The authors have declared that no competing interests exist.
Conceived and designed the experiments: KGH POJ KIK ATHF. Analyzed the data: KIK BAG. Contributed reagents/materials/analysis tools: KIK BAG CAT. Wrote the paper: KGH POJ KIK ATHF BAG CAT KE MRC LPP. Designed the figures: KGH, KIK. Designed and populated tables: KGH. Designed and performed sensitivity analyses: KIK CAT. Provided critical edits after first draft and subsequent drafts: KE MRC LPP.
Our current understanding of Asian American mortality patterns has been distorted by the historical aggregation of diverse Asian subgroups on death certificates, masking important differences in the leading causes of death across subgroups. In this analysis, we aim to fill an important knowledge gap in Asian American health by reporting leading causes of mortality by disaggregated Asian American subgroups.
We examined national mortality records for the six largest Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) and non-Hispanic Whites (NHWs) from 2003-2011, and ranked the leading causes of death. We calculated all-cause and cause-specific age-adjusted rates, temporal trends with annual percent changes, and rate ratios by race/ethnicity and sex. Rankings revealed that as an aggregated group, cancer was the leading cause of death for Asian Americans. When disaggregated, there was notable heterogeneity. Among women, cancer was the leading cause of death for every group except Asian Indians. In men, cancer was the leading cause of death among Chinese, Korean, and Vietnamese men, while heart disease was the leading cause of death among Asian Indians, Filipino and Japanese men. The proportion of death due to heart disease for Asian Indian males was nearly double that of cancer (31% vs. 18%). Temporal trends showed increased mortality of cancer and diabetes in Asian Indians and Vietnamese; increased stroke mortality in Asian Indians; increased suicide mortality in Koreans; and increased mortality from Alzheimer’s disease for all racial/ethnic groups from 2003-2011. All-cause rate ratios revealed that overall mortality is lower in Asian Americans compared to NHWs.
Our findings show heterogeneity in the leading causes of death among Asian American subgroups. Additional research should focus on culturally competent and cost-effective approaches to prevent and treat specific diseases among these growing diverse populations.
As one of the fastest growing racial/ethnic groups in the U.S., the Asian Americans population is expected to double in size from18 million in 2010 to 34 million in 2050.[
The aggregation of Asian Americans masks important differences in mortality among subgroups. To date, the majority of death record data available in the U.S. is from California, where several studies have suggested important differences in cause-specific mortality, with Asian Indians having higher mortality due to coronary heart disease[
Immigration history differs among Asian subgroups, and has not only shaped geographic concentration, but also demographic characteristics and socioeconomic disparities between subgroups, and may also play an important role in observed mortality differences.[
Subgroup | Total Population (margin of error) | Foreign-Born Population (%) | Education (Bachelor’s Degree or higher |
Median Household Income ($) (margin of error) |
---|---|---|---|---|
NHW | 197,084, 523 (+/- 22,989) | 7,599,684 (3.9%) | 31.9% | 55,305 (+/-104) |
Asian Indian | 2,908,204 (+/- 52,033) | 2,071,853 (71.2%) | 32.6% | 92,418 (+/-1,820) |
Chinese | 3,520,150 (+/-44,000) | 2,451,814 (69.7%) | 24.9% | 63,999 (+/-1,442) |
Filipino | 2,538,325 (+/-47,496) | 1,688,391 (66.5%) | 39.4% | 78,700 (+/-1,772) |
Japanese | 756,898 (+/-18,355) | 293,457 (38.8%) | 31.4% | 66,146 (+/-2,114) |
Korean | 1,449,876 (+/-30,304) | 1,066,171 (73.5%) | 34.7% | 51,625 (+/-1,264) |
Vietnamese | 1,669,447 (+/-40,719) | 1,119,126 (67.0%) | 18.4% | 54,670 (+/-1,950) |
1Data from 2011 American Community Survey 1-Year Estimates;
2Based on the population ≥25 years of age
There is currently a knowledge gap in the health of these rapidly expanding populations with little evidence to recommend research agendas, create public health policy, and offer clinical guidelines. The White House,[
We examined the U.S. mortality records from the National Center for Health Statistics’ (NCHS) Multiple Cause of Death mortality files from 2003–2011 for Asians and non-Hispanic Whites (NHWs) in 36 states and the District of Columbia. Decedents represent the following Asian ethnicities: Asian Indian, Chinese, Filipino, Japanese, Korean or Vietnamese. Any decedents reported as more than one Asian race, Asian Hispanic, “Other Asian”, were excluded from this analysis. The 36 states were selected based on their adoption of the 2003 revision of the U.S. Standard Certificate of Death during the study period: Arizona, Arkansas, California, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York (including New York City), North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Washington, and Wyoming.
