1. National nutrition survey september 17 to october 17 2012 CBS, ICN, MOPH, UNICEF, WFP, WHO

2. Content Methodology Children’s results Mothers’ results Conclusion
Sampling
Indicators
Survey staff
Data management
Children’s results
Nutritional status
Breastfeeding
Complementary feeding
Mothers’ results
Multi-Micronutrient supplementation
Feeding practices
Conclusion

3. Survey description Objectives Type of survey Target population:
To collect updated information on the nutritional and health status of children and women in DPRK
To inform policy makers and program managers on priority sectors and strategies.
Type of survey
Cross-sectional, stratified, two-stage cluster survey based on the SMART and MICS methodologies
Provide estimates for:
10 Provinces (Nampo included in South Pyongan Province)
National level estimates derived by weighting the un-weighted Provincial results according to population size
Target population:
All children aged 0 to 59 months
Their mothers aged 15 to 49 years

4. SMART / MICS
SMART:
S-Standardized
M-Monitoring
A-Assessment
R-Relief
T-Transition
Simplified, standardized survey methodology for emergency situations
MICS:
Multiple Indicator Cluster Survey

5. Methodology

6. Sampling The primary sampling unit (PSU) is the Ri/Up/Ku/Dong
Random selection by the Central Bureau of Statistics (CBS) among all the Ri/Up/Ku/Dong in each Province with a systematic probability proportional to size (PPS) method
Final planned number of children to be assessed was:
840 children for all Provinces but only 440 children for haemoglobin
480 children for Pyongyang for all indicators

7. Indicators for children
Age group (months)
Global chronic malnutrition / Stunting
0-59.9
Severe chronic malnutrition / Severe stunting
Moderate chronic malnutrition / Moderate stunting
Global acute malnutrition (GAM) / Wasting
0-59.9,
Severe acute malnutrition (SAM) / Severe wasting
Moderate acute malnutrition (MAM) / Moderate wasting
% with MUAC <125mm and % with MUAC <115mm
6-59.9
Prevalence of anaemia
% who received Vitamin A in last 6 months
Morbidity prevalence (sickness) over 14 previous days
Prevalence of diarrhea and Respiratory Tract Infection
Exclusive breastfeeding proportion
0-5.9
Timely introduction of solid, semi-solid, soft foods
6-8.9
Minimum dietary diversity
6-23.9
Early initiation of breastfeeding
0-23.9
Continued breastfeeding proportion at 1 year

8. Measurements of children

9. Indicators for women Mothers Age group (years) % with MUAC <210mm
% with MUAC <180mm
% with MUAC <225mm
Prevalence of anaemia in all women
Prevalence of anaemia in pregnant women (only national estimate)
Proportion of women who received multi-micronutrient supplement during pregnancy
with U2 children
Length of multi-micronutrient supplementation
Minimum dietary diversity

10. Measurement of Mothers

11. Survey staff Total of 60 surveyors
2 teams of 3 surveyors per province
1 team leader, 2 enumerators from CBS and ICN
Ri/Dong doctor available to take blood samples for hemoglobin test 
Training of trainers (4 days) for CBS and ICN
Training of surveyors (6 days) in the 2 weeks previous data collection

12. Results for children

13. Chronic malnutrition in children 0-59 months – Stunting (Height for Age)
Public Health issue*: Very High
Public Health issue: High
Public Health issue: Medium
* WHO (2000) Public health issue classification

14. Stunting according to age groups

15. Acute malnutrition in children 0-59 months – Wasting (Weight for Height)
Public Health issue*: Serious
Public Health issue: Acceptable
* WHO (2000) Public health issue classification
Public Health issue: Poor

16. Acute Malnutrition (wasting) according to age groups

17. Anemia in children aged 6-59 months and mothers
Public Health issue*: Severe
Public Health issue: Moderate
Public Health issue: Mild
Public Health issue: Normal
* WHO (2000) Public health issue classification

18. Anemia in children 6-59 months

19. Mothers who received multi-micronutrient supplementation during their last pregnancy

20. Length of multi-micronutrient supplementation during last pregnancy

21. Infant and Young Child Feeding Practices
IYCF indicators
Age group
1. Early initiation of breastfeeding
0 to 23.9 months
2. Exclusive breastfeeding under 6 months
0 to 5.9 months
3. Continued breastfeeding at 1 year
Continued breastfeeding at 2 years
12 to 14.9 months
20 to 23.9 months
4. Introduction of solid, semi-solid or soft foods
6 to 8 months
5. Minimum dietary diversity
6 to 23.9 months
6. Minimum meal frequency
Not assessed
7. Minimum acceptable diet
(compilation of 1,2,3,4,5,6)
8. Consumption of iron-rich or iron-fortified food
Consumption of vitamin A rich food was also assessed

22. Feeding practices in children and mothers

23. Early initiation of breastfeeding (within 1 hour after birth)

24. Exclusive breastfeeding
Exclusive breastfeeding in the 647 children aged months: 68.9%
No difference between boys and girls
Actual results for exclusive breastfeeding:
Correspond to the DPRK 2004 Nutrition Assessment in which 65.1% of children <6 months were exclusively breastfed
Are much lower than the 88.6% reported in MICS 2009
Due to small sample size, comparison of exclusive breastfeeding and breastfeeding up to 1 and 2 years by province and with stunting, wasting and anaemia could not be done
Why exclusive and continued breastfeeding are so important ?
Exclusive breastfeeding from birth to 5.9 months can prevent up to 13% of children’s death
Breastfeeding is exclusive when no fluids including water and no food items are given beside breastmilk
Continued breastfeeding up to 1 year or 2 years old has positive impact on children’s death through the prevention of main childhood disease killers which are diarrhoea and pneumonia

