Some groups of minority women are more likely to die from heart disease, stroke, and cancer than are White women. Other health problems-including obesity, diabetes, and hypertension-occur more frequently among most populations of minority women than among White women. Although these important disparities have been identified, we do not know all the reasons why women's disease risks and mortality rates vary by race and ethnicity.
We do know that higher poverty rates coupled with barriers to health education, preventive services, and medical care result in disparities between White and minority women in several areas:
the likelihood of premature death (mortality),
life expectancy,
the risk factors for developing major diseases, and
the extent and severity of illnesses (morbidity).
[Note: Unless otherwise specified, information on the leading causes of death and mortality rates was obtained from Table 1, Leading Causes of Death for Females of All Ages in the United States, by Race and Ethnic Origin (2000)32 , and Table 2, Mortality Rates for Selected Major Causes of Death for Females of All Ages, Age-Adjusted, by Race/Ethnicity, United States (2000) 33. These two tables can also be found at the end of this document.]
A. Mortality Rates
(Note: Mortality rate is defined as the number of deaths in a given year per 100,000 persons in the population.)
1) African American women. The four leading causes of death among African American women are, in order of prevalence: heart disease; all malignant neoplasms (cancer) combined; cerebrovascular diseases, including stroke; and diabetes. These women have higher mortality rates from a number of diseases than do White women, including heart disease, stroke, and most cancers.
2) American Indian/Alaska Native women. The four leading causes of death among American Indian/Alaskan Native women are, in order of prevalence: heart disease; all cancers combined; unintentional injuries; and diabetes. These women have lower death rates from most major diseases than do White women, including cancer, stroke, and chronic obstructive pulmonary diseases. However, their mortality rates from motor vehicle-related injuries34 , diabetes 35, chronic liver disease (cirrhosis)36 , and homicide37 are higher than those for White women38.
3) Asian American/Pacific Islander women. The four leading causes of death for Asian American/Pacific Islander women are, in order of prevalence: all cancers combined; heart disease; cerebrovascular disease, including stroke; and unintentional injuries. These women have lower death rates from most major diseases than do White women, including heart disease, stroke, and AIDS. However, heart disease accounts for more than one-fourth (25%) of deaths. Their mortality rate from breast cancer and all cancers combined was the lowest of all population groups in 2000.
4) Hispanic women. The four leading causes of death among Hispanic women are the same as for African American women: heart disease; all cancers combined; cerebrovascular diseases; and diabetes. Among Hispanic women, mortality rates from several diseases are lower than those of White women, including stroke, chronic obstructive pulmonary disease, and cancers of the respiratory system and breasts. Mortality rates from AIDS and homicide, however, are significantly higher for Hispanic women than White women.
B. Life Expectancy
U.S. vital statistics data in 2001 show that the average life expectancy at birth for men and women of all races was 77.2 years, in contrast to 70.8 years in 1970.39 Life expectancy varies by race, sex, and family income level. At birth, the life expectancy for women is 79.8 years compared to 74.3 years for men40. Women have a longer life expectancy than men by an average of 5.5 years, and Whites have a longer life expectancy than African Americans by almost 6 years 41. In 2001, life expectancy at birth for Asian Americans (both men and women) was 81.5 years 42 and for White women, 79.9 years; Hispanic women, 83.0 years; American Indian/Alaska Native women, 74.7 years; and African American women, 74.7 years.43
C. Risk Factors for Disease
Chronic diseases are the leading cause of death and disability among all Americans and account for 70% of all deaths in this country44. More than 90 million Americans live with chronic diseases45. The risk behaviors most often leading to premature death and disability are tobacco use, alcohol and drug use, poor diet, and physical inactivity. Many of these risk factors are serious issues for minority women.
