Is the US worse than North Korea for malnutrition deaths?

Summary

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More or Less Podcast Summary

Episode: Is the US worse than North Korea for malnutrition deaths?
Host: Tim Harford
Date: June 20, 2026
Podcast: BBC Radio 4

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Overview

In this episode of More or Less, Tim Harford examines the startling claim circulating on social media that the United States suffers more deaths from malnutrition than North Korea or China. Using statistics from the Global Burden of Disease database, the episode critically investigates what lies behind these numbers, the reliability of international statistics, and how malnutrition is recorded as a cause of death in the US.

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Key Discussion Points and Insights

1. The Viral Claim and Source Data ([00:00]–[01:38])

• Claim: "The United States has surpassed China and North Korea in deaths from malnutrition." ([00:48])
• Source: Graph from Our World in Data, based on the Global Burden of Disease (GBD) data.
• Statistic: US death rate from malnutrition reportedly at 2.8 per 100,000, higher than North Korea’s 1.7 per 100,000. ([00:54])

Host’s Immediate Reaction:

• Tim Harford expresses skepticism:

  “From what we know about the two countries, this seems unlikely. So what's going on here?” ([01:18])

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2. Understanding Data Limitations, Especially for North Korea ([01:38]–[02:49])

• IHME’s Approach: Uses all available data sources (UN agencies, WHO, household surveys, etc.).

• Data Quality Issues:

  • North Korea’s isolation means little reliable, direct data available.
  • Even the UN admits:

    “An independent assessment of the humanitarian situation is not possible.” ([01:57], UN’s human rights lead quoted by Tim Harford)

• Context for North Korea:

  • Approximately 40% of the population malnourished; 18% of children stunted ([02:10]).
  • Agricultural and infrastructure limitations, history of drought/famine.

• IHME’s Caution:

  “Finding that the US age standardized death rate exceeds North Korea's estimated is best interpreted with appropriate caution.” ([02:41])

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3. Why Are US Malnutrition Death Rates Rising? ([02:49]–[05:08])

Guest Expert: Dr. Christina Newport (Penn State Health, American Academy of Hospice and Palliative Care Medicine)

• What Is Malnutrition?

  “Malnutrition is a state that results from deficiencies or imbalances in a person's intake of energy or nutrients.” ([03:20], Dr. Newport)

• What’s Being Measured?

  • US data is based on death certificates listing malnutrition, which covers a broad range of diagnoses—sometimes just abnormal weight loss.

  “It doesn't always mean that it's an issue of somebody not taking in nutrition or their body not using it correctly.” ([03:43], Dr. Newport)

• Primary vs. Secondary Malnutrition:

  “There's a very small number of people for whom malnutrition is listed as a cause of death who are dying from a primary nutritional problem. ... The majority ... are dying from another cause, and weight loss is a symptom of that condition.” ([04:08], Dr. Newport)

• Populations Affected:

  • Most victims are elderly (mostly over 85 years old), where malnutrition is often secondary to chronic diseases like cancer or dementia.
  • The rate for those over 85 is 60 times higher than the general US population. ([04:30])

• Is food security the root cause?

  “We don't have any evidence to say that primary malnutrition is actually on the rise. We are just identifying it better and documenting it better than we had in the past.” ([05:08], Dr. Newport)

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4. Why Did Numbers Rise After 2012? ([05:08]–[06:13])

• Change in Reporting Practices:
  • 2012 Initiative: ASPEN launched an educational campaign pushing for more careful documentation of malnutrition in medical records.

  “It became a tool for regulatory bodies to measure the quality of care that was being delivered.” ([05:46], Dr. Newport)

  • Hospitals now more likely to note malnutrition or weight loss, especially for influencing patient care metrics/outcomes.

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5. Consequences of Documentation and Certification Practices ([06:13]–[08:34])

• Intersection with Hospice & Medical Reporting:

  • Malnutrition now tracked to qualify patients for hospice care and for hospital reporting.

  "Measurements of nutrition have become an important component of identifying whether a person is dying from your condition." ([07:02], Dr. Newport)

• How Death Certificates Get Filled Out:

  • Non-specialists often complete them; if malnutrition is in the medical record, it’s more likely to appear as a contributing cause on the certificate.
  • Greater scrutiny (e.g., autopsies) often removes malnutrition as a primary listed cause.

