Health Risks & Outcomes
Despite reductions in cancer mortality and lower rates of premature death than the state and nation, a sizable percentage of Houstonians continue to experience poor physical health and well-being
More Houstonians have become sedentary, food insecure, unwell, obese and diabetic in recent years, with people of color disproportionately burdened by health challenges. These outcomes ultimately lead to a decline in quality of life and contribute to the most common causes of death.
Why health risks and outcomes matter to Houston
Broadly, the Social Determinants of Health (SDOH) are the myriad everyday conditions that affect our health, functioning, and quality of life. Income, education, employment, the neighborhoods in which we live, and whether our housing is safe and affordable are among the most well known factors influencing our overall health. In addition, our health is affected by elements of our environment, including the extent to which we are exposed to life-threatening toxins in our air or water, our ability to access affordable, healthy foods, and the strength of social support networks. Established research has found that these factors have a substantial effect on our health and well-being.1 Between one-third and one-half of all health outcomes are influenced by the social determinants of health — a greater effect than health care or lifestyle, according to the World Health Organization (WHO).
Because SDOH have such a significant effect on health outcomes, they are also responsible for most health disparities, which the WHO defines as the “unfair and avoidable differences in health status.” These health disparities are most prominent when comparing neighborhood to neighborhood and race/ethnicity. This is because place-based inequality remains inextricable from racial inequality — the result, in part, of residential segregation, economic exclusion and uneven investment that has shaped the life of most Black communities and other communities of color in the U.S.2 Inequitable social, economic, built and physical conditions within and across neighborhoods and race/ethnicity can reduce opportunities for better health and well-being, which explains racial health disparities, according to the Robert Wood Johnson Foundation. A 2021 report by the Commonwealth Fund ranked Texas among the worst in the nation for health equity disparities.
The more we directly address SDOH for Houston-area residents, the more we can improve their overall health and reduce the disparities we see by race/ethnicity, place, and income level.
More than one out of four adults in the Houston region does not get enough exercise
Physical inactivity can have serious impacts on a person’s health. Low levels of physical activity can increase the risk for diseases, including cardiovascular diseases, diabetes and obesity, hypertension, cancer, depression, and anxiety.3 In addition, physical inactivity is associated with reduced expenditures on health care treatments for circulatory system diseases.4
About 26% of adults across the U.S. reported no physical activity in 2019, as did 27% of Texans. Adults in Fort Bend County were slightly less likely to report no leisure-time physical activity compared to those in Harris and Montgomery counties, where the rates were higher than both with the state and nation.
Research shows that trends in physical activity correlate strongly with income and education level, a finding consistent with Texas trends as well.5 On average, those with lower household incomes and lower levels of educational attainment were more likely to be physically inactive.6 Research from the Robert Wood Johnson Foundation suggests this is because people with more education tend to have higher paying jobs, which allows them the option to live in neighborhoods that have lower crime rates and greater access to recreational facilities. Additionally, people with high levels of educational attainment are more likely to work one job only, which affords them more time for recreational activities. Because of the high correlation between race and income/education, it is not surprising that Black and Hispanic adults in Texas are more likely to be physically inactive than white adults, according to Behavioral Risk Factor Surveillance System (BRFSS) data from the Texas Department of State Health Services; in 2020, about 78.4% of white Texans engaged in recreational physical activity compared to 72.4% of Black and 70.2% of Latino Texans. Additionally, women in Texas are more likely to be physically inactive than men by 3.5 percentage points.
Prior to the pandemic, food insecurity in the Houston region was in decline
The U.S. Department of Agriculture (USDA) defines food insecurity as a lack of consistent access to adequate food for a healthy life. In 2020, more than one in 10 Americans were food insecure (10.5%). That is equivalent to about 38 million people, including more than 11 million children.7 Food insecurity is most common amongst people living below the poverty line, people of color, single adults and single-parent households. Although food insecurity is closely related to poverty, people living above the poverty line may also experience food insecurity.