1) Tobacco use. Smoking is the single most preventable cause of death and disease in the United States. As of 1998, roughly 22% of all adult women reported smoking, and in 2000, almost 30% of female high school seniors reported smoking within the past month46. Among women, the use of tobacco has been shown to increase the risk of cancer, heart and respiratory diseases, and reproductive disorders47. Researchers have identified more than 250 chemicals in tobacco smoke that are toxic or cause cancer in humans and animals48. In 1999, approximately 165,000 women died prematurely from smoking-related diseases, such as cancer and heart disease49. The proportion of women age 18 and older who report currently smoking cigarettes range from less than 10% (Asian and Pacific Islander) to a high of almost 32% (American Indian/Alaska Native)50.
Nearly all women who smoke started as teenagers, usually before graduation, and smoking rates among women with less than a high school education are three times higher than for college graduates51. The earlier a young woman begins to use tobacco, the more heavily she is likely to use it as an adult. Among high school seniors between 1990 and 1994, 39% of American Indian/Alaska Native females, 33% of White females, 19% of Hispanic or Latino females, 14% of Asian American/Pacific Islander females, and 9% of African Americans females were found to be current smokers52. In addition, 39% of White, 32% of Hispanic, and 18% of African American female high school students reported they were current smokers in 199953.
- American Indian/Alaska Native women ages 18 and over were the most likely to smoke cigarettes (37.3%) compared to all women54. However, 54% of American Indian women living on reservations have never smoked. In addition, smoking prevalence varies by reservation55.
African American women had the third highest percentage of current smokers (20.6%), after White women (22.3%)56. Sixty-four percent of African American women, however, have never tried smoking57.
Of Hispanic women, 12.4% reported current cigarette smoking, in contrast to 22.3% of White women58. Hispanic women smoke less on a daily basis than do White women or African American women. Among Hispanic women, foreign-born women have much lower rates of smoking than U.S.-born Hispanic women59.
- Asian American/Pacific Islander women are the least likely population to smoke (10.2%)60. In 1998, less than 17% reported having ever smoked at all61. The prevalence of smoking among Asian American female subpopulations, however, ranged from a low of less than 1% among Vietnamese American women to a high of 19% among Japanese American women62.
2) Body Weight. The National Institutes of Health (NIH) defines the term overweight as an excess amount of body weight for height-which includes muscle, bone, fat, and water-as determined by weight-for-height tables. Obesity is defined as the excess accumulation of body fat. Doctors and scientists generally agree that women with more than 30% body fat are obese63.
Body-mass index measures (BMI), which do not measure body fat, are used to determine if a person is at a desirable body weight. (BMI is found by dividing a person's weight in kilograms by height in meters squared.) When a woman's BMI exceeds 25 to 29.9 kg/m2, that person is considered overweight64. Defining overweight as a BMI of greater or equal to 25 is consistent with the recommendations of the World Health Organization65. The degree of obesity associated with a particular BMI varies, but the NIH identifies obesity as a BMI greater than or equal to 30. These guidelines are based on an increase of adverse health effects in people whose BMI is greater or equal to 2566. An estimated 54.9% (97.1 million) of the entire American population over the age of 20 has a BMI greater than or equal to 2567.
In 1999-2000, 62.0% of all women between the ages of 20 and 74 were defined as overweight, and 34% of these women were considered obese68. Since 1980, the number of obese women in this country has more than doubled (17.1% in 1980 to 34.0% on 2000)69. Overweight women are at increased risk for hypertension, heart disease, diabetes, osteoarthritis, and some types of cancer70. Risk factors include poor nutrition, physical inactivity, environmental factors (such as education and income level), and genetics. The high incidence of adult-onset diabetes is a major problem for women of color, especially Native American, Mexican American, and African American women, in part because of obesity71.
More than three-quarters (78.0%) of African American women between the ages of 20 and 74 were classified as overweight in 1999-2000 and 50.8% were classified as obese. In contrast, over half (57.5%) of White women were overweight and almost one-third (30.6%) were obese72.
According to the Indian Health Service, 60% of all American Indian women living on reservations and 63% of urban American Indian women are obese73.
Among subpopulations of Hispanic women, Mexican American women have the highest rate of overweight (71.8%) and obesity (40.1%)74. Hispanic immigrants who have lived in this country for less than 15 years are less likely to be obese (25%) than more acculturated immigrants (35%)75.
