Community and International Nutrition

The Prevalence of Wasting, but Not Stunting, Has Improved in the

Democratic Peoples Republic of Korea
Daniel J. Hoffman1 and Soo-Kyung Lee
Department of Nutritional Sciences, Rutgers, the State University of New Jersey, New Brunswick, NJ

KEY WORDS:

undernutrition

stunting

wasting

The prevalence of wasting and stunting in children 5 y

old decreased in most developing nations between 1990 and
2000 (1). The decreased prevalence of stunting throughout
the world is associated with improved water sanitation, increased food supply, increased education of women, as well as
improved treatment of acute and infectious diseases (25).
However, 150 million children continue to suffer from undernutrition and many survive, often remaining growth retarded or stunted, defined as a height-for-age Z-score (HAZ)2
less than 2.00 (6,7). In particular, underweight and stunting
are still highly prevalent in countries that are economically
unstable due to conflict or isolation (8). The reason for the
high prevalence of undernutrition in these countries stems
from continued civil unrest, infectious disease outbreaks, increased food insecurity, poorly managed or nonexistent national public health ministries, and difficulties experienced by
nongovernmental organizations (NGOs) attempting to deliver
food aid. Such is the case in the Democratic Peoples Republic
of Korea (DPRK), where food aid and economic development
have met challenges attributed to international isolation, a
strict political system, and natural disasters, resulting in documented cases of severe starvation and increased levels of food
shortage across the lifespan.

children

North Korea

The population of the DPRK now exceeds 23 million and

is facing continued economic and political difficulties that
impede development efforts. Since the fall of the Soviet
Union in 1989, communist societies, such as the DPRK, have
struggled to maintain viable economies, but have experienced
a deterioration of agricultural and health systems. The DPRK
has experienced a 30% contraction in its economy, limiting its
ability to purchase foreign food to balance production inadequacies (9). For the DPRK, in particular, this situation has
been made worse by recurring environmental disasters, including hailstorms in 1994, floods in 1995, and droughts in 1997
and 2000 (9). Recent rainstorms in the northern Provinces
destroyed key roads and bridges, and damage to cereals pipelines, major trade routes that transport cereals to rural provinces, prevented almost 3 million children from receiving aid
from the World Food Program (WFP) (9). These events have
taken a cumulative toll on the overall state of nutrition in the
DPRK, in general, and on the health of children, in particular.
The current state of food supply in the DPRK is precarious.
Between 1989 and 2001, there was a decrease of 240 kJ in per
capita food supply, even among major food products, such as
cereal, meat, eggs, and vegetable oil (10). The per capita
supply of protein and fat has decreased by 286 and 357 kJ,
respectively (10). Efforts to reverse this trend are challenged
by the fact that the DPRK remains politically and economically isolated, but relief efforts by WFP and other NGOs have
provided food aid to 161 of a total 203 districts (85% of the
population) (11). Still, the feasibility of continuing these
programs in the long term is questionable and the need to
assess the nutritional health of children requires surveys that

1
To whom correspondence should be addressed.
E-mail: dhoffman@aesop.rutgers.edu.
2
Abbreviations used: DPRK, Democratic Peoples Republic of Korea; HAZ,
height-for-age Z-score; NCHS, National Center for Health Statistics; NGO, nongovernmental organization; OR, odds ratio; PSU, primary sampling unit; WAZ,
weight-for-age Z-score; WFP, World Food Program; WHZ, weight-for-age Zscore.

0022-3166/05 $8.00 2005 American Society for Nutritional Sciences.

Manuscript received 21 May 2004. Initial review completed 18 July 2004. Revision accepted 3 December 2004.
452