  "That leads us again to presume that in many of these cases a diagnosis is being used because it was measuring a symptom of another condition.” ([07:35], Dr. Newport)

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Notable Quotes and Memorable Moments

• Statistical Whiplash:

  “Our heads rotated 360 degrees, like that girl in the Exorcist. Or, you know, a wise old owl.”
  — Tim Harford ([00:28])

• Expert Caution:

  “The US is now logging and tracking people with malnutrition while they're still alive, both to protect themselves as doctors and to help advocate for patients.”
  — Tim Harford ([07:20])

• Expert on Documentation Practices:

  “Most death certificates are completed by people who are not forensic pathologists... it's more likely that when the person ... reviews their chart, they see a nutritional diagnosis ... and so it gets included.”
  — Dr. Newport ([07:35])

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Key Takeaways

• US Malnutrition Deaths Are Largely a Documentation Phenomenon: The increase reflects changes in medical reporting, not a real rise in people dying because they can't afford or access food.
• North Korea’s Figures Are Unreliable: Lack of trustworthy data and severe humanitarian conditions render international comparisons suspect.
• Context Is Essential: Most US deaths attributed to malnutrition occur in the elderly and as a side effect of serious illness, not from lack of food per se.
• Popular Claims Often Ignore Nuance: Viral statistics can mislead if their context and collection methods aren’t scrutinized.

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Important Timestamps

• [00:48] — The shocking claim laid out
• [01:38] — How the Global Burden of Disease arrives at its numbers
• [02:10] — Food insecurity and agriculture in North Korea
• [03:20] — Dr. Newport explains what "malnutrition" actually means in medical data
• [04:08] — Why most US deaths "with" malnutrition aren't caused "by" malnutrition
• [05:08] — Documentation changes, not social conditions, explain rising US numbers
• [05:46] — Impact of 2012 ASPEN reporting campaign
• [07:02] — Malnutrition as a metric in hospice care qualification
• [07:35] — Death certificates and how diagnostic codes drive malnutrition figures

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Conclusion

It is not credible that the US has a higher genuine death rate from malnutrition than North Korea or China—the data actually reflect the nuances of medical documentation, not a dire public health crisis. Statistical claims, especially when they go viral, must always be examined in light of how the numbers are gathered and what they actually measure.

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Transcript

[A]

Hello and thanks for downloading the More or Less podcast with a program that looks at the numbers in the news, in life, and the inbox of more or lessbc.co.uk. and I'm Tim Harford. As sleuths of a statistical persuasion, we are used to doing double takes as bad stats whiz by. It is amazing. They're everywhere. On the sides of buses, billboards, vans, newspaper articles, government speeches, and of course, one of the main culprits, social media. One such claim on X made us do a double take so violent that our heads rotated 360 degrees, like that girl in the Exorcist. Or, you know, a wise old owl. Anyway, this was the claim the United

[B]

States has surpassed China and North Korea in deaths from malnutrition.

[A]

Below the claim was a graph from our world in data which used analysis from the Global Burden of Disease database for their sums. The data does indeed show that the US records more deaths from malnutrition than China and North Korea. The rate in the US was 2.8 deaths per 100,000, compared to just 1.7 deaths per 100,000 for North Korea. From what we know about the two countries, this seems unlikely. So what's going on here? First things first, we cannot trust the data for North Korea. The Institute for Health Metrics and Evaluation, the IHME who compile the Global Burden of Disease database, told us that they

[B]

use a systematic synthesis of all available data sources, including data from UN agencies, who mortality data, household surveys where available, and demographic and nutritional indicators.

[A]

The problem is that the UN currently cannot access North Korea, with the UN's head of human Rights in North Korea

[C]

stating that means that the humanitarian and development assistance that the United nations could provide is constrained and an independent assessment of the humanitarian situation is not possible.

[A]

Despite the lack of access, the UN reckons that around 40% of the population are malnourished and 18% of children are stunted due to not getting enough nutrients. We know their agricultural capabilities fall short of meeting the population's needs, and that they don't have access to modern equipment and fertilizers, and that they've experienced periods of drought and famine. The IHME acknowledged the high level of uncertainty with the North Korean figures, and

[B]

they told us that finding that the US age standardized death rate exceeds North Korea's estimated is best interpreted with appropriate caution.

