum salt threshold indicated in Circular 23/2012/TT-BYT is twice as high as the WHO recommendation; also, the circular has not taken into account the updated WHO nutritional profile model on sugar, salt, and fat ingredients. C IND1.2.1 Food composition targets/standards/restrictions have been established in industrially processed foods - SUGAR The issue of high sugar content in processed food is acknowledged; however, there are no specific targets, standards, or restrictions for limiting sugar content in processed food. C IND1.2.1 Food composition targets/standards/restrictions have been established in industrially processed foods – TRANS FAT The issue of fat content in processed food is acknowledged; however, there are no specific targets, standards, or restrictions for limiting trans-fat content in processed food. C 22 IND1.2.2 Food composition targets/standards/restrictions have been established in meals sold from food service outlets - SALT Standards for salt content have been established in school meals. However, these standards are mainly guidance documents and are not mandatory. C IND1.2.2 Food composition targets/standards/restrictions have been established in meals sold from food service outlets - SUGAR Standards are set for students’ sugar consumption. However, there are no standards in terms of sugar content in meals served in educational institutions and other food service outlets. No clear targets and restrictions either. C IND1.2.2 Food composition targets/standards/restrictions have been established in meals sold from food service outlets – TRANS FAT The issue of trans-fat content in meals sold from food service outlets is not recognized as a concern in any of the policy documents. D Vietnam has only issued a few policies in relation to the nutritional quality of processed food. The focus of these policies has been primarily on salt reduction, with the establishment of consumption targets and (incomplete) standards. Notably, consumption limits have been implemented for food outlets in educational institutions. However, while quantitative national-level objectives for salt reduction have been set for processing companies, the existing restrictions appear to be relatively unambitious, lacking precise targets in terms of salt content. Furthermore, policies pertaining to other nutrients of concern, namely sugar and trans-fat, are notably less well-defined. While the need to manage and monitor the sugar content of processed foods and food service outlets is expressed, the absence of a regulatory framework to achieve this remains a significant limitation. 4.2.2 Food outlet properties 4.2.2.1 Supporting and restricting certain types of retail Indicators Justification Final Score IND2.1.1 Standards have been established to define and identify healthy/unhealthy food retailers No policies found. The existing policy documents do not recognize the significance and necessity of establishing standards to define and identify healthy and unhealthy food retailers D IND2.1.2 Policies to support the development and modernization of healthy food retailers (i.e., retail channels that provide affordable fresh food, such as traditional channels like wet markets). No policies found. Overall, the limited support (and restrictions) put on some of the traditional retail channels does not favor the development of healthy food outlets. Policies typically foster the process of modernization in the retail sectors; yet inadequate attention is paid to the availability of healthy food in these retail outlets. D IND2.1.3 Policies to restrict the development of unhealthy food retailers (i.e. retail channels that provide food rich in nutrients of concern, such as fast-food chains). Experts stated that these modern retail channels are necessary in a modern society. Policies only recommend diverse food items sold on these channels, including fresh fruits. There are no specific guidelines considering the healthy or unhealthy aspects of these retail types. D The existing policies do not make a distinction between retailers of healthy and unhealthy foods. Within the policy literature, retailers are commonly categorized as either modern or traditional. Policies at the national and regional levels support and endorse the development of modern retail channels, which are 23 more likely to provide unhealthy food options to consumers (see Annex 6). Several policies strive to promote these modern food retailers, such as chain convenience stores and vending machines, yet specific regulations for this type of outlets are lacking. By contrast, policies designed to support the development and upgrading of traditional markets receive comparatively less attention in policy documents. In several cases, informal traditional retail channels are even proscribed. For instance, the guidelines for food safety assurance in educational institutions from 2008 (08/2008/TTLT-BYT-BGDĐT) included provisions to prohibit street food vending around schools where vendors failed to satisfy hygiene requirements. Furthermore, the plan (266/KH-UBND) to implement the 2021 National Strategy on Nutrition in Hanoi covering the period 2022-2030 (266/KH-UBND) reaffirms the necessity of banning street food vending around schools. However, this strategy is even more restrictive since it eliminates hygiene conditionality and extends the prohibition to all street food vendors operating around schools. While this approach is understandable from a strict food safety management perspective, it may possibly constrain the accessibility of fresh food options, such as mobile fruit vendors for example. 