Noncommunicable diseases risk factors in Bhutan: A secondary analysis of data from Bhutan's nationwide STEPS survey 2014.

BACKGROUND: Bhutan is facing an epidemic of noncommunicable diseases; they are responsible for 53% of all deaths. Four main modifiable risk factors, including tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet, are the causes of most noncommunicable diseases (NCDs). This study aimed to assess 1) the prevalence of NCDs modifiable risk factors in Bhutan's adult population and 2) associations between the sociodemographic factors and the NCDs modifiable risk factors with overweight or obesity, hypertension, and diabetes. METHODS: We used the 2014 Bhutan WHO Stepwise Approach to NCD Risk Factor Surveillance (STEPS) Survey dataset in this study. Data were analyzed using multiple logistic regressions, constructed with overweight or obesity, hypertension, and diabetes as outcome variables and modifiable risk factors as independent variables. RESULTS: The prevalence of tobacco use, harmful use of alcohol, unhealthy diet (low fruits and vegetables intake) and physically inactive was 24.8% (95% CI: 21.5, 28.5), 42.4% (95% CI: 39.4, 45.5), 66.9% (95% CI: 61.5, 71.8), and 6.2% (95% CI: 4.9, 7.8), respectively. The prevalence of overweight or obesity, hypertension and diabetes was 32.9% (95%CI: 30.0, 36.0), 35.7% (95% CI: 32.8, 38.7) and 6.4% (95% CI: 5.1, 7.9), respectively. Multiple logistic regression showed that older age groups were more likely to be overweight or obese, hypertensive, and diabetic. Our analysis also found that tobacco users were less likely to be overweight or obese (aOR 0.71, 95% CI 0.52, 0.96), and to be hypertensive (aOR 0.74, 95% CI 0.56, 0.97); but they were more likely to be diabetic (aOR 1.64, 95% CI 1.05, 2.56). Alcohol users were more likely to be hypertensive aOR 1.41 (95% CI 1.15, 1.74). Furthermore, vigorous physical activity could protect people from being overweight or obese, aOR 0.47 (95% CI 0.31, 0.70), and those consuming more than five serves of fruits and vegetables per day were more likely to be overweight or obese, aOR 1.46 (95% CI 1.17, 1.82). CONCLUSION: The prevalence of NCDs modifiable risk factors and overweight or obesity and hypertension was high in Bhutan. We found strong associations between tobacco use and diabetes, alcohol use, hypertension, physically inactive, and overweight or obesity. The results suggest that the government should prioritize NCDs prevention and control programs, focusing on reducing modifiable risk factors. The health sector alone cannot address the NCDs epidemic in Bhutan, and we recommend the whole of government approach to tackle NCDs through the Bhutan Gross National Happiness framework.

Epidemiology of anaemia in children, adolescent girls, and women in Bhutan.

Anaemia inhibits health and development in Bhutan. We estimated anaemia prevalence and explored risk factors in children and women using data from Bhutan's National Nutrition Survey 2015. Prevalence was calculated using life-stage-specific cut-offs adjusted for altitude and survey design. Risk factors were evaluated in modified Poisson regressions. Anaemia affected 42%, 29%, 36%, and 28% of children, adolescent girls, and non-pregnant and pregnant women, respectively. Risk of anaemia was greater in children who were younger (RR 2.0, 95% CI [1.7, 2.3] and RR 1.9, 95% CI [1.6, 2.3], respectively, for 12-23 and 6-11 vs. 24-59 months), male (1.2, 1.1-1.4, ref.: female), and stunted (1.2, 1.0-1.3, ref.: height-for-age ≥ -2z). Older (15-19 years) versus younger (10-14 years) adolescents were at higher risk (1.5, 1.2-1.8), as were adolescents living at home versus at school (1.2, 0.9-1.6) and those working versus studying (1.3, 1.0-1.7). Among adult women, anaemia risk increased with age (1.2, 1.0-1.4 and 1.3, 1.1-1.5, for 30-39 and 40-49, respectively, vs. 20-29 years) and was higher for women without schooling (1.1, 1.0-1.3, vs. primary schooling), who were unmarried or separated (1.4, 1.2-1.7 and 1.3, 1.1-1.6, respectively, vs. married), without a child <5 years (1.1, 1.0-1.3), and lacking improved sanitation (1.1, 1.0-1.3). High coverage of antennal iron and folic acid supplementation may contribute to the lower prevalence of anaemia among pregnant women and women with young children. Expansion of iron supplementation programmes, fortification, and other strategies to improve dietary iron intake may reduce the prevalence of anaemia, but causes of anaemia other than iron deficiency (e.g., thalassemias) should also be investigated.