25. Complementary feeding
Mix breastfeeding
Exclusive BF

26. Proportion of children 6-23 months and mothers who consumed specific food groups essential for growth and health
Food groups consumed by children
% children 6-23m who had at least once
Food groups consumed by mothers
% mothers who had at least once 1
Grains, roots, tubers
89.2%
Starchy staples
99.6% 2
Legumes and nuts
28.1%
53.2% 3
Milk, yogurt, cheese
15.8%
Milk and milk products
2.4% 4
Meat, fish poultry and liver/organ meats
30.0%
Meat and fish
40.4% 5
Eggs
12.6%
7.7% 6
Vitamin A rich fruits and vegetables (pumpkin, carrots, etc.)
38.3%
Organ meat
2.2% 7
Other fruits and vegetables
37.4%
Dark green leaf vegetables
54.4% 8
Other caloric foods (fats and sweets)
73.9%
Other vitamin A rich fruits and vegetables
26.8% 9
Other non-caloric foods (spices, clear soup, water)
86.2%
69.3% 10
Breastmilk
64.6%
Others (fats, sugar, water, etc.)
99.5

27. Number of food groups consumed by children 6-23m and mothers
Minimum dietary diversity: 4 food groups / day over the recommended 7 food groups for children or 9 food groups for mothers

28. Proportion of children 6-23m and mothers who eats at least 4 recommended food groups per day

29. Iron and vitamin A rich foods consumption in children 6-23 months and mothers
Iron-rich food by children
Iron-rich food by mothers
Liver, kidney, heart, or other organ meats
Dark green leafy vegetables
Any meat, such as beef, pork, lamb, goat, chicken, or duck
Organ meat
Fresh or dried fish, shellfish or seafood
Meat and fish
spinach, broccoli, sea weed and other dark green vegetables
Vitamin A rich food by children
Vitamin A rich food by mothers
Liver, kidney, heart, or other organ meats
Dark green leafy vegetables
Eggs of all sorts
Other vitamin A rich fruits and vegetables
Pumpkin, carrots, sweet potatoes, and other vitamin A rich vegetables (yellow or orange inside)
Organ meat
spinach, broccoli, sea weed and other dark green vegetables
Eggs
Apricot, peach

30. Iron and vitamin A rich-food consumption in children 6-23
Iron and vitamin A rich-food consumption in children months and mothers

31. Discussion and recommendations

32. Stunting (chronic malnutrition) and Wasting (acute malnutrition) in absolute numbers
Total number of cases of global stunting malnutrition (chronic)
Total number of cases of severe stunting malnutrition (chronic)
Total number of cases of global acute malnutrition
Total number of cases of severe acute malnutrition
DPRK
68 225
10 234

33. Undernutrition
Stunting (chronic malnutrition) has irreversible impact on the development of children and then also on the Country development:
Implementation of interventions directly in the communities while improving the role of the Provincial and County levels is essential
Wasting (acute malnutrition) situation does not suggest emergency operations but still impairs child growth during acute episode so it cannot be forgotten
The management of acute malnutrition at hospital and community levels need to continue and to be expanded
MDG1 partially achieved with the reduction by 50% of the underweight since 1990
Underweight is a mix indicator of stunting and wasting

34. Infant and Young Child Feeding (IYCF) practices
Exclusive breastfeeding practice is good but improvement is necessary to increase its practice up to 6 months
Increase of the early initiation of breastfeeding is essential to have more impact on neo-natal mortality
Delayed complementary feeding at 6 months and the low food diversity needs to be strongly addressed
This has high impact on the development of children (stunting and acute malnutrition)

35. Anemia
High prevalence of anemia in children and women and requires more attention as it has important impact on the outcome of pregnancy and children development
Despite similar anemia prevalence, women (74.3%) consume more animal or vegetal iron-rich foods than children (49.5%)
Anemia in children could be lowered with:
Intensified promotion efforts on the importance of iron-rich food in development
Multi-micronutrient supplementation associated with deworming

36. Mothers’ nutritional status
Moderate decrease in undernutrition since MICS 2009 from 25.6% to 23.2% but still a lot of progress to be done
The high prevalence of anemia and the low food diversity strengthens the need to:
Improve the multi-micronutrients supplementation during pregnancy and in lactating women
Improve the iron and folic acid supplementation in pre-pregnant women
Actively promote adequate food diversity based on accessible / available food at home
Although improvement is needed, the better food diversity in mothers illustrate the possibilities to improve children’s food diversity with accessible / available food groups at household level

37. Recommendations
Enhance the coordination of interventions needed in early life, starting during or even before pregnancy, up to two years old
Re-dynamize of the promotion of infant and young child feeding practices for both breastfeeding and complementary feeding
Strengthen of the promotion of healthy feeding practices among women mainly during pregnancy and lactation
Implement multi-sectoral interventions combining mother’s nutrition, infant and young child feeding, hygiene practices, other nutrition interventions, health, WASH, food security and agriculture

38. Conclusion
The achievement in decreasing underweight over time (MDG 1), as well as stunting (chronic malnutrition) and wasting (acute malnutrition), are due to concerted efforts between the Government, the UN Agencies and others partners in DPRK in addressing the different causes of malnutrition
Despite all efforts, malnutrition is still of serious concern and requires continued and strengthened interventions on acute and especially chronic malnutrition in order to have more impact on the underweight prevalence and to ensure a more optimal growth of Korean children

39. Thank you !