4.2.2.2 Food procurement and food provision Indicators Justification Final Score IND2.2.1 Clear, consistent policies (including nutrition standards) in schools and early childhood education services for food service activities (canteens, food at events, fundraising, promotions, vending machines etc.) to provide and promote healthy food choices. Only guidelines (no mandatory regulations) for implementation in secondary schools. B IND2.2.2 Clear, consistent policies in other public sector settings for food service activities (canteens, food at events, fundraising, promotions, vending machines, etc.) to provide and promote healthy food choices. Policies have acknowledged the need to regulate the provision and promotion of healthy options in parts of the public sector (hospitals, health care services, and military agencies), but have not yet developed policies for other public sector agencies. C IND2.2.3 Clear, consistent procurement standards in public sector settings for food service activities to provide and promote healthy food choices. Food in public sector settings is not in the list of public procurement activities of the government. There are no policies about public procurement for food. Policies related to procurement for food will be normally issued by relevant ministries, such as Ministry of Education and Training and Ministry of Health. D IND2.2.4 Training system to help schools and other public sector organizations and their caterers meet the healthy food service policies and guidelines. Policies acknowledge the need for training public officers, and the need to develop nutrition training and school health programs. However, there are no regulations for granting certificates to trainees after nutrition training, only food safety certificates are issued. C IND2.2.5 Policies that actively encourage and support private companies to provide and promote healthy foods and meals in their workplaces. A few policies just encourage dissemination activities about sufficient nutrition. There are no specific regulations to encourage and support private companies to provide and promote healthy food and meals in their workplaces. D 24 Current policies represent a joint effort across different Ministries, including MOH and MOET, in order to positively influence the nutrition transition in Vietnam and improve long-term nutritional outcomes, with a particular focus on school children. Several school-based interventions — including guidelines for school meals and measures to ban unhealthy foods at school canteens and street food vendors surrounding school zones — have been developed. However, these measures are incomplete, and the management and control system are yet to be established to ensure the effective implementation of these policies. Despite significant political efforts to provide and promote healthy foods and meals for school children at different levels, a significant gap exists in policies regarding the regulation of food service activities in other public sectors, as well as the private sector. Although policy documents show a clear inclination towards more nutritious diets, there are no policies or procurement standards promoting healthy food choices within other public sectors, except for one policy that specifies a set of criteria for meals at hospitals (Decision 2879/QD-BYT). 4.2.3 Food Marketing 4.2.3.1 Food promotion Indicators Justification Final Score IND3.1.1 Policies to restrict exposure and power of promotion of unhealthy foods through broadcast media (TV, radio) and online/social media. Minimum regulations to regulate, control, and limit the promotion and transparently inform consumers whether products are healthy or unhealthy have been mentioned. However, restricting the promotion of unhealthy foods in mass media and online/social networks has not been specifically mentioned and has clear regulations. D IND3.1.2 Policies to restrict exposure and power of promotion of unhealthy foods to children and adolescents through broadcast media (TV, radio) and online/social media. There are minimal regulations regarding restrictions on advertising of unhealthy foods to children. There are no specific regulations to limit advertising of unhealthy foods to children in mass media and online/social networks. C IND3.1.3 Policies to ensure that unhealthy foods are not commercially promoted to children and adolescents in settings where children gather (e.g. preschools, schools, sport, and cultural events). Restrictions on advertising of unhealthy foods in and around schools have been recognized in the documents. However, the new regulations only stop at incentives without specific policies and sanctions. C IND3.1.4 Policies to ensure that unhealthy foods are not commercially promoted to children and adolescents on food packages. The need to restrict promotion of unhealthy food to children on food packages is not acknowledged in existing policy documents. D IND3.1.5 Restrict marketing of breast milk substitutes. Existence of multiple policies to restrict the marketing of breast milk substitutes. These policies prohibit aggressive marketing practices, misleading advertising, and promotional activities that undermine breastfeeding. The policies also include regulations on the labeling, packaging, and