[Napsnet] SPECIAL REPORT: DPRK 2004 Nutrition Assessment Report of Survey Results

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NORTHEAST ASIA PEACE AND SECURITY NETWORK
***** SPECIAL REPORT *****

-"DPRK 2004 Nutrition Assessment Report of Survey Results"
By the Central Bureau of Statistics, Institute of Child Nutrition DPRK

October 27th, 2005

This is the introduction read the full report at:
<http://www.nautilus.org/napsnet/sr/2005/0587Nutrition.pdf>http://www.nautilus.org/napsnet/sr/2005/0587Nutrition.pdf

The report published by UNICEF:
http://www.unicef.org/dprk/dprk_national_nutrition_assessment_2004_final_report_07_03_05.pdf

Nautilus invites your contributions to this forum, including any responses 
to this report.

--------------------
CONTENTS
I.  Introduction
II. Report by the Central Bureau of Statistics, Institute of Child 
Nutrition DPRK
III.  Nautilus invites your responses

I.  Introduction

The Central Bureau of Statistics, Institute of Child Nutrition of the DPRK 
in collaboration with UNICEF and WFP, released this report on nutrition in 
the DPRK. The report states:  "The most common source of staple foods was 
the PDC rations or Farmers rations, but a quarter of the households 
reported WFP foods as a source of their staple food. The most common 
sources of beans were farmer's rations, self production, markets, kin 
support and WFP foods. The sources of fruits and vegetables were state 
shops, markets, self production and farmer's rations. WFP foods were not a 
source of these foods."

The views expressed in this article are those of the author and do not 
necessarily reflect the official policy or position of the Nautilus 
Institute.  Readers should note that Nautilus seeks a diversity of views 
and opinions on contentious topics in order to identify common ground.

II. Report by the Central Bureau of Statistics, Institute of Child 
Nutrition DPRK

-"DPRK 2004 Nutrition Assessment Report of Survey Results"
By the Central Bureau of Statistics, Institute of Child Nutrition DPRK

Summary of Survey Findings

SURVEY METHODOLOGY

The DPRK 2004 National Nutrition Assessment is the fourth national 
nutrition assessment with the previous surveys taking place in 1998, 2000 
and 2002. It aimed to assess the nutritional status of children from birth 
to six years of age and of mothers with children less than 2 years of age, 
and to identify possible causal factors of malnutrition.

It was a cross sectional survey of a representative sample of children and 
women living in seven provinces and one municipal city, and was conducted 
in October 2004. Multi stage cluster sampling was used with provinces as 
strata and dong or ri within the provinces as clusters. An approximation of 
random sampling, based on the random selection of two index children from a 
nursery within the dong or ri was used to select the households and 
children for the survey within each cluster. Twenty clusters were selected 
in each province and 30 households within each cluster giving a total 
sample of 4800 children.

Three main questionnaires were used in the survey; the household 
questionnaire; the maternal and newborn health questionnaire; and the child 
and maternal anthropometric measurement form. Food availability was 
assessed by asking about the frequency of consumption of fourteen different 
food groups by the households and mothers in the six months prior to the 
survey. Anthropometry measurements of weight and height were collected from 
all children using standard methods. Anthropometry measurements of mid 
upper arm circumference and body weight, and haemoglobin were collected 
from women with a child less than two years of age. Anthropometry 
standardization exercises were conducted prior to the data collection. All 
measurements were directly monitored for quality by the survey teams, which 
included staff from the supporting international organisations.

Maternal malnutrition was defined as a MUAC of<22.5 centimetres. For all 
indicators of child and maternal malnutrition 95% confidence intervals were 
estimated using SPSS (V. 13); the statistical program.

SURVEY POPULATION AND DATA QUALITY

Survey population
Data was collected in the survey from a total of 4800 households from 160 
dong or ri clusters of which 97 were from urban areas and 63 from rural 
areas (Table 4). There was 2109 children aged less than two years (44% of 
children <6 years) and all the mothers of these children participated in 
the anthropometric measurements. However participation in the haemoglobin 
testing was lower with only 1253 women (59%) agreeing to be tested. of 
participation varied by province.

Data quality
Assessment of child age data revealed it was of good quality and had no 
patterns that could bias the calculation of anthropometric indices. The 
evaluation of the child anthropometric data found the WHO recommended 
quality indicators (standard deviations of indices) were within the usual 
range for all three indicators. Also there was a similar quality of the 
anthropometric data collected by the survey teams. The data quality 
indicators for the 2002 and 2004 assessment were similar indicating the 
survey results could be validly compared.