Infant and young child feeding practices and nutritional status in Bhutan.

In South Asia, childhood undernutrition persists while overweight is increasing. Internationally recommended infant and young child feeding (IYCF) practices promote healthy nutritional status; however, little is known about IYCF in Bhutan, investigated here using 2015 National Nutrition Survey data. WHO/UNICEF IYCF indicators, anthropometry and household socio-economic status were available for 441 children <24 months. Stunting, wasting, and underweight prevalence (<-2Z length-for-age [LAZ], weight-for-age, [WAZ] and weight-for-length [WLZ], respectively) were 15%, 9%, and 5%, respectively, whereas overweight (WLZ >2) prevalence was 6%. In survey-design-adjusted analyses, 52% of mothers of 0- to 5-month olds reported exclusive breastfeeding (EBF), with EBF less common for girls than boys (OR: 0.2 [95% CI: 0.1-0.9]). Although 61% of children were breastfed at 2 years and 75% of children >6 months met a minimum daily meal frequency, only 18% of children 6-23 months met minimum dietary diversity. IYCF was unassociated with risk of stunting, wasting, or underweight, possibly due to relatively low prevalence of anthropometric failure and small sample size. However, currently-breastfed children were less often overweight [OR: ~0.1 (95% upper limit ≤1.0)]. Neither breastfeeding nor most complementary feeding practices differed by socio-economic status, but children in the highest two fifth of a wealth index had 7.8 (1.3-46.9) and 5.3 (1.1-25.2) times greater odds than children in the lowest fifth of meeting minimum dietary diversity criteria. Low rates of EBF, given possible protection of breastfeeding against overweight, and inadequate dietary diversity offer evidence to guide future program interventions to improve nutritional status of young children.

Nutritional status and risk factors for stunting in preschool children in Bhutan.

Childhood malnutrition remains endemic in South Asia, although the burden varies by country. We examined the anthropometric status and risk factors for malnutrition among children aged 0-59 months through the 2015 National Nutrition Survey in Bhutan. We assessed in 1,506 children nutritional status (by z-scores of height-for-age [HAZ], weight-for-height [WHZ], and weight-for-age [WAZ]), estimating prevalence, adjusted for survey design, of stunting, wasting, underweight, and overweight (<-2 for HAZ, WHZ, and WAZ and >2 for WHZ). Children were also assessed for pedal oedema. We conducted multivariable linear/logistic regression analysis to identify child, maternal, and household risk factors for childhood undernutrition and overweight, excluding children with oedema (1.7%). Mean (SE) HAZ, WHZ, and WAZ were -0.82 (0.13), 0.10 (0.04), and -0.42 (0.05), respectively. Prevalence of stunting, wasting, underweight, and overweight were 21.2%, 2.6%, 7.4%, and 2.6%, respectively. In multivariable regressions, risk of stunting significantly increased by age: 5.3% at <6 months (reference), 16.8% at 6-23 months (OR = 3.06, 95% CI [0.63, 14.8]), and 25.0% at 24-59 months (OR = 5.07, [1.16, 22.2]). Risk of stunting also decreased in a dose-response manner with improved maternal education. None of the examined variables were significantly associated with wasting or overweight. Despite a WHZ distribution comparable with the World Health Organization reference (with ~2.6% vs. an expected 2.5% of children beyond 2 z in each tail), stunting persists in one fifth of preschool Bhutanese children, suggesting that other nutrient deficits or nonnutritional factors may be constraining linear growth for a substantial proportion of children.

Prevalence of Exclusive Breastfeeding and Factors Associated With Exclusive Breastfeeding of Children in Trongsa District, Bhutan.

