The number of North Korean refugees (NKRs) in South Korea (SK) increased dramatically from an average of 8.5 per year in the early 1990s to over 1,000 per year in the 2000s [1]. Initially, the defections were driven by financial constraints and food shortages in North Korea (NK) [2], and recently, NKRs have been migrating to SK with their families, resulting in an increase in the number of adolescent refugees [3]. As of June 2021, a total of 33,788 NKRs have entered SK, with 3,591 of them being between the ages of 10 and 19. However, this data may not reflect the actual number of NKRs in SK, as it does not account for those born in other countries [4].

Adolescents from NKR families in SK have been impacted by the drastic differences in the lifestyles of the two countries after defection, including changes in dietary habits that could affect their physical development in addition to academics and other factors [5]. Studies have shown that children and adolescents who have fled NK and entered Hanawon, a resettlement center in SK, are 19% shorter and weigh 15% lower than South Korean children and adolescents of the same age [6]. This has led to North Korean adolescents being more concerned about their height, compared to those from SK [7, 8]. North Korean adolescents are also at a higher risk of chronic diseases due to nutritional deficiencies seen in early childhood [9]. Adolescence is an important stage of growth and development. It is therefore crucial that adolescents have a balanced diet and healthy eating habits to provide them with adequate nutrition for healthy growth [10]. However, adolescents in general, including those from NKR families, often have irregular eating habits, miss breakfast, and consume high-calorie, low-nutrient foods, which can lead to nutritional imbalances. NKR adolescents are also likely to be less involved in regular physical activities due to academic pressures [11]. Given the history of poverty and starvation that the NKR youths have experienced, it is important to provide them with adequate nutritional support and to find ways to improve their diet and eating behavior.

Research on the nutritional status or dietary habits of adolescents from migrant families has been poorly reported, particularly from developed countries. Eating behavior varies greatly between ethnic groups, families, and individuals, and has a significant impact on an individual's health. Several studies regarding the nutritional status of NKRs have been conducted, but most of them have focused on assessing their nutritional status [4, 12]. Thus, studies that analyze their eating behavior using an objective instrument are lacking.

This study aimed to examine the nutritional status and eating behavior of adolescents from NKR families settled in SK. The study applied the Nutrition Quotient for Korean Adolescents (NQ-A) to investigate and evaluate their eating habits in terms of their nutritional status. The results of this study could provide a better understanding of the nutrition and eating behavior of North Korean adolescent refugees which would help in the design of health and nutrition education programs for them in the future.

This study assessed the nutritional status of 178 adolescents from NKR families who grew up in SK and examined the association between their dietary behavior and nutritional status using the NQ-A.

Ascertaining appropriate eating behavior and maintaining proper nutrition during adolescence is crucial, as it can greatly influence physical and emotional development, academic performance, and lifetime health [10]. According to the 2017-2019 Korea National Health and Nutrition Examination Survey, the proportion of underweight Korean adolescents with a standard score < -2SD in WAZ was 4.2% in 2017, 4.7% in 2018, and 3.5% in 2019 [16]. The prevalence of malnutrition among North Korean adolescent refugees observed in this study was about three times (11.8%). On the other hand, the obesity rate of the study participants was 10.1%, which is not greatly different from the obesity rate of 15.7% among adolescents in Korea in 2019 [16]. This may suggest that NKR adolescents are experiencing the issue of the 'double burden’ of malnutrition wherein both undernutrition and obesity coexist [12].

The relatively high rates of malnutrition and obesity among adolescent refugees seem to be related to the socioeconomic problems faced by the NKR families. The Ministry of Unification, SK reported that the monthly household income of NKRs has improved but is still lower than that of the general South Korean population [3]. The lower socioeconomic status of NKRs is associated with poor meal quality and/or starvation. Leading to a higher prevalence of the double burden of undernutrition and obesity [17]. Kim et al. [5] also reported that NKRs experience physical and mental stress due to differences in their eating pattern compared to their place of birth. NKRs need to adapt to unfamiliar ingredients, recipes, and condiments which are integral to South Korean culture. Studies have shown that refugee adolescents have low adherence to new types of vegetables such as broccoli and celery, dairy products, and sauces (e.g. mayonnaise), which they had not consumed till their shift to SK [18]. These socioeconomic and dietary differences faced by the adolescent refugees in addition to other general problems commonly associated with adolescents, such as poor eating behavior - missing breakfast, lower intake of natural foods, and increase in the intake of instant foods, may influence the nutritional status of these youth. These factors could explain the poor nutritional status and associated health issues among them.

