REGISTRO DOI: 10.5281/zenodo.10951643
Bruna Maria Vieira Paccola1
Malnutrition in the United States is a significant cause of disease, resulting in more than half a million deaths a year. This is linked to an increased risk of obesity, diabetes and heart disease, as well as having wider impacts such as high health costs and low productivity. In addition to health effects, malnutrition affects academic performance, increases financial stress and has social impacts, including low productivity, weakened military readiness, growing health disparities and high healthcare costs. Approximately 85% of healthcare spending is related to the treatment of chronic diseases associated with poor diet.1
The prevalence of obesity is 39.8% among adults aged 20 to 39, 44.3% among adults aged 40 to 59 and 41.5% among adults aged 60 and over. The estimated annual medical cost of obesity in the United States was almost $173 billion in 2019. The medical costs for adults who were obese were $1,861 higher than the medical costs for people with a healthy weight.2
The World Obesity Federation report estimates that the total cost of overweight and obesity to the global economy will reach US$ 2.0 trillion per year by 2025 and US$ 4.2 trillion per year by 2035. This includes direct costs, such as health expenses, as well as indirect costs, such as lost productivity and absenteeism.3
Two of the main causes of heart disease and stroke are high blood pressure and high blood cholesterol. Excessive sodium consumption raises blood pressure, increasing the risk of these conditions. The guidelines recommend less than 2,300 mg of sodium per day, but the average in the US is more than 3,400 mg. An unhealthy diet can increase the risk of some cancers. Consumption of unhealthy foods and drinks, such as sugary drinks and highly processed foods, can lead to weight gain, obesity and increase the risk of at least 13 types of cancer, including endometrial cancer, breast cancer in postmenopausal women and colorectal cancer. The latter is particularly associated with the consumption of red and processed meat.4
Public health programs, such as Medicaid and Medicare, face an increasing cost burden due to the treatment of obesity-related health conditions in beneficiaries. These costs fall on taxpayers and the healthcare system as a whole. In one study, total government spending related to obesity, including Medicaid and Medicare spending and federal spending, was estimated at $91.6 billion per year. This accounts for approximately 30% of Medicare spending.5
A study led by John Cawley of Cornell University has revealed that obesity is causally linked to increased absenteeism at work and associated productivity losses. The research, which analyzed data from more than 50,000 employed adults, found that obese workers miss around three additional days of work per year due to illness or injury compared to those of normal weight, representing an increase of 128%. The estimated annual productivity losses due to obesity vary significantly, from US$ 271 to US$ 542 per employee, with a total estimated cost of billions to employers. This highlights the importance of including obesity prevention and reduction as part of a cost-effective workplace strategy.6
Unlike obesity, we should also be concerned about malnutrition in the elderly, especially in the United States, as it can have significant impacts on the health and well-being of this population. While obesity is a widely recognized and discussed concern, malnutrition often goes unnoticed, but is no less important.
More than 50 million Americans are 65 or older, according to the Census Bureau’s population estimates, which corresponds to 16.5% of the total U.S. population. Florida has the highest percentage of seniors (21%), followed by Maine (20%). In the state of New Jersey, 15.9% of the population is elderly, totaling 8,878,503 individuals.7
The number of Americans aged 65 and over will more than double in the next 40 years, reaching 80 million by 2040. The number of adults aged 85 and over, the group that most often needs help with basic personal care, will almost quadruple between 2000 and 2040.8
Elder malnutrition is a growing crisis in America that has been exacerbated by the COVID-19 pandemic, which has intensified disparities and social isolation. It is estimated that almost 50% of older Americans are malnourished. Malnutrition is the inadequate intake of nutrients. Often, malnutrition presents as a result of another acute and/or chronic disease or condition. Fifty percent of the elderly are at risk of becoming malnourished after hospital admission, but only 8% are diagnosed. It is estimated that $51.3 billion is spent annually on disease-related malnutrition in the elderly in the United States.9
The number of Americans participating in Medicare, the federal government’s healthcare program for seniors and individuals with disabilities, is on the rise, with more than 61 million lives covered. Medicare Advantage (MA), a public-private option with private health insurance benefits, is chosen by more than 40% of Medicare beneficiaries, and this preference continues to rise. Malnutrition is a problem for many Medicare beneficiaries. Malnutrition can prolong recovery and increase medical complications and readmissions. Up to half of older Americans are at risk of malnutrition or are malnourished.10
According to Downer et al., 2020, the consequences of poor health caused by poor diet affect many sectors, resulting in high health expenditures that divert funds from other policy priorities, such as education and increasing economic prosperity. As health systems continue to evolve to address the global crisis of nutrition-related diseases, food and drug interventions must be held to rigorous standards when decisions are made about implementation, coverage and care.
