Prevalence of Current Areca Nut Use and Its Associated Factors among Bhutanese Aged 15-69 Years: Analysis of the Nationally Representative STEPS Survey 2019.

BACKGROUND: Areca nut (AN) use receives less global attention than tobacco use. Studies have linked AN consumption to a range of adverse health effects, including oral cavity and pharyngeal cancers, periodontal diseases, cardiovascular diseases, diabetes, hypertension, and addiction. The masticatory use of AN is rampant in Bhutan. There is a paucity of local evidence and limited empirical studies to understand the factors associated with current AN use in Bhutan. METHODS: This analysis uses secondary data from the Bhutan STEPS Survey 2019 that included 5575 participants aged 15-69 years, selected using multistage stratified cluster sampling. The outcome variable of interest was current AN use. Weighted analysis was done to calculate the prevalence of AN use. Factors associated with AN use were assessed using multivariable logistic regression models. RESULTS: The prevalence of current AN use was 56.82% (95% confidence interval [CI]: 54.27-59.33). A significantly higher prevalence of 63.58% (95% CI: 60.58-66.48) was found in the age group of 25-39 years. Tobacco users were 17% more likely to use AN as compared to those who do not consume tobacco (adjusted odds ratio: 1.17, 95% CI: 1.08-1.26). Current alcohol consumers were 45% more likely to consume AN as compared to lifetime alcohol abstainers. CONCLUSIONS: Age, alcohol use, and tobacco use were associated with current AN use in Bhutan. There is a need to regulate access to AN while targeting young and middle-aged individuals with public health and behavioral interventions.

Dietary behavior of school-going adolescents in Bhutan: Findings from the global school-based student health survey in 2016.

OBJECTIVES: Bhutan is experiencing a dual burden of undernutrition and overnutrition among adolescents. Understanding dietary behavior is vital to designing evidence-based interventions to improve adolescent nutrition and prevent non-communicable diseases in adults. The aim of this study was to assess the pattern of dietary behavior and associated sociodemographic, behavioral, and metabolic risk factors among school-going adolescents in Bhutan. METHODS: The Bhutan Global School-based Student Health Survey 2016 studied students in grades 7 to 11 (N = 7576), sampled from 50 schools, randomly selected based on probability proportional to enrollment size, using a standardized self-administered questionnaire. Consumption of adequate fruits and vegetables (each at least twice daily, or a combination of at least five times daily), high-protein food at least twice weekly) in the past 30 d, no fast food in the past week, and no carbonated/sweetened drinks in the past 30 d were studied. Weighted prevalence of dietary behaviors and adjusted prevalence ratio (95% confidence interval) for factors associated with them were calculated. RESULTS: Of 5809 students from 13 to 17 y of age comprising 3255 (56%) girls and 3184 (54.8%) day students, 1166 (20.1%) were underweight, 1655 (28.5%) were tobacco users, and 1349 (23.2%) were alcohol users. Adequate fruit and vegetable intake, high protein consumption, not consuming fast foods and carbonated beverages were reported by 29.6%, 31.8%, 9.6%, and 14.9%, respectively. Being a day student, sex, and not reporting health risk behaviors were significantly associated with any healthy dietary behavior. CONCLUSION: Healthy eating behavior was low among Bhutanese adolescents. Policies influencing availability, affordability, and acceptability of healthy diets through peer-led, school- and community-based interventions are required to promote adolescent health and prevent non-communicable diseases.

Variation in the Proportion of Adults in Need of Blood Pressure-Lowering Medications by Hypertension Care Guideline in Low- and Middle-Income Countries: A Cross-Sectional Study of 1 037 215 Individuals From 50 Nationally Representative Surveys.

