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Deaths from malnutrition are rare in Minnesota, but they increased in the first year of the COVID-19 pandemic — primarily among women 85 and older living alone in rural areas.

The unexpected finding was part of a broader Mayo Clinic analysis of final death certificate data in 2020, when 10% of the state's 52,030 deaths were caused by COVID-19.

Social-distancing measures in Minnesota might have prevented hundreds or thousands of COVID-19 deaths, Mayo researchers said, but the resulting isolation contributed to the state's 123 malnutrition deaths that year. The state had averaged about 80 malnutrition deaths in the prior two years.

Older, rural Minnesotans lost contact with friends or relatives or support programs that brought them meals to maintain their health, said Dr. Rozalina McCoy, a Mayo primary care provider and lead author of the study.

"Churches went virtual. Food shelves closed or people were afraid to go to them," McCoy said. "So, it really was a death of social isolation. For me, in primary care, that was the saddest part."

The researchers also expected an isolation-related increase in deaths from unmanaged heart disease, cancer and stroke because patients in 2020 weren't going to clinics for regular care or hospitals for acute flareups. But that didn't happen. Suicides didn't increase, either, possibly because families were huddled together and young adults didn't have isolated moments in which to act on fleeting impulses of self-harm.

Mortality trends are viewed beyond a numerical count of deaths in years of potential life lost — a measure that is heavily influenced by young people who die from preventable causes. Minnesota's 12% increase in that measure in 2020 was driven beyond COVID by homicides involving firearms, drug overdoses, and liver diseases that often were related to alcohol abuse.

"It confirmed that a lot of people died from COVID and deaths of despair," such as overdoses, McCoy said. "It also confirmed what people have been seeing, and almost didn't believe, about (the lack of an increase in) deaths from chronic diseases or accidents or suicides."

Some of these trends were observed in earlier studies, but McCoy said the eventual use of final death certificate data provides the strongest evidence. Mayo's research was perhaps the first to identify the rise in malnutrition, though, because it was a trend involving elderly rural women. Other studies focused on urban states or regions.

McCoy said Minnesota's pandemic response was absolutely necessary to reduce the death toll from COVID-19, but that health officials should learn from the residual consequences of social and business restrictions and find ways to maintain social cohesion. Outdoor activities where viral risks are lower should be encouraged, for example.

"We're not meant to be isolated," she said, "and I think all of these deaths, whether its homicides or overdoses or alcohol or (malnutrition as a result of) social isolation, I think it all stemmed from this really sudden and unprecedented breakdown in how we live."

Malnutrition was a developing concern in late 2019 for Louise Wiley, but worsened during the pandemic when her assisted living facility in Alexandria, Minn., canceled group meals and limited staff contact with residents. Sundown Syndrome meant she was confused by her schedule and needed regular prompting to eat, said her daughter, Diane Wiley.

"She ... wasn't hungry unless I was there to help her with eating," said her daughter, who would bring favorites like salmon and blackberries. "I lived three hours away and I would travel every two weeks to see her. Assisted living didn't have the workforce to push or help her to eat, especially during COVID."

Wiley lost more than 70 pounds and died Nov. 10, 2020, of complications of malnutrition at age 95. Her legacy included four children and numerous grandchildren, a competitive streak in cribbage and a love of B-25 aircraft because she traveled by train to California as a teenager to help build them during World War II.

Minnesota in 2020 had the fourth-lowest rate among U.S. states of deaths by malnutrition, according to the Centers for Disease Control and Prevention. However, a Star Tribune review of preliminary death certificate data indicates a rising problem — with malnutrition listed as the underlying cause of 190 deaths in Minnesota last year.

Among those, 137 involved people in homes or independent living facilities. Another 53 involved residents of nursing homes. Staffing shortages in home care agencies and nursing homes have worsened and could be extending the problem even in the absence of pandemic restrictions.

Jona Birr said her mother, Susie, lost extreme weight at a hospital and nursing home in spring 2020, because she didn't like the food and caregivers made minimal trips into her room amid COVID-19 isolation protocols and cumbersome gowning requirements. Birr tried through an outdoor nursing home window to encourage her mother to eat.

Back home in Emmons, Minn., Birr found something her mother liked — a scramble of spaghetti, corn and brown sugar that she enjoyed growing up in the Philippines. Birr added brown sugar to all her food, and her mother regained a little weight, but she died of malnutrition at age 86 on Dec. 7, 2020.

Nursing homes routinely must review the nutrition and hydration needs of residents, and can be cited for falling short of this licensure requirement. Self-neglect by residents can be a challenge, though, and was more of a problem during the pandemic, said Kari Everson, vice president of clinical services for LeadingAge Minnesota, an advocacy group for the state's long-term care industry.

"Isolation exacerbated depression and other mental health conditions that could increase the risk for residents to choose not to take food or fluids or complete other usual daily activities," she said.

Mayo is planning follow-up research to see if mortality trends changed or carried into 2021, when COVID-19 vaccines became available and Minnesota refrained from lockdown measures and repealed a mask mandate.