A 2017 study revealed that food insecurity contributed to an additional $77.5 billion in healthcare costs in the US, highlighting the importance of initiatives that promote the use of food as medicine to reduce these costs.
The US federal government is leading several programs and collaborations to tackle hunger, nutrition and diet-related diseases, but recognizes that more action is needed. In September 2022, the Biden-Harris administration released a national strategy to end hunger, improve nutrition and physical activity and eliminate disparities. The plan will involve all government agencies in regulatory, programmatic, educational and research actions, as well as seeking expanded collaborations and coordination. All sectors, including local, state and tribal governments, community organizations and private businesses, must work together to achieve these goals by 2030.11
More than 50 years since the first White House Conference on Food, Nutrition and Health, the United States has yet to end hunger and faces an urgent nutrition-related health crisis – the growing prevalence of food-related diseases such as type 2 diabetes, obesity, hypertension and certain cancers. The consequences of food insecurity and food-related diseases are significant, far-reaching and have a disproportionate impact on historically disadvantaged communities. However, food insecurity and food-related diseases are largely preventable if we prioritize the health of the nation (THE WHITE HOUSE, 2022).
Main Difficulties, Challenges and Threats that prevent the American Elderly Population from Receiving Adequate Nutritional Care and Combating Malnutrition:
- Lack of awareness among the elderly: Some elderly people may not be aware of the importance of proper nutrition for their health and well-being.
- Lack of Training for Caregivers and Health Professionals: Caregivers and health professionals may not receive adequate training in geriatric nutrition, which limits their ability to provide nutritional guidance.
- Distances and Limited Access: Many rural areas have a significant lack of medical facilities and health services. The elderly may live long distances from hospitals, clinics and nutritionists’ offices, making regular access to nutritional care difficult.
- High Hospitalization Costs: These represent one of the main difficulties and threats in relation to malnutrition and quality nutritional care for the elderly population in the United States. These costs can negatively impact the ability of the elderly to receive the nutritional care they need in a number of ways.
- Limited access to nutritionists: Hospitals generally have nutritionists and dietitians who can assess and plan patients’ nutrition during hospitalization. However, after discharge, continued access to these professionals can be restricted due to high costs.
- Lack of Post-Discharge Nutritional Follow-Up: Adequate nutrition after hospital discharge is fundamental for recovery and the prevention of complications. However, many elderly people may not receive the necessary nutritional follow-up after leaving hospital, due to financial concerns.
- Cycle of Hospital Readmissions: Untreated malnutrition can lead to recurring health problems, resulting in frequent hospital readmissions. This not only increases healthcare costs, but also represents a burden for the elderly.