Feeding America provides estimates for food insecurity at different community levels. Using the relationship between food insecurity and its closely linked indicators (poverty, unemployment, homeownership, disability prevalence, etc.) an estimated food insecurity rate is generated.
According to Feeding America, the food insecurity rate declined in Houston’s three-county area between 2017 and 2019. However, the effects of COVID-19 led to an increase in the estimated food insecurity rate in 2020, with effects continuing into 2021. These estimated effects mirror the high food insecurity rate found by the Household Pulse Surveys conducted by the U.S. Census Bureau. Feeding America estimates that food insecurity is highest in Harris County and lowest in Montgomery County, and Texas has a higher rate than the national average. It is important to note that in the U.S., children are more vulnerable to food insecurities, 16.1% compared to 11.8% for all individuals.
Nearly one out of four adults in Harris County rates their health as “fair” or “poor”
How one rates their own health is a reliable indicator of a person’s overall physical state and well-being and has been found to be a strong indicator of mortality.8 People who rate their health as “poor” had twice the mortality risk, compared with those with “excellent” self-rated health.9 This measure is found to be closely correlated with the results of physical exams by health providers.10
Harris County had the highest proportion of adults who rated their current state of health as “fair” or “poor,” at 23% in 2019, compared to 16% in Fort Bend County and 19% in Montgomery County. The percentage of adults in Harris County who considered themselves to be in poor or fair health was also higher than the state, which was higher than the national average. Rates of “fair” or “poor” health grew about two percentage points in the three-county region and Texas between 2018 and 2019.
Another measure for health-related quality of life is the average number of physically unhealthy days in the past 30 days, which shows how people rate their recent health. A study on the number of healthy days reported in a county found that counties with more unhealthy days were likely to have higher unemployment, poverty, percentage of adults who did not complete high school, mortality rates, and prevalence of disability than counties with fewer unhealthy days.11
In 2019, Texas had slightly fewer physically unhealthy days compared to the nation, 3.6 and 3.9 respectively. Residents in Fort Bend County (3.1) reported fewer physically unhealthy days than both the state (3.6) and nation (3.9), whereas Harris County reported the most unhealthy days (4.0).
Nearly one-third of adults in the Houston region have obesity
Obesity, defined as having a body mass index (BMI) of 30 or more, is a complex health condition affecting both adults and children. Obesity increases the risk for health conditions such as coronary heart disease, type 2 diabetes, cancer, hypertension, and more.
Among all the “modifiable” behavioral risk factors, obesity is found to take more years of life than diabetes, tobacco use, hypertension or high cholesterol. Obesity also has significant economic consequences. On average, adults with obesity spend $3,429 more per person annually on medical expenses than those with medically healthy weights.12
Obesity rates continue to increase across the nation and Texas. In 2020, 35.8% of adults aged 18 and older in Texas are considered obese, and that share of the population is higher than the national average (31.9%). The proportion of adults 18 years and older who are classified as obese increased five percentage points in Texas and three points in the U.S. in the last decade.
Similarly, despite some fluctuations over the last decade, obesity rates continue to rise in the Houston region. According to the most recent estimates, one in three adults aged 20 and over in Montgomery County are considered obese — the highest rate among the three counties — and significantly higher than in 2011 when one in five adults were obese (the lowest rate in the region at the time). Fort Bend County has the lowest obesity rate in the region at 28.6%, which is about five percentage points higher than it was in 2011. Obesity rates in Harris County have ticked up to 31% in 2019 from 28% in 2011.
Adults 65 years and above have the lowest obesity rate, but one in three was still considered obese in 2020 — an increase of eight percentage points from the year before. Nearly half (47.7%) of adults between 45 and 64 years of age in Harris County were classified as obese in 2020 — a seven-point increase from 2019.
Obesity in Harris County is more prevalent among individuals with less education. About 25% of college-educated adults are obese compared to 42% of people with a high school diploma only or some college education.
In terms of income, half of adults in Harris County who earn less than $25,000 annually are obese compared to about one-third of higher-earning adults.
