As Bhutan has progressed financially, its health indicators have also progressed. It has achieved significant gains in all the Millennium Development Goals (MDGs). Yet two major indicators of significant undernutrition remain persistently elevated: stunting of children younger than 5, and anemia in women and children. Some factors can be interpreted as direct or nutrition-specific determinants of undernutrition in Bhutan, among them diarrheal diseases, high parasite loads in parts of the country, and a very high prevalence of Helicobacter pylori infections. Other, more indirect, factors can be considered nutrition-sensitive, such as diseases related to environmental and personal hygiene. The most important causes of stunting are indirect and nutrition-sensitive: poor nutrition and care of women before and during pregnancy as reflected in the profound female anemia rates. Beyond factors that directly impact on the nutrition of women and children are other issues
specific to Bhutan: many villages and settlements are inaccessible, some at altitudes that strongly influence crop selection and production; a dependency on imported foods makes the country vulnerable to price fluctuations; ethnic and other cultural variables influence access to services and alter feeding practices; urban migration is further impinging on a decreasing agrarian work force; communities are not aware of the nutrition problems of stunting and anemia and have no understanding of their causes, their significance, and what could be done to remediate them; and there are few people knowledgeable about public nutrition who have the skills needed to educate and motivate changes in community behavior. The report conclusions highlight four major public nutrition problem areas, and to focus government actions, suggests five priorities from the sector-specific recommendations because they are considered most feasible and would lead to immediate gains in reducing undernutrition—gains that could then draw attention and support to the problem of undernutrition in Bhutan.