Data reveals a sharp spike in malnutrition-related fatalities in the United States, with individuals aged 85 and older being disproportionately affected. This article analyzes the reasons behind this sudden data surge. May 29, 2024, at a Buehler's supermarket in the Pine Ridge area of South Dakota. Columnist: Andrew Van Dam Malnutrition is spreading in an anomalous pattern. Our analysis, based on death certificate data from the U.S. Centers for Disease Control and Prevention, indicates that malnutrition has become the fastest-growing cause of death in the United States, with related fatalities surging sixfold over the past decade or so. Admittedly, malnutrition-related deaths are not yet a common occurrence—accounting for less than 1 in 100 deaths. However, given its astonishing growth rate, its current death toll now places it in the same tier as fatalities from arterial diseases, mental disorders, and violent injuries. Yet, a deeper dive into the data reveals that real-world malnutrition differs starkly from the stereotype associated with food banks and famine. Firstly, its connection to economic hardship is not as strong as one might think. Overall, malnutrition-related deaths are indeed more prevalent among residents of low-income states and those with lower education levels, but the correlation is much weaker than expected. Furthermore, state-level indicators like food insecurity rates and SNAP benefits show surprisingly low correlation with malnutrition mortality rates.
More critically, our focus is on the explosive growth in the number of deaths, not their absolute level. This surge is difficult to explain by demographic changes—it is occurring across all states, education levels, races, and genders in the country. When we dissect the data across various dimensions, only one metric shows a significant disparity: age. The malnutrition mortality rate among Americans aged 85 and older is approximately 60 times higher than that of other age groups.
What is the reason? Are American seniors facing a dietary crisis? The answer is yes, but there's more to the story. Uche Akobundo, a nutritionist and Director of Nutrition Strategy at Meals on Wheels, stated that the organization's local service providers "consistently report that many older adults, living on fixed incomes while facing rising costs for housing, utilities, and healthcare, find it very difficult to afford or access nutritionally adequate food." In fact, 2023 saw a record high proportion of U.S. adults aged 65 and older experiencing some level of food insecurity. While the rate for those aged 85 and above is relatively lower, it remains near historic highs. However, this record might not be broken after 2024—the data we cite comes from a supplement to the Census Bureau's Current Population Survey, which has been discontinued by the U.S. Department of Agriculture, making the upcoming report potentially the last of its kind. But before drawing final conclusions, let's step back and view the data in a broader context: between 2011 and 2023, the food insecurity rate among American seniors increased by 5%. While this figure is certainly concerning and not to be dismissed lightly, it simultaneously fails to explain the 746% surge in malnutrition mortality during the same period (data adjusted for population aging). Consequently, we contacted the American Society for Parenteral and Enteral Nutrition (ASPEN, more intuitively understood as the leading authority on intravenous nutrition and tube feeding in the U.S.). If there were indeed a surge in malnutrition cases among American seniors, this organization would certainly be aware of it. Peggy Guenter, who has led clinical practice, quality control, and policy advocacy at ASPEN for 20 years, offered a straightforward hypothesis: "Malnutrition has always been there... it's just that we are now identifying and documenting it more accurately than ever before." So, what was the situation in the past? Critically ill patients often lose weight, and loved ones wasting away is not a new phenomenon. However, historically, doctors often viewed malnutrition as a concomitant symptom of the patient's overall deteriorating health. It wasn't until around 2010 that researchers began accumulating evidence confirming a long-held suspicion: nutritional deficiency itself is a risk factor for disease. Numerous studies demonstrated that malnourished individuals have more emergency room visits, longer hospital stays, and greater healthcare needs. Alison Steiber, an official at the Academy of Nutrition and Dietetics, pointed out that because research shows diagnosing malnutrition isn't simply achieved through a single lab test, doctors are not typically trained to diagnose malnutrition independently during their professional education. This began to change in 2012. At that time, new research found that inflammation, just like insufficient caloric intake, could trigger malnutrition. Inspired by this, ASPEN and the Academy of Nutrition and Dietetics jointly released the "Consensus Statement: Recommended Characteristics for the Identification and Documentation of Adult Malnutrition (Undernutrition)." Soon after, by 2014, the number of death certificates listing malnutrition as the underlying cause of death saw its first significant jump. No one would definitively claim that this consensus statement directly caused the increase in diagnoses—after all, in medicine, "causation" is an extremely rigorous and hard-earned term. But it's equally undeniable that the Academy, ASPEN, and their allied organizations worked tirelessly to implement the statement, urging doctors to recognize the need to diagnose malnutrition more frequently. ASPEN and its partners trained clinicians nationwide, teaching them that diagnosing malnutrition involves not just weight loss, but