BACKGROUND: Current hypertension guidelines vary substantially in their definition of who should be offered blood pressure-lowering medications. Understanding the effect of guideline choice on the proportion of adults who require treatment is crucial for planning and scaling up hypertension care in low- and middle-income countries. METHODS: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults 30 to 70 years of age from nationally representative surveys in 50 low- and middle-income countries (N = 1 037 215). We aimed to determine the effect of hypertension guideline choice on the proportion of adults in need of blood pressure-lowering medications. We considered 4 hypertension guidelines: the 2017 American College of Cardiology/American Heart Association guideline, the commonly used 140/90 mm Hg threshold, the 2016 World Health Organization HEARTS guideline, and the 2019 UK National Institute for Health and Care Excellence guideline. RESULTS: The proportion of adults in need of blood pressure-lowering medications was highest under the American College of Cardiology/American Heart Association, followed by the 140/90 mm Hg, National Institute for Health and Care Excellence, and World Health Organization guidelines (American College of Cardiology/American Heart Association: women, 27.7% [95% CI, 27.2-28.2], men, 35.0% [95% CI, 34.4-35.7]; 140/90 mm Hg: women, 26.1% [95% CI, 25.5-26.6], men, 31.2% [95% CI, 30.6-31.9]; National Institute for Health and Care Excellence: women, 11.8% [95% CI, 11.4-12.1], men, 15.7% [95% CI, 15.3-16.2]; World Health Organization: women, 9.2% [95% CI, 8.9-9.5], men, 11.0% [95% CI, 10.6-11.4]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood pressure-lowering medications were largest in the oldest (65-69 years) age group (American College of Cardiology/American Heart Association: women, 60.2% [95% CI, 58.8-61.6], men, 70.1% [95% CI, 68.8-71.3]; World Health Organization: women, 20.1% [95% CI, 18.8-21.3], men, 24.1.0% [95% CI, 22.3-25.9]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood pressure-lowering medicines, whereas the South and Central Americas had the lowest. CONCLUSIONS: There was substantial variation in the proportion of adults in need of blood pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policy makers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.

Diabetes Prevalence and Its Relationship With Education, Wealth, and BMI in 29 Low- and Middle-Income Countries.

OBJECTIVE: Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs), but empirical data on its prevalence and relationship to socioeconomic status are scarce. We estimated diabetes prevalence and the subset with undiagnosed diabetes in 29 LMICs and evaluated the relationship of education, household wealth, and BMI with diabetes risk. RESEARCH DESIGN AND METHODS: We pooled individual-level data from 29 nationally representative surveys conducted between 2008 and 2016, totaling 588,574 participants aged ≥25 years. Diabetes prevalence and the subset with undiagnosed diabetes was calculated overall and by country, World Bank income group (WBIG), and geographic region. Multivariable Poisson regression models were used to estimate relative risk (RR). RESULTS: Overall, prevalence of diabetes in 29 LMICs was 7.5% (95% CI 7.1-8.0) and of undiagnosed diabetes 4.9% (4.6-5.3). Diabetes prevalence increased with increasing WBIG: countries with low-income economies (LICs) 6.7% (5.5-8.1), lower-middle-income economies (LMIs) 7.1% (6.6-7.6), and upper-middle-income economies (UMIs) 8.2% (7.5-9.0). Compared with no formal education, greater educational attainment was associated with an increased risk of diabetes across WBIGs, after adjusting for BMI (LICs RR 1.47 [95% CI 1.22-1.78], LMIs 1.14 [1.06-1.23], and UMIs 1.28 [1.02-1.61]). CONCLUSIONS: Among 29 LMICs, diabetes prevalence was substantial and increased with increasing WBIG. In contrast to the association seen in high-income countries, diabetes risk was highest among those with greater educational attainment, independent of BMI. LMICs included in this analysis may be at an advanced stage in the nutrition transition but with no reversal in the socioeconomic gradient of diabetes risk.

Suicidal ideation and attempt among school going adolescents in Bhutan - a secondary analysis of a global school-based student health survey in Bhutan 2016.

