Race by Gender Differences in the Protective Effects of Education and Income Against Subsequent Changes in Self-rated Health, Physical Activity, and Body Mass Index Among Older Americans

Document Type : Original Article


1 Department of Family Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA

2 Department of Family Medicine, Charles R. Drew University of Medicine and Sciences, Los Angeles, CA 90095, USA


Background: Educational attainment and income are central to maintenance of body mass index (BMI), physical activity, and self-rated health (SRH). However, less is known about how social groups differ in the role of educational attainment and income on subsequent changes in these health outcomes. This study compared race/ethnicity by gender groups of older Americans for the effects of baseline educational attainment and income on subsequent changes in BMI, physical activity, and SRH.
Methods: The Health and Retirement Study (HRS) followed 37,495 male and female White and African American people above age 50 for 6 years from 2004 to 2010. This number included 15,581 White women, 12,495 White men, 5,580 African American women, and 3,839 African American men. Physical activity, BMI, and SRH were measured every two years. Multi-group structural equation modeling (latent growth curve modeling) was used to compare race/ethnicity by gender groups for the protective effects of educational attainment and income in 2004 on a decline in physical activity, BMI, and SRH from 2004 to 2010.
Results: Major race/ethnicity by gender differences were observed in theeffects of baseline educational attainment and income on changes in BMI, physical activity, and SRH. Educational attainment and income showed more salient roles for White men and women than African American men and women. To give some examples, baseline education (years) was associated with changes in physical activity of White women and changes in BMI of White men, while baseline income was associated with changes in SRH of White Women. We did not find evidence suggesting that baseline income fully mediates the effect of baseline educational attainment on health outcomes, as in many instances, educational attainment but not income was associated with health changes over time.
Conclusion: The intersection of race/ethnicity and gender alters how educational attainment and income protects against subsequent changes in physical activity, BMI, and SRH. Social groups may vary in operant mechanisms by which social determinants of health prevent health decline in the United States.


1.  Pampel FC, Krueger PM, Denney JT. Socioeconomic Disparities in Health Behaviors. Annu Rev Sociol. 2010 Aug;36:349-370.
2.   Nancy E. Adler and Katherine Newman. Health Affairs 21, no.2 2002:60-76 Socioeconomic Disparities In Health: Pathways And Policies doi: 10.1377/hlthaff.21.2.60
3.  Pamuk, E, ed. Health United States 1998: With Socioeconomic Status and Health Chart Book. DIANE Publishing, 1999.
4.  Mare R.D. , “Socio-Economic Careers and Differential Mortality among Older Men in the U.S.,” in Measurement and Analysis of Mortality—New Approaches, ed. J. Vallin, S. D’Souza, and A. Palloni (Oxford: Clarendon, 1990), 362–387;
5.   Nandi A, Glymour MM, Subramanian SV. Association among socioeconomic status, health behaviors, and all-cause mortality in the United States. Epidemiology. 2014 Mar;25(2):170-7.
6.  Assari S, Lankarani RM, Lankarani MM. Cross-country differences in the association between diabetes and disability. J Diabetes Metab Disord. 2014 Jan 6;13(1):3. doi: 10.1186/2251-6581-13-3.
7.    Assari S. Cross-country variation in additive effects of socio-economics, health behaviors, and comorbidities on subjective health of patients with diabetes. J Diabetes Metab Disord. 2014 Feb 21;13(1):36. doi: 10.1186/2251-6581-13-36.
8.    Assari S, Lankarani MM. Does Multi-morbidity Mediate the Effect of Socioeconomics on Self-rated Health? Cross-country
Differences. Int J Prev Med. 2015 Sep 3;6:85. doi: 10.4103/2008-7802.164413.
9.    Assari S. Cross-Country Differences in the Additive Effects of Socioeconomics, Health Behaviors and Medical Comorbidities on Disability among Older Adults with Heart Disease. J Tehran Heart Cent. 2015;10(1):24-33.
10.   Adams P, Hurd MD., McFadden D, Merril A, Ribeiro T. Health, wealthy and wise. Tests for direct causal paths between health and socioeconomic status. J. Econometrics. 2003;112:3–56. doi: 10.1016/S0304-4076(02)00145-8.