The World Health Organization estimated that about 800 000 infant deaths could be prevented annually by exclusively breastfeeding infants for the first 6 months of life. This study aimed to examine the prevalence of exclusive breastfeeding and its associated factors. A total of 192 mothers participated. The prevalence of exclusive breastfeeding practice in Trongsa district was 97% at 1 month, declining to 58% at 6 months. Mothers who returned to formal work were less likely to exclusively breastfeed than those who were farmers or housewives. The main reasons stated by the mothers for not exclusively breastfeeding were lack of the mother's self-confidence that the child is getting enough breastmilk and mothers having to return to work, 59% and 22%, respectively. The rate of exclusive breastfeeding in Trongsa district of Bhutan is high, and every effort should be made to maintain and improve this rate.

Infant and young child feeding practices and nutritional status in Bhutan.

In South Asia, childhood undernutrition persists while overweight is increasing. Internationally recommended infant and young child feeding (IYCF) practices promote healthy nutritional status; however, little is known about IYCF in Bhutan, investigated here using 2015 National Nutrition Survey data. WHO/UNICEF IYCF indicators, anthropometry and household socio-economic status were available for 441 children <24 months. Stunting, wasting, and underweight prevalence (<-2Z length-for-age [LAZ], weight-for-age, [WAZ] and weight-for-length [WLZ], respectively) were 15%, 9%, and 5%, respectively, whereas overweight (WLZ >2) prevalence was 6%. In survey-design-adjusted analyses, 52% of mothers of 0- to 5-month olds reported exclusive breastfeeding (EBF), with EBF less common for girls than boys (OR: 0.2 [95% CI: 0.1-0.9]). Although 61% of children were breastfed at 2 years and 75% of children >6 months met a minimum daily meal frequency, only 18% of children 6-23 months met minimum dietary diversity. IYCF was unassociated with risk of stunting, wasting, or underweight, possibly due to relatively low prevalence of anthropometric failure and small sample size. However, currently-breastfed children were less often overweight [OR: ~0.1 (95% upper limit ≤1.0)]. Neither breastfeeding nor most complementary feeding practices differed by socio-economic status, but children in the highest two fifth of a wealth index had 7.8 (1.3-46.9) and 5.3 (1.1-25.2) times greater odds than children in the lowest fifth of meeting minimum dietary diversity criteria. Low rates of EBF, given possible protection of breastfeeding against overweight, and inadequate dietary diversity offer evidence to guide future program interventions to improve nutritional status of young children.

Determinants of child wasting in Bhutan. Insights from nationally representative data.

OBJECTIVE: To characterize the epidemiology of wasting and identify the main predictors of wasting, severe wasting and poor weight-for-height in children. DESIGN: We analysed a nationally representative sample of 2028 children (Multiple Indicator Survey, 2010). SETTING: Royal Kingdom of Bhutan. SUBJECTS: Children aged 0-23 months. RESULTS: Wasting prevalence was significantly higher among infants aged 0-11 months than among children aged 12-23 months (12·0 v. 6·7 %; P=0·004) and among boys than girls (11·0 v. 7·5 %; P=0·04). Children from the Western region had 63 % higher odds of being wasted than children from the Central/Eastern regions (adjusted OR (AOR)=1·63; 95 % CI 1·14, 2·34). Poor feeding practices were among the most significant predictors of wasting and severe wasting. Children who were given prelacteal feeds in the first days of life had 2·5 times higher odds of being severely wasted than those who were not (AOR=2·49; 95 % CI 1·19, 5·19); inadequate complementary feeding in children aged 0-23 months was associated with 58 % higher odds of being wasted (AOR=1·58; 95 % CI 1·02, 2·47) and 2·3 times higher odds of being severely wasted (AOR=2·28; 95 % CI 1·13, 4·58). The association of poor infant feeding practices with wasting and severe wasting was particularly significant in infants (0-11 months). CONCLUSIONS: Programmes for the detection and treatment of severely wasted children need to prioritize very young children (0-11 months), particularly in the Western region. Programmes for the prevention of wasting need to prioritize the improvement of complementary foods and feeding practices in children aged 6-23 months.