Something strange is happening with malnutrition.
It’s by far the fastest-growing cause of death in America, soaring sixfold over the past decade or so, according to our analysis of death certificate data from the Centers for Disease Control and Prevention.
To be sure, we wouldn’t yet call it commonplace. But while it accounts for fewer than 1 in 100 deaths, its toll is rising so fast that it’s now in the same league as arterial disease, mental disorders and deaths from assault.
But when you dig into the data, it doesn’t look like our mental image of malnutrition, one which revolves around food banks and famine. For starters, it doesn’t quite map to economic hardship.
It tends to kill somewhat more people in lower-income states, and among folks with less education in general. But the relationship isn’t as strong as you’d think, and it bears surprisingly little relation to state measures of food insecurity or food-stamp use.
More important, we’re worried here about the meteoric rise in deaths, not the level. And the rise is much harder to explain with demographics. We see it across the board. Every state, every education level, every race, every gender.
When we split the numbers every which way, only one metric showed clear differences: age. Americans 85 or older die from malnutrition at around 60 times the rate of the rest of the population, and such deaths are rising about twice as fast among that group.
What’s going on? Are older Americans struggling to eat?
Indeed, the share of Americans 65 or older who report some level of food insecurity hit a high in 2023. The rate among the 85-plus crowd was lower, but still near record levels.
And those records may not be broken, at least after 2024. The source we used, a supplement to the Census Bureau’s Current Population Survey, has been canceled by the Agriculture Department. The upcoming release could be the last.
But before we declared this a closed case, we stepped back and put the numbers in context. Food insecurity among older Americans has risen 5 percent from 2011 to 2023. That’s not a good number, or one you can just wave off. But at the same time, it can’t explain a 746 percent increase in malnutrition deaths over that period. (And, yes, we adjusted for the aging population.)
So, we called the American Society for Parenteral and Enteral Nutrition — also known as ASPEN or, more descriptively, the nation’s intravenous-nutrition and feeding-tube experts. If there’d been a sudden surge of malnutrition among older Americans, ASPEN would have noticed.
Peggi Guenter led clinical practice, quality and advocacy at ASPEN for two decades. Her best guess is simple: Malnutrition “has always been there. … We’re just identifying and documenting it better than we ever have in the past.”
What happened in the past? Well, it has never been unusual for someone with a serious condition to lose weight. Watching a loved one waste away isn’t a modern phenomenon. But physicians used to see malnutrition as part of the patient’s overall decline.
But around 2010, researchers started accumulating evidence that showed what they had long assumed: The lack of nutrients was, itself, a risk factor. A pile of papers now tell that malnourished people have more emergency room visits, spend longer in the hospital and need more health care.
Doctors weren’t trained to diagnose it separately, especially since research has shown it wasn’t as easy as lab-testing for a single indicator, according to Alison Steiber, a top official at the Academy of Nutrition and Dietetics.
That started to change in 2012. That’s when, prompted partly by new research finding malnutrition could be driven by inflammation as well as lack of calories, ASPEN and the nutrition academy released the Consensus Statement on “Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition).”
Not long after, in 2014, we saw the first big jump in death certificates labeled with malnutrition as the underlying cause of death. Nobody’s willing to say the declaration caused the rise in diagnoses. “Cause” is a sacred, hard-earned word in medicine. But it’s also true that the nutrition academy, ASPEN and their allies went all out to ensure that the statement caused physicians to be aware that they needed to diagnose malnutrition more often.
ASPEN and its allies taught clinicians from all over the country to diagnose malnutrition by looking not just for weight loss, but also for factors such as muscle loss, loss of under-the-skin fat pads, fluid retention and simply not eating enough. They held awareness weeks, tons of trainings and — perhaps most notably — launched an ambitious Malnutrition Quality Improvement Initiative,which worked with hundreds of hospitals starting in 2013.
All those efforts paid off.
“I started practicing in 2010, and I was not trained to identify malnutrition in my education program, like in my internship,” said Michelle Schneider, ASPEN’s manager of clinical practice. And the 2012 paper and awareness push “is when I myself started … really evaluating the set of clinical characteristics that can identify and diagnose malnutrition.”