Asian American women, in general, have the lowest rates of obesity. However, among subpopulations, the percentage of women who are obese ranges from 26% of Filipino American women to 13% of Chinese American women76.
3) Alcohol and Illicit Drug Use. Heavy and chronic use of alcohol and other drugs have numerous harmful effects on the body. Recent studies have indicated that gender differences in the absorption and metabolism of alcohol place women at higher risk than men for adverse effects of alcohol consumption. Alcohol is a serious health concern for women and adolescent females of all races and ethnic backgrounds. Thousands of women die each year from chronic liver disease or cirrhosis, both of which were the results of sustained alcohol abuse. In cirrhosis of the liver, scar tissue replaces healthy tissue and prevents it from working as it should77. Other adverse effects include liver disease, hepatitis and damage to the heart and brain78. Heavy alcohol consumption during pregnancy can cause Fetal Alcohol Syndrome (FAS), the leading cause of physical and mental birth defects. FAS is one of the most common known causes of mental retardation, and it is entirely preventable79.
Death rates from drug-induced causes-including motor vehicle crashes, unintentional injuries, homicides, and suicides-are significant among minority populations (see Table 2). The use of marijuana and other illicit substances is also linked to sexually transmitted diseases (including HIV/AIDS), poor maternal and infant health, and violence, all of which are experienced disproportionately by minority females.
a) Alcohol Use. In 1998, 113 million Americans age 12 and older reported currently using alcohol, that is, that they had used alcohol at least once during the previous 30 days. Roughly 33 million of this group engaged in binge drinking, meaning they drank 5 or more drinks on one occasion during that 30-day period. An estimated 12 million were heavy drinkers, meaning they had 5 or more drinks on one occasion on 5 or more days during the past 30 days80.
Although the consumption of alcoholic beverages is illegal for those under 21 years of age, 10.5 million current drinkers (of the reported 113 million) were between the ages of 12 and 20 in 199881. Of this group, 5.1 million engaged in binge drinking, including 2.3 million who would also be classified as heavy drinkers82. The rates of heavy drinking (consuming five or more drinks at one time) are highest among Hispanic (27%) and White (32%) female adolescents, in contrast to 15% of young African American females and 14% of American Indian/Alaska Native female adolescents83. More than 37% of Hispanic, 35% of African American, and 32% of White female adolescents reported riding in a vehicle with someone who had recently consumed alcohol. Ten percent of Hispanic, 5% of African American, and 8% of White female adolescents have driven an automobile under the influence of alcohol84.
Eighty-three percent of White women, 68% of African American women, and 58% of Hispanic women have used alcohol at some point in their lives85. In 2000, 37.7% of women ages 18 and over reported they were regular drinkers (12 or more drinks during the past year), a decrease from 38.9% in 199786. The highest rate of drinking among women occurs between the ages of 25-44, in which 64.1% of women reported being current drinkers87.
While the majority of adult women are not problem drinkers, a small proportion drink either frequently or heavily. Rates of alcohol consumption, reported symptoms of alcoholism, and mortality rates vary greatly among minority populations and within the same group. Chronic liver disease and cirrhosis are two conditions often related to the consumption of excessive amounts of alcohol. Between 1995 and 1997, 18 American Indian/Alaska Native women per 100,000 died from liver disease and cirrhosis, compared to 6 deaths per 100,000 for both Hispanics and black non-Hispanic females; 4 deaths per 100,000 white, non-Hispanic females; and 2 deaths per 100,000 for Asian and Pacific Islanders88.
Among American Indian/Alaska Native women and White women, 2-3% consumed at least 60 drinks within 30 days89. The alcoholism death rate among the American Indian/Alaska Native population is 7 times higher than the national rate for persons of all racial/ethnic groups. American Indian/Alaska Native women have the highest mortality rates related to alcoholism of all American women. A sharp increase in alcohol-related deaths among American Indian/Alaska Native women occurs with increasing age. Among 15- to 24-year-old women, 2.1 per 100,000 die from alcohol-related causes compared to 87.6 per 100,000 for the 44-to-54 age group90. Contributing factors to the high mortality rates from drinking include distance to care and reduced availability of services91.