11.  Frijters P, Haisken-DeNew JP, Shields MA. The causal effect of income on health: Evidence from German reunification. J. Health Econ. 2005;24:997–1017. doi: 10.1016/j.jhealeco.2005.01.004.
12. Assari S, Lankarani MM. Education and Alcohol Consumption among Older Americans; African American-White Differences. Front Public Health. 2016 Apr 21;4:67. doi: 10.3389/fpubh.2016.00067. eCollection 2016.
13.   Mustard CA, Etches J. Gender differences in socioeconomic inequality in mortality. J Epidemiol Community Health. 2003 Dec;57(12):974-80. R
14.   Assari S. Combined Racial and Gender Differences in the Long-Term Predictive Role of Education on Depressive Symptoms and Chronic Medical Conditions. J Racial Ethn Health Disparities. 2016 Jun 7.
15. Vlassoff C. Gender differences in determinants and consequences of health and illness. J Health Popul Nutr. 2007 Mar;25(1):47-61.
16.   Assari S, Moghani Lankarani M, Kazemi Saleh D, Ahmadi K. Gender modifies the effects of education and income on sleep quality of the patients with coronary artery disease. Int Cardiovasc Res J. 2013; 7(4):141-6.
17.  Assari S, Lankarani MM. Race and Urbanity Alter the Protective Effect of Education but not Income on Mortality. Front Public Health. 2016;4:100. doi: 10.3389/fpubh.2016.00100.
18.    Zajacova A, Hummer RA. Gender differences in education effects on all-cause mortality for white and black adults in the United States. Soc Sci Med. 2009;69(4):529-37. doi: 10.1016/j.socscimed.2009.06.028.
19.   Assari S. Veterans and risk of heart disease in the United States: a cohort with 20 years of follow up. Int J Prev Med. 2014;5(6):703-9.
20.    Hauser RM, Willis RJ. Survey design and methodology in the health and retirement study and the Wisconsin longitudinal study. In: Waite LJ, editor. Aging, Health, and Public Policy: Demographic and Economic Perspectives. New York: The Population Council, Inc; 2005. pp. 209–35.
21.   Heeringa SG, Connor JH. Technical description of the health and retirement survey sample design. 1995. Available from: http://www.hrsonline.isr.umich.edu/sitedocs/userg/HRSSAMP.pdf .
22.    Sonnega A, Faul JD, Ofstedal MB, Langa KM, Phillips JW, Weir DR. Cohort Profile: the Health and Retirement Study (HRS). Int J Epidemiol. 2014 Apr;43(2):576-85. doi: 10.1093/ije/dyu067.
23.    Kaufmann CN, Canham SL, Mojtabai R et al.  Insomnia and health services utilization in middle-aged and older adults: results from the Health and Retirement Study. J Gerontol A Biol Sci Med Sci. 2013;68:1512–1517. doi:10.1093/gerona/glt050
24.    Leggett A, Pepin R, Sonnega A, Assari S. Predictors of New Onset Sleep Medication and Treatment Utilization Among Older Adults in the United States. J Gerontol A Biol Sci Med Sci. 2016;71(7):954-60. doi: 10.1093/gerona/glv227.
25.  Feinglass J, Thompson JA, He XZ, Witt W, Chang RW, Baker DW. Effect of physical activity on functional status among older middle-age adults with arthritis. Arthritis Rheum. 2005 Dec 15;53(6):879-85.
26.   Taylor AW, Dal Grande E, Gill TK, Chittleborough CR, Wilson DH, Adams RJ, et al. How valid are self-reported height and weight? A comparison between CATI self-report and clinic measurements using a large cohort study. Aust N Z J Public Health. 2006;30(3):238–46.
27.   Simon GE, Von Korff M, Saunders K, Miglioretti DL, Crane PK, van Belle G, et al. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry. 2006;63(7):824–30. doi: 10.1001/archpsyc.63.7.824.
28.    Gavin AR, Rue T, Takeuchi D. Racial/ethnic differences in the association between obesity and major depressive disorder: findings from the Comprehensive Psychiatric Epidemiology Surveys. Public Health Rep. 2010;125(5):698–708.