When she and her colleagues started looking for malnutrition, their hospital’s related case numbers went up. It happened all over the country. As a rule of thumb, multiple experts told us that at least 1 in 5 hospital patients probably suffer from some kind of malnutrition. In 2010, about 3 percent were diagnosed with it. By 2018, it hit 9 percent, Guenter and her colleagues found.
“As with other conditions, such as celiac disease, increased prevalence rates do not necessarily reflect more cases, but rather improved detection, diagnosis and intervention,” Steiber told us.
But what about older patients specifically? We called on the American Academy of Hospice and Palliative Medicine and got ludicrously lucky: They put us in touch with their chief medical officer, Kristina Newport.
Newport runs palliative medicine at Penn State Health, speaks in fully formed paragraphs and probably could have dictated a better version of this column over breakfast before she’d had her first coffee. She confirmed everything we’d heard — then added another variable.
“The other thing that happened around this timeline is that CMS, the Center for Medicare and Medicaid Services, changed the impact of the diagnosis of some of these diagnoses that fall under malnutrition,” she said.
“When hospitals are measured on their mortality, the calculation includes a comparison of how many people actually die compared to how many people are expected to die. And that expected number is determined by the complexity of documented illnesses as reflected in diagnosis codes. So when there was more weight given to malnutrition as a diagnosis code — when it was better defined, based on the understanding that nutrition often correlates with severity of illness — all of a sudden, it changed the calculation.”
So, hospitals and other providers were given a strong incentive to look out for malnutrition, because now official statistics (correctly) recognized it increases the odds that someone will have an awful outcome, which means you’re not penalized as much if said outcome occurs.
“Long-term care facilities have also started paying very close attention to weight loss and are held accountable for folks having abnormal weight loss,” she added. In fact, nursing homes must have a dietitian or nutrition specialist on staff.
And hospice, which can be part of many medical or at-home settings, has its own incentives.
“You’re only eligible for hospice enrollment if you’re expected to die within six months and if you’re not pursuing life-prolonging treatments,” she told us. “The hospice clinicians have to regularly demonstrate that somebody is progressing towards death, which is crazy, right? And so one of the ways that they have to routinely demonstrate that there’s evidence that this person is dying is to routinely assess different aspects of nutrition.”
It might not be weight loss, since people in failing health might retain water, but you can still look at arm circumference and other metrics. It helps demonstrate the decline needed to maintain eligibility (and payment) for hospice services, she said, and it can be an indirect way to measure the progress of a patient’s disease, particularly for folks who might not have a clear terminal illness.
“So your 85-year-old woman who has a little bit of cognitive impairment but has never been diagnosed with dementia — she gets a urinary tract infection every once in a while, but she doesn’t have one right now. She had mild diabetes. None of those things are explicitly taking her life,” Newport said. “The most objective thing you can say is she continues to lose weight.”
“Somebody like that may end up with a diagnosis of malnutrition on her death certificate because none of those other things obviously took her life. Right? But it wasn’t because she didn’t have access to food.”
In fact, regardless of your condition, weight loss and loss of appetite are one of the most common pathways toward death as the body shuts down.
So, malnutrition is often a normal part of dying. It hints at the presence of other underlying conditions. So how did it end up as the underlying cause of death on almost 25,000 death certificates last year?
Newport had a hint for us on that one, too. We cherish death certificates as one of the most authoritative data sources out there — and they are, since they cover pretty much the entire population and are certified by professionals. But those professionals are human.
“Despite the importance of the cause of death and filling out this form, there’s very little education or standardization of doing it,” she told us. “So that’s just something to keep in mind.”
And we did. So we set out to learn about death certificates.
We started with the folks who quarterback the entire certification process and make sure the families and doctors get what they need. We called the funeral directors.
Chris Robinson just finished his term as president of the National Funeral Directors Association. He also runs Robinson Funeral Homes at the foot of South Carolina’s sliver of the Blue Ridge.
When someone dies, Robinson gets a report from the hospital, hospice or coroner. It tells him their next of kin and date of birth. He meets with the family to fill in vital statistics. But he’s not allowed to fill in the cause of death.
“We submit it electronically to the certifying physician or coroner, whoever’s going to certify the death,” Robinson told us. “And then they send it back to us with the cause of death.” Robinson then sends the certificate to the health department to be finalized, so he can get official paper death certificates for the family.