promotion of breast milk substitutes to ensure that they are used appropriately and as a last resort. However, Vietnam's regulations are not consistent with WHO and Codex recommendations. According to WHO and Codex recommendations, advertising and marketing of products for children under 36 months old is prohibited, while Vietnamese law only prohibits advertising and marketing for children under 24 months old. A 25 The mention of banning the advertising of unhealthy foods in and around schools in numerous policy documents is a clear indication that policymakers have acknowledged the issue and are taking steps towards addressing it. However, Vietnam still lacks robust regulations to control the sale and marketing of highly processed food and drinks. The Advertising Law currently requires food products to have hygiene, safety, and quality registration certificates. It limits advertisements in newspapers, magazines, radio, and television broadcasts in terms of duration and frequency. Nonetheless, the law does not impose any restrictions on the types of food and drink products or services that can be advertised. While Decree 38/2021/NĐ-CP prohibits the advertising of unhealthy goods to children, it does not provide a clear definition of what is unhealthy, nor does it make any reference to food. Restrictions on advertising activities of food-related items are only applied for breast milk substitutes, overlooking the negative influence of other unhealthy food and beverage advertisements on the public. Public communication makes use of social media to provide dietary guidelines and improve public awareness of nutritional diets. However, less attention is paid to restricting the exposure of unhealthy food products through these social media. It is crucial for the Vietnamese government to establish stricter regulations on food advertising to protect consumers, in particular children, and promote informed food choices. 4.2.3.2 Food labelling Indicators Justification Final Score IND3.2.1 Policies to ensure that ingredient lists and nutrient declarations in line with NIN/WHO recommendations are present on the labels of all packaged foods. The need for labelling is acknowledged. Ingredient lists and nutrition declarations are required by law. However, these regulations are still not in sync with WHO recommendations, especially regulations related to trans fats and added sugar content. B IND3.2.2 Evidence-based regulations for reviewing and approving claims on foods, so that consumers are protected against unsubstantiated and misleading nutrition and health claims. There are regulations on a management system based on evidence review and approval of claims on food labels to protect consumers from misleading or unfounded nutritional and health claims. However, nutritional content claims are lacking if consumed above a certain level of fat, saturated fat, cholesterol or sodium. C IND3.2.3 Policies to ensure that evidence- informed front-of-pack supplementary nutrition information system, which allow consumers to assess a product’s healthiness, is applied to all packaged foods (e.g. Nutri-Score, Traffic light label). No relevant content found in the existing policy documents to acknowledge the need for, or establish, an evidence-informed front-of-pack supplementary nutrition information system. D IND3.2.4 Policies to set a simple and clearly visible system of labelling the menu boards of all quick service restaurants (i.e. fast-food chains), which allows consumers to interpret the nutrient quality and energy content of foods and meals on sale. No relevant content found in the existing policy documents to acknowledge the need for, or set up, a simple and clearly visible system of labelling the menu boards of all quick service restaurants. D The labeling of processed foods in Vietnam is subject to legal requirements which emphasize the importance of nutritional information labelling, as evidenced in policy documents. In alignment with international standards, Vietnamese policies dictate that all packaged food products must contain ingredient lists and a nutrition declaration. However, the absence of clear guidelines and mechanisms for the review and approval of food label claims in Vietnam renders such regulations incomplete. This 26 regulatory loophole may facilitate the dissemination of false or misleading claims by manufacturers, hence the need to establish a regulatory framework that guarantees accurate and truthful food labeling. Another regulatory loophole pertains to non-packaged processed food items, such as "bim bim" snacks or sweets, that are sold by weight and often contained in large plastic bags without any labeling information. These products are frequently sold in convenience stores (hàng ăn vặt - snack stores) located near schools, making it easier for unhealthy foods to reach consumers, particularly children who seek cheap snacks after school. Furthermore, our investigation reveals a conspicuous absence of evidence regarding the implementation of a front-of-pack supplementary nutrition information system or the requirement for labeling menu boards in quick service restaurants. These omissions deprive consumers of the ability to assess the nutritional value of food products at the point of sale, leading to a deficiency in their knowledge and decision-making ability. Therefore, the implementation of such labeling strategies would be instrumental in improving consumers' understanding of the healthiness of their food choices, as well as promoting healthier eating habits. 