CHILD NUTRITIONAL STATUS

Child malnutrition
The prevalence of stunted children (height-for-age < -2 Z-score) aged 0-71 
months in 2004 was 37.0%. The prevalence of severe stunting (<-3 Z-score) 
was 12.2%. There was a progressive increase in the prevalence of stunting 
from birth through to 48-59 months. but a slight decline with the oldest 
age group. The prevalence of stunting was higher in boys (38.6%) than in 
girls (35.2%). The prevalence of stunting varied significantly by province. 
Two provinces, South Hamgyong, and Ryanggang, had a very high level of 
stunting.

The prevalence of underweight children (weight-for-age < -2 Z-score) aged 
0-71 months in 2004 was 23.4%. The prevalence of severe underweight (<-3 
Z-score) was 8.1%. There was a progressive increase in the prevalence of 
underweight from birth until 24-35 months and then a slight decline. 
Prevalence of underweight was similar in girls and boys. The prevalence of 
underweight children varied significantly by province. The highest 
prevalence were in South Hamgyong, North Hamgyong and Ryanggang provinces.

The prevalence of wasted children (weight-for-height <-2 Z-score) aged 0-71 
months in 2004 was 7.0% which is a medium level based on WHO criteria. The 
prevalence of severely wasted (<-3 Zscore) children aged 0-71 months was 
1.8%. There was a slight increase in the prevalence of wasting in children 
12-23 months, and thereafter a slow decline with increasing age. Wasting 
levels were similar in girls and boys. The prevalence of wasted children 
varied significantly by province. Two provinces, South and North Hamgyong, 
had a high level of wasting (>10%). Other 4 provinces had a medium 
level(5-9%) based on WHO criteria.

Factors associated with child malnutrition
Maternal malnutrition was associated with an increased prevalence in 
stunting. Low birth size was associated with more stunting. The prevalence 
of stunting increased by 62% as reported birth size decreased from 19% in 
children who were very large at birth to 30.7% in children who were 
perceived to be very small at birth. Higher usual frequency of household 
consumption of rice and rice products, poultry or meat, red or yellow 
vegetables, and oils and fats were associated with reduced childhood 
malnutrition.

Trends in childhood malnutrition
The reliable indicator to assess trends in children malnutrition prevalence 
is low height-for-age or stunting. This indicator changes slowly and is not 
influenced by recent acute shortages of food or of illness in the children. 
Trends in child malnutrition were examined by comparing the unweighted 
prevalence of stunting in the two surveys.

The prevalence of stunting in children 0-71 months in DPRK has fallen by 
2.9% from 38.8% in 2002 to 35.9% in 2004. This is an average decline of 
stunting prevalence of 1.45% per year. The decline was greater for girls 
(4%) than for boys (2.1%). There was a significant decline in the 
prevalence of severe stunting between the two surveys, from 14.4% in 2002 
to 11.8% in 2004.

The age specific trends in stunting also revealed the following.

Firstly, there was no change in the stunting rates between the surveys for 
children 0-11 months. Stunting in this age group is largely influenced by 
foetal growth and maternal malnutrition. The observed association between 
small birth size and stunting indicates that more efforts to improve 
maternal nutritional status will be required to rapidly reduce the 
prevalence of stunting in infants.

Secondly, the stunting rate in children 12 to 35 months has fallen sharply 
and was approximately 30% lower than 2002. If this progress in reducing 
stunting continues the overall prevalence of stunting will fall by a 
substantial amount in future surveys.

Thirdly, the stunting rate in the children 36 to 71 months did not change 
between the surveys. Children usually do not exhibit catch up growth beyond 
three years of age even if their diets improve. So it is critically 
important to provide interventions that have an impact on the growth of 
very young children.

The prevalence of stunting decreased in all provinces and on average the 
decline was from 2% to 3% in each province. These findings indicate 
improvements occurred uniformly across the country.

MATERNAL NUTRITIONAL AND HAEMOGLOBIN STATUS

Maternal malnutrition
Thirty two percent of the women with a child less than 24 months were 
malnourished as indicated by a mid upper arm circumference (MUAC) less than 
22.5 centimetres. The prevalence of low MUAC demonstrated a U shaped 
relationship with age where by both younger and older women had higher 
levels. The prevalence of maternal malnutrition was similar in all 
provinces except for South Hwanghae, which was lower than the national average.

Similar patterns were observed for low maternal body weight. Low intakes of 
rice and rice products, poultry and meat, and green leafy vegetables had a 
weak relationship with higher prevalence of maternal body weight < 45 kg

Trends in maternal malnutrition were examined by comparing the prevalence 
of MUAC in the two surveys. There were some improvements in maternal 
nutritional status between the 2002 and 2004 assessments mainly for women 
25 to 29 and 30 to 34 years and these improvements were observed in some 
provinces.