That pointed us to the next step in following the certificate on its journey. That step was Reade Quinton. Quinton is president of the National Association of Medical Examiners. He also runs the pathology residency at the Mayo Clinic. Filling out the cause of death on certificates — and teaching others to do so — is a large part of his career.
“There’s a science and an art to filling out a death certificate,” he told us. It’s a forensic pathologist’s job to ask why, to get to the root of the problem. Ideally, he said, you’ll rarely see malnourishment on a death certificate by itself — the document should also define the underlying cause.
You see, under cause of death, a typical certificate has four blanks. You start with what Quinton would call the “final insult,” and then tease out the causal chain until, by the fourth blank — if you need that many — you’ve listed the underlying cause.
So, the chain might go something like: Gastrointestinal bleeding due to swollen veins in the esophagus due to cirrhosis due to alcohol use disorder. In that case, the alcohol abuse would be the underlying cause.
Malnutrition could play a role in that four-step mortality chain. But why are people listing it as the ultimate cause? Quinton’s not sure, but death certification isn’t really taught in depth outside of pathology residencies, and most deaths aren’t certified by pathologists.
“There’s a large number of people … who fill out death certificates,” Quinton explained. “So you may have forensic pathologists filling them out in certain cases, you may have hospitalists filling them out, residents on service who are still in training, coroners. It’s incredibly variable depending on whose jurisdiction the death occurred in.”
And looking at the data, we see clues that most of these malnutrition deaths probably weren’t certified by medical examiners.
For example, we’ve seen very little growth in malnutrition deaths in hospitals in recent years. The increase has been sharpest at nursing homes and long-term care facilities, where some residents may arrive with nutrition issues, followed by deaths at home or hospice. Similarly, almost no patients who had an autopsy got malnutrition listed as a cause of death.
Is it a perfect smoking gun? No. Malnutrition is a routine part of death. And unless someone suspects neglect, routine deaths often don’t cross the desk of specialists such as Quinton and his protégés.
But we reckon it’s a hint, especially when paired with something else we heard from Quinton and several others.
“Electronic records are so accessible now,” he told us. “We have a lot more information at our fingertips than we had 10 or 20 years ago. So is it possible that now they’re getting a better list of underlying conditions and saying, ‘Oh, he’s got malnutrition,’ and so they put that on there as well.”
And that’s our best guess. A better understanding of malnutrition means it has appeared on more medical charts. And from there, it occasionally makes its way onto a death certificate, perhaps helped by a harried physician.
But does that mean rising malnutrition deaths are a mirage?
We didn’t really expect Kurt Soffe to answer that question. The fine folks at the National Funeral Directors Association put us in touch with Soffe, the director of Jenkins-Soffe Funeral Home south of Salt Lake City, to answer questions about death certificates in Utah, the state with the highest rate of malnutrition deaths.
But when he logged on to Zoom, we saw Soffe was on his phone. He was in the driver’s seat of his vehicle, parked outside the retirement facility where he’d just dropped off his wife. Her 93-year-old father had just entered hospice.
He said he’d seen diagnoses like malnutrition on more and more death certificates. But all the time he spent with grieving families still didn’t prepare him for the reality.
“He was a robust healthy man just a few months ago,” Soffe said. “And he basically is 120 pounds of nothing now.”
His father-in-law suffered a stroke. Doctors removed the blockage, but away from his beloved home and even-more-beloved yard, he lost the desire to eat. He told them everything tasted like “sand.”
“We tried Boost protein drinks, we tried protein bars, we tried steak and potatoes, we tried everything,” Soffe told us.
It reminded us of something we heard from Newport, the palliative care physician.
“One of the main ways we take care of people we love is we feed them, right? And so it’s very distressing for caregivers to look at their loved ones and to see that they don’t want to eat … we have to understand that in some situations, it’s not something we can fix.”
We watched Soffe struggle with that conflict in real time.
“You watch his mental change, his physical change, his capacity to communicate change, and then just watch him decline by the millimeter,” Soffe said, his voice breaking.
“I’ve been in funeral service all my life and have been a caregiver all my life. Born and raised in the building, and I found myself absent of words because I didn’t know what to even say to my own father-in-law, who I knew was dying.”
“There really isn’t anything to say other than ‘I love you’ and ‘thank you.’
Soffe’s father-in-law died about 12 hours later.
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