4.2.4 Food Desirability Indicators Justification Final Score IND4.1.1 Existence of clear and evidenced-informed, food-based dietary guidelines supporting nutrition information and communication. Nutrition related policies are well established for the target groups such as infants, young children, and pregnant mothers. There are also nutritional regulations on meals for crew members and laborers, ensuring food hygiene and food safety for collective kitchens. Nutrition related policies should also pay more attention to remote areas. A IND4.1.2 Policies supporting the establishment of national communication campaign and nutrition awareness activities. Policies are not mandatory. They mostly provide recommendations. There remains a lack of policies to assist consumers in reading and understanding nutrition contents on food labels and gaining general understanding about nutrition. B Various policy documents outline a comprehensive approach to improving nutrition knowledge and to promoting diverse food consumption in Vietnam. This approach includes a variety of initiatives such as organizing annual communication campaigns, developing communication materials and tools for nutrition counselling, disseminating guidelines on proper nutrition, and building platforms for implementing nutrition communication and practice activities. The policies target various groups, including pregnant and nursing mothers, adolescent girls, the elderly, and disadvantaged communities. They also advocate for structural changes to incorporate nutrition content into strategies, programs, and implementation plans at all levels. Additionally, policies recommend measures such as developing training materials for nutrition staff, educating people through mass media, and promoting children's right to participate in nutrition education and communication. Multiple conferences and seminars were also organized. Integrated multimedia communication strategies are to be developed to raise awareness and promote the practice of micronutrient deficiency prevention. The development of national guidelines on proper nutrition and physical activity (IND 4.4.1) are also part of this comprehensive approach. 27 4.2.5 Food prices and affordability 4.2.5.1 Food prices Indicators Justification Final Score IND5.1.1 Taxes on healthy foods are minimized to encourage healthy food choices (e.g. low or no sales tax, value-added or import duties on fruit and vegetables). There are exemption policies on VAT for locally produced products. VAT and import tax exemptions are applied for fresh fruit and vegetables and meats imported to Vietnam as a result of a trade agreement to encourage availability and consumption of healthy products. A IND5.1.2 Excise taxes on unhealthy foods (e.g. sugar-sweetened beverages, foods high in nutrients of concern) are in place and increase the retail prices of these foods to discourage unhealthy food choices. The issue is acknowledged, with a few policy documents mentioning the need to impose a special tax on sugary drinks and unhealthy foods, but no clear regulations were found. C The Vietnamese government's strategy to incentivize healthy food choices has primarily involved the exemption of value-added tax for agricultural cultivated products, livestock, and aquaculture products (Law 13/2008/QH12). Additionally, there is a recommendation for the implementation of financial policies aimed at encouraging the production and consumption of healthy products (Decision 376/QD- TTg). However, no further information or documents related to these financial policies were found. While indirect policies such as investment incentives and tax deductions have been employed to promote the production of safe fruits and vegetables, there remains a notable absence of clear financial policies directly incentivizing healthy food choices. Several policy documents have acknowledged the need to implement a special tax on sugary drinks and unhealthy foods to promote healthier dietary habits. However, no specific regulatory framework was identified regarding this matter. Decision 376/QD-TTg highlights the necessity of researching and proposing suitable tax rates for products deemed unhealthy, to curtail their consumption. Two Decisions recommend appropriate tax increases to discourage the consumption of sugary drinks, processed foods, food additives, and other products posing health risks, especially for children. In a similar vein, recent Decision 1294/QD-BYT and Decision 02/QD-TTg, approved in 2022, recommend levying a special consumption tax on sugary drinks. However, these documents no longer include processed products in their scope, but only sugary drinks. This omission may suggest a reduced focus on the potential health risks associated with processed foods. Recently, the Ministry of Finance has proposed an amendment to the Law on Special Consumption Tax, which includes the imposition of taxes on sugary beverages. These proposals have undergone several rounds of discussions with different stakeholders to obtain their opinions. 