29.   Steffick DE . Documentation of Affective Functioning Measures in the Health and Retirement Study. HRS AHEAD Documentation Report. Ann Arbor, MI: University of Michigan; 2000.
30.   Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.
31.    Allison PD. Structural equation modeling with Amos: Basic concepts, applications, and programming. 2 ed. New York, NY: Taylor and Francis Group; 2002.
32.   Arbuckle JL. Amos 18 user's guide. Chicago, IL: Amos Development Corporation; 2009.
33.   Kline RB. Principles and practice of structural equation modeling. 3 ed. New York: Guilford press; 2011.
34.    Hu G, Bouchard C, Bray GA, Greenway FL, Johnson WD, Newton RJ, et al. Trunk versus extremity adiposity and cardiometabolic risk factors in white and African American adults. Diabetes Care. 2011;34(6):1415-8.
36.  Lei M, Lomax RG. The Effect of Varying Degrees of Nonnormality in Structural Equation Modeling. Struct Equ Modeling. 2005;12(1):1-27.
37.   Tabachnick BG, Fidell LS. Using Multivariate Statistics. 3 ed. New York: Harper Collins; 1996.
38.  Assari S. Race and ethnic differences in additive and multiplicative effects of depression and anxiety on cardiovascular risk. Int J Prev Med 2016 7(1):22.10.4103/2008-7802.173931
39.  Watkins DC, Assari S, Johnson-Lawrence V. Race and Ethnic Group Differences in Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Chronic Medical Conditions. J Racial Ethn Health Disparities. 2015 Sep;2(3):385-94.
40.  Assari S, Lankarani MM. Association Between Stressful Life Events and Depression; Intersection of Race and Gender. J Racial Ethn Health Disparities. 2016 Jun;3(2):349-56. doi: 10.1007/s40615-015-0160-5.
41. Assari S, Lankarani MM. Stressful Life Events and Risk of Depression 25 Years  Later: Race and Gender Differences. Front Public Health. 2016 Mar 24;4:49. doi: 10.3389/fpubh.2016.00049.
42.   Assari S, Moazen-Zadeh E, Lankarani MM, Micol-Foster V. Race, Depressive Symptoms, and All-Cause Mortality in the United States. Front Public Health. 2016 Mar 17;4:40. doi: 10.3389/fpubh.2016.00040.
43.    Assari S, Sonnega A, Pepin R, Leggett A. Residual Effects of Restless Sleep over Depressive Symptoms on Chronic Medical Conditions: Race by Gender Differences. J Racial Ethn Health Disparities. 2016 Jan 28. [Epub ahead of print]
44.   Assari S, Lankarani MM, Burgard S. Black-white difference in long-term predictive power of self-rated health on all-cause mortality in United States. Ann Epidemiol. 2016 Feb;26(2):106-14. doi: 10.1016/j.annepidem.2015.11.006.
45. Spalter-Roth R. Race and ethnicity in the labor market; employer practices and worker strategies. In: Hernan V, Feagin JR, editors. , editors. Handbooks of the Sociology of Racial and Ethnic Relations. USA: Springer; (2007). p. 263–83.
46. Altonji JG, Blank RM. Race and gender in the labor market. In: Ashenfelter O, Card D, editors. , editors. Handbook of Labor Economics. Vol. 3C Amsterdam: Elsevier Science; 1999. p. 3143–259.
47. Proudford KL, Nkomo S. Race and ethnicity in organizations. In: Konrad A, Prasad P, Pringle J, editors. editors. Handbook of Workplace Diversity. London: SAGE; 2006. p. 323–44.
48. Grodsky E, Pager D. The structure of disadvantage: individual and occupational determinants of the black-white wage gap. Am Sociol Rev (2001) 66(4):542–67.
49.  Huffman ML, Cohen PN. Racial wage inequality: job segregation and devaluation across US labor markets. AJS (2004)109(4):902–36.10.1086/378928 
51.   Tomaskovic-Devey D. The gender and race composition of jobs and the male/female, white/black pay gaps. Soc Forces (1993)72(1):45–76.10.1093/sf/72.1.45 
52.  Jencks C, Mayer SE. Residential Segregation, Job Proximity, and Black Job Opportunities. Inner-City Poverty in the United States. Washington, DC: National Academy Press; (1990). p. 187–222.
