77218 Nutrition at a GLANCE BHUTAN The Costs of Malnutrition Annually, Bhutan loses over US$2.4 million • Over one-third of child deaths are due to undernu- trition, mostly from increased severity of disease.2 in GDP to vitamin and mineral deficiencies.3,4 • Children who are undernourished between con- Scaling up core micronutrient interventions ception and age two are at high risk for impaired would cost US$340,000 per year. cognitive development, which adversely affects the (See Technical Notes for more information.) country’s productivity and growth. • The South Asia region is anticipated to lose a cu- Key Actions to Address Malnutrition: mulative US$20 billion to chronic disease by 2015.5 Improve infant and young child feeding through effective • The economic costs of undernutrition and over- education and counseling services. weight include direct costs such as the increased burden on the health care system, and indirect Reduce iron deficiency through multiple interventions including deworming and multi-micronutrient costs of lost productivity. supplements for young children, iron-folic acid • Childhood anemia alone is associated with a 2.5% supplementation for pregnant women, and fortification drop in adult wages.6 Country Context of staple foods. Continue to invest in universal salt iodization and vitamin HDI ranking: 132nd out of 182 Where Does Bhutan Stand? A supplementation of young children. countries1 • 37% of children under the age of five are stunted, 11% are underweight, and 5% are wasted.15 Improve dietary diversity and design policies that will Life expectancy at birth: 66 • 40% of those aged 15 and above are overweight or increase access to healthy diets both for those at risk of years2 obese.7 undernutrition and those at risk of obesity. Lifetime risk of maternal death: • 9% of infants are born with a low birth weight.15 1 in 552 • Bhutan is currently on track to meet MDG 1c (halving 1990 rates of child underweight by 2015).8 Under-five mortality rate: 81 per Figure 1  Bhutan has Higher Rates of Stunting than 1,000 live births2 As seen in Figure 1, Bhutan has similar high rates Many of its Income Peers of stunting relative to its South Asian neighbors. 60 Prevalence of Stunting Among Countries with comparable per capita incomes, Nepal 50 India however, exhibit lower rates of child stunting, Bhutan Children Under 5 (%) Technical Notes which demonstrates the ability to achieve better nu- 40 Bangladesh Pakistan Philippines Stunting is low height for age (too short). trition outcomes despite low income. Bhutan also 30 Egypt Maldives has higher maternal and infant mortality rates rela- 20 Underweight is low weight for age (too small). tive to income and health spending than all of its 10 South Asian neighbors.14 This indicates that avail- Wasting is low weight for height 0 (too thin). able funds can be used more effectively to benefit 0 1000 2000 3000 4000 women and children’s health and nutrition. GNI per capita (US$2008) Current stunting, underweight, and wasting estimates are based on Source: Stunting rates were obtained from WHO Global Database on Child comparison of the most recent survey data Growth and Malnutrition. GNI data were obtained from the World Bank’s with the WHO Child Growth Standards, Most of the irreversible damage due to World Development Indicators. released in 2006. malnutrition happens during gestation Low birth weight is a birth weight less and in the first 24 months of life.8 than 2500g. low-birth weight infants and stunted children may be at greater risk of chronic diseases such as dia- Overweight is a body mass index (kg/m ) of ≥ 25; obesity is a BMI of ≥ 30. 2 The Double Burden of Undernutrition betes and heart disease than children who start out The methodology for calculating and Overweight well-nourished.9 nationwide costs of vitamin and mineral While more than a third of all children in Bhutan deficiencies, and interventions included in are undernourished, the country has also seen a This “double burden� is the result of various the cost of scaling up, can be found at: recent increase in adult obesity. The coexistence of factors. Progress in improving community infra- www.worldbank.org/nutrition/profiles under- and overnutrition can cause particular risks: structure and development of sound public health Solutions to Primary Causes of Undernutrition BHUTAN Poor Infant Feeding Practices High Disease Burden Limited Access to Nutritious Food • During the important transition period to a mix • Undernutrition increases the likelihood of falling • Achieving food security means ensuring qual- of breast milk and solid foods between six and sick and severity of disease. ity and continuity of food access, in