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ABSTRACT The Democratic Peoples Republic of Korea (DPRK) is one of the nutritionally vulnerable countries of
the world. The objectives of this paper were to determine the current prevalence of undernutrition among children
using data from the latest national survey and to compare the findings with those from the previous national survey
in 1997. In 2002 with cooperation from UNICEF and the World Food Program (WFP), the government of the DPRK
conducted a survey of 6000 households with children 7 y old using multiple-stage sampling methods. Data were
collected for sociodemographic variables, use of WFP food aid, and anthropometric measures of the youngest
child in the household. The prevalence of stunting (height for age Z-score less than 2.0) in all children was 39.4%
(40.2 and 38.5% for boys and girls, respectively). The prevalence of wasting (weight for height Z-score less than
2.0) was 8.2% in all children (9.1 and 7.3% for boys and girls, respectively). Although the prevalence of wasting
has decreased from 1997 (16.5%) to 2002 (8.2%), the prevalence of stunting has not changed between those
years, 38.2 vs. 39.4%. Thus, we conclude that acute undernutrition is decreasing in the DPRK, but chronic
undernutrition that results in stunting is still highly prevalent. Continued surveillance of nutritional status of children
in the DPRK is warranted given the continued state of undernutrition in that country. J. Nutr. 135: 452 456, 2005.

NUTRITION IN THE DEMOCRATIC PEOPLES REPUBLIC OF KOREA

SUBJECTS AND METHODS

This study used data from the Nutrition Assessment 2002 conducted by the government of the DPRK (25), in cooperation with
UNICEF and the WFP. Access to this dataset was obtained through
a cooperative agreement with officials from UNICEF.
Sample design. The DPRK is divided into 9 provinces and 3
municipal cities that are further divided into Ri (village for rural
counties) or Dong (neighborhood for urban counties or cities). The
Primary Sampling Unit (PSU) was formed by randomly selecting 200
Ri or Dong in 7 provinces and 3 cities based on the ratio of 20
urban/10 rural Ri/Dong. If a PSU was located in a region that was not
accessible to UNICEF, the next PSU in the random list was selected
until a PSU in an accessible county was chosen. For each PSU
selected, 1 nursery was randomly selected for the survey and 2
children from the enrollment list were randomly selected to be
included in the survey. The families of these children became the
index household and 14 families with children 7 y old and living
close to each index household were randomly selected to become the
Secondary Sampling Unit.
Subjects. Children 7 y old were selected from 30 randomly
chosen households in 7 provinces and 3 cities in the DPRK. This
provided 6000 households from which 1 child was selected for the
study. For families that had more than 1 child, the last child born was
enrolled in the survey.
Administration of questionnaires. Each household selected was
visited by a member of the survey team who administered a questionnaire to assess household food availability and source of food, maternal food intake and frequency, and general health questions.
Anthropometric measurements. Data collection was completed
by a team of trained staff members from the DRPK Central Bureau of
Statistics using the standardized protocol established by the WHO.
Each child selected and his/her mother had their weight, height, and
mid-upper arm circumference measured. Weight was measured with a
UNISCALE, and height/length was measured with a wooden board
specially developed for this project. UNICEF provided plastic insertion tapes that were used to measure mid-upper arm circumferences of
children under 2 y. Anthropometric measurements were conducted
following the manufacturers instructions and the UNICEF recommendations. All staff received follow-up training based on the standards established by the WHO as described in Nutrition Assessment

2000 DPRK (11). We used the WHO definition of stunting and

wasting in which stunting is defined as an HAZ of 2.0 or lower, and
wasting is defined as a weight-for-height Z-score (WHZ) of 2.0 or
lower, relative to the NCHS/WHO reference (26).
The World Food Program. The DRPK, a communist country,
supplies foods to the population through a public distribution system,
rather than through markets often seen in capitalist countries. Because this food distribution system has not been sufficient to ensure
adequate nutrient intake for all citizens, the use of food assistance
from international organizations, such as the WFP is required. Therefore, mothers of the children were asked to identify the main source
of foods for the household. In this paper, the children in households
that used the WFP food aids as a main source of foods stored by the
household were compared with those in households that reported
other (e.g., public distribution system) as a main source of foods.
Mothers were also asked if they received food supplements (e.g.,
300-kcal biscuits) from the WFP.
Statistical methods. Means SD are presented in the tables and
differences between sexes for subject characteristics were assessed
with Students t test (SPSS for Windows 10.0). Logistic regression
was used to explore factors (childs age and sex and mothers age and
education) that might be associated with stunting and wasting (11)
and odds ratios (OR) were estimated from these equations (SAS
Institute). Differences were considered significant at P 0.05 and
95% CI were calculated for the OR.