53.  Grogger J. Does school quality explain the recent black/white wage trend? J Labor Econ 1996 14(2):231–53.10.1086/209810
54.   Pager D, Western B, Bonikowski B. Discrimination in a Low-Wage Labor Market: A Field Experiment. Am Sociol Rev. 2009; 74(5):777-799.
55.  IWPR. Importance of Social Security by Gender, Race/Ethnicity, and Marital Status. The Institute for Women’s Policy Research (IWPR) (2010). [accessed March 2016]. Available from:http://www.iwpr.org/publications/pubs/importance-of-social-security-by-gender-race-ethnicity-and-marital-status-2010
56.   Pager D, Western B, Sugie N. Sequencing Disadvantage: Barriers to Employment Facing Young Black and White Men with Criminal Records. Ann Am Acad Pol Soc Sci.  2009 May;623(1):195-213.
57.    Assari S, Racial disparities in the link between education and mortality in United States. JAMA. (Under review, 2016).
58. Montez JK, Hayward MD, Brown DC, Hummer RA.. Why is the educational gradient of mortality steeper for men? J Gerontol B Psychol Sci Soc Sci 2009 64(5):625–34.10.1093/geronb/gbp013
59.    Zajacova A, Hummer RA.. Gender differences in education effects on all-cause mortality for white and black adults in the United States. Soc Sci Med 2009) 69(4):529–37. 
60.   Amin V, Behrman JR, Spector TD. Does more schooling improve health outcomes and health related behaviors? Evidence from U.K. twins. Econ Educ Rev (2013) 35:134–48.
61.   Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci 2010; 1186(1):69–101.
62.   Crimmins EM, Hayward MD, Seeman TE. Race/ethnicity, socioeconomic status, and health. Critical Perspectives on Racial and Ethnic Differences in Health in Late Life. Washington, DC: National Academies Press; (2004). p. 310–52.
63.  Everett BG, Rehkopf DH, Rogers RG. The nonlinear relationship between education and mortality: an examination of cohort, race/ethnic, and gender differences. Popul Res Policy Rev 2013: 32(6):893–917.
64.   Montez JK, Hummer RA, Hayward MD, Woo H, Rogers RG.Trends in the educational gradient of US adult mortality from 1986 through 2006 by race, gender, and age group. Res Aging (2011)33(2):145–71.
65.  Mackenbach JP, Kulhánová I, Bopp M, Deboosere P, Eikemo TA, Hoffmann R, et al. Variations in the relation between education and cause-specific mortality in 19 European populations: a test of the “fundamental causes” theory of social inequalities in health. Soc Sci Med (2015) 127:51–62.10.1016/j.socscimed.2014.05.021 
66.   Assari S. Distal, intermediate, and proximal mediators of racial disparities in renal disease mortality in the United States. J Nephropathol. 2016 Jan;5(1):51-9. doi: 10.15171/jnp.2016.09.
67.  Annang L, Walsemann KM, Maitra D, Kerr JC. Does education matter? Examining racial differences in the association between education and STI diagnosis among black and white young adult females in the U.S. Public Health Rep (2010) 125(Suppl 4):110–21.
68.    Schnittker J, Bacak V. The increasing predictive validity of self-rated health. PLoS One. 2014 Jan 22;9(1):e84933. doi: 10.1371/journal.pone.0084933.
69.   Dowd JB, Zajacova A. Does the predictive power of self-rated health for subsequent mortality risk vary by socioeconomic status in the US? Int J Epidemiol. 2007 Dec;36(6):1214-21.
70.  Singh-Manoux A, Dugravot A, Shipley MJ, Ferrie JE, Martikainen P, Goldberg M, Zins M; GAZEL Cohort. The association between self-rated health and mortality in different socioeconomic groups in the GAZEL cohort study. Int J Epidemiol. 2007 Dec;36(6):1222-8.
71.  Assari S. Race by gender differences in the effects of socioeconomic factors on sustained health problems in five domains. Journal of Racial and Ethnic Health Disparities. 2016. In Press.