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.

BACKGROUND: Diabetes is a metabolic disorder affecting millions of people globally. The incidence of type 2 diabetes is increasing rapidly in Bhutan. Anecdotal evidences show poor compliance and loss to follow up among the Bhutanese population living with diabetes. This study was conducted to understand the case load, age and gender distribution and compliance to follow up among diabetic patients registered at Central Regional Referral Hospital, Gelephu, Bhutan. MATERIALS & METHOD: All the patients diagnosed and registered with Diabetic Clinic between 1st January 2014 to 31st December 2018 were included in the study.RESULTS: There was a sharp increase in number of registered diabetic patients from 641 cases in 2014 to 1590 cases in 2018. A total of 949 new cases were diagnosed and registered during the study period of which 52% were women. The overall diabetes prevalence under Gelephu CRRH catchment area is found to be 2.91% with lowest at Chhudzom (1.01%) and highest in Samtenling Gewog (3.18%). Lost to follow up among new cases for past four years was found to be 3.96%, 5.0%, 6.47% and 5.85% from 2015 to 2018 respectively.CONCLUSION: The ageing population and sedentary lifestyle has contributed to the sharp escalation of type 2 diabetes cases in Gelephu. The hospital recorded total of 1590 cases in 2018 which is a two-fold increase in case load within a span of five years. The current analysis found that loss to follow up was 3.96%, 5.0%, 6.47% and 5.85% from 2015 to 2018 respectively among new cases of diabetes registered with the hospital.

Introduction: Bhutanese school children are vulnerable to vitamin B12 deficiency as outbreaks of micronutrient deficiency diseases have been a common occurrence. The study presents the status of vitamin B12 deficiency among boarding school children from those seven districts. Methods: A cross-sectional study was conducted to determine serum vitamin B12 level. Data and blood samples were collected from 448 boarding school children from the seven districts of Bhutan. Serum cobalamin levels were assessed and relationship between factors analyzed. Results: The study found that 64 % of the school children were found to have vitamin B12 deficiency. Adjusted Odds Ratio for the vitamin deficiency among boarding school children from lower secondary and higher secondary schools were 4.05 and 3.3 respectively, when compared to those from the primary school. Starches were the most commonly served foods in boarding schools, while the animal source foods were served twice or less in a month. Conclusion: The study found a high prevalence of Vitamin B12 deficiency among boarding school children from seven districts. Boarding school meals had very less frequency of animal source foods.

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 similar to 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.

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.

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.

Background: A suspected peripheral neuropathy outbreak was reported from Dechentsemo Central School, Thinleygang, Punakha, following which the investigation team was immediately dispatched in the field.Objective: The aim of investigation was to ascertain the cause and risk factor for the outbreak in order to implement control measures.Methods: A case control study was devised for the investigation to study about the past exposure or deficiencies in order to find out the suspected cause and risk factors. A semi-quantitative food frequency questionnaire was administered to both cases and controls to collect information on the type of food they have consumed. The information garnered was analyzed using Chi-Square or Fischer Exact test for categorical variables and Man-Whitney U-test for quantitative variables. Results: All 17 cases were females with mean age of 13 years (SD 2.7 years). The average daily amount of thiamine intake was 0.6 mg/day for case and 0.8 mg/day for controls against the recommended daily allowance (RDA) of 1.2 mg/day. Case and control patients differed significantly with respect to fat intake (p-value = 0.02), more strongly with folate and iron intake (p-value 0.01).Conclusion: The outbreak of peripheral neuropathy in Dechentsemo Central School appears to be linked to reduced dietary intake rich in vitamin B1 coupled with low intake of folate and iron in their diet.

AbstractObjectiveTo characterize the epidemiology of wasting and identify the main predictors of wasting, severe wasting and poor weight-for-height in children.DesignWe analysed a nationally representative sample of 2028 children (Multiple Indicator Survey, 2010).SettingRoyal Kingdom of Bhutan.SubjectsChildren aged 0–23 months.ResultsWasting 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).ConclusionsProgrammes 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.

