A Hidden Epidemic Threatens Older Adults: Malnutrition

For most of her life, Jenny Anne Horst-Martz’s mother worked hard to stay slender. But now, at age 90, her mother struggles to keep enough weight on. 

The problem started a few years ago when her mother was injured in a fall and then diagnosed soon after with a recurrence of lung cancer. Between the cancer itself, the multiple hospital stays, an array of new medications and the slowdown in her activity level, her mother’s appetite disappeared. Her weight dipped to 104 pounds—too low for her 5’6” frame. 

“We were really worried,” Horst-Martz said. 

Horst-Martz’s mother faces a common struggle among older adults: malnutrition. The Alliance for Aging Research calls malnutrition a “hidden epidemic in the United States,” one that is underrecognized and undertreated. An estimated 25 percent of older Americans are malnourished or at risk of malnutrition, and not all are at risk due to poverty or lack of access to healthy food. 

“We see this all the time: people who have very good means and good caregiver support, but they’re struggling with malnutrition,” said Alex Foxman, MD, president of Mobile Physician Associates in Beverly Hills, CA.

Malnutrition triggers a vicious cycle, weakening the immune system and causing sarcopenia (loss of muscle mass), which can lead to frailty and falls. Malnutrition rates are especially high among older adults who are hospitalized, leading to longer hospital stays, higher infection rates, poor wound healing, higher readmission rates, poorer outcomes and death. The Alliance for Aging Research estimates the resulting increased economic burden due to malnutrition among older adults in the United States at more than $51 billion each year. 

How the Cycle Begins

A host of factors make older adults more prone to malnutrition. 

Many of the chronic medical problems affecting older adults can contribute. Some, like cancer, diabetes and Alzheimer’s disease, can depress the appetite, as can many medications or combinations of medications. Other diseases—and even normal age-related changes, such as lower stomach acidity—lessen the body’s ability to absorb nutrients. 

“Sometimes it’s not that people are not eating, it is that they are not absorbing the nutritional value of foods through their gastrointestinal system,” Foxman said. 

People with dementia can lose the ability to handle daily activities, including feeding themselves. Older adults may develop dental problems, dry mouth or difficulty handling tableware, chewing or swallowing food. Age-related changes may alter the ability to smell and taste food.  

“If you were a big meat eater when you were younger, and now suddenly chewing and swallowing meat becomes a challenge, you might end up just eating cheese and crackers all day long,” said Suzannah Gerber, a nutrition epidemiology researcher at Tufts Friedman School of Nutrition Science and Policy.

Isolation, leading to depression, can shrink a person’s appetite.

Older adults with mobility challenges may not be able to prepare meals. Others may lack transportation to get to the grocery store regularly. 

“Altogether, this means that older adults may choose more convenient, processed foods because they are accessible, easier to cook, available in [single-serving] packages and easy to swallow and digest,” said Gerber. “This means more empty calories.”

Psychological factors can contribute too. Eating is a social activity that loses its appeal for an isolated older adult. And many older adults are isolated; according to the 2023 University of Michigan National Poll on Healthy Aging, one in three older adults (ages 50–80) reported feeling isolated from others in the past year.  

“Isolation and loneliness lead to depression, which can have a negative impact on appetite,” said Michelle Rauch, MNutr, a registered dietician for the Actors Fund Home, a senior living community in Englewood, NJ, for retired members of the entertainment community. 

Food Insecurity Plays a Role

For a significant number of older adults, malnutrition stems from an inability to afford healthy food. According to a 2021 survey, 5.5 million Americans over age 60 are food insecure. 

Older adults with functional limitations or chronic disease are especially prone to food insecurity. People with two or more chronic conditions, for example, were two to three times more likely to be food insecure compared to those with no chronic conditions. 

Food insecurity especially affects people of color. 

“Food insecurity is caused by financial insecurity, which is rooted in systemic racial, gender and health inequities.” said Gretchen Dueñas-Tanbonliong, MS, a registered dietician and associate director of health and wellness at the National Council on Aging (NCOA.) “Black older adult households are over three times more likely to experience food insecurity compared to white households.” Similarly, Latino older adults are three times as likely to experience food insecurity compared to white older adults

Food insecure older adults often resort to harmful coping strategies. They may skip medication, forgo medical care or choose cheap, unhealthy foods to stretch their budgets, according to a Food Research & Action Center (FRAC) study. 

In addition, many older adults who are eligible for Supplemental Nutrition Assistance Program (SNAP) benefits aren’t getting them. A 2016 NCOA study showed that 79 percent of older adults have heard of SNAP, but only one in six who were eligible are actually enrolled. Survey respondents said the application process was too tedious, or they didn’t know how to apply or they were worried that, by accepting benefits, they’d deprive people who needed the help more. 