Among African American women, 2-3% consume at least 60 drinks within a month92. The alcohol-induced death rate for African American women was very small in 1997 (4 per 100,000), slightly higher than that of White women (3 per 100,000)93. Deaths directly and indirectly caused by alcohol occurred at higher rates for African American than White women, 29 per 100,000 women and 16 per 100,000 women, respectively94.
Forty-nine percent of Hispanic women abstain from using alcohol. Women of Hispanic origins other than Mexican, Puerto Rican, and Cuban are most likely to abstain from alcohol consumption. However, they are also the most likely to be heavy drinkers (4%), consuming five or more drinks at one sitting at least once a week95.
Asian American women are more likely to abstain from alcohol (61%) than other minority populations96. Less than 1% are heavy drinkers and consume 60 drinks within one month97. Among subpopulations, considerable variation exists between drinking alcohol and reporting symptoms of alcoholism. Larger proportions of Japanese American women reported being heavy drinkers (12%) than Korean American women (0.8%). No Chinese American women reported heavy drinking98. In addition, more than one-quarter of Japanese American women, half of Chinese American women, and three-quarters of Korean American women reported abstaining from alcohol99.
b) Illicit drug use. In 1998, more White women (33%) and African American women (26%) reported having used illicit drugs at some point in their lives than did Hispanic women (20%)100. White women have also used a greater number of illicit substances than have African American and Hispanic women.
Marijuana is the most common illicit substance used by women, with almost one-third of White women (31%), almost one-fourth of African American women (24%), and one-sixth (17%) of Hispanic women using marijuana at least once in their lives101. Other illicit substances include inhalants, hallucinogens, tranquilizers, sedatives, and analgesics (a medication capable of reducing or eliminating pain)102. In 1998, approximately 6% of Latino and African American women reporting having ingested cocaine at least once in their lifetimes; 9% of White women have used this drug103. When asked if they had used cocaine within the last year, 1.3% of Latino, African American, and White women reported use within the last year104.
Drug use among American youth remained high during the 1990s105. In 1998, 46% of Hispanic, 43% of African American and 42% of White females reported using marijuana106. A study in 1993 found that of American Indian high school students (both sexes), 56% surveyed had used marijuana in their lifetimes and 40% reported use within the past month107. Significantly more Hispanic female adolescents used cocaine in 1999 (5.4%) than either young White females (2.8%) or African American high school females (1.1%)108. High school-age Hispanic females had the highest lifetime use of cocaine, glue (for sniffing), and other illegal substances, such as heroin and LSD, than either their African American and White class-mates. Among female high school students, African American students have a lower prevalence of substance use than either Hispanic or White female youth109.
Although African American women comprise only 12.7% of the female population, they accounted for 26.4% of drug-related deaths among women in 1999110. Among the African American women who died due to drug use that year, 57% were between 26 and 44 years of age at the time of their deaths111.
Hispanic women accounted for 7.2% of drug-related deaths among women in 1999112. Among the Hispanic women who died due to drug use that year, 53% were between 26 and 44 years old at the time of their deaths113. Among young women between the ages of 18 and 25, 11% of Latina, compared to 8% of White and 5% of African Americans, died from drug-related causes114.
Asian American/Pacific Islander women represented 1.1% of drug-related deaths among women in 1999115.
American Indian/Alaska Native women accounted for 0.6% of all drug-induced deaths in 1999116. American Indian/Alaska Native women have a mortality rate from illicit drug use ranging from under 0.5% per 100,000 women for those ages 15 to 24 and 55 to 64, to 8 per 100,000 women for those ages 25 to 34 and 45 to 54117.
Among all American women who died from drug-induced causes in 1999, 64.6% were White women of non-Hispanic origin118. Of this population, half (50%) were between 26 and 44 years of age at the time of their deaths119.