4.2.5.2 Food affordability Indicators Justification Final Score IND5.2.1 The intent of existing subsidies on foods is to favor The issue is not acknowledged. Current subsidies do not have a specific focus on promoting the consumption of nutritious and healthy foods. In fact, some price stabilization measures have been observed to apply to products D 28 healthy rather than unhealthy foods that are generally considered unhealthy, such as salt and sugar (among the nutrients of concern). Current subsidies in Vietnam lack a specific focus on promoting the consumption of nutritious and healthy foods. Some measures even apply to products that are generally considered unhealthy, such as salt and sugar. The Law on prices, enacted by the National Assembly in 2012, includes price stabilization measures for salt, milk, sugar, and rice, with a focus on food security rather than promoting healthy food choices. Resolution 34/2021/NQ-CP reiterates the need to subsidize rice for ethnic minorities and households residing in mountains, as well as for those in areas suffering from hunger due to natural hazards and epidemics. Additionally, several other policy documents regulate rice subsidies in the case of unforeseeable events. They emphasize the need to support rice production (from food sovereignty and food security perspectives), while also planning to mobilize national reserves of rice to aid those affected by disasters. Overall, these policies prioritize food security and aid for disadvantaged communities, rather than promoting healthy food choices. 4.2.6 Food availability and accessibility 4.2.6.1 Food availability Indicators Justification Final Score IND6.1.1 Existence of policies to encourage food stores to promote the in-store availability of healthy foods and to limit the in-store availability of unhealthy foods. The issue of encouraging food stores to promote in- store availability of healthy food is not acknowledged. No specific policies were found that directly encourage food stores to promote in-store availability of healthy foods. D IND6.1.2 Existence of policies to encourage the promotion and availability of healthy foods in food service outlets and to discourage the promotion and availability of unhealthy foods in food service outlets. The issue of encouraging food service outlets to promote in-store availability of healthy food is not acknowledged. No relevant content was found in the existing policy documents about this topic. However, there are some policy measures that might indirectly contribute to it. D The policies identified do not prioritize or specifically aim to increase or maintain the availability of healthy foods in food stores. However, some policies might indirectly contribute to this goal. For example, incentivizing or supporting the sale of fresh vegetables may encourage food stores to stock and promote healthier options. Two other Decisions (222/2006/QĐ-UBND and 885/QD-TTg) both aim to encourage investment and trading in safe and organic agricultural products, which could indirectly enhance the availability of healthy foods in food stores. Additionally, policies such as Decision 272/QĐ- BCT and Decision 9762/QĐ-BCT, which aim to facilitate and incentivize direct sourcing of agricultural products from rural producing areas, could also indirectly enhance in-store availability of fresh fruits and vegetables. However, policies promoting the development of the food processing industry, (e.g., Decision 1408/QD-TTg) may not necessarily contribute to promoting healthy food options. They may even have negative impacts on public health. Therefore, it seems that while some policies might indirectly contribute to increasing or maintaining the availability of healthy foods, others might inadvertently contribute to the opposite. No specific policies were identified that directly aim to reduce the availability of unhealthy foods in Vietnam. However, some policies might indirectly contribute to this objective. One example is Decision 29 3073/QĐ-BNN-QLCL, which aims to build and develop a safe agro-forestry-fishery food supply chain nationwide. This policy recommends the mobilization of distributors, restaurants, hotels, and collective kitchens to select agricultural, forestry, and fishery products from business establishments participating in the safe chain model. While not directly related to our indicator, this decision could have indirect positive effects on the availability of fresh and healthy foods in food service outlets. By promoting the selection of agricultural products from safe sources, this policy could discourage the use of unhealthy food ingredients in food service outlets. Another example is Decree 98/2020/ND-CP, which prohibits the sale of alcohol and beer through vending machines and imposes fines for non-compliance. Although not directly related to discouraging the promotion and availability of unhealthy foods in food service outlets, this example demonstrates the possibility of implementing laws in Vietnam that prohibit the sale of certain categories of food. In summary, while no specific policies were identified that directly aim to decrease the availability of unhealthy foods, the policies mentioned above could have indirect positive effects on this objective. By promoting the use of safe agricultural products and prohibiting the sale of certain categories of food, these policies could contribute to a healthier food environment in Vietnam. However, more targeted policies aimed specifically at reducing the availability of unhealthy foods may be necessary to achieve significant improvements in public health outcomes. 