Year of death, age, location, race/ethnicity of the decedent and the underlying cause of death (disease or injury that initiated the events resulting in death) were identified from death certificate data obtained from the National Center for Health Statistics (NCHS). “Underlying cause of death” was coded by NCHS using International Classification of Diseases, 10th revision (ICD-10). Race/ethnicity was recorded on death certificates by the funeral director using national guidelines and coded to the 7 categories of interest (NHW, Asian Indian, Chinese, Filipino, Japanese, Korean or Vietnamese) by the NCHS. We selected only the six Asian subgroups represented explicitly in both the 2003 U.S. Standard Certificate of Death and U.S. Census forms. We also excluded individuals classified as more than one Asian race because they account for a very small portion of all Asian Americans within our study population.
In order to estimate denominator population counts for the study period, we examined trends in the total U.S. population by racial/ethnic groups using American Community Survey (ACS) data and found that all groups grew linearly from 2000 to 2010.[
We first determined the leading causes of death for NHW and each Asian subgroup by sex. Causes of death were ranked according to death counts as recommended by the 1951 Public Health Conference on Records and Statistics and the National Vital Statistics Reports published by NCHS.[
The study population included 13,208,036 NHW and Asian decedents collected from 36 states during 2003 to 2011. All-cause age-adjusted mortality rates and rate ratios were overall higher for NHWs compared to “Aggregate Asians” and each of the disaggregated subgroups (
Female | NHW | Aggregate Asian | Asian Indian | Chinese | Filipino | Japanese | Korean | Vietnamese |
---|---|---|---|---|---|---|---|---|
Total # Deaths | 6,608,844 | 124,600 | 13,118 | 37,166 | 30,806 | 18,960 | 14,196 | 10,354 |
Population Size [ |
73,030,653 | 4,908,967 | 976,037 | 1,375,599 | 1,084,108 | 300,131 | 579,867 | 593,225 |
Adjusted mortality rate [ |
658.9 | 353.3 | 340.8 | 330.2 | 363.3 | 388.8 | 381.8 | 330.7 |
Adjusted Rate Ratio | 1.0 | 0.54 | 0.52 | 0.5 | 0.55 | 0.59 | 0.58 | 0.5 |
Total # Deaths | 6,342,612 | 131,980 | 19,270 | 41,418 | 30,694 | 14,435 | 12,675 | 13,488 |
Population Size[ |
70,544,365 | 4,429,486 | 1,064,888 | 1,232,121 | 863,474 | 219,570 | 476,646 | 572,786 |
Adjusted mortality rate[ |
921.0 | 499.5 | 446.7 | 462.3 | 574.9 | 561.8 | 495.7 | 441.2 |
Adjusted Rate Ratio | 1.0 | 0.54 | 0.49 | 0.5 | 0.62 | 0.61 | 0.54 | 0.48 |
Female | NHW | Aggregate Asian | Asian Indian | Chinese | Filipino | Japanese | Korean | Vietnamese | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Cause of Death | Rk | Count | % | Rk | Count | % | Rk | Count | % | Rk | Count | % | Rk | Count | % | Rk | Count | % | Rk | Count | % | Rk | Count | % |
6,608,844 | 100 | 124,600 | 100 | 13,118 | 100 | 37,166 | 100 | 30,806 | 100 | 18,960 | 100 | 14,196 | 100 | 10,354 | 100 | |||||||||