RESULTS
Boys and girls did not differ with respect to anthropometric
measurements, age, or maternal age and weight (Table 1).
HAZ was 1.72 0.99, WHZ was 0.50 1.01, and WAZ
was 1.48 0.86; boys and girls did not differ for these
variables. Of the children examined, 7.4% lived in households
that identified food aid from the WFP as their main food
source and 5.5% reported having received the supplement
from the WFP. These data were reported as household, not
individual, use of the food aids and supplements from the
WFP.
For the entire 6000 child sample, 39.4% were stunted and
8.2% were wasted (Table 2). When the data were split by sex,
40.2 and 9.1% of the boys were stunted and wasted, respectively. Among girls, 38.5% were stunted and 7.3% were

TABLE 1
Physical characteristics of children 17 y old living
in the DPRK1
Variable
n
Age, y
Height, cm
Weight, kg
Maternal age, y
Maternal weight,
kg
HAZ
WHZ
WAZ
WFP foods,2 %
WFP
supplements,3
%

All children

Boys

Girls

6000
2.55 1.77
82.3 14.1
10.85 3.38
30.75 4.11

3115
2.55 1.76
82.9 14.00
11.09 3.40
30.74 4.10

2885
2.55 1.78
81.7 14.1
10.59 3.35
30.77 4.13

49.57
1.72
0.50
1.48
7.4

49.51
1.75
0.53
1.51
7.2

49.63
1.68
0.46
1.45
7.6

5.5

5.33
0.99
1.01
0.86

5.6

5.18
0.98
1.01
0.84

4.13
1.01
1.01
0.88

5.4

1 Values are means SD or %.

2 The percentage of households responding that they used WFP

Foods as their primary source of food.

3 The percentage of households responding that they used WFP
Food Supplements.

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are both logistically and fiscally difficult. This is of particular

importance for an entire generation that has become growth
retarded, a condition that could have serious detrimental
effects on health and development even if (when) economic
conditions improve.
Stunting is of particular concern to the long-term health
status of any society because evidence from both human and
animal studies supports the hypothesis that chronic undernutrition, severe enough to cause permanent growth retardation,
is associated with later risk for chronic metabolic diseases
(1216). In addition, substantial evidence supports a significant role of growth retardation in impaired cognitive functions
(17,18), physical capacity for labor (19 21), and impaired
immune function (3,22). Taken together, it is clear that preventing or treating growth retardation in countries with precarious economic conditions may play a major role in promoting future productivity and overall social and economic
development (23).
Thus, there is a great need for surveillance of the nutritional status of both adults and children during such periods of
widespread and chronic food insecurity. Children in particular
require periodic monitoring to ensure that they are not being
subjected to excessive periods of undernutrition. Therefore,
the specific aim of this paper was to present the prevalence of
stunting and wasting in children living in the DPRK in comparison to the earlier report by Katona-Apte and Mokdad (24)
and to explore characteristics that are associated with stunting.

453

HOFFMAN AND LEE

454

TABLE 2

TABLE 3

Prevalence of stunting and wasting in boys and girls and by

age from 1 to 7 y in the DPRK

Odds ratio for stunting among 2- to 7-y-old children

living in the DPRK1

Stunted

Wasted
%

Sex
Boys
Girls
Age, y
1
11.99
22.99
33.99
44.99
55.99
66.99

OR (95% CI)
Variable

40.2
38.5

9.1
7.3

20.8
41.4
46.5
47.4
47.9
44.7
45.9

6.3
12.8
8.1
6.4
7.2
6.1
6.0

Equation 2

1.22 (1.18, 1.27)

1.07 (0.96, 1.18)
0.92 (0.81, 1.04)
0.98 (0.96, 0.99)

1.23 (1.18, 1.27)

1.07 (0.96, 1.18)
0.92 (0.81, 1.04)
0.98 (0.96, 0.99)

0.73 (0.56, 0.94)

0.62 (0.50, 0.78)

1 Logistic regression was used to explore factors that might be

associated with stunting and wasting (2) and OR were estimated from
these equations.
2 Reference for sex: Boys.
3 Reference for use of WFP products: Yes.