And, consistent with national trends, obesity rates are highest among Hispanic/Latino and Black adults in the county (43.5% and 41.2%, respectively). However, one in three white adults also experienced obesity in 2020, which is a 10-percentage-point increase from the year before.
In 2020, obesity rates rose for all demographic groups compared to 2019, except for those with a college degree. Children also experience health risks associated with obesity.
The prevalence of diabetes in the Houston region has ticked up in the last decade
Diabetes is the seventh leading cause of death in America, accounting for over 100,000 or 3% of total deaths in 2020. About 1 out of 10 Americans (more than 37 million people) have diabetes, and 90-95% of them are diagnosed with type 2 diabetes, according to the Centers for Disease Control and Prevention (CDC). An additional 96 million U.S. adults are pre-diabetic — where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes — and over 80% are not aware they are headed toward a full diabetes diagnosis. The total medical costs and lost work and wages for people with diagnosed diabetes was estimated at around $327 billion yearly.
The percentage of adults in Texas with diabetes increased to 12.0% in 2018 from 10.3% in 2011. The percentage of adults with diabetes in Texas is consistently higher than the national rate, which stood at 8.3% in 2019 — a slight decline over 2018 (9.1%).
The percentage of adults aged 20 and older with diagnosed diabetes in the Houston region is in the top quartile of the state. In 2019, Fort Bend and Harris counties both had 10.2% of adults over 20 years of age diagnosed with diabetes. Prevalence of diabetes in the region has ticked up about two percentage points since 2011.
As of 2019, men in all three counties were more likely to have diabetes than women. The difference is most pronounced in Montgomery County. National statistics also show the racial differences in the prevalence of diagnosed diabetes. Overall, people of color have higher rates of diabetes compared to white adults.
Cancer mortality and incidence rates in Houston’s three-county region have declined over the past decade
In 2020, over 600,000 people in the U.S. died of cancer, making it the second leading cause of death in the nation. In 2018, the latest year for which incidence data are available, 1.7 million new cases of cancer were reported in the United States. According to the latest national statistics from the CDC, cancer death rates have decreased 27% in the past 20 years. Reasons for this overall decline can be attributed to several factors, including the rapid decrease in lung and melanoma deaths.
Cancer mortality rates have fallen in Houston’s three-county region, and the rates for all three counties are lower than the U.S. and Texas rate.
Between 2010 and 2018, the cancer mortality rate in the United States dropped from 171.8 deaths per 100,000 people to 149.2 per 100,000, a decline of 13.2%. During the same period, the cancer mortality rates for Fort Bend County fell by more than 22% — faster than the state and the nation. Harris and Montgomery counties also experienced a decline over the same time at 13.3% and 15.3%, respectively. At 111 deaths per 100,000, Fort Bend’s cancer mortality rate is already below the Healthy People 2030 target of 122.7 deaths per 100,000.
Risk of cancer and cancer mortality is affected by many behaviors, diseases and genetic factors. It is also influenced by health disparities in socioeconomic status and access to care. In general, men had higher rates of cancer mortality than women, and Hispanic and Asian-American residents had lower cancer mortality rates than Black or white residents in 2018.
In a similar fashion, age-adjusted cancer incidence rates in the three-county area are lower than the state and national rates. Additionally, annual rates of new cancer cases have declined in the past few years. In Texas, over 120,000 cancer cases were reported in 2018, equivalent to 409 cases for every 100,000 people, lower than the national rate of 436 per 100,000 people. In the three-county area, a total of 22,407 new cancer cases were reported in 2018.
A “cancer cluster” refers to a greater than expected number of cancer cases that occur within a group of people in a geographic area over a defined period of time, according to the CDC. In 2019, the Texas Department of State Health Services (DSHS) identified a cluster of lung and throat cancers among adults between 2000 and 2016 in the communities of Fifth Ward and Kashmere Gardens in North East Houston. In an analysis one year later, an additional cancer cluster was found in the same neighborhoods when children were diagnosed with leukemia at five times the state rate during the same time period. While direct causation has not been established, the clusters have been found near a rail yard site known to be contaminated by creosote, a probable cancer-causing substance, according to the Environmental Protection Agency, which created a toxic plume underneath more than 100 properties. Learn more about cancer clusters in Texas here.
