Introduction: Nutritional anemia represents a common and significant public health challenge in the elderly. Nutritional anemia includes iron deficiency anemia (the most common

form), megaloblastic anemia, folate-deficiency anemia, and protein-deficiency anemia, among others. Demographic and geographically stratified mortality trend analyses concerning nutritional anemia amongst the elderly in the United States are limited. This study examines national mortality trends in adults aged ≥ 65 years with nutritional anemia from 1999 to 2023.

Methods: The CDC WONDER Multiple Cause-of-Death dataset (1999-2023) was used to analyze mortality trends in adults aged ≥ 65 years using ICD-10 codes for nutritional anemia (D50-D53). Results were stratified by place of death, year, sex, age group, race, U.S. census region, state, and urbanization. Age-adjusted mortality rates (AAMRs) were quantified per 100,000 persons by standardizing crude mortality rates (CMRs) with 95% confidence intervals (95%CI). Annual percent change (APC) and average annual percent change (AAPC) were calculated using Joinpoint regression software.

Results: A total of 63,616 nutritional anemia-related deaths occurred in adults ≥ 65 years in the United States from 1999 to 2023. Most of the deaths occurred in medical facilities (35.07%), followed by nursing home/long term care facilities (30.85%), the decedent's home (26.85%), other/place of death unknown (3.92%), and hospices (3.30%). Overall AAMRs declined from 8.53 in 1999 to 5.62 in 2003 (APC: -9.52; 95%CI: -15.15 to -6.41) and down to 4.14 in 2014 (APC:-2.42; 95%CI: -3.49 to -0.90), followed by increasing values until 8.63 in 2023 (APC: 9.14; 95%CI: 8.05 to 10.53). This culminates in increasing AAMRs represented by an AAPC of 0.49 (95%CI: 0.09 to 0.87) from 1999 to 2023. Men had a higher average AAMR (6.05) compared to women (5.61), and had increasing values (AAPC: 0.55; 95%CI: 0.09 to 1.08), compared to stable values in women. In terms of age group, adults ≥ 85 years had the highest average CMR (24.69), while adults aged 65-74 years had the highest rate of increase (AAPC: 4.77; 95%CI: 3.36 to 6.96). Racially, non-Hispanic (NH) Whites had the highest average AAMR (6.03) and had the highest rate of increase (AAPC: 0.69; 95%CI: 0.34 to 1.04). Regarding census regions, the Midwest had the highest average AAMR (7.13), followed by the South (5.66), the West (5.44), and the Northeast (4.85). The West and Northeast saw increasing mortality rates (AAPC West: 1.95; 95%CI: 1.53 to 2.39; AAPC Northeast: 1.02; 95%CI: 0.58 to 1.59),

while the Midwest and South saw stable rates. From 1999 to 2023, states in the top 90th percentile of deaths include California, Florida, Ohio, Pennsylvania, and Texas, while states in the bottom 10th percentile were Alaska, Delaware, Nevada, Wyoming, and the District of Columbia. From 1999-2019, state-specific AAMRs ranged from 2.38 in Nevada to 11.75 in North Dakota. From 2020-2023, state-specific AAMRs extended from 4.40 in Florida to 21.57 in Wyoming. From 1999-2020, non-metropolitan areas had a higher average AAMR (7.69) compared to metropolitan areas (4.93). Metropolitan areas had their AAMRs decline while non-metropolitan areas had stable rates (AAPC metropolitan areas: -0.68; 95%CI: -1.03 to -0.27).

Conclusion: Generally, nutritional anemia-related mortality rates have increased from 1999 to 2023, with periods of decrease interspersed throughout. Disparities among demographic and geographical stratifications were significant. Further research to address such disparities and the implementation of public health strategies to address at-risk communities is critical.

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2025
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