1 | 1,705,306 | 25.8 | 2 | 29,294 | 23.5 | 1 | 3,651 | 27.8 | 2 | 8,795 | 23.7 | 2 | 7,519 | 24.4 | 2 | 4,289 | 22.6 | 2 | 3,060 | 21.6 | 2 | 1,980 | 19.1 | |
2 | 1,451,773 | 22 | 1 | 35,582 | 28.6 | 2 | 2,952 | 22.5 | 1 | 11,156 | 30 | 1 | 8,854 | 28.7 | 1 | 5,421 | 28.6 | 1 | 4,307 | 30.3 | 1 | 2,892 | 27.9 | |
3 | 442,875 | 6.7 | 3 | 11,526 | 9.3 | 3 | 947 | 7.2 | 3 | 3,497 | 9.4 | 3 | 3,068 | 10 | 3 | 1,670 | 8.8 | 3 | 1,233 | 8.7 | 3 | 1,111 | 10.7 | |
4 | 421,534 | 6.4 | 7 | 3,217 | 2.6 | 7 | 322 | 2.5 | 8 | 914 | 2.5 | 7 | 834 | 2.7 | 7 | 563 | 3 | 7 | 338 | 2.4 | 8 | 246 | 2.4 | |
5 | 312,547 | 4.7 | 8 | 3,183 | 2.6 | 9 | 155 | 1.2 | 7 | 933 | 2.5 | 9 | 633 | 2.1 | 4 | 872 | 4.6 | 8 | 306 | 2.2 | 7 | 284 | 2.7 | |
6 | 223,733 | 3.4 | 6 | 4,080 | 3.3 | 5 | 481 | 3.7 | 6 | 1,158 | 3.1 | 5 | 911 | 3 | 8 | 523 | 2.8 | 4 | 600 | 4.2 | 4 | 407 | 3.9 | |
7 | 166,547 | 2.5 | 5 | 4,277 | 3.4 | 6 | 343 | 2.6 | 4 | 1,594 | 4.3 | 6 | 906 | 2.9 | 6 | 587 | 3.1 | 6 | 537 | 3.8 | 6 | 310 | 3 | |
8 | 164,077 | 2.5 | 4 | 4,934 | 4 | 4 | 631 | 4.8 | 5 | 1,274 | 3.4 | 4 | 1,469 | 4.8 | 5 | 611 | 3.2 | 5 | 552 | 3.9 | 5 | 397 | 3.8 | |
9 | 106,140 | 1.6 | 9 | 2,197 | 1.8 | 8 | 232 | 1.8 | 10 | 619 | 1.7 | 8 | 700 | 2.3 | 10 | 260 | 1.4 | 10 | 199 | 1.4 | 10 | 187 | 1.8 | |
10 | 86,787 | 1.3 | 10 | 1,167 | 0.9 | 11 | 188 | 1.4 | 12 | 282 | 0.8 | 11 | 337 | 1.1 | 15 | 136 | 0.7 | 12 | 109 | 0.8 | 12 | 115 | 1.1 | |
6,342,612 | 100 | 131,980 | 100 | 19,270 | 100 | 41,418 | 100 | 30,694 | 100 | 14,435 | 100 | 12,675 | 100 | 13,488 | 100 | |||||||||
1 | 1,713,546 | 27 | 2 | 33,148 | 25.1 | 1 | 6,025 | 31.3 | 2 | 9,629 | 23.2 | 1 | 8,647 | 28.2 | 1 | 4,011 | 27.8 | 2 | 2,431 | 19.2 | 2 | 2,405 | 17.8 | |
2 | 1,573,285 | 24.8 | 1 | 37,043 | 28.1 | 2 | 3,477 | 18 | 1 | 13,312 | 32.1 | 2 | 7,847 | 25.6 | 2 | 3,687 | 25.5 | 1 | 4,340 | 34.2 | 1 | 4,380 | 32.5 | |
3 | 372,517 | 5.9 | 5 | 5,243 | 4 | 8 | 427 | 2.2 | 4 | 1,896 | 4.6 | 4 | 1,451 | 4.7 | 7 | 510 | 3.5 | 8 | 403 | 3.2 | 5 | 556 | 4.1 | |
4 | 368,914 | 5.8 | 4 | 6,194 | 4.7 | 3 | 1,254 | 6.5 | 6 | 1,645 | 4 | 6 | 1,191 | 3.9 | 4 | 569 | 3.9 | 4 | 753 | 5.9 | 4 | 782 | 5.8 | |
5 | 280,776 | 4.4 | 3 | 9,269 | 7 | 4 | 993 | 5.2 | 3 | 2,986 | 7.2 | 3 | 2,457 | 8 | 3 | 1,004 | 7 | 3 | 775 | 6.1 | 3 | 1,054 | 7.8 | |
6 | 172,964 | 2.7 | 6 | 4,804 | 3.6 | 5 | 914 | 4.7 | 7 | 1,173 | 2.8 | 5 | 1,367 | 4.5 | 6 | 551 | 3.8 | 6 | 438 | 3.5 | 7 | 361 | 2.7 | |
7 | 152,732 | 2.4 | 8 | 3,064 | 2.3 | 6 | 550 | 2.9 | 8 | 735 | 1.8 | 13 | 487 | 1.6 | 9 | 265 | 1.8 | 5 | 635 | 5 | 6 | 392 | 2.9 | |
8 | 136,415 | 2.2 | 7 | 4,532 | 3.4 | 7 | 470 | 2.4 | 5 | 1,844 | 4.5 | 7 | 881 | 2.9 | 5 | 566 | 3.9 | 7 | 436 | 3.4 | 8 | 335 | 2.5 | |
9 | 133,028 | 2.1 | 10 | 1,608 | 1.2 | 10 | 123 | 0.6 | 11 | 529 | 1.3 | 10 | 306 | 1 | 8 | 382 | 2.6 | 10 | 130 | 1 | 10 | 138 | 1 | |
10 | 104,836 | 1.7 | 9 | 2,168 | 1.6 | 9 | 328 | 1.7 | 9 | 636 | 1.5 | 8 | 647 | 2.1 | 10 | 224 | 1.6 | 11 | 144 | 1.1 | 8 | 189 | 1.4 |