NCHS data. The prevalence of stunting (Table 2) by year of

age for children 1 y old was similar (between 41.4 and
47.9%), whereas 21% of children 1 y old were stunted.
Wasting (Table 2) was most prevalent in children 12 y old
(12.8%) and, except for those in the 1- to 2-y range, all
children had a similar prevalence of wasting (between 6.0 and
8.1%).
Possible factors that may be related to risks of stunting and
wasting were explored with logistic regression analysis (Table
3). The risk for being stunted was higher for older children and
children born to younger mothers (OR 1.22, 95% CI: 1.18,
1.27 and OR 0.98, 95% CI: 0.96, 0.99, respectively), but
lower for children from families reported using WFP Food Aid
as the primary source of food (OR 0.73, 95% CI: 0.56, 0.94).
When the use of WFP supplements was substituted for the use
of WFP Food Aid, the risk of stunting was increased for older
children and children born to young mothers, but decreased
for children whose families reported use of WFP supplements
(OR 1.23, 95% CI: 1.18, 1.27; OR 0.98, 95% CI: 0.96,
0.99; OR 0.62, 95% CI: 0.50, 0.78, respectively).
With respect to wasting (Table 4), when analyzed with the
use of WFP Food Aid as the primary source of food, older

TABLE 4
Factors associated with wasting among 2- to 7-y-old children
living in the DPRK1
OR (95% CI)
Variable
Age
Sex2
Mothers education
Mothers age
WFP food aid as primary
source of food3
Use of WFP food supplements
FIGURE 1
The distribution of stunting (HAZ less than 2.00,
panel A) and wasting (WAZ less than 2.00, panel B) among 6000
children 17 y old based on a survey conducted by UNICEF and the
Central Bureau of Statistics in the DPRK in 2002.

Equation 1

Equation 2

0.93 (0.87, 1.00)

1.28 (1.06, 1.54)
0.89 (0.72, 1.12)
1.01 (0.98, 1.04)

0.93 (0.87, 0.99)

1.28 (1.06, 1.54)
0.90 (0.72, 1.12)
1.01 (0.98, 1.04)

1.14 (0.78, 1.67)

1.21 (0.88, 1.69)

1 Logistic regression was used to explore factors that might be

associated with stunting and wasting (2) and OR were estimated from
these equations.
2 Reference for sex: Boys.
3 Reference for use of WFP products: Yes.

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wasted. The distribution of HAZ was below that for the

NCHS/WHO reference (26) (Fig. 1A) and was consistent
with a high prevalence of stunting. The WHZ was normally
distributed (Fig. 1B) and similar to that expected from the

Age
Sex2
Mothers education
Mothers age
WFP food aid as primary
source of food3
Use of WFP food supplement3

Equation 1

NUTRITION IN THE DEMOCRATIC PEOPLES REPUBLIC OF KOREA

455

children had a borderline significant decreased risk of being

wasted (OR 0.93, 95% CI: 0.87, 1.00) and boys had an
increased risk of wasting (OR 1.28, 95% CI: 1.06, 1.54).
When WFP supplement use was included in the analysis, the
same pattern was found in which the risk for wasting was
decreased among older children and increased for boys (OR
0.93, 95% CI: 0.87, 0.99 and OR 1.28, 95% CI: 1.06,
1.54, respectively). The use of WFP Food Aid or supplements
did not influence the risk of being wasted.
DISCUSSION

FIGURE 2 A comparison of stunting (HAZ less than 2.00, panel

A) and wasting (WAZ less than 2.00, panel B) among 6000 children
17 y old based on a survey conducted by UNICEF and the Central
Bureau of Statistics in the DPRK in 2002 and results from a survey
taken in 1997 (24).

be ruled out completely. Finally, we examined the data for

HAZ using both years of age as well as months of age and
found the same distribution pattern. In addition, we used
smaller groupings of HAZ, defining them by 0.25 Z-score and
the same distribution occurred. Thus, we are not able to
explain exactly why there was a larger frequency of stunted
children between 3.00 and 3.50 and between 2.00 and
2.50 compared with the other Z-scores because there is no
apparent biological or statistical explanation for this observation.
Although our analysis of factors associated with growth
retardation was limited by the lack of some relevant variables,
such as monthly income and sanitation history, the results
tend to support those reported by others (2). That is, girls and
children born to younger mothers are more likely to be stunted
or wasted, but maternal education was not a significant predictor of stunting. This is of particular interest because several
previous studies reported a significant negative relation be-