also assessing muscle loss, reduced subcutaneous fat, fluid accumulation, and inadequate food intake. They held awareness weeks, organized extensive professional training, and, most notably, launched an ambitious "Malnutrition Quality Improvement Initiative" starting in 2013, involving hundreds of hospitals. These efforts ultimately bore fruit. Michelle Schneider, ASPEN's Clinical Practice Manager, stated: "I started practicing in 2010. During my education and residency, I never received training on identifying malnutrition. It was the release of that 2012 consensus statement and the subsequent advocacy that really made me start... systematically evaluating those clinical characteristics that identify and diagnose malnutrition." When she and her colleagues began actively screening for malnutrition, the number of confirmed cases in their hospital rose. This phenomenon was occurring nationwide. Research by Guenter and her team found that in 2010, about 3% of patients were diagnosed with malnutrition; by 2018, this proportion had climbed to 9%. Steiber told us: "Similar to other conditions like celiac disease, an increase in incidence data doesn't necessarily mean more actual cases, but rather can indicate that our detection, diagnosis, and intervention methods have improved." So, is there something particular about elderly patients? We contacted the American Academy of Hospice and Palliative Medicine and unexpectedly received a valuable lead—they referred us to their Chief Medical Officer, Dr. Christina Newport. Newport, who leads palliative care at Penn State Health, is articulate and logical, capable of dictating a column better than this one even before her first morning coffee. She confirmed everything we had learned and added another crucial factor. "Around the same time, the Centers for Medicare & Medicaid Services (CMS) adjusted the weighting for several diagnoses, including those related to malnutrition," she explained. "Hospital mortality metrics compare actual deaths to expected deaths. The expected number is calculated based on the complexity of patient comorbidities reflected by diagnosis codes. So, when the weight assigned to a malnutrition diagnosis code was increased—based on the understanding that 'nutritional status often correlates with disease severity'—and its diagnostic criteria were clarified, the calculation for hospital mortality rates changed accordingly." This created a strong incentive for hospitals and other healthcare facilities to screen for malnutrition. Because official statistics now formally recognize that malnutrition increases the risk of adverse outcomes, institutions potentially face less penalty if a patient has a poor outcome. She added: "Long-term care facilities are now also closely monitoring patients for weight loss and are held accountable for significant, unexplained weight loss." In fact, nursing homes are legally required to have a dedicated dietitian or nutrition specialist. Similarly, incentives exist within hospice care, whether provided in facilities or at home. "For a patient to qualify for hospice, two conditions must be met: a life expectancy of six months or less, and the cessation of life-prolonging treatments," Newport said. "Hospice providers must periodically demonstrate that the patient's condition is continuously declining towards death—it might sound harsh, but that's the reality. Regularly assessing nutritional metrics is one way they document this terminal decline." She noted that since deteriorating patients might experience edema, weight loss isn't always reliable, but providers can use other measures like mid-upper arm circumference. This assessment serves both to document decline for maintaining hospice eligibility (and associated payments) and to indirectly gauge disease progression, especially for patients without a clear terminal diagnosis. "For example, an 85-year-old woman with mild cognitive impairment but no dementia diagnosis, occasional UTIs but no current infection, and mild diabetes. None of these conditions alone would directly cause her death," Newport illustrated. "In such cases, the most objective indicator is her ongoing weight loss." "For such an individual, malnutrition might end up listed on the death certificate because other conditions aren't the immediate cause. But it's absolutely not because she couldn't access food." In fact, regardless of the underlying disease, weight loss and loss of appetite are common signs of the body shutting down as death approaches. Given this, why were nearly 25,000 death certificates last year listing malnutrition as the underlying cause of death? Newport offered a clue here as well. We tend to view death certificates as a highly authoritative data source—and rightly so, as they cover nearly the entire population and are completed by professionals. But these professionals are human. "Despite its importance, there's remarkably little training or standardization around determining cause of death and filling out death certificates. That's something we must always remember," Newport said. With this hint, we delved deeper into the death certification process. We first turned to the key figures who manage the process and interface with families and doctors: funeral directors. Chris Robinson recently stepped down as President of the National Funeral Directors Association and operates Robinson Funeral Home at the foot of a small section of the Blue Ridge Mountains in South Carolina. Robinson explained that when someone dies, he receives a report from a hospital, hospice, or medical examiner containing the deceased's family information and date of birth. He meets with the family, fills out basic information, but he is not authorized to determine the cause of death. "We electronically submit the information to the physician