Source: National Center for Health Statistics: Diseases of the heart (International Classification of Diseases- 10th revision [ICD-10] codes I00-I09, I11, I13, I20-I51); Malignant Neoplasms (C00-C97); Chronic lower respiratory diseases (J40-J47); Accidents-unintentional injury (V01-X59, Y85-Y86); Cerebrovascular disease (I60-I69); Diabetes Mellitus (E10-E14); Intentional self-harm (suicide) (U03, X60-X84, Y87.0); Influenza and pneumonia (J09-J18); Alzheimer’s Disease (G30); Nephritis, nephrotic syndrome, and nephrosis (N00-N07, N17-N19, N25-N27); Septicemia (A40-A41).
For males, patterns between the proportions of deaths due to heart disease and cancer differed from those found in females. Cancer was the leading cause of death for aggregated Asian males (27.4%); however when disaggregated, cancer is the leading cause of death only for Chinese, Korean, and Vietnamese males (
Female | NHW | Aggregate Asian | Asian Indian | Chinese | Filipino | Japanese | Korean | Vietnamese |
---|---|---|---|---|---|---|---|---|
Cause of Death | AR |
AR | AR | AR | AR | AR | AR | AR |
Diseases of the heart | 158.5 | 88.5 | 111.8 | 80.5 | 95.9 | 83.3 | 93.8 | 72.3 |
Malignant neoplasms | 155.8 | 91.2 | 60.4 | 93.7 | 89.1 | 115.9 | 98.9 | 76.5 |
Cerebrovascular diseases | 41.2 | 33.7 | 28.9 | 31.7 | 36.9 | 32.9 | 34.7 | 37.5 |
Chronic lower respiratory diseases | 42.6 | 9.9 | 10.8 | 8.4 | 11.0 | 10.9 | 10.3 | 9.3 |
Alzheimer’s Disease | 27.0 | 10.3 | 6.0 | 8.6 | 9.2 | 16.2 | 10.3 | 12.2 |
Accidents-Unintentional injuries | 27.8 | 10.5 | 8.8 | 9.9 | 9.8 | 12.6 | 13.1 | 10.2 |
Influenza and pneumonia | 15.4 | 13.3 | 10.6 | 14.7 | 12.1 | 11.1 | 16.9 | 12.2 |
Diabetes Mellitus | 16.7 | 14.3 | 17.5 | 11.7 | 17.6 | 12.3 | 15.8 | 13.9 |
Nephritis, nephrotic syndrome, and nephrosis | 10.2 | 6.4 | 6.8 | 5.6 | 8.56 | 5.2 | 5.8 | 6.4 |
Septicemia | 8.7 | 3.3 | 5.2 | 2.5 | 4.1 | 2.7 | 2.9 | 3.9 |
Diseases of heart | 248.7 | 131.9 | 152.8 | 111.3 | 168.9 | 152.9 | 107.7 | 87.6 |
Malignant neoplasms | 219.1 | 130.5 | 75.9 | 139.3 | 133.8 | 145.1 | 153.9 | 127.1 |
Chronic lower respiratory diseases | 53.8 | 23.7 | 14.6 | 23.3 | 33.2 | 19.6 | 21.2 | 24.9 |
Accidents-Unintentional injuries | 56.5 | 18.9 | 17.4 | 16.7 | 18.1 | 24.0 | 21.5 | 19.0 |
Cerebrovascular diseases | 41.6 | 37.1 | 28.1 | 34.2 | 47.4 | 38.1 | 32.2 | 38.5 |
Diabetes Mellitus | 24.4 | 18.3 | 22.1 | 13.3 | 24.5 | 21.2 | 18.7 | 13.2 |
Intentional self-harm (suicide) | 22.9 | 7.7 | 5.7 | 6.5 | 6.0 | 11.5 | 15.9 | 7.5 |
Influenza and pneumonia | 20.6 | 20.8 | 15.6 | 22.9 | 19.5 | 21.4 | 23.8 | 15.8 |
Alzheimer’s Disease | 20.7 | 8.2 | 5.8 | 6.9 | 8.0 | 14 | 7.8 | 7.5 |
Nephritis, nephrotic syndrome, and nephrosis | 15.6 | 8.9 | 9.8 | 7.6 | 12.9 | 8.6 | 6.2 | 7.4 |
1Age-adjusted mortality rates standardized to 2000 US standard population
Cause-specific age-adjusted mortality rates for the leading causes of death were generally higher for NHWs compared to all Asian subgroups (