BACKGROUND: Suicide is one of the leading causes of death and Disability Adjusted Life Years (DALYs) worldwide. The economic, emotional and human cost of suicidal behaviour to individuals, families, communities and society makes it a serious public health issue. We aim to determine the prevalence and factors associated with self-reported suicidal behaviour (suicidal ideation and attempt) among school going adolescents (13-17 years). METHODS: This is a secondary analysis of a nationally representative data for Bhutan namely Global School Based Student Health Survey in 2016 which reports on various dimensions of adolescent health including suicidal behaviour. The survey employed a multistage sampling method to recruit participants aged 13-17 years (n = 5809) from 50 schools (25 each in rural and urban area). The survey used an anonymous self-administered pre-tested 84-item questionnaire. Weighted analysis was done. Adjusted prevalence ratios (aPRs) and adjusted Odds Ratios (aORs) have been presented with 95% confidence intervals (95% CI). RESULTS: A total of 667 (11.6%) adolescents reported considering a suicide attempt whereas 656 (11.3%) reported attempting suicide in the past 12 months. Among those reporting suicidal ideation, 388 (58.6%) reported attempting a suicide and 274 (41.4%) had ideation alone, whereas, 247 (38.9%) reported attempting a suicide without previous ideation. Female sex, food insecurity, physical attack, sexual violence, bullying, feeling of loneliness, low parental engagement, reported worry about lack of sleep, urge to use drugs/alcohol, smokeless tobacco use, drug abuse and parental smoking were the factors associated with suicidal attempt. All these factors except smokeless tobacco use and parental smoking were associated with suicidal ideation. Having helpful/close friends was found to be protective against suicide ideation. CONCLUSION: Suicidal behaviour among school going adolescents in Bhutan is high and alarming, especially among girls. Bullying, sexual violence, feeling of loneliness and drug abuse were some of the key risk factors identified. It is important to identify these risk factors early and effectively tackle them in order to prevent suicides. It requires a multi-faceted intervention with the support of the children, community, teachers and parents.

Alarming prevalence and clustering of modifiable noncommunicable disease risk factors among adults in Bhutan: a nationwide cross-sectional community survey.

BACKGROUND: Bhutan is currently facing a double burden of non-communicable (NCDs) and communicable diseases, with rising trends of NCDs. The 2014 STEPS survey identified high prevalence of several NCD risk factors; however, associations with socio-demographic characteristics as well as clustering of risk factors were not assessed. This study aimed to determine the distribution and clustering of modifiable NCD risk factors among adults in Bhutan and their demographic and social determinants. METHODS: This was secondary analysis of data from NCD Risk Factors WHO STEPS Survey 2014 in Bhutan. A weighted analysis was conducted to calculate the prevalence of NCD risk factors, and associations were explored using weighted log-binomial regression models. RESULTS: This study included 2822 Bhutanese aged 18-69 years; 52% were 18-39 years, 62% were female, and 69% were rural resident. Prevalence of high salt intake, unhealthy diet and tobacco use were 99, 67 and 25% respectively. Raised blood pressure was the commonest (36%) modifiable biological risk factor followed by overweight (33%). The median NCD risk factors per person was 3 (Inter Quartile Range: 2-4); 52.5%% had > = 3 risk factors. A statistically significant difference was found between male vs. female in alcohol consumption(aPR 0.71, 95% CI: 0.53-0.97), low physical activity(aPR 2.06, 95% CI: 1.54-2.75), impaired fasting glycaemia(aPR 1.24, 95% CI: 1.01-1.52), and being overweight(aPR 1.46, 95% CI: 1.31-1.63). Low physical activity was more common among those with secondary and above education level vs. those without any formal education(aPR 1.71, 95% CI: 1.24-2.35), and among those residing in urban areas vs. those in rural(aPR 3.43, 95% CI: 2.27-5.18). Older participants and urban residents were more likely to have > = 3 NCD risk factors compared to younger(aPR 1.46, 95% CI: 1.35-1.58) and rural residents(aPR 1.21, 95% CI: 1.10-1.32). CONCLUSION: Lifestyle modifications at the population level are urgently required in Bhutan as several NCD risk factors such as high salt intake, unhealthy diet, overweight, and high blood pressure were alarmingly high and frequently clustered. Moreover there is a need to consider policy and socio-political and economic factors that have undermined global and national progress to address the rise of NCDs and their risk factors in Bhutan as elsewhere.

Current tobacco use and its associated factors among adults in a country with comprehensive ban on tobacco: findings from the nationally representative STEPS survey, Bhutan, 2014.

