The Journal of Nutrition Vol. 128 No. 8 August 1998, pp. 1315-1319

Malnutrition of Children in the Democratic People's Republic of North Korea¹

Judit Katona-Apte^{*, 2} and Ali Mokdad

^* World Food Programme, United Nations, Rome, Italy and  Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30333

	ABSTRACT

Abstract Introduction Methods Results Discussion References

Natural disasters have caused extensive damage to crops and to infrastructure in the Democratic People's Republic of North Korea (DPRK). The international community has responded by providing emergency food aid. To improve understanding of the magnitude of food deficiency in the DPRK. The World Food Programme (WFP) conducted a nutritional assessment survey in August 1997. The survey measured the height and weight of a total of 3984 children <7 y of age in 40 government-selected institutions. Additional information was obtained on institutional access to food and on the care, treatment and parental support of a subsample of severely malnourished and nonmalnourished children. The prevalence of acute malnutrition (wasting), based on weight-for-height Z-score < 2, varied from 0 to 32.7% among institutions, and the prevalence of chronic malnutrition (stunting), based on height-for-age < 2 Z-score varied from 0.6 to 74.1%. The findings from this survey indicate the presence of areas with severe acute or chronic malnutrition in the DPRK.

	INTRODUCTION

Abstract Introduction Methods Results Discussion References

The Democratic Peoples' Republic of Korea (DPRK), in the northern part of the Korean peninsula, has a total population estimated as 23.9 million in 1996, ~60% of which is urbanized (DPRK 1995, UNICEF 1997). The capital, Pyongyang, has ~2.7 million inhabitants. DPRK is administratively divided into 9 provinces and 3 municipalities that are subdivided into 200 counties. The land size is 122,762 square kilometers; ~20% is suitable for farming. The government is a centralized socialist economic system. The life expectancy is ~74.5 y. Adult literacy is 100%. The gross national product was about U.S. $970 per capita in 1996.

In addition to economic and credit problems, DPRK has recently suffered major natural disasters. These disasters included hailstorms in 1994, floods in 1995 and 1996, drought in 1997 and tidal waves in 1997 (FAO/WFP 1995, 1996 and 1997). The 1995 floods caused damage in 145 of the total 200 counties. About 5.2 million people were affected and ~1.9 million tons³ of grain were destroyed. The 1996 floods damaged 117 counties, affected 3 million people and destroyed ~300,000 tons of grain. The 1997 drought is believed to have had the worst effect on the yearly harvest and will potentially affect next year's harvest as well. It is estimated that between 1.6 and 1.9 million metric tons of corn and rice were lost.

DPRK's yearly harvest of cereals has declined from 4.8 million metric tons in 1991 to 3.7 million metric tons in 1996 and is estimated to be 3.0 million metric tons for 1997 (FAO/WFP 1997). The total requirement of the country is about 5.0 million metric tons. Even with all of the food assistance pledged and delivered by international agencies, DPRK was ~1 million metric tons short of projected need in 1997.

All basic necessities in DPRK are allocated through the Public Distribution System (PDS), a ration system in which the country purchases food from surplus-producing collective farms and sells it to others at a heavily subsidized rate. This distribution is based on a work-points system that accounts for the physical requirements of a specific job. In August 1997, the average PDS distribution was about 100 g cereals per person per day, which is far below the daily requirement. Domestic food production is largely carried out on cooperative farms involving an estimated 37% of the population.

The health system in DPRK includes 8177 hospitals of various kinds across the country with a capacity of 200,000 beds (DPRK 1995, UNICEF 1997). There are ~30 physicians and surgeons, 11 nurses and 6 maternity assistants per 10,000 people. Physicians are responsible for districts of ~950 families. Medical treatment is free and available to the entire population.

Child care is seen as a state responsibility, allowing women to be economically active. DPRK provides optional day care for children from the ages of 3 mo to 4 y in nurseries. Children aged 5-7 y attend kindergartens for which registration is compulsory. Each provincial capital has a children's center that houses orphans and other children who cannot be looked after by their families.

In August 1997, the World Food Programme (WFP) was granted permission by the DPRK government to conduct a nutritional assessment. However, access was limited to certain parts of the country and to children <7 y of age. Therefore, instead of a random sample of the population, a study was undertaken to measure the height and weight of a total of 3965 children in selected nurseries and kindergartens in four provinces. Data collection was conducted by a team of international nutritionists led by WFP and supported by the Food and Agriculture Organization (FAO), United Nations' Children's Fund (UNICEF) and Save the Children Fund (SCF/UK), in collaboration with national authorities, the Flood Disaster Relief Committee (FDRC), the Ministry of Public Health (MOPH) and a national institute, the Institute of Child Nutrition (ICN). In this report, we present the findings of the survey.