Some advocates want programs like Medicaid expanded to cover food and nutrition.

To help older adults navigate benefits more easily, NCOA created a website, BenefitsCheckup.org. Visitors enter their zip codes and other information to determine their eligibility for SNAP and a variety of other government programs.

Many older adults who receive Social Security are eligible for only the minimum SNAP payments, according to LaMonika Jones, interim director of state initiatives for FRAC. Rules and minimum amounts vary by state, but in Washington, DC, where Jones is based, the minimum is only $30 a month, which doesn’t go far in funding a healthy diet. 

Older adults with diabetes or hypertension should take particular care in choosing healthy foods, Jones said. “But that’s a challenge because the cost of fresh foods is high.” 

Some hunger advocates propose expanding Medicaid and similar programs to cover food and nutrition, as part of a movement broadly called “Food is Medicine.”

“We’d like to see medically tailored meals as an option, as well as the potential to purchase fresh fruit and vegetables, to treat those diet-related diseases,” Jones said. 

Assessment and Diagnosis

While malnutrition is prevalent, diagnosing it is not always easy. 

“An older adult who is overweight can still be malnourished,” said Dueñas-Tanbonliong. “If they aren’t getting enough important vitamins and minerals, that can result in nutrient deficiencies.” 

Even the definition of malnutrition varies. Medical researchers typically define malnutrition as a lack of nutrient quality, or nutrient quantity or both. By contrast, other agencies, including the World Health Organization, consider malnutrition more broadly to include any “deficit, excess or imbalance of protein, energy and other nutrients” that adversely affects health. By that definition, obesity is counted as a form of malnutrition.

Common symptoms of malnutrition include loss of appetite, unexplained weight loss, weakness, fatigue or edema (swelling). Sunken eyes or protruding bones are other clues. Blood tests can detect anemia, an iron or protein deficiency. Screening tools assess factors such as appetite, dietary intake, weight loss, appetite and body mass index (BMI). 

“Health care teams must be vigilant in promptly diagnosing and treating malnourished patients in the hospital,” wrote Dueñas-Tanbonliong in an article she co-authored. “It is equally important, however, for patients and their families to be knowledgeable and to speak up when they feel something is amiss.” 

Improving Nutrition

Interventions to combat malnutrition vary depending on the older adult’s situation. 

Medically, a physician might begin by treating any underlying conditions that are contributing to malnutrition and reviewing the older adult’s medications to reduce or replace any that suppress appetite or cause gastrointestinal side effects. Doctors may also prescribe appetite-inducing medication or, in extreme cases, a feeding tube. 

“You start by trying to figure out what nutrients the person is lacking, and then you try to supply that in the form of real food, if possible,” Rauch said. 

That may mean helping the older adult prepare or obtain tempting meals with plenty of fresh fruits and vegetables, lean meats or other proteins, and whole grains. This could mean in-home assistance with meal preparation, Meals on Wheels or arranging for the individual to eat meals at a local senior center. 

Some interventions focus on simply upping a person’s calorie or protein intake. While meal-replacement supplements like Ensure or Boost are often loaded with sugar or corn syrup, they still may be a good option for people who need more calories or who can’t eat solid food.

Those who have had an eating disorder in the past sometimes struggle with malnutrition in their later years.

Sometimes tackling malnutrition means educating the older adult or caregiver on healthier food choices, according to Tina Baxter, GNP, a nurse practitioner in Anderson, IN, and a parish nurse in her church. In a home visit, she discovered a parishioner was surviving on frozen dinners and sodium-packed processed foods after suffering a stroke. 

“I was able to get her refrigerator stocked with healthier versions of ready-made food, donated by the church, contact her family for assistance for future needs and show her how to make simple meals using the microwave, as she was not able to stand long due to the stroke,” Baxter said. 

Psychological factors may also need to be addressed. Rauch occasionally sees retired dancers or performers with a history of eating disorders. When they move into the Actors Fund Home, where meals are provided, Rauch said, “The family may be thinking that I can just fatten them up, but there’s a big psychological component with eating disorders. With malnutrition, there really needs to be a multidisciplinary approach.” 

Several different strategies have helped Jenny Anne Horst-Martz’s mother make progress. Thankfully, immunotherapy has kept the cancer at bay. Today, at 112 pounds, she is still underweight, but her appetite is improving. To up her calorie intake, she snacks on protein drinks between meals, slathers her apple slices with nut butter at lunch and enjoys a dish of vanilla bean ice cream at night. Her doctors seem pleased with her nutritional status, and her blood work is good.  

“Mom eats nutritiously, tries to exercise and enjoys food at least some of the time,” said Jenny Anne Horst-Martz. “She’s doing much better.”