The Rate Of Older Californians Dying Of Malnutrition Has Accelerated

A growing number of California’s oldest residents are dying of malnutrition, a yearslong trend that accelerated during the COVID pandemic.

Deaths attributed to malnutrition more than doubled, from about 650 in 2018 to roughly 1,400 in 2022, according to preliminary death certificate data from the California Department of Public Health. The same trend occurred nationwide, with malnutrition deaths more than doubling, from about 9,300 deaths in 2018 to roughly 20,500 in 2022, according to the U.S. Centers for Disease Control and Prevention.

Malnutrition is particularly common among older people, especially those who are ill, low-income, homebound, or without reliable access to healthy food or medical services. It can result from not eating enough but also from poor eating habits that lead to nutritional deficiencies. The majority of deaths in California from malnutrition last year occurred in residents 85 and older.

Several experts said COVID lockdowns likely cut off access to healthy food. Because the oldest people were the most likely to die from COVID, officials encouraged them to limit their exposure to others who might have the disease.

“People who may have been reliant on public transportation or reliant on others to get to the grocery store — suddenly they're nervous to take the bus,” said Lindsay Clarke, senior vice president of health education and advocacy at the Alliance for Aging Research, a nonprofit group in Washington, D.C. “That family member or friend who would have come to pick them up and take them to the grocery store is worried about having them in their car.”

Pandemic lockdowns also hindered safety net programs that feed seniors. For example, many adult day care centers closed, eliminating places for seniors to go during the day as an alternative to nursing care. Dr. Louise Aronson, a geriatrician and professor at the University of California-San Francisco, said seniors who used the programs “may rely on the food they get there as their best meal of the day.”

Malnutrition deaths rose in 2022 even as lockdowns faded. Experts said the persistence of the trend could be due to some of the oldest residents continuing to isolate.

COVID remains a serious danger for that demographic. About 5,400 Californians 85 and older died from COVID last year, making it the fifth leading cause of death for that age group — responsible for more than twice as many deaths as diabetes, preliminary state data show.

“For a lot of people who are older adults and people with disabilities, it's not really over,” said Trinh Phan, who works from California for the nonprofit Justice in Aging. Phan said many older Californians are afraid of COVID, asking themselves, “Do I actually want to risk that for myself given my own risk factors?”

While the number of California malnutrition deaths jumped during the pandemic, it had been increasing for years. Some of that increase may be due to the overall aging of the population, experts said.

About 678,000 Californians are 85 or older, a number that increased by roughly 59% from 2000 to 2021, census data show.

Californians 85 or older accounted for almost three in five malnutrition deaths in the state last year. Those 95 or older make up almost one in five malnutrition deaths, even though only about one in 700 Californians fall within that age group.

“Biologically we do eat less as we grow older,” Aronson said. “You're just literally less hungry.”

In addition, particularly old people have slower metabolism and digestion than younger people. “When you're eating less food overall, it's hard to get all the nutrients you need,” she said.

More factors beyond pandemic lockdowns and an aging population may be causing the steep rise in reported malnutrition among older people. The rate of malnutrition deaths per 100,000 residents in California among those 85 or older rose precipitously around 2013, jumping fivefold by 2019 and from there doubling during the pandemic.

Complicating the picture is how often malnutrition appears in conjunction with other illnesses. Older adults are more vulnerable to diseases — such as heart failure, cancer, Alzheimer’s, and depression — that can reduce their appetites and lead to malnutrition as a secondary cause of death.

Malnutrition was a contributing cause in 5,600 deaths in California on top of the 1,400 deaths for which it was the primary, underlying cause, provisional CDC data show. The number of deaths for which malnutrition was a secondary cause of death rose by about 1,700, or 43%, from 2018 through 2022.

“You might be admitted with diabetes but at the same time you're also malnourished, and so the malnourishment adds to your problems,” said Paul Brown, a professor at the University of California-Merced who has co-presented papers on malnutrition in California at an American Public Health Association conference.

There is also an increased push to recognize malnutrition. Two of the nation's leading nutrition science organizations released updated guidelines in 2012 to better standardize diagnosis.

The highest malnutrition death rates among older Californians from 2020 through 2022 were in rural or semirural counties: Lake, Merced, Butte, Tuolumne, and Sutter.

Brown said older residents living in rural counties often live in “food deserts,” which are areas that lack access to healthy food.

Among large, urban counties, Sacramento had the highest rate of malnutrition deaths among those 65 or older from 2020 through 2022. County spokesperson Macy Obernuefemann said the public health agency helps control and manage chronic diseases often accompanied by malnutrition and that several programs help seniors get the food they need.

Several programs in California seek to lower malnutrition among older people. The state’s network of 33 Area Agencies on Aging often offer healthy meals to older adults, according to Sara Eisenberg, a spokesperson for the California Department of Aging. Organizations such as Meals on Wheels do so as well. The agencies also regularly try to make sure seniors are enrolled in CalFresh, the state’s food assistance program for eligible low-income residents, Eisenberg said.

CalFresh benefits increased in late 2021 by 27%, helping many seniors afford food. A bill in the legislature, SB 600, would increase the minimum CalFresh benefits from $23 a month to $50. There’s also a push to expand CalFresh benefits to more undocumented immigrants, many of whom face food insecurity.

“I think that there has been really positive movement,” Phan said.

However, enhanced CalFresh benefits that gave millions of people more money during the pandemic expired in late March.

Population trends suggest malnutrition will continue to be a problem. The number of Californians 85 and older, the group most prone to malnutrition, is projected to grow by about 420,000, or 54%, from 2020 to 2030, according to state Department of Finance projections.