Females | ||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Cause of Death | Aggregate Asian | Asian Indian | Chinese | Filipino | Japanese | Korean | Vietnamese | |||||||
SRD |
% | SRD | % | SRD | % | SRD | % | SRD | % | SRD | % | SRD | % | |
All Cause | -438.8 | 100 | -460.7 | 100 | -472.8 | 100 | -422.6 | 100 | -393.4 | 100 | -382.9 | 100 | -479.2 | 100 |
Diseases of the heart | -106.1 | 24.2 | -70.8 | 15.4 | -119.3 | 25.2 | -92.1 | 21.8 | -113.7 | 28.9 | -92.5 | 24.2 | -136.6 | 28.5 |
Malignant neoplasms | -89 | 20.3 | -134.4 | 29.2 | -83.9 | 17.7 | -94.8 | 22.4 | -56.4 | 14.3 | -76.3 | 19.9 | -110.9 | 23.1 |
Cerebrovascular diseases | -11.8 | 2.7 | -18.6 | 4 | -14.8 | 3.1 | -6.9 | 1.6 | -13 | 3.3 | -9.4 | 2.5 | -6.3 | 1.3 |
Chronic lower respiratory diseases | -47.2 | 10.8 | -45.8 | 9.9 | -49.4 | 10.4 | -44.6 | 10.5 | -47.2 | 12 | -45.7 | 11.9 | -48 | 10 |
Alzheimer’s disease | -28.1 | 6.4 | -36.3 | 7.9 | -31.4 | 6.6 | -29.7 | 7.0 | -17.4 | 4.4 | -28.3 | 7.4 | -24.9 | 5.2 |
Accidents—unintentional injuries | -19.6 | 4.5 | -21.8 | 4.7 | -20.3 | 4.3 | -20.9 | 4.9 | -16.8 | 4.3 | -16.6 | 4.3 | -20.1 | 4.2 |
Influenza and pneumonia | -1.6 | 0.4 | -7.2 | 1.6 | 0.5 | -0.1 | -3.3 | 0.8 | -5.2 | 1.3 | 5.6 | -1.5 | -4.1 | 0.9 |
Diabetes mellitus | -1.8 | 0.4 | 2.6 | -0.6 | -5.4 | 1.1 | 3.3 | -0.8 | -6.1 | 1.5 | 0.8 | -0.2 | -2.2 | 0.5 |
Nephritis, nephrotic syndrome, and nephrosis | -5.6 | 1.3 | -5.2 | 1.1 | -6.7 | 1.4 | -2.2 | 0.5 | -8 | 2 | -6.3 | 1.6 | -5.9 | 1.2 |
Septicemia | -7.9 | 1.8 | -4.9 | 1.1 | -9 | 1.9 | -6.8 | 1.6 | -9.1 | 2.3 | -8.3 | 2.2 | -6.9 | 1.4 |
All Cause | -463.4 | 100 | -507.9 | 100 | -506.9 | 100 | -385.6 | 100 | -397.3 | 100 | -459.7 | 100 | -517.5 | 100 |
Diseases of the heart | -129 | 27.8 | -99.5 | 19.6 | -152.8 | 30.1 | -91.3 | 23.7 | -106.5 | 26.8 | -154.3 | 33.6 | -175 | 33.8 |
Malignant neoplasms | -101.7 | 21.9 | -161.8 | 31.9 | -92.8 | 18.3 | -97.6 | 25.3 | -85.9 | 21.6 | -72.7 | 15.8 | -102.2 | 19.7 |
Chronic lower respiratory diseases | -34.2 | 7.4 | -43.1 | 8.5 | -34.8 | 6.9 | -24.5 | 6.4 | -38.2 | 9.6 | -36.5 | 7.9 | -32.7 | 6.3 |
Accidents—unintentional injuries | -38.3 | 8.3 | -39.5 | 7.8 | -40.7 | 8.0 | -39.3 | 10.2 | -33.1 | 8.3 | -35.1 | 7.6 | -38.2 | 7.4 |
Cerebrovascular diseases | -4.6 | 1.0 | -13.6 | 2.7 | -7.8 | 1.5 | 6.4 | -1.7 | -4 | 1 | -9.1 | 2 | -2.2 | 0.4 |
Diabetes mellitus | -7.1 | 1.5 | -2.4 | 0.5 | -13 | 2.6 | 0.1 | 0 | -4.3 | 1.1 | -6.9 | 1.5 | -12.7 | 2.5 |
Intentional self harm—suicide | -15.8 | 3.4 | -17.9 | 3.5 | -17 | 3.4 | -17.9 | 4.6 | -11.5 | 2.9 | -6.4 | 1.4 | -16.3 | 3.1 |
Influenza and pneumonia | -0.4 | 0.1 | -5 | 1.0 | 1.7 | -0.3 | -1.7 | 0.4 | 0.5 | -0.1 | 2.9 | -0.6 | -5.1 | 1.0 |
Alzheimer’s disease | -12.9 | 2.8 | -14.9 | 2.9 | -14.2 | 2.8 | -13.2 | 3.4 | -7 | 1.8 | -13.2 | 2.9 | -13.2 | 2.6 |
Nephritis, nephrotic syndrome, and nephrosis | -7.0 | 1.5 | -5.9 | 1.2 | -8.6 | 1.7 | -2.8 | 0.7 | -7.5 | 1.9 | -9.8 | 2.1 | -8.5 | 1.6 |