Incidence of Malnutrition and Food Insecurity in the U.S.:
In the United States, hunger and food insecurity are widespread problems, affecting millions of families. In 2020, around 10.5% of the population, or almost 14 million families, did not have enough food to meet their needs, negatively impacting their health and quality of life. As recently as June 2022, more than 24 million families reported not having enough food during the week, and more than 7 million of them were food insecure, even though they received federal food benefits. This is a serious problem that needs to be addressed. The current COVID-19 pandemic and subsequent economic crisis, along with supply chain issues and other challenges, have resulted in rising prices for goods and services – including food. This has worsened the hunger crisis in the US, illuminating decades of policy failures in the US food system and the racial and poverty-related disparities that have long existed.12
Senior malnutrition in the United States is an epidemic hiding in plain sight. It is estimated that almost 50% of older Americans are malnourished. Malnutrition is defined as a nutritional imbalance that affects overweight and underweight individuals and infiltrates people. Malnutrition greatly affects the ability to stay healthy, especially when faced with a serious health situation. In fact, approximately 30% of elderly people admitted to hospital arrive malnourished and being malnourished while in hospital will generally increase their length of stay.13
Final Considerations
Good nutrition is essential to keep current and future generations healthy throughout their lives. Adults who eat a healthy diet live longer and have a lower risk of obesity, heart disease, type 2 diabetes and certain types of cancer. Healthy eating can help people with chronic diseases manage these conditions and avoid complications. On the other hand, a diet poor in nutrients and rich in processed and ultra-processed foods can lead to health problems and put a strain on the healthcare system.
One of the essential factors that encompass well-being is health. Health is a fundamental basis for people’s physical, mental and emotional balance. When people are healthy, they have more energy, greater resilience in the face of challenges and the ability to fully enjoy life. In addition, health directly influences social interactions, the ability to carry out daily activities and quality of life as a whole.
The World Health Organization has stated that at least 80% of all heart disease, stroke and type 2 diabetes, and up to 40% of cancer could be prevented if people ate better, engaged in more physical activity and stopped using tobacco.14
The Centers for Medicare and Medicaid Services (CMS) has begun testing the “food as medicine” program in response to growing awareness that access to nutritious food aids human health. The Biden administration began approving requests in certain states for Medicaid to cover nutritional interventions aimed at reducing health costs. The “food as medicine” programs were instituted in response to a growing awareness that access to nutritious food not only supports human health, but also increases enrollment in health services.15
Efforts to improve health in the United States have traditionally focused on the health system as the main driver of health outcomes. However, it is increasingly recognized that achieving health equity requires more comprehensive approaches that consider the social, economic and environmental factors that influence health. In addition, nutrition programs and policies can play an important role in promoting health.16
Health professionals, such as doctors and nurses, with knowledge of nutritional education, play a key role in benefiting the population. This can lead to fewer drugs being prescribed, which in turn reduces the costs associated with healthcare. In addition, this approach can also help to minimize the potential side effects and negative impacts associated with the overuse of medicines. Ultimately, it results in an improvement in patients’ quality of life, the prevention of chronic diseases and the empowerment of people to make informed decisions about their health.
Good nutrition is crucial for all ages, but it is especially beneficial for the elderly, as they face increasing health challenges, a reduced metabolic rate and changes in appetites. Choosing healthy foods is essential for the well-being of the elderly, providing not only a sense of well-being, but also health benefits that are often underestimated. However, many older people don’t realize that their nutritional needs change with age, which can leave them unsure about how to start a proper diet. Therefore, understanding these changes is fundamental for older people to do.
Home-based nutritional care for adults and the elderly in farms and rural areas in the USA offers numerous benefits. In addition to providing essential access to health care in regions with limited resources, it provides personalized nutritional support to prevent and manage chronic conditions, promoting healthy eating and improving quality of life. This not only alleviates long-term healthcare costs, but also strengthens ties between nutrition professionals and local communities, resulting in a positive and lasting impact on the health and well-being of adults and seniors in rural areas, while integrating them into the wider community.
In addition, nutrition care in languages other than English in the US is essential to making health services accessible and culturally sensitive to non-English speaking communities. This improves understanding between patients and health professionals, strengthens patient confidence, reduces health disparities and contributes to the prevention and management of chronic diseases. In addition, this care promotes healthy food choices and improves patients’ quality of life, playing a key role in promoting a more inclusive and healthy society.
The challenges outlined in the report on the Biden-Harris administration’s strategy to address the nutritional crisis reflect common hurdles faced in professional nutrition practices globally. Issues such as inadequate eating patterns, limited health and nutrition education, and cultural resistance to dietary changes are prevalent concerns in various countries.