BACKGROUND: Despite a comprehensive ban on cultivation, manufacture, distribution, and sale of tobacco products since 2004, two nationwide surveys conducted in 2012 and 2013 reported high tobacco use in Bhutan. National Health Survey 2012 reported that 4 % of the population aged 15-75 years used smoked tobacco and about 48 % used smokeless tobacco. Similarly, Global Youth Tobacco Survey (GYTS) of Bhutan reported tobacco use prevalence of 30.3 % in 2013. However, factors associated with this high tobacco use were not systematically studied. Hence, we assessed the prevalence of tobacco use and its associated sociodemographic, behavioral, and environmental factors. METHODS: This cross-sectional analytical study used secondary data collected in a nationally representative Non-communicable Disease Risk Factors Surveillance STEPS Survey 2014 conducted among Bhutanese adults (18-69 years). The survey included a total of 2820 adults; selected using multistage stratified cluster sampling. Weighted analysis was done to calculate the prevalence of tobacco use. Unadjusted and adjusted prevalence ratios were calculated using log binomial regression. RESULTS: The prevalence of current overall tobacco use was 24.8 % (95 % CI: 21.4-28.3) and that of smoked, smokeless, and dual forms (smoked and smokeless forms) were 7.4 % (95 % CI: 5.8-9.0), 19.7 % (95 % CI: 16.5-22.9), and 2.3 % (95 % CI: 1.8-2.9), respectively. Significantly higher prevalence of tobacco use in all forms was found among males, younger age groups, and alcohol users. The prevalence of smoked form was higher in urban areas compared to rural areas (11 % vs 6 %; aPR 1.8, 95 % CI: 1.5-2.0). Among individuals who reported having a non-communicable disease, the prevalence of smoked tobacco use was significantly lower than those who did not have disease (3.5 % vs. 8.3 %; aPR 0.5, 95 % CI: 0.3-0.9). Exposure to health warnings was protective for current tobacco use and smokeless tobacco use, while exposure to tobacco warnings through the media was helpful among smokers and overall tobacco users. CONCLUSIONS: Despite a comprehensive ban on tobacco, tobacco use was high in Bhutan, especially the smokeless form. Males, younger age groups, and alcohol users should be targeted with behavioral interventions along the stricter implementation of tobacco control measures.

Increasing compliance with alcohol service laws in a developing country: intervention trial in the Kingdom of Bhutan.

AIM: Bhutan is a low-middle income country that, like many others, experiences significant alcohol-related harm and low compliance with laws restricting availability and promotion. This study assessed changes in compliance of alcohol outlets with sales restrictions following a multi-sector programme aimed at improving this. DESIGN: Pre-post design with covert observation of service practices. SETTING: Thimphu, Bhutan, June-November 2013. Alcohol is not permitted for sale except from 1 to 10 p.m. Wednesday-Monday. Serving minors (< 18 years old) or intoxicated patrons is illegal. PARTICIPANTS: Seventy-one outlets selected randomly from all 209 on-premises outlets in downtown Thimphu. INTERVENTION: Multi-sector programme involving visits to outlets, education of owners and staff, a toolkit and implementation checks. MEASUREMENTS: Ten mystery-shopper visits were made to each outlet both before and after the intervention. We assessed compliance in five purchasing scenarios: (1) before 1 p.m., (2) after 10 p.m., (3) on Tuesdays and (4) shoppers who appeared to be underage or (5) intoxicated. Changes in compliance rates were assessed using multi-variable logistic regression models. FINDINGS: Overall compliance increased from 20 to 34% [difference: 14%; 95% confidence interval (CI) = 7-22%]. Improvement was found in refusals of service before 1 p.m.: 10-34% (difference(adj) = 24%; 95% CI = 12-37%) and on Tuesdays: 43-58% (difference(adj) = 14%; 95% CI = 1-28%). Differences in refusal to serve alcohol: after 10 p.m. (difference(adj) = 15%; 95% CI = -8 to 37%); to underage patrons (difference(adj) = -5%; 95% CI = 14 to 4%); and to intoxicated patrons (difference(adj) = 7%; 95% CI = -7-20%) were not statistically significant. Younger servers, stand-alone bars and outlets permitting indoor smoking were each less likely to comply with the alcohol service laws. CONCLUSION: A multi-sector programme to improve compliance with legal restrictions on serving alcohol in Bhutan appeared to have a modest effect but even after the programme, in two-thirds of the occasions tested, the laws were broken.