4.2.6.2 Food accessibility Indicators Justification Final Score IND6.2.1 Zoning laws and policies to place limits on the density or placement of quick serve restaurants or other outlets selling mainly unhealthy foods in communities and/or access to these outlets (e.g. opening hours). The issue is not acknowledged. No relevant content found in the existing policy documents. D IND6.2.2 Zoning laws and policies to encourage the development of outlets selling fresh fruit and vegetables and/or to increase access to these outlets (e.g. opening hours, frequency i.e. for markets). The issue of encouraging the development of outlets selling fresh fruit and vegetables or increasing their accessibility has not been acknowledged. There is only a policy on planning and developing a network of wholesale markets for agricultural products to ensure the supply of outlets selling fresh fruit and vegetables. D There are currently no zoning laws or policies in place that restrict the density or placement of quick- service restaurants, including fast food outlets and others primarily offering unhealthy food in the country. Hanoi, however, has a singular policy document that designates specific zones for food service and street food businesses. This regulation focuses on addressing food safety concerns specific to the location rather than imposing restrictions on the population's access to unhealthy food outlets through measures such as limited opening hours or increased distances from school zones. The existing policies lack supportive systems to promote and encourage the availability and accessibility of fruit and vegetable outlets to end consumers. Instead, they emphasize mechanisms to enhance trading, commercial activities, and connectivity between producers and markets. Notable decisions in this regard include Decision 6481/QD-BCT (Master Plan on the Development of the National Market Network up to 2025, with a vision to 2035), Decision No. 645/QD-TTg (Approval of the National E-commerce Development Master Plan for the period 2021-2025), and Decision 1034/QD- BTTTT (Plan to support bringing agricultural production households to the e-commerce platform, promoting agricultural and rural digital economic development). 30 5. Policy recommendations 5.1 Recommendations per domain Domain 1: Food composition 1.1. Food safety Develop and provide tailored food safety manuals and training programs designed to meet the specific needs of diverse food system stakeholders. Strengthen local-level food safety inspection processes and implementation plans with the appropriate financial support. Expand funding and technical assistance for sustainable and clean production practices, emphasizing agro- ecology. 1.2. Food nutritional quality Define clear and transparent standards for classifying healthy and unhealthy foods and incorporate them into legal documents. Establish and implement specific standards for added salt, sugar, trans, and saturated fat in processed and ultra-processed foods, aligning with WHO and Codex recommendations. Establish specific standard guidelines for food service establishments and quick service restaurants (including fast food outlets) on the content of nutrients of concern (salt, sugar, trans, and saturated fats) in prepared meals and meals sold from food service establishments. Develop mandatory regulations for processed food formulation, including standards specifying maximum content levels for salt, sugar, trans, and saturated fat. Establish a mandatory policy with stricter targets for reducing salt, sugar, trans, and saturated fat in processed food and meals from service outlets. Define responsible authorities and their roles in controlling and inspecting nutrient content in processed food, with penalties for non-compliance. Monitor changes in the nutrient profile of processed foods. Domain 2: Food outlet properties and food procurement 2.1. Supporting healthy retail and restricting unhealthy retail Consider encouraging innovative research to establish national standards categorizing food retailers as healthy or unhealthy. Design policies to support healthy food retailers, particularly those offering affordable fresh food. Develop voluntary guidelines for food service establishments, including quick-service restaurants, focusing on reducing salt, sugar, trans, and saturated fat in prepared meals. 2.2. Food procurement and food provision Set nutritional standards for all products served or sold in schools, hospitals, prisons, senior care facilities, and child protection centers, outlining maximum and minimum nutrient limits for each food product. Establish mandatory guidelines for promoting healthy food choices in schools, including nutrient limits, and restrict ultra-processed food sales on school premises. Develop mandatory guidelines for public sector settings, limiting supply and sale of ultra-processed foods. Enhance training programs for public officers by improving the quality of training materials and increasing the frequency of these sessions, ensuring they are better equipped for the effective implementation of healthy food choice regulations. Create tools and resources for promoting healthy eating and catering policies in workplaces, offering incentives for company compliance with voluntary agreements. Domain 3: Food marketing 3.1. Food promotion 31 Prohibit the advertising and marketing of foods high in salt, added sugar, trans, and saturated fat, to children and adolescents across all media platforms (including broadcast, online and social media, games, competitions, and apps) and areas where children gather (in and around kindergarten, schools, etc.). Develop mandatory policies to restrict advertising of ultra-processed food (and overall, food rich in nutrients of concern). Develop regulations to restrict promotional strategies, including product design, packaging, premium offers, etc., for unhealthy food products targeting children and adolescents (e.g. food businesses are prohibited from using content and images that attract children under 15 years old to advertise and market products high in salt, sugar, trans, and saturated fat). 