View larger version (16K): [in this window] [in a new window]   Fig 1. Comparison of weight-for-height distribution of children surveyed in the Democratic Peoples's Republic of North Korea in 1997 with that of international growth reference.

	SUBJECTS AND METHODS

Abstract Introduction Methods Results Discussion References

International nutritionists conducted a 4-d training course at the ICN to prepare the field teams. The training was attended by 30 staff members from ICN and MOPH and concentrated on anthropometry and household food security assessment. Before data collection, a pretest was conducted to enable those trained to familiarize themselves with actual data collection. For this purpose, participants visited a kindergarten and a nursery in Sariwon, North Hwanghae Province and measured the weight and height of all attending children. During the pretest, several discoveries came to light: ICN and MOPH staff members were skillful in collecting data, malnourished children were present in the classroom and useful additional information could be collected through interviewing institutional staff.

View larger version (15K): [in this window] [in a new window]   Fig 2. Comparison of height-for-age distribution of children surveyed in the Democratic Peoples's Republic of North Korea in 1997 with that of international growth reference.

The field teams visited a total of 18 counties within four provincesKangwon, South Hwanghae, South Pyongan and South Hamgyong; the sample for anthropometric measurement was restricted to children attending government-selected nurseries and kindergartens, between the 25th and 31st of August 1997. Each team consisted of three members, one staff member from the ICN and MOPH and the international nutritionist. All anthropometric measures for a province were done by the ICN staff. Kindergartens and nurseries were situated mainly in capital county towns and had relatively large registration lists (100 children or more), although smaller cooperative farm nurseries and factory nurseries were also included in the sample. The directors of selected kindergartens and nurseries were given at least one day's notice of the visit. Within each county, at least one kindergarten and one nursery were visited, for a total of 40 institutions. All children attending on the day of the data collection were measured.

The heights or lengths and weights of children were measured and recorded according to internationally accepted procedures, i.e., length for children <85 cm and standing height for children >85 cm (WHO 1995). A metal stadiometer was used to measure height and length to the nearest 0.1 cm, and UNICEF electronic, solar-powered scales (UNISCALE) were used to measure weight to the nearest 0.1 kg. Infants <1 y of age were weighed without any clothes; older children were measured in their underwear. Acute malnutrition or wasting status was defined as a weight-for-height Z-score < 2 and chronic malnutrition or stunting as height-for-age < 2 (WHO 1995). Edema was assessed by the presence of pitting after pressing over the medial malleolus for 3 s and recorded with no grading for severity. In addition, the sex, date of birth and boarding status of each child were recorded from lists provided by the institutions.

The first five children measured and identified as having acute malnutrition were included in a subsample. After each selected malnourished child, the first child who did not appear to be acutely malnourished was included in a control subsample. In some institutions, fewer than five children were acutely malnourished; in others, such information was not collected. A total of 110 children were included in the acutely malnourished subsample and 108 children in the control subsample. A questionnaire on the care and treatment of these selected children was completed by interviewing the responsible staff member. Information on the following was collected: attendance, previous hospitalization, current sickness and treatment, meals served, employment status of parents and primary caretaker at home. The purpose was to identify potential risk factors or outcomes associated with acute malnutrition.

The directors of each institution were interviewed for information on access to food and other resources. The questions included the number of children registered, number of children attending, number of staff and their training, amount of food received last month by the institution, kitchen garden size, wild food gathering, number of meals served, food types and frequencies, water availability, morbidity, mortality and whether the staff measured and kept records of the height and weight of the children. All study protocols were jointly approved by WFP, MOPH and the North Korean Ministry of Foreign Affairs.

ANOVA was used to compare the means of continuous variables, and the Cochran-Mantel-Haenszel statistics were used to test the association between categorical variables and to adjust for age and sex (Kleinbaum et al. 1982). We also compared the nutritional status of children surveyed with that of the international growth reference developed by the National Center for Health Statistics and the Centers for Disease Control and Prevention (Dibley et al. 1987). In total 3780 children were measured for the survey and 204 children during the pretest. EpiInfo was used for data entry and editing and SAS (SAS Institute, Cary, NC) for the analysis. For this report we included the data collected during the pretest. Of the 3984 children measured, 19 children had weight-for-height Z-scores less than 4.0 and 24 had height-for-age Z-scores less than 5.0.

	RESULTS

Abstract Introduction Methods Results Discussion References

The overall prevalence of wasting was 16.5% (Table 1). Boys had a higher prevalence of wasting than did girls. Children aged 6-24 mo had the highest prevalence of wasting. Comparison of weight-for-height distribution of children surveyed in DPRK with that of the international growth reference indicated that the majority of children were below the normal weight-for-height (Fig. 1). Only a very small proportion of the children exhibited even moderate overweight (Z-score >1, Fig. 1).