Maternal anaemia
There was an improved participation in the haemoglobin assessment with 59% 
of women with a child less than two years agreeing to the test. Overall, 
34.7% of the women had anaemia (Hb < 12.0 g/DL), but only 0.5% had moderate 
to severe anaemia (Hb < 9.0 g/DL). Anaemia tended to be higher in the 
youngest and oldest age groups and was slightly lower in women who had 
completed tertiary education. There was a variation in the prevalence of 
anaemia by province. The highest prevalence of anaemia was found in South 
Phyongan (61.3%) followed by North Phyongan (47.8%).

The prevalence of anaemia in 2002 (33.6%) was very similar to the level 
found 2004.

FOOD AVAILABILITY

Household food availability was assessed in the survey by asking the women 
respondents about the usual frequency of consumption of fourteen different 
food groups during the six months prior to interview. Usual household 
consumption of rice was lowest in Ryanggang and North Hwanghae, but these 
provinces had high daily consumption of other cereals and potatoes. The 
usual consumption of poultry or meat and fish was about half that of beans 
and bean products across most provinces. The consumption of poultry or meat 
and fish was very low in Ryanggang. Green leafy vegetables and non-coloured 
vegetables were consumed with a similar high frequency across all 
provinces. There was more variation by province in the consumption of 
red/yellow vegetables with the highest levels in Ryanggang and North 
Hamgyong. Overall the average consumption of red/yellow vegetables was much 
lower than for the other vegetables. Oils and fats were consumed least 
frequently in the Ryanggang and more frequently in lowland southern 
provinces. The frequency of consumption of fortified foods was high in the 
northern provinces.

The most common source of staple foods was the PDC rations or Farmers 
rations, but a quarter of the households reported WFP foods as a source of 
their staple food. The most common sources of beans were farmer's rations, 
self production, markets, kin support and WFP foods. The sources of fruits 
and vegetables were state shops, markets, self production and farmer's 
rations. WFP foods were not a source of these foods.

MATERNAL AND CHILD CARE

Child feeding patterns
At <6 months, 6-9 months, 12-13 months and 22-23 months 98.5%, 86.1%, 71.2% 
and 38.9% of the children respectively were still breastfed. Based on 24 
hour recall prior to interview, 65% of children less than six months of age 
were exclusively breastfed. About 22% of the children less than six months 
were receiving both breast feeds and other water based liquids. A smaller 
percentage was being given other milks. Amongst the breastfed children 31% 
were receiving at least some complimentary food at 6-9 months.

Use of micronutrients
The coverage of Vitamin A supplementation in the six months prior to the 
survey was uniformly very high for age eligible children across all 
provinces. The majority of children who received vitamin A obtained it from 
local nurseries.

Overall, 33.5% of women received vitamin A postpartum. The coverage of 
maternal postpartum vitamin A supplementation varied considerably by 
province with the highest levels in Pyongyang. Six percent of women 
reported night blindness during their last pregnancy.

Forty percent of households were using iodised salt. There was less 
consumption of iodised salt in the northern mountainous provinces.

Immunisations of children
There was a uniformly high coverage of all childhood immunisations.

Childhood illnesses
About one in five children had diarrhoea in the two weeks prior to the 
survey. The prevalence of diarrhoea was lower in Pyongyang than other 
provinces. No relationship was seen between the type of toilet or water 
source and diarrhoea. This might be expected given the high level of 
appropriate methods of disposal of the children's stools. Overall 83% of 
the mothers gave ORS or other acceptable fluids during the diarrhoea 
episode. Also 62% of the mothers appropriately continued to breastfed. 
However 30% of mothers did report reducing food intake during the diarrhoea 
episode and 20% reported giving fewer fluids.

Twelve percent of the children had ARI symptoms, 20% had a fever and 85% 
had both ARI and fever in the two weeks prior to the survey. Children 6 to 
17 months were more likely to have ARI and ARI with fever. The vast 
majority of children with ARI were taken for treatment.

Pregnancy care
There was a very high level of antenatal care during pregnancy with 
approximately 60% of women attending ten or more antenatal care checks 
during their last pregnancy. The coverage of antenatal care was uniformly 
high across all provinces. Similarly, there was a uniformly high level of 
care during delivery from medically trained birth attendants.

WATER AND SANITATION

Overall 82% of the households in DPRK have water piped into the dwelling 
even in the remote northern provinces. Approximately 57% of households have 
flush toilet system and 43% have pit toilets. There was similar pattern 
found in all provinces. Overall 80% of mothers with a young child 0-3 years 
disposed of their children's stools using a method that contained the stools.

III. Nautilus Invites Your Responses

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this essay. Please send responses to: bscott at nautilus.org. Responses will 
be considered for redistribution to the network only if they include the 
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