1SRDs were calculated by subtracting cause-specific adjusted rates for NHW from cause-specific adjusted rates for each Asian subgroup. The SRDs for all cause mortality were decomposed into percent attributable to each cause by dividing the individual cause SRD by the all-cause SRD.
Temporal trends with average annual percent changes (AAPC; %) showed an overall decrease in cause-specific mortality rates among NHWs, and increasing rates for some Asian subgroups, particularly Asian Indians (Fig
Females | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Cause of Death | NHW | Aggregate Asian | Asian Indian | Chinese | Filipino | Japanese | Korean | Vietnamese | ||||||||
AAPC | 95% CI | AAPC | 95% CI | AAPC | 95% CI | AAPC | 95% CI | AAPC | 95% CI | AAPC | 95% CI | AAPC | 95% CI | AAPC | 95% CI | |
All Cause | -2.09, -0.14 | -0.50 | -1.83, 0.85 | 1.44, 4.29 | -3.07, -0.34 | -0.93 | -2.23, 0.40 | -0.55 | -1.82, 0.74 | 0.73 | -0.57, 2.04 | 0.35 | -1.04, 1.75 | |||
Diseases of the heart | -5.74, -1.86 | -5.59, -0.39 | -0.02 | -2.39, 2.40 | -6.88, -1.49 | -6.18, -1.22 | -5.63, -0.26 | -2.06 | -4.58, 0.53 | -1.85 | -4.73, 1.10 | |||||
Malignant neoplasms | -1.16 | -3.14, 0.86 | 0.33 | -2.30, 3.03 | 0.42, 7.25 | -0.59 | -3.15, 2.04 | 0.39 | -2.26, 3.13 | -0.18 | -2.51, 2.20 | 1.28 | -1.27, 3.90 | 1.25 | -1.64, 4.24 | |
Cerebrovascular diseases | -8.01, -0.43 | -3.47 | -7.59, 0.80 | 2.67 | -2.07, 7.67 | -8.99, -0.46 | -3.68 | -7.61, 0.40 | -3.55 | -7.72, 0.79 | -3.33 | -7.39, 0.89 | -2.59 | -6.52, 1.50 | ||
Chronic lower respiratory diseases | 0.90 | -2.94, 4.89 | -0.19 | -7.94, 8.21 | -1.73 | -9.02, 6.11 | -0.68 | -8.99, 8.37 | 0.89 | -6.53, 8.92 | 0.22 | -7.21, 8.24 | 0.11 | -7.49, 8.33 | -0.38 | -8.34, 8.25 |
Alzheimer’s disease | 1.88 | -2.96, 6.98 | 1.31, 19.37 | 0.50, 24.97 | 8.51 | -0.64, 18.71 | 2.42, 22.13 | 1.81, 15.99 | 2.26, 20.61 | 3.90, 21.06 | ||||||
Accidents—unintentional injuries | 1.71 | -3.06, 6.72 | -2.20 | -9.58, 5.75 | 1.60 | -6.77, 10.76 | -1.57 | -9.22, 6.68 | -6.58 | -13.90, 1.24 | 1.46 | -5.52, 8.98 | 1.58 | -5.30, 8.98 | -3.19 | -10.59, 4.76 |
Influenza and pneumonia | -4.94 | -10.94, 1.40 | -3.10 | -9.60, 3.83 | 1.28 | -6.33, 9.54 | -4.08 | -10.22, 2.43 | 0.34 | -6.70, 7.92 | -6.10 | -12.99, 1.23 | -2.82 | -8.60, 3.31 | -5.85 | -12.44, 1.15 |
Diabetes mellitus | -2.90 | -8.75, 3.30 | -1.22 | -7.61, 5.60 | 3.23 | -2.87, 9.75 | -2.94 | -9.88, 4.49 | -1.42 | -7.19, 4.69 | -3.09 | -9.89, 4.17 | -0.60 | -6.74, 5.94 | 3.12 | -3.70, 10.47 |
Nephritis, nephrotic syndrome, and nephrosis | 0.28 | -7.37, 8.57 | 1.81 | -7.91, 12.62 | 4.98 | -4.82, 15.94 | -0.79 | -10.86, 10.39 | 0.89 | -7.54, 10.10 | 4.94 | -6.28, 17.70 | 5.75 | -4.90, 17.80 | 1.75 | -7.98, 12.57 |
Septicemia | -0.36 | -8.55, 8.57 | 1.24 | -11.91, 16.44 | 1.85 | -8.86, 13.89 | -0.24 | -15.00, 17.06 | 1.18 | -10.77, 14.78 | -1.00 | -15.24, 15.55 | 4.16 | -10.19, 21.09 | 0.38 | -11.72, 14.15 |
All Cause | -2.12, -0.48 | -0.81 | -1.92, 0.32 | 1.03, 3.50 | -2.97, -0.66 | -2.31, -0.23 | -2.29, -0.18 | -0.06 | -1.19, 1.08 | 0.54, 3.01 | ||||||