3.2. Food labeling Revise food labeling regulations to align with WHO recommendations, especially regarding salt, sugar, trans, and saturated fat. Establish and implement national regulations for front-end nutrition labeling on pre-packaged foods, making it mandatory to disclose the quantity (and recommended limits) of calories, salt, sugar, trans, and saturated fat. Establish and implement regulations on labeling to distinguish healthy foods from unhealthy foods on product packaging. Provide technical and financial support for small businesses in label development. Review and define national criteria, norms and standards for nutrition and health claims written on food packages. Regulate health and nutrition claims on foods with high nutrients of concern content, including regular monitoring and reviews of products containing claims for compliance. Require food service establishments to display nutritional information, such as energy, total salt, sugar, trans, and saturated fat, on their menus. Domain 4: Food desirability Issue a mandatory policy for a nationwide nutrition awareness campaign. Develop a mandatory nutrition education plan for early childhood facilities and schools. Formulate regulations and guidelines to enhance consumer understanding of nutrition-related food labeling. Refine existing strategies to promote healthy, domestic cooking and reduce excessive use of salt, sugar, trans, and saturated fat in cooking (e.g. developing customized cooking guidelines for households and allocating public resources for training programs and community engagement activities to effectively share this knowledge). Develop policies to support stores in raising consumer awareness and encouraging the consumption of healthy foods through effective communication strategies. Domain 5: food prices and affordability 5.1. Food prices Introduce a special tax on drinks with added sugar and a total sugar content of 5 grams or more per 100 ml, as well as on energy drinks containing stimulants. 5.2. Food affordability Establish grants or funding to support agri-food value chain actors in producing and distributing healthy foods. Reevaluate the inclusion of sugar and salt in disaster response program subsidies and price stabilization measures, prioritizing more nutritious food options for the benefit of those affected by emergencies. Regulate the use of funds collected from taxing unhealthy foods to promote healthy, fresh food consumption. Domain 6: food availability and accessibility 6.1. Food availability Develop guidelines for food stores and service outlets to promote in-store availability of healthy foods. Implement a sign system in chain food service outlets to identify healthy food choices. Establish mandatory guidelines for food service outlets to ban incentive items with children's meals unless they meet nutrition standards. 32 6.2. Food accessibility Develop policies for providing infrastructure and financial incentives for the establishment and growth of healthy food retail stores, particularly in underserved areas. Establish "green food zones" to restrict the sale of unhealthy food within a defined perimeter around schools (e.g. create public spaces free from food rich in nutrients of concern). Ease street food vending restrictions for fresh fruit and vegetables vendors. Initiate a policy dialogue to integrate public health considerations into national and subnational urban planning policies. 5.2 General recommendations • Support research to monitor, evaluate and assess the effect of the policies on food environments and on diets; in particular develop standardized tools and metrics for assessing the impact of policies on public health, economic factors, and societal well-being. • Encourage interdisciplinary research and cooperation between health, agriculture, education, and other relevant sectors to address complex food environment issues. • Promote ongoing dialogues and consultations with various stakeholders — including government agencies, health experts, industry representatives, and civil society — to gather diverse perspectives and ensure policy relevance. • Create mechanisms for citizens, businesses, and organizations to provide feedback on policy effectiveness and suggest improvements. • Collaborate with international organizations and other countries to share best practices and align policies with global health and nutrition guidelines. • Support knowledge transfer and capacity building between research and policy making processes. • Develop policies with a long-term perspective, and with built-in flexibility to adapt to changing circumstances, emerging trends, and new scientific findings. • Consider the potential effects of policies on different socioeconomic groups and strive to reduce health disparities. 33 6. 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