4) Physical Inactivity. Research has shown that physical activity has many benefits for health. It can reduce the risk of chronic diseases, helps control weight, appears to relieve symptoms of depression, helps to maintain independent living, and enhances overall quality of life120. Conversely, the lack of exercise can negatively affect one's health, contributing to such diseases as coronary heart disease, colon cancer, hip fractures, high blood pressure, and adult onset diabetes121.
Regular exercise is important to obtain substantial health benefits. The Surgeon General recommends light to moderate physical activity 30 minutes a day on most days of the week122. Light and moderate activities include walking for exercise, gardening, and stretching123. More challenging forms of exercise include stair climbing, swimming, aerobics, cycling, jogging, and weightlifting. More men engage in physical activity than do women.
More than 60% of women in the United States do not engage in the recommended amount of physical activity124. Among White women, 39% did not exercise125. Of the 61% who did report engaging in physical activity, 26% of them engaged in moderate physical activity126.
In 1997, 57% of Hispanic female immigrants over 18 years of age were sedentary (not engaging in any physical activity)127. According to a national youth survey of high school girls, 50% of Hispanic girls engaged in vigorous activity (physical activities that produced hard breathing at least three times a week for more than 20 minutes), and 17% engaged in moderate physical activity (walking or bicycling no fewer than 5 days a week for a half an hour each day)128.
Among African American women, 57% of African American women reported leading a sedentary lifestyle129. In 1999, 47% of African American girls engaged in vigorous physical activity several times a week and an additional 18% engaged in moderate activity130.
Among Asian American women, 49% reported that they did not engage in exercise131.
Adult women in both urban and rural areas exercised much less than their younger counterparts. Women over age 40 were less likely to exercise if they lived in urban areas than women in rural areas. For women age 40 and older living in urban areas, only 12% of Latinas and White, 8% of African American, and 8% of American Indian/Alaska Native women were regularly active. For women ages 40 and older living in rural areas, 21% of Latina, 5% of African American, and 8% of American Indian/Alaska and White women were active132.
Overall, half of women ages 40 and over are sedentary, and African American women in rural areas are the most likely to be sedentary (60%)133.
D. Morbidity
Two overall measures of morbidity are commonly used to reflect one's health status:
The percent of women (and men) who are limited in their daily activities due to a chronic condition; and
The percent of women (and men) who report fair or poor health status134.
Limited activity is measured by asking people questions on their limitations in their ability to perform usual activities for their age group - such as limitations in daily living, or in instrumental activities of daily living, play, school, and work. People are considered limited if one of more of these activities is hindered because of their health.
These measures (as do mortality rates) continue to reflect the disparities between minority and White populations. For example, a higher proportion of African Americans (14.3%), in comparison to Whites (11.5%), reported some limitation in their activity as a result of chronic conditions in 2000135. Almost twenty percent (19.2%) of African Americans reported that they needed help performing "instrumental" activities such as shopping, everyday household chores, and other routine needs, in contrast to 12.1% of Whites136. For daily activities such as eating, bathing, and getting around the home, 10.2% of African Americans in comparison to 5.8% of Whites had limitations137.
A higher proportion of minority populations report being in fair or poor health than do Whites. Based on self-assessments in 2000, 17.2% of American Indian/Alaska Natives reported fair or poor health, as did 14.6% of African Americans of non-Hispanic origin, and 7.4% of Asian Americans138. (Among Whites of non-Hispanic origin, 8.2% reported fair or poor health status.)139
A greater number of poor (those whose family income is below the poverty threshold) than non-poor families reported fair or poor health in 2000 (20.9% and 6.3% respectively)140. Across ethnicities, poverty is associated with health: the lower the income level, the higher percentage of people who reported fair or poor health. Among poor or near poor minority groups, 44.7% of African Americans and 35.6% of Hispanics reported only fair or poor health141. (Among poor and near poor Whites of non-Hispanic origin, 34.8% reported fair or poor health.)142
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July, 2003