The overall prevalence of stunting was 38.2% (Table 2). Boys had a higher prevalence of stunting than did girls. Children 5 y of age had the highest prevalence of stunting. The prevalence of stunting varied significantly among the provinces. The distribution of height-for-age of children in DPRK was lower overall than that of the international growth reference (Fig. 2).

Children with acute malnutrition were more likely to have diarrhea, respiratory problems, skin diseases, or a deceased parent or to have been treated in a hospital in the last 3 mo (Table 3). Children with acute malnutrition were more likely to receive medication, most of which was herbal.

The number of children registered at any single institution varied from 26 to 620, and attendance rates on the day of the data collection ranged from 21 to 100% (Table 4). The reported staff-to-child ratio varied substantially, from 1 staff member for every 4 children to 1 staff member per 20 children. Although not significant (P > 0.05), institutions with a prevalence of wasting <10% were more likely to serve more meals or snacks, have fewer children who had received any medication the previous month, and to have reported fewer deaths than did other institutions. There was no association between the rates of acute malnutrition in institutions and the number of teachers, staff, availability of water or the amount of food reported received in the previous month. Eleven children (0.3%) had edema, which may suggest an acute protein deficiency.

	DISCUSSION

Abstract Introduction Methods Results Discussion References

In half of the institutions, >15% of the children were wasted, indicating that there are areas in the DPRK with high rates of acute malnutrition. Indeed, a prevalence of wasting >15% is considered a serious situation and suggests that mortality rates have already increased (WHO 1995). Child wasting is the most important measure of malnutrition in emergency situations, because it results from recent inadequacies of dietary intake or infection or both (WHO 1995). That children 5 y of age had the highest levels of stunting is an important indicator of chronic malnutrition, which could be an indication of the presence of malnutrition from even before the natural disasters.

The levels of wasting and stunting reported in our study are not necessarily representative of the DPRK population. Because provinces, counties and institutions were all selected by the authorities, the major limitation of the survey is potential selection bias. Moreover, the provinces selected were near the capital and part of the "rice bowl" area of the DPRK; therefore, they are not representative of the whole country, especially of the mountainous area in the north. In addition, children who may have been too sick to attend the institutions or who may have been hospitalized would not have been present for measurement. Although registration at kindergartens is compulsory, certain children may have been instructed to stay away from school on the day of assessment, which could bias our findings. The degree of bias in information gathered through the two questionnaires is unknown. Questions asked by foreigners may elicit "correct" answers by the respondent or interpreter rather than valid answers.

Our survey is the largest ever carried out in DPRK. Previous assessments of the food and nutrition situation in DPRK have relied on observations during field trips, data released by the government and discussions with international and national personnel (CDC 1997, Natsios 1997). All studies reported substantial acute or chronic malnutrition or both, and a lack of medical supplies in clinics and hospitals.

The majority of the subsample of wasted children attending institutions had been hospitalized previously, suggesting either that they had been discharged before rehabilitation had been completed or that they had become acutely malnourished again after leaving the hospital. Besides inadequate access to food, wasting and stunting are associated with underlying infection; rehabilitation of wasted children involves a combination of treatment for infections and special feeding (Yip and Sharp 1993, Yip and Scanlon 1994). Inadequate rehabilitation in the hospital may be due to a lack of sufficient beds in pediatric wards (some hospitals were destroyed or damaged by floods) and to a lack of pharmaceutical supplies and special foods. In our subsample, the high percentage of wasted children with one parent deceased was surprising and may indicate that adults are also significantly affected by the food shortage. This apparently high mortality rate among parents of such young children requires further investigation.

Food assistance to the DPRK arrives through a variety of channels; the government transports and distributes food within the country. Large differences were reported in the quantities of food received among institutions or per child. Therefore, transport should be monitored to ensure that food is delivered to institutions caring for children and to identify problems with the food transport system that might need improvement. Effective food aid must be distributed in a timely and predictable manner. Nurseries and kindergartens have to be able to count on both the quantity and availability of food so that their staff does not habitually hoard food for the future. Moreover, if food aid is to be effective, additional assistance is essential; this includes pharmaceutical supplies and technical expertise for training on the prevention and treatment of malnutrition and its complications.

The chronic and cumulative shortage of food, the shortages of basic medicine and fuel, the damage to the infrastructure from floods, and the difficult economic circumstances of DPRK pose substantial challenges to improving the nutritional status of its children. On the other hand, the presence of the PDS, the evident order and discipline in DPRK society, the universal access to health care, the dedication of the care providers and the high literacy rate augur well for the likelihood of successful resolution of the crisis if adequate food, medication and training can be made available.

	FOOTNOTES

Manuscript received 12 December 1997. Initial reviews completed 22 January 1998. Revision accepted 23 March 1998.

	LITERATURE CITED

Abstract Introduction Methods Results Discussion References

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