Diseases of the heart | -4.79, -1.68 | -4.87, -0.60 | 0.45 | -1.59, 2.53 | -6.40, -1.81 | -4.82, -1.05 | -4.93, -0.96 | -1.36 | -3.73, 1.07 | -0.52 | -3.17, 2.20 | |||||
Malignant neoplasms | -1.37 | -3.04, 0.33 | -0.19 | -2.38, 2.04 | 2.52 | -0.43, 5.57 | -1.33 | -3.42, 0.81 | 0.16 | -2.01, 2.37 | -0.56 | -2.63, 1.55 | -0.31 | -2.33, 1.74 | 0.38, 5.02 | |
Chronic lower respiratory diseases | -0.20 | -3.59, 3.30 | -1.29 | -6.29, 3.97 | 4.97 | -1.84, 12.32 | -2.59 | -7.57, 2.64 | -1.11 | -5.36, 3.32 | -1.74 | -7.22, 4.05 | -0.99 | -6.28, 4.59 | 3.10 | -2.05, 8.54 |
Accidents—unintentional injuries | 0.65 | -2.68, 4.10 | -0.09 | -5.75, 5.92 | 4.40 | -1.81, 11.04 | -0.76 | -6.72, 5.57 | -2.09 | -7.74, 3.90 | 0.26 | -4.81, 5.60 | -1.47 | -6.70, 4.05 | 0.79 | -4.93, 6.86 |
Cerebrovascular diseases | -8.20, -0.70 | -8.05, -0.11 | 1.12 | -3.61, 6.09 | -9.66, -1.51 | -8.38, -1.39 | -3.70 | -7.57, 0.31 | -2.81 | -7.04, 1.60 | -2.19 | -6.08, 1.86 | ||||
Diabetes mellitus | -1.65 | -6.57, 3.52 | -0.37 | -6.10, 5.70 | 2.96 | -2.48, 8.73 | -2.02 | -8.60, 5.01 | 0.56 | -4.45, 5.84 | -0.97 | -6.27, 4.62 | -2.10 | -7.66, 3.78 | 2.96 | -4.01, 10.49 |
Intentional self harm—suicide | 2.19 | -3.08, 7.77 | 2.84 | -6.15, 12.77 | 4.01 | -6.51, 15.85 | 4.02 | -5.83, 15.02 | 1.91 | -8.13, 13.10 | -0.60 | -7.75, 7.09 | 4.34 | -2.10, 11.25 | 3.91 | -5.34, 14.18 |
Influenza and pneumonia | -4.72 | -9.92, 0.73 | -2.59 | -7.85, 2.94 | -1.24 | -7.36, 5.27 | -2.88 | -7.87, 2.36 | -0.62 | -6.16, 5.24 | -4.52 | -9.61, 0.83 | -2.95 | -7.85, 2.18 | -2.13 | -8.15, 4.25 |
Alzheimer’s disease | 2.03 | -3.51, 7.89 | 9.49 | -0.01, 20.15 | 11.21 | -0.32, 24.51 | 0.86, 23.51 | 5.36 | -3.71, 15.41 | 0.62, 15.64 | 0.77, 21.81 | 6.57, 30.54 | ||||
Nephritis, nephrotic syndrome, and nephrosis | 0.20 | -6.04, 6.85 | 1.91 | -6.37, 10.96 | 6.76 | -1.71, 16.10 | 0.84 | -8.03, 10.59 | 1.37 | -5.54, 8.80 | 4.19 | -4.51, 13.78 | 1.37 | -8.48, 12.32 | 0.55 | -8.41, 10.40 |
Supplemental data was included for 50-state data (
Asian Americans have been traditionally thought of as the “model minority” with higher socioeconomic status and education levels, and with lower mortality rates compared to NHWs.[
Stroke was the third leading cause of death among nearly every Asian subgroup, as well as NHW females, suggesting a broader approach may be needed in treating or preventing risk factors for stroke. Hypertension, an important stroke risk factor, is more prevalent in certain Asian American subgroups such as Filipinos.[
We found that malignant neoplasms are the first or second leading cause of death for all Asian ethnicities. Compared to NHWs, studies have shown that Asian American subgroups have higher incidence of cancer stemming from infectious conditions, such as tumors of the liver (hepatitis-related), stomach (h. pylori-related), and cervix (HPV-related), while they have lower incidence rates of lung, colorectal, breast, and prostate cancer.[
