National Academies Press US ; Berkman and Jewel M. Since data have been collected in the United States on racial differences in health status, blacks have been found to be at increased risk for almost every poor health outcome from most causes of morbidity to mortality and disability.
Such inequalities in health are documented for men and women from birth to old age. Even crossovers in very old age in which blacks have been shown to have a survival advantage are now viewed with renewed skepticism see Elo and Prestonand Manton and Stallardin this volume.
Furthermore, while health status has improved over the last decades for all Americans, the gains have been greater for whites than for blacks, producing an even larger health disparity for blacks in the last decade or two. For instance, during the last 30 years, life expectancy at age 65 increased 2. The corresponding increases for women are 3. Department of Health and Human Services, The reasons offered to account for these disparities range from genetic and selection factors to environmental exposures and differential access to medical care.
Rather than explore this multitude of possibilities, this paper explores the extent to which health-damaging and health-promoting behaviors explain black-white differences in health status. In addition, we have taken the perspective that while behaviors are de facto performed by individuals, individual behaviors occur in a social context. They are heavily influenced by the "Older white women and black men" social structure.
For instance, laws regulating the consumption and taxation of alcohol and cigarettes lead directly to altered patterns of consumption. Most behaviors, in fact, vary across social strata. In this paper we are specifically interested in the extent to which there are differences in the distribution of health behaviors or social networks between blacks and whites in the United States and whether this differential distribution is related to underlying differences in socioeconomic status.
The paper is divided into several sections. First we review the evidence on the distribution of health-damaging and health-promoting behaviors among blacks and whites.
We take a rather broad perspective on such behaviors, reviewing those that are traditionally called risk behaviors, such as cigarette and alcohol consumption, as well as health-promoting activities, such as physical exercise and maintaining social community ties. In the second section we examine the distribution of health-damaging and health-promoting behaviors in a large study of older men and women, the New Haven Established Populations Older white women and black men the Epidemiologic Study "Older white women and black men" the Elderly EPESE.
In that section, we examine both traditional health behaviors and cardiovascular risk factors as well as social conditions related to social networks and socioeconomic status.
Comparisons of the health practices of black and white older men and women should not be made without the following considerations:. In this section we examine the influence of and interaction between race and socioeconomic status on the following attitudes, behaviors, and social environments of black and white older men and women: We selected these risk factors because of the recognition that their effects on many chronic diseases, especially cardiovascular and cerebrovascular disease, are interrelated.
Many investigators suggest that it is important to study preventive health practices of older adults in order to elucidate the behavioral determinants of successful aging Lubben et al. Others explore racial differences in health practices in an attempt to understand why blacks experience excess morbidity and mortality Rogers, ; Mutchler and Burr, ; Duelberg, Comparisons of health-protective attitudes and behaviors among blacks and whites are also made for the Older white women and black men of explaining the possible crossover of their mortality rates Ford et al.
In a study of the interaction between the extent to which adults worry about heart disease, Ransford found that at all educational levels, blacks reported greater concern about heart disease.
Surprisingly, those concerns translated into more health-protective behavior exercise, changed dietary habits, or smoking cessation only Older white women and black men blacks who had less than a high school education.
In a survey examining the relationship between socioeconomic characteristics and health beliefs, Weissfeld et al. After adjustment for race, the association between perceived health threats and socioeconomic status diminished. A survey by Mutchler and Burr demonstrated a similar disparity in self-appraisal of health that persisted after adjustment for socioeconomic status. Whites were more likely to maintain their desired body weight, but there were no significant racial differences in smoking, exercising, alcohol intake, or maintenance of social networks.
Thus, these studies would suggest, albeit not conclusively, that blacks, especially older blacks, are concerned about chronic disease, appraise their health status as worse than whites, and place an equal or higher value on health-protective behaviors.
These findings reinforce the theory that behavior change does not rest on knowledge and awareness alone. The behavioral aspects of obesity have an impact on the difference in disease patterns between blacks and whites. Obesity is associated with hypertension, non-insulin-dependent diabetes mellitus, and osteoarthritis Pi-Sunyer,all of which are more prevalent among blacks National Center for Health Statistics, It is now believed that weight loss and maintenance are probably best achieved through a combination of dietary control and Older white women and black men physical activity DiPietro et al.
For this reason, we will discuss issues related to diet and exercise together. As many as 60 percent of black women are overweight Kumanyika, The higher prevalence of obesity in older black women is related to their higher baseline body mass index in middle age Williamson et al. That black women express a positive attitude about their weight more often than white women is a behavioral element that is felt to influence the potential success of dietary interventions designed for them.
Although studies about weight perceptions have generally been done in younger populations Kumanyika et al. status was not included in that analysis. In a study of dietary patterns of centenarians and adults who were in their sixties and eighties, Johnson et al.
In that study, blacks also reported larger fluctuations in their adult weight. Again, we see that blacks maintain a desire to eat more nutritiously although they tend to be more overweight. Comparisons of activity levels in elderly racial groups have more often included examination of the effects of socioeconomic status than have studies of dietary patterns Folsom et al.
Numerous studies have shown that blacks exercise less than whites and engage is less leisure time physical activity Burke et al. The comparative proportions of black and white men who so exercise is In the cohort above 65 years old, Using data from the National Health Interview Survey NHIS and adjusting for education and income, Duelberg showed that these racial differences in exercise patterns could not be entirely explained by socioeconomic status.
In a study of how education level and race were associated with risk factors for coronary artery disease among younger men and women, Sheridan et al. The prevalence of cigarette smoking among older Americans is complex and is related to cohort effects and different norms among men and women. Population-based estimates provide valuable information about smoking patterns in all blacks and whites, as well as in elderly subgroups. Some general observations are that 1 overall, whites are heavier smokers than blacks; 2 black men smoke more and black women smoke less than their white counterparts; and 3 smoking rates are higher and cessation rates are lower in persons with less education Centers for Disease Control [CDC] Also in that survey, 50 percent of respondents over age 65 had never smoked, compared with 67 percent in This decrease in the percentage of elderly abstainers was not consistent among all gender and racial subgroups.
Whereas abstention rates increased among elderly men, they decreased in women. Moreover, between Older white women and black menthe net increase in the percentage of those who had never smoked was twice as high for older blacks as for whites Despite these trends, smoking rates are higher for elderly black men than for their white counterparts.
In women, the rates are higher in whites than in blacks. These differences are illustrated by NHIS data National Center for Health Statistics,which show that in30 percent of elderly black Older white women and black men were smokers, compared with 16 percent of white men. Although the racial differences in the percentage of smokers among both genders was a bit lower in the NHIS National Center for Health Statistics,the overall trends were identical.
Smaller studies have also described the epidemiology of smoking in older adults.
In his sample, the prevalence of smoking in elderly black and white men and women was very similar to that found in the population-based studies. Other investigators have described similar differences in the tobacco use of black and white elders. For example, in a study of hypertensives, Svetkey et al.
Among Medi-Cal recipients in the study by Lubben et al. Additional research is needed to identify possible correlates including social class of tobacco use for older blacks and whites.