The kingdom of Bhutan is a tiny country, landlocked between the two Asian giants of India and China, and has a population of about 762 864 (Bhutan at a glance 2014). Despite the very small size, the country has made remarkable progress towards modern development since initiating planned development in the 1960s. Bhutan has also experienced rapid progress in many of the key determinants of nutrition and health. The life expectancy of the Bhutanese has been increasing steadily over the years, currently standing at 68 years (Statistical Yearbook of Bhutan 2014). The country's infant mortality rate has declined to 30 per 1000 live births down from 90 per 1000 in 1990 (National Health Survey (NHS) 2012). The 2010 Multiple Indicator Survey showed the prevalence of stunting in children under 5 years to be 33.5%, indicating a 24% decline from 1986 levels (Bhutan Multiple Indicator Survey). Stunting or poor linear growth, in young children, is caused by multiple determinants, including antenatal, intra-uterine and postnatal malnutrition (Waterlow 1994). According to the 2010 Multiple Indicator Survey, the prevalence of stunting is higher in the poorer districts, particularly, in the east of the country. In that region, 43% of the children under five are stunted compared with 31% in the West region and 28% in the Central region. In the poorest wealth quintile, the prevalence of stunting is 41% compared with 21% in the richest quintile (Bhutan Multiple Indicator Survey (BMIS) (2011)). A situation analysis of nutrition in Bhutan points to the following as major determinants of stunting: diarrheal diseases, high parasite loads in parts of the country and high prevalence of Helicobacter pylori infections. Diseases related to environmental and personal hygiene and the poor nutrition and care of women before and during pregnancy were also identified as risk factors for stunting (Atwood et al. 2014). The nutrition agenda, including stunting reduction, has become a national priority in Bhutan. In the current 5-year plan (which ends at 2018), stunting reduction is one of the key performance indicators at the national level, which needs to be achieved by the end of the planned period (Eleventh Five Year Plan (2013–2018) 2013). Specific interventions undertaken by Bhutan in the past decade to reduce undernutrition include a focus on optimizing infant and young child feeding practices, supplementation for children, adolescents and pregnant and lactating women with essential micronutrients and the establishment of treatment and rehabilitation centres in health facilities for severely malnourished children. Although the interventions undertaken by Bhutan are time-tested and known to have worked in other countries, there is still room for improvement. Strengthening the existing programmes, and continuing to advocate to high level decision makers, to ensure that nutrition remains the top agenda, is important. Coordinating with multiple sectors for targeted funding to improve the coverage and quality of maternal and child nutrition services will also help the nation's effort to improve linear growth in children. These programmes should be undertaken in the backdrop of broader socio-economic improvements if stunting is to be reduced in the country. Stunting really begins at conception, and maternal nutrition plays an important role in the development and growth of the fetus. Poor maternal nutrition has been related to intrauterine growth retardation and adverse birth outcomes (Villar et al. 2003). In Bhutan, many interventions to promote maternal health and fetal growth are delivered through the health system. It is recommended for pregnant women to come for a minimum of eight antenatal care visits (ANC). An in-depth analysis of determinants of child stunting in Bhutan found that, after controlling for many other variables, children whose mothers received three or fewer ANC visits during the last pregnancy had 31% higher odds of being stunted, while children whose mother did not receive any ANC visits had 51% higher odds of being stunted (Aguayo et al. 2015). ANC promotes optimal nutrition and delivers specific interventions, such as anaemia prophylaxis and treatment, de-worming prophylaxis, monitoring of fetal growth and assessment of the mothers health. However, during the last nationally represented survey, only 26% of pregnant women in Bhutan were found to have had eight ANC visits. Adequate nutrition during infancy and early childhood is essential to ensure the growth, health and development of children to their full potential. In terms of infant and young child feeding practices, Bhutan has not been faring well. Only 49% of children under 6 months are exclusively breastfed, while 63% of the infants between the ages of 6 and 23 months receive the minimum frequency of complementary feeds. The role of infant and young child feeding is particularly important for Bhutan as children who were not fed complementary foods at 6–8 months had about threefold higher odds of being severely stunted than children who were fed complementary foods (Aguayo et al. 2015). In Bhutan, 96% of the population use improved sources of drinking water, while 3% of the population practice open defecation. However, only 58% of the population has access to improved sanitation. The lack of safe drinking water and basic sanitation are known to undermine efforts to combat poverty and diseases. The 2010 Multiple Indicator Survey found the highest stunting rates in the eastern region and among people from the poorest wealth quintile, which was also where the sanitation coverage was the lowest. Gaps are still present in child feeding, maternal nutrition and household sanitation in Bhutan, but many encouraging changes are also taking place to cover these shortcomings. Every mother in Bhutan is now tracked to ensure that she benefits from the required number of ANC visits; discussions to extend maternity benefits have started among the highest levels of decision makers and advocacy campaigns to improve breastfeeding, and complementary feeding are ongoing. Efforts are also underway to improve water and household sanitation in the country. In addition to ongoing child feeding, maternal nutrition and household sanitation interventions, Bhutan has also been making significant strides in socio-economic development. Between 2007 and 2012, the percentage of poor halved to 12%, and Bhutan has nearly ended extreme poverty (a low of 2% in 2012) (Bhutan Poverty Assessment 2014). The average economic growth between 2009 and 2013 was 6.7 % (National Accounts Statistics 2014), which is a very respectable number for a small donor dependent country (12). Bhutan's interventions are similar to the interventions undertaken by Brazil, which were very successful in reducing stunting levels through vast targeted funding to improve access to maternal and child health and nutrition services coupled with broad social, economic and political changes (Requejo 2015). With the set of interventions that are already in place and those that are being scaled up, there is no reason why Bhutan cannot replicate or even exceed the Brazilian success. United Nations Children's Fund (UNICEF). The authors declare that they have no conflicts of interest. LD did the research, planning, and manuscript writing. KD did the review and manuscript writing. All authors have read and approved the final manuscript. The opinions expressed in this paper are those of the authors and do not necessarily represent an official position of the organizations they are affiliated with.

Introduction: Peripheral neuropathy outbreaks have been a common occurrence amongst boarding schoolchildren from seven districts in Bhutan. Thiamin deficiency has always been suspected to be the cause but the status of the vitamin has never been established. This study aims to find the status of thiamin and dietary intake of micronutrients in boarding schoolchildren from seven districts with previous history of peripheral neuropathy outbreaks. Methods: Whole blood thiamin and dietary intake of micronutrients were assessed in 448 school children for four study periods (SP). Baseline data (SP1) was collected when the school children just joined the school at the start of the school academic year. SP2 was the first half of the school year and the data was collected just before the midterm break. SP3 was the short summer break and SP4 the second half of the school academic year. Results: 50.58% of the school children were found to be thiamin deficient at baseline which increased to 90.1% in SP2. The percentage of thiamin deficient school children increased to 91.8% in SP3 and then decreased to 79.82% in SP4. The requirements for vitamin B1, B12, vitamin A and iron were never met by dietary intakes in all the study periods. Conclusions: In conclusion, this study found a high prevalence of Thiamin deficiency in schoolchildren at baseline and the number of school children with Thiamin deficiency increased when in schools. The school children also had inadequate dietary intake of many micronutrients.