Age-adjusted mortality rates and ratios are overall higher for NHWs compared to Asian subgroups (
Immigration histories and acculturation may also play an important role for varying mortality causes among Asian American subgroups. Acculturation has been associated with the development of heart disease and unfavorable changes in heart disease risk factors among Chinese and Japanese Americans.[
Potential limitations of our study include data based on death certificates, which may contain errors in the documented cause of death and race/ethnicity classification. Many studies have tested the reliability of race on death certificates by comparing it with self-reported race on separate data collection instruments such as the census or surveys.[
A separate limitation is the gradual adoption of the 2003 revision of the U.S. Standard Certificate of Death that encourages explicit reporting of Asian subgroup race/ethnicity. As of 2011, 36 states and the District of Columbia had implemented the 2003 revision of the U.S. Standard Certificate of Death. In our sensitivity analysis, we identified some states with differential reporting of Asian Indians, Koreans, and Vietnamese deaths’ by year, but, due to small populations of these ethnicities in the affected states, we suspect this would minimally affect our results. Regardless, mortality trends over time in these subgroups should be interpreted with caution as they may be slightly exaggerated due to gradual uptake of the new death certificate over the study period. Lastly, our presented analysis only considers underlying cause of death (as opposed to all listed causes of death).
While this analysis helps lay a foundation for understanding health disparities among Asian American subgroups, much more research needs to be done. As summarized in the 2010 “Call to Action” for heart disease in Asian Americans, recommendations for future studies include: changing existing data collection to include at least the 6 largest Asian American subgroups, developing standard measurement tools (widely applicable and comprehensive acculturation instruments and culturally-tailored food frequency questionnaires), and developing new research studies utilizing disaggregated data.[
To our knowledge, no studies have previously reported the leading causes of death among diverse Asian American subgroups at the national level. Our findings show heterogeneity in the leading causes of mortality among Asian American subgroups that would otherwise be masked when these diverse subgroups are aggregated. These findings suggest that Asian American subgroups have unique disease risks, underscoring the need for further study and separation of subgroups on national health surveys. With additional research, culturally competent and cost-effective approaches can be tailored to optimize strategies in management and prevention of the leading causes of death among these rapidly growing ethnic populations.
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