Cultural diversity within the nutrition profession is recognized as a critical factor in overcoming these obstacles, as understanding the cultural, religious, and social influences on dietary choices significantly impacts the success of dietary interventions. Therefore, emphasizing the importance of diversity within the nutrition field is crucial, aligning with the report’s acknowledgment of this aspect.
Experience has shown that personalized dietary plans tailored to different cultures can have a positive impact on patients’ health outcomes. Ensuring that healthcare professionals are well-equipped with cultural competence and receive adequate training to address diverse dietary needs is essential for effective patient care, as mentioned in the report.
Enhancing nutrition education among healthcare practitioners is imperative to improve patient outcomes and promote a cohesive approach to healthcare. Strategies that embrace cultural diversity and engage a diverse and well-educated workforce can lead to more effective and inclusive health systems, benefiting individuals worldwide regardless of their background or condition.
1U.S. Department of Agriculture (2023, Sept. 13). Food and Nutrition Security. https://www.usda.gov/nutrition-security
2Centers for Disease Control and Prevention (2022, Sept. 8). Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html
3Norman Regional Health System (2023, Mar. 7). Economic Impact of Obesity Expected to Exceed $4 Trillion by 2035. https://www.journeyclinic.com/blog/1-economic-impact-of-obesity-expected-to-exceed-4-trillion-by-2035
4Centers for Disease Control and Prevention (2022, Sept. 8). Poor Nutrition. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/nutrition.htm#diabetes
5National Council on Aging (2021, Jul. 17). Obesity Treatment and Medicare: A Guide to Understanding Coverage. https://www.ncoa.org/article/obesity-treatment-and-medicare-a-guide-to-understanding-coverage
6American College of Occupational and Environmental Medicine (2021, Nov. 7). Obesity Has Causal Impact on Job Absenteeism and Related Costs. https://acoem.org/Publications/Press-Releases/Obesity-Has-Causal-Impact-on-Job-Absenteeism-and-Related-Costs
7Population Reference Bureu (2021, Dec. 22). U.S. Census Bureau, Vintage 2020 Population Estimates. Which U.S. State Has the Oldest Population?https://www.prb.org/resources/which-us-states-are-the-oldest/.
8Urban Institute (2023, Sept. 12). The US Population is Aging. https://www.urban.org/policy-centers/cross-center-initiatives/program-retirement-policy/projects/data-warehouse/what-future-holds/us-population-aging.
9North Carolina Medical Journal (2023, Mar. 6). Malnutrition and Food Insecurity in Older Adults. https://ncmedicaljournal.com/article/73010
10National Institutes of Health (2022, Mar. 8). Opportunities to Improve Quality Outcomes: Integrating Nutrition Care Into Medicare Advantage to Address Malnutrition and Support Social Determinants of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8908402/
11The White House (2022, Sep. 27). Biden-Harris Administration National Strategy on Hunger, Nutrition and Health. https://www.whitehouse.gov/briefing-room/statements-releases/2022/09/27/executive-summary-biden-harris-administration-national-strategy-on-hunger-nutrition-and-health/
12CAP (2022, Aug. 11). The United States Can End Hunger and Food Insecurity for Millions of People. https://chat.openai.com/c/62d9e7fd-8992-412d-8602-98248e81c1c2
13U.S. Department of Health and Human Services (2016, Sep. 28). Administration for Community Living. Combatting Senior Malnutrition. https://acl.gov/news-and-events/acl-blog/combatting-senior-malnutrition
14Kansas State University (2013, Jun. 13). Benefits and statistics about eating healthfully are detailed. https://www.k-state.edu/today/announcement/?id=8989
15Health (2023, Mar. 2). Medicaid Testing ‘Food as Medicine’ Program in Some States-How Could It Impact Health? https://www.health.com/medicaid-food-as-medicine-7152259#citation-1
16KFF (2018, May 10). Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/