[A]

But the trend for the US is interesting. The estimated death rate from protein energy malnutrition per 100,000 people is flat or declining in most countries in the US the rate seems to have been going up since around 2012. To find out why, we spoke to Dr. Christina Newport, lead for Palliative Care for Penn State Health and the Chief Medical Officer for the American Academy of Hospice and Palliative Care Medicine.

[D]

The actual definition of malnutrition is a state that results from deficiencies or imbalances in a person's intake of energy or nutrients.

[A]

People can and do die of malnutrition, but that's not really what's going on in the U.S. the data from the U.S. is gathered by looking at death certificates and seeing if malnutrition affects appears on them.

[D]

The data that we're actually looking at here actually encompasses a whole list of diagnoses that fall under malnutrition. And that includes just something as simple as abnormal weight loss. It doesn't always mean that it's. That it's an issue of somebody not taking in nutrition or their body not using it correctly.

[A]

The people are also generally dying with malnutrition, not of malnutrition.

[D]

There's a very small number of people for whom malnutrition is listed as a cause of death who are dying from a primary nutritional problem. A very small number. The majority of the folks that are being captured with these diagnoses are dying from another cause, and weight loss is a symptom of that condition.

[A]

For example, people suffering from cancer or often develop cachexia, a syndrome that affects how the body processes energy and causes rapid loss in weight and muscle. People with dementia can suffer from loss of appetite, difficulty chewing or swallowing, or simply forgetting to eat. The vast majority of people who die while malnourished are over the age of 85, at a rate 60 times higher than that of the general population. So is there a problem with American octogenarians not being able to afford food in general? No.

[D]

We don't have any evidence to say that primary malnutrition is actually on the rise. We are just identifying it better and documenting it better than we had in the past. And we are identifying not just nutritional issues that are a problem on their own, but we're identifying weight loss in people from for whom it's caused by another disease.

[A]

The reason the numbers have shot up since 2012 is simply that before then, they weren't recording malnutrition in the same way. In 2012, Aspen, the American Society for Parenteral and Enteral Nutrition, started an initiative

[D]

that actually led to a whole PR campaign, an educational effort to help people understand the impact of malnutrition and to better Document when we see that people are losing weight. And it became a tool for regulatory bodies to measure the quality of care that was being delivered.

[A]

Hospitals started recording symptoms of malnutrition more carefully, as malnourishment can have a huge effect on patient outcomes.

[D]

We report on how often people die in our hospitals in this country, and one of the ways that that gets reported is to take a look at how many people are expected to die of a certain condition, as opposed to how many people actually die in that hospital. And nutrition is one of the many diagnoses that can be included that can affect how high the expectation is that someone may die from a certain illness.

[A]

So it helps to clarify whether the hospital care affected the likelihood of the person's death, as people who are malnourished are much more likely to die. For this reason, malnutrition is also often used by doctors and insurance companies as a measure of whether people qualify for hospice care.

[D]

If someone lives more than six months, the healthcare clinicians on the hospice team have to explain why they think hospice is still the best way to care for someone. And so measurements of nutrition have become an important component of identifying whether a person is dying from your condition.

[A]

So the caregivers and institutions in the US are now logging and tracking people with malnutrition while they're still alive, both to protect themselves as doctors and to help advocate for patients. This then has a knock on effect when they die.

[D]

Most death certificates are completed by people who are not forensic pathologists, they're not medical examiners. It's really kind of a simple explanation that because these diagnoses are following people along through their medical documentation from a hospital, from a nursing home, from a hospice, it's more likely that when the person who's responsible for filling out the death certificate reviews their chart, they see a nutritional diagnosis listed in front of them as contributing to the death. And so it gets included in the death certificate. What we see is that it's less likely to be listed when someone has had an autopsy or has had a pathologist complete the death certificate, which tells us that when there is very close consideration and really objective measurement of what caused the death, it's less likely for the diagnosis to be used. That leads us again to presume that in many of these cases a diagnosis is being used because it was measuring a symptom of another condition.

[A]

To conclude, it's very unlikely that the US Truly has a higher death toll for malnutrition than North Korea and China. Our thanks to Christina Newport. And that's all we have time for this episode. Please do keep your questions and comments coming in to more or less at BBC Co UK until next time. Goodbye.