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.

Strengthening non-communicable disease policy with lessons from Bhutan: linking gross national happiness and health policy action.

There is growing global interest in Gross National Happiness (GNH) as a metric to capture population well-being and economic development. Empirical evidence suggests that health is necessary for achievement of happiness. The growing epidemic of non-communicable diseases (NCDs) threatens to undermine the achievement of GNH. We analyze synergies between current policy priorities and the institutional mechanism for GNH and the Global NCD Action Plan 2013-2020 that has informed Bhutan's approach to NCDs. We identify strategic policy opportunities to strengthen outcomes for both policy areas. Lessons from Bhutan also suggest strategic opportunities to address NCDs in other countries where happiness is on the national agenda, or where action on NCDs could be improved through engagement between health and other sectors, especially where ways to promote and measure GNH (population well-being) already exist.

Socioeconomic, religious, spiritual and health factors associated with symptoms of common mental disorders: a cross-sectional secondary analysis of data from Bhutan's Gross National Happiness Study, 2015.

OBJECTIVE: Common mental disorders (CMDs) are a major cause of the global burden of disease. Bhutan was the first country in the world to focus on happiness as a state policy; however, little is known about the prevalence and risk factors of CMDs in this setting. We aim to identify socioeconomic, religious, spiritual and health factors associated with symptoms of CMDs. DESIGN AND SETTING: We used data from Bhutan's 2015 Gross National Happiness (GNH) Survey, a multistage, cross-sectional nationwide household survey. Data were analysed using a hierarchical analytical framework and generalised estimating equations. PARTICIPANTS: The GNH Survey included 7041 male and female respondents aged 15 years and above. MEASURES: The 12-item General Health Questionnaire was used to measure symptoms of CMDs. We estimated the prevalence of CMDs using a threshold score of ≥12. RESULTS: The prevalence of CMDs was 29.3% (95% CI 26.8% to 31.8%). Factors associated with symptoms of CMDs were: older age (65+) (ß=1.29, 95% CI 0.57 to 2.00), being female (ß=0.70, 95% CI 0.45 to 0.95), being divorced or widowed (ß=1.55, 95% CI 1.08 to 2.02), illiteracy (ß=0.48, 95% CI 0.21 to 0.74), low income (ß=0.37, 95% CI 0.15 to 0.59), being moderately spiritual (ß=0.61, 95% CI 0.34 to 0.88) or somewhat or not spiritual (ß=0.76, 95% CI 0.28 to 1.23), occasionally considering karma in daily life (ß=0.53, 95% CI 0.29 to 0.77) or never considering karma (ß=0.80, 95% CI 0.26 to 1.34), having poor self-reported health (ß=2.59, 95% CI 2.13 to 3.06) and having a disability (ß=1.01, 95% CI 0.63 to 1.40). CONCLUSIONS: CMDs affect a substantial proportion of the Bhutanese population. Our findings confirm the importance of established socioeconomic risk factors for CMDs, and suggest a potential link between spiritualism and mental health in this setting.

Association between Sleep Duration and Self-Reported Health Status: Findings from the Bhutan's Gross National Happiness Study.

STUDY OBJECTIVES: Short and long sleep durations have been found to be associated with chronic conditions like diabetes mellitus, hypertension and cardiovascular disease. However, most studies were conducted in developed countries and the results were inconsistent. The aim of this study is to investigate the association between sleep duration and self-reported health status in a developing country setting. METHODS: We conducted secondary data analysis of the 2010 Gross National Happiness study of Bhutan, which was a nationwide cross sectional study with representative samples from rural and urban areas. The study included 6476 participants aged 15-98 y. The main outcome variable of interest was self-reported health status. Sleep duration was categorized as ≤ 6 h, 7 h, 8 h, 9 h, 10 h, and ≥ 11 h. Multiple logistic regressions were conducted to investigate the association between sleep duration and self-reported health status. RESULTS: The mean sleep duration was 8.5 (± 1.65) h. Only 9% of the respondents slept for 7 h; 6% were short sleepers (≤ 6 h) and 84% were long sleepers (21%, 8 h; 28%, 9 h; 22%, 10 h; 13%, ≥ 11 h). We found that both short (≤ 6 h) and long sleep duration (≥ 11 h) were independently associated with poor self-reported health status. CONCLUSIONS: This study found that people with shorter and longer sleep durations were more likely to report poorer health status.

Epidemiology of soil-transmitted helminths in the western region of Bhutan.

In May 2003, a survey was conducted in the western region of Bhutan to assess the prevalence and intensity of soil-transmitted helminth (STH) infections after 15 years of school deworming in the country. Five schools were randomly selected in the region and 266 schoolchildren were examined. Stool samples were collected from each child as well as nutritional indicators and general information on each school. The survey found a cumulative prevalence of 16.5% STH (4.8% in schools treated in the last three months and 24% in the untreated schools). An unexpected finding was that the tapeworm infection rate of 6.7%. These results indicate a high reinfection rate in this area. WHO recommends a 50% prevalence as the threshold for the establishment of community intervention. However, in our view, Bhutan needs to continue its deworming program because the present, relatively low, prevalence level was found despite a long period of intervention; an interruption of the control activities will result in a return to very high levels of prevalence and intensity of infection.