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The prevalence of stunting has decreased throughout the

world, but the prevalence of undernutrition and starvation
remains relatively high in many developing nations (1,7).
Efforts to reduce the prevalence of stunting and wasting, when
available or accepted by the country in question, have focused
on providing humanitarian and technical assistance to improve both dietary intake and overall health. The DPRK is an
example of a country that is suffering unknown fallout from its
economic and political isolation, coupled with military spending that exceeds 20% of the gross domestic product (27), but
continued efforts to provide food aid have been successful
(11). The objective of this paper was to document the state of
nutrition for children living in the DPRK and to explore those
factors that are associated with stunting among children.
Based on a survey of 6000 households in the DPRK, stunting
and wasting continue to be major public health problems for
that countrys children.
In 1998 Katona-Apte and Mokdad reported that the prevalence of stunting and wasting in the DPRK was 39.6 and
17.4% among boys and 36.8 and 15.5% among girls (24). This
suggests that, in 2002, stunting is still highly prevalent,
whereas wasting is less prevalent (Fig. 2). However, it should
be noted that the sampling methodologies used in the 2
surveys were different. The earlier survey was conducted
among 3965 children in selected nurseries and kindergartens
in 4 provinces (Kangwon, South Hwanghae, South Pyongan,
and South Hampyong), whereas the 2002 survey utilized a
multistage random sampling method to obtain a sample of
6000 children with a wider age range and from more provinces
in the country (7 provinces and 3 cities). Given that the 2
surveys did not use the same sampling protocol, comparing the
results between them may not provide a complete understanding of the changes in the undernutrition status in the DRPK.
However, they are the only data available on the children in
the DRPK, and the surveys were conducted through direct
involvement of or in collaboration with the UNICEF. Therefore, the comparison will allow us to understand the general
direction of the trend in the nutritional status of the children
in the DRPK.
The prevalence of wasting decreased, whereas that of stunting did not change between 1997 and 2002 (24). Although
the prevalence of wasting was normally distributed, the distribution of HAZ had a trimodal distribution. We have no
definitive reason for this distribution, but possible explanations include a disproportionate number of children 1 y old
in the survey, measurement error, or an effect of rounding of
age to years. Regarding the first explanation, 80% of the
6000 children measured were 1 y old and the mean HAZ of
these children was 1.86 compared with those 1 y old
whose mean HAZ was 1.25. When these children were
excluded from the dataset, the distribution pattern persisted,
suggesting that the first explanation is unlikely. For the second
possibility, given that the distribution for WHZ was normal, it
is not likely to result from measurement error, but this cannot

HOFFMAN AND LEE

456

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tween maternal education and degree of growth retardation

(2,5). Why our results for these 2 decidedly important factors
differ from other studies is a difficult question given the large
number of households surveyed. One possible explanation
could be that the socioeconomic status of citizens living outside of the capital, Pyongyang, does not vary widely between
households. This would basically leave us with a sample of
mothers and children who vary in few real ways, especially
education and nutritional status. At the same time, it is
important to take away the indirect message of this discrepancy, i.e., that food aid in and of itself is only one factor that
can promote nutrition in impoverished areas of the world. It is
important to continue to improve womens status and education, and this should be integrated into long-term development programs.
The results of this survey provide encouraging evidence
that acute undernutrition in the DPRK has abated somewhat,
but there is substantial evidence that chronic, mild undernutrition exists and is leaving a large proportion of children
growth retarded. This observation has important long-term
implications because recent studies suggest that a positive
relation exists between stunting and poor physical outcomes
(12,13,28 33). In addition, growth retardation is also associated with impaired cognitive functioning (17,18,34). Taken as
a whole, growth retardation can leave an individual physically
(20,35,36) and cognitively less able to contribute to the workforce, a significant factor that may influence productivity and
overall development.
In conclusion, we found that the prevalence of stunting
remains high in the DPRK, whereas the prevalence of wasting
appears to have declined since 1997. Continued efforts to
improve nutritional status among children in the DRPK are
warranted.