Previous studies have reported that the malnutrition rate of NKRs improves by 0.7% - 3.4% after 5 years of resettlement in SK [4]. In addition, growth may vary depending on the living environment and the food intake levels of adolescents [15]. In line with this, analyses were performed to examine whether the age and period of resettlement of the NKR youths affect their nutritional status. However, the results suggested that the period of resettlement and the puberty period spent in SK were not significantly associated with nutritional status. This may be due to the differences between the participants of this study and those in earlier studies. Unlike earlier studies conducted with children under 12, this study was conducted on adolescents. The onset of puberty in an individual and the rate of growth varies by a differential degree. Additionally, malnutrition in the early stages of life may not be compensated for by later environmental changes and improved nutrition [19]. These factors may be associated with the lack of significant changes in the nutritional status based on the timing and duration of settlement in SK of these study participants.

In this study, the total NQ-A scores and individual factor scores of the adolescents with three different types of nutritional status were compared, but there was no significant difference between the normal, malnourished and obese groups. In an earlier study on a nationwide scale, the overall average NQ-A score was 56.0, and for each factor, the scores were as follows: 58.6 for balance, 55.6 for diversity, 48.1 for moderation, 70.6 for the environment, and 52.1 for practice [11]. Inconsistencies have been reported from many earlier studies that examined the distribution of nutritional status and NQ/NQ-A/NQ-preschoolers scores [20, 21, 22]. In this study, the overall NQ-A scores of the participants tended to be low, and hence there was no significant difference in the scores between the groups. The participants of this study also had lower scores for overall average, balance, diversity, moderation, and environment of eating behavior, but higher scores for practice, compared to South Korean adolescents. A large difference in scores was evident in the area of environment between the SK and NKR groups. The practice factor includes items such as checking nutrition fact labeling, washing hands before meals, and frequency of exercise. The environment factor includes items such as intake frequency of breakfast, not moving around while eating, and screen time [11]. As described above, although an earlier study had shown that the malnutrition rate for NKRs who have lived in SK for more than 5 years improved, the rate was still higher than that in South Koreans [4]. The lower socioeconomic status of NKRs and their children in SK may lead to health disparities. However, the relatively higher score for practice for NKR adolescents may play a positive role in improving their nutritional status in the future. Eating behaviors are known to be influenced by the home environment for younger children. However, school and social-environmental factors, such as nutritional knowledge and the preferences of friends have a greater effect with time [23]. Also, parents’ eating behavior, which determines the dietary pattern for the entire family, remains important with respect to the acceptance of new foods for children from outside SK [22]. Considering the differences in the environmental factor scores seen in this study, to improve the nutritional status of adolescents in NKR families, it is important to implement educational programs that encourage or strengthen parental participation, taking into account the socioeconomic environment of NKRs.

The nutritional status of the study subjects was classified into three groups - high, middle, and low grades, using NQ-A scores and most of the NKRs in this study were in the low to middle group requiring continuous monitoring [11]. Adolescents in SK who belong to the low grade have shown significantly lower values for vitamin C, potassium, and zinc intake, but higher values for fat, compared to the recommended level, than those in the high group [11]. Additionally, according to the 2020 Korea Youth Risk Behavior Survey data, increased intake of high-calorie and high-fat foods with high lipid content, but reduced vitamin C, folic acid, and potassium intake from fruits and vegetables and lower physical activity have been reported [11, 24]. Given this, although dietary consumption data was not investigated in the present study, NKR youth may also have poor nutritional intake. Such inappropriate dietary intake should be considered while formulating the nutrition and dietary behavior education of adolescents from NKR families [11].

This study has some limitations. First, due to the limited sample size, analysis of the nutritional status and dietary behavior by gender was not performed. Additionally, the study subjects were not representative of all NKR adolescents in SK because they were not randomly recruited. Also, the study did not survey food and nutrient consumption. The economic status of the family or the educational qualifications of parents that may affect the growth and nutritional status of adolescents were not considered in the analyses. Last, NQ-A is a dietary evaluation tool for South Korean adolescents, and its use in evaluating the eating habits of NKR youth with different food and cultural backgrounds may not be appropriate. However, the results of this study provide preliminary data for a better understanding of the eating behavior and nutritional status of NKR adolescents in SK.

NKR adolescents showed a higher prevalence of malnutrition, compared to SK adolescents. However, no significant differences in dietary behavior between nutritional groups were evident as evaluated by the NQ-A scores. Given the socioeconomic challenges for NKR families and the importance of nutrition for adolescents, it is necessary to develop and implement appropriate nutrition education programs to improve the nutritional status and dietary behaviors of NKR adolescents.