or medical examiner responsible for certifying the death. They complete the cause of death section and return it to us," Robinson said. He then submits the certificate to the health department for final approval to provide the family with an official paper copy. This lead directed our research to the next critical step in the process, and its key figure: Dr. Reed Quinton. Quinton is President of the National Association of Medical Examiners and oversees pathology residency training at the Mayo Clinic. A significant part of his career involves instructing others on how to complete the cause of death section. "Completing a death certificate is both a science and an art," he told us. The role of a forensic pathologist is to trace the sequence back to the underlying cause. He indicated that, ideally, "malnutrition" would rarely appear alone as a cause; accompanying documentation should note the underlying condition. The "cause of death" section typically has four lines. One starts with what Quinton calls the "immediate cause," then traces the causal sequence back until the fourth line (if needed) specifies the underlying cause. For example, the chain might read: gastrointestinal hemorrhage due to esophageal varices, due to cirrhosis, due to alcohol use disorder. Here, alcohol abuse is the underlying cause. Malnutrition might fit into this four-part chain, but why would it be listed as the final, underlying cause? Quinton couldn't say for sure, but he noted that aside from pathology residency training, other medical specialties provide little deep instruction on death certificate completion, and the vast majority of death certificates are not completed by pathologists. "There are numerous different people... involved in filling out death certificates," Quinton explained. "In some cases, it might be a forensic pathologist, a hospitalist, a resident in training, or a coroner. Who does it depends largely on the jurisdiction where the death occurs." We found clues in the data suggesting that the vast majority of malnutrition death certificates are likely not completed by medical examiners. For instance, malnutrition deaths occurring in hospitals have seen little recent growth. The most significant increases are among residents of nursing homes and long-term care facilities—some admitted with existing nutritional issues—followed by those dying at home or under hospice care. It's also noteworthy that among patients who underwent autopsy, almost none had malnutrition listed as the cause of death. Is this conclusive evidence? No. Malnutrition is a common part of the dying process. And unless neglect is suspected, such routine deaths are typically not reviewed by professionals like Quinton and his peers. But we believe it is a significant clue, especially when combined with another point we learned from Quinton and several other experts. "Electronic health records are incredibly accessible now," Quinton said. "We have far more medical information at our fingertips than we did ten or twenty years ago. So, one possibility is that doctors now have a more complete picture of a patient's comorbidities, and when they see 'patient has malnutrition,' they include it on the death certificate." This is our most plausible hypothesis so far: improved medical recognition of malnutrition leads to its increased documentation in medical records; coupled with potentially rushed diagnostic simplification by some busy physicians, the malnutrition diagnosis occasionally gets written onto the death certificate. So, is the rise in malnutrition deaths merely a statistical artifact? We didn't initially expect Kurt Sofe to answer this question. The National Funeral Directors Association connected us with Sofe—the manager of Jenkins-Soffe Funeral Homes in the southern suburbs of Salt Lake City—hoping to learn about death certification in Utah, the state with the highest malnutrition mortality rate. But when Sofe joined the video call, we found him on his phone, sitting in his car parked outside a nursing home—he had just dropped off his wife to visit her 93-year-old father, who had recently begun hospice care. Sofe said he does indeed see more death certificates listing diagnoses like malnutrition. But even for someone accustomed to working with grieving families, the reality was hard to accept. "Just a few months ago, he was a strong, vibrant man," Sofe said, his voice catching. "Now, he's skin and bones, down to 120 pounds (approx. 54 kg)." Sofe's father-in-law had suffered a stroke. While doctors successfully cleared the clot, being away from his beloved home and, even more so, his cherished garden, caused him to lose all desire to eat. He told his family all food tasted "like sand." "We tried Ensure high-protein shakes, protein bars, steak and mashed potatoes—we tried everything," Sofe said. His words reminded us of what palliative care physician Newport had said earlier: "One of the primary ways we show love and care for someone is by feeding them, right? So, when caregivers see their loved one losing interest in food, it's profoundly distressing... But we have to understand that in some situations, this is a process we cannot change." During the video call, we witnessed Sofe's struggle between reason and emotion. "You watch his spirit decline, his functions fail, his ability to communicate fade, the life just ebbing away until it's gone," Sofe said, his voice trembling with emotion. "I've been in funeral service my whole life, and a caregiver my whole life. I was born and raised in a funeral home, and yet I'm at a loss for words with my dying father-in-law." "In the end, beyond 'I love you' and 'thank you,' I couldn't think of anything else to say." Approximately 12 hours later, Sofe's father-in-law passed away.
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