addition to nine months of age, it is critical that infants • Undernourished children who fall sick are much quantity, for all household members. are fed appropriately with both breast milk and more likely to die from illness than well-nourished • Dietary diversity is essential for food security. nutrient-dense complementary foods. children. Solution: Involve multiple sectors including agricul- Solution: Support women and their families to • Parasitic infestation diverts nutrients from the ture, education, transport, gender, the food industry, practice optimal breastfeeding and ensure timely body and can cause blood loss and anemia. health and other sectors, to ensure that diverse, nutri- and adequate complementary feeding. Breast milk Solution: Prevent and treat childhood infections tious diets are available and accessible to all house- fulfills all nutritional needs of infants up to six and other diseases. Hand-washing, deworming, zinc hold members. months of age, boosts their immunity, and reduces supplements during and after diarrhea, and continued exposure to infections. feeding during illness are important. References systems has been slow, thwarting efforts to reduce • Iron: 80% of preschool aged children and 50% of 1. UNDP. 2009. Human Development Report. undernutrition; while rapid urbanization and the pregnant women in Bhutan are anemic.12 Iron- 2. UNICEF. 2009. State of the World’s Children. adoption of Western diets high in refined carbohy- folic acid supplementation of pregnant women, 3. UNICEF and the Micronutrient Initiative. drates, saturated fats and sugars, combined with a deworming, provision of multiple micronutrient 2004. Vitamin and Mineral Deficiency: a more sedentary lifestyle are commonly cited as the supplements to infants and young children, and Global Progress Report. 4. World Bank. 2009. World Development major contributors to the increase in overweight fortification of staple foods are effective strate- Indicators (Database). and chronic diseases.10 gies to improve the iron status of these vulnerable 5. Abegunde D et al. 2007. The Burden and subgroups. Costs of Chronic Diseases in Low-Income • Iodine: Currently 96% of households in Bhutan and Middle-Income Countries. Lancet 370: Vitamin and Mineral Deficiencies Cause consume iodized salt.8 Efforts to maintain uni- 1929–38. Hidden Hunger versal salt iodization will ensure that children 6. Horton S, Ross J. 2003. The Economics of Although they may not be visible to the naked eye, Iron Deficiency. Food Policy. 28:517:5 continue to be protected from iodine deficiency 7. WHO. 2009. WHO Global InfoBase vitamin and mineral deficiencies impact well-being disorder. (Database). and are pervasive in Bhutan, as indicated in Figure 2. 8. UNICEF. 2009. Tracking Progress on Child • Adequate intake of micronutrients, particularly and Maternal Nutrition. iron, vitamin A, iodine and zinc, from concep- 9. Victora, CG et al. Maternal and Child Figure 2  High Rates of Vitamin A and Iron Deficiency tion to age 24 months is critical for child growth Undernutrition: Consequences for Adult Contribute to Lost Lives and Diminished Productivity and mental development. Health and Human Capital. Lancet 2008: 371:340–57. 90 10. Popkin BM. et al. 1996. Stunting is 80 World Bank Nutrition-Related Activities Associated with Overweight in Children of Four Nations that are Undergoing the 70 in Bhutan Prevalence (%) 60 Nutrition Transition. J Nutr 126:3009–16. 50 In 2005, a policy note was produced that examined 11. WHO. 2009. Global Prevalence of Vitamin A 40 human development outcomes in Bhutan, with par- Deficiency in Populations at Risk 1995–2005. WHO Global Database on Vitamin A 30 ticular attention to areas of nutrition, food security, 20 Deficiency. and child health. 10 12. WHO. 2008. Worldwide Prevalence of 0 Anemia 1993–2005: WHO Global Database Preschool Children Pregnant Women on Anemia. Vitamin A Deficiency Anemia 13. Horton S. et al. 2009 Scaling Up Nutrition: Addressing undernutrition is cost What Will it Cost? Source: 1995–2005 data from the WHO Global Database on Child Growth and 14. WHO World Development Indicators, & Royal Malnutrition. effective: Costs of core micronutrient Monetary Authority (2009). interventions are as low as 15. National Nutrition, Infant and Young Child Feeding Survey, 2008. Nutrition Programme, • Vitamin A: More than 1 in 5 preschool aged chil- US$0.05–3.60 per person annually. Dept. of Public Health, Ministry of Health, dren (22%) and 17% of pregnant women in Bhu- Returns on investment are Bhutan. as high as 8–30 times the costs.13 tan are deficient in vitamin A.11 THE WORLD BANK Produced with support from the Japan Trust Fund for Scaling Up Nutrition