Life spans vary by 23 years within the Houston region
Life expectancy is a reflection of the mortality patterns of a population and is a common measure used to describe overall public health across different communities. It refers to the average number of years one person can expect to live (from a specified age) based on the age-specific mortality rates of the population.
Across the country, life expectancy from birth has increased by decades over the past 120 years. The greatest improvements occurred in the first half of the 20th century. Since then, life expectancy has steadily and consistently increased, though at a slower rate. Until the COVID-19 pandemic.
Life expectancy in the U.S. fell to 77.0 years in 2020 from 78.8 in 2019. This reduction of 1.8 years of life was the largest single-year decline in more than 75 years. In addition to COVID-19, the decline was also attributed to the increase in deaths from unintentional injuries, heart disease, homicide, and diabetes.
While life expectancy has grown for both Black and white Americans, a gap between the two groups remains. In 1900, the gap was nearly 15 years, but that has narrowed to 3.5 years in 2017.
Overall, the life span of residents in Houston’s three-county area is slightly longer than the state average (78.4). Across the three counties, the life expectancy for residents of Fort Bend County (82.3 years) is higher than that of Harris (79.2) and Montgomery (79.5) counties. Life expectancy remained essentially flat from the combined years 2015-2017 to 2018-2020.
Disparities in life expectancy among race/ethnicity continue in Harris County, with white residents living an average of five more years than Black residents. How long we live depends on a variety of interrelated factors, including genetics, whether one accesses medical care, and quality of nutrition. More significantly, however, is the fact that established research has found direct links among health, economic opportunity, race, and place, both nationally and locally.13 Put another way, differences in life expectancy are closely related to socioeconomic opportunity, which is why we see disparities in life span across race/ethnicity, income level, and place.
It is also worth noting that Hispanic residents in the region average longer lifespans than white residents by three to six years, despite the fact that Hispanics tend to have greater economic insecurity and uninsured rates, a national phenomenon known as the “Hispanic paradox” or the “Latino Mortality Advantage.”14 While more research is necessary, research suggests the counter-intuitive outcome can be attributed to lower smoking rates, family structure and strong social networks among Latinos.15 However, some research also suggests this advantage could disappear as the prevalence of obesity and diabetes increases among Latinos.16
Comparing life expectancy to income reveals the extent to which higher income is associated with greater longevity. Nationally, research has shown that the richest men live 15 years longer than the poorest men, while the gaps in lifespan between the richest women and the poorest women is 10 years.17
Further, life expectancies vary depending on where one lives within the three-county area — by as much as 23.4 years. Residents in a high-poverty East Houston neighborhood have the lowest life expectancy in the three-county area (65.7 years). On the other side of the spectrum, a wealthy neighborhood in the Clear Lake area near Bay Oaks Country Club has the longest life span of 89.1 years. This gap is almost equivalent to the difference between low-income developing countries and high-income developed countries.
Total deaths in the Houston region rose significantly in 2020
There were nearly 3.4 million deaths in the U.S. in 2020, an increase of over half a million from 2019. The number of deaths attributed to COVID-19 was 350,831, making it the third leading cause of death in the nation, state, and Houston’s three-county region. The death rate (age-adjusted) increased for men and women, all race/ethnicity groups, and for all age groups 15 years and older — the death rates for children under 15 did not significantly change from 2019 to 2020.
The Houston region has lower rates of premature death compared to the state and nation
Premature death measures deaths among those under age 75 per 100,000 population. Deaths at younger ages contribute more to the premature mortality rate than deaths closer to age 75.
According to the CDC, the leading causes of premature death (before the age of 65) in the United States were unintentional injuries, cancer, heart disease, cancer, and suicide. Social determinants such as poverty, lower educational attainment and social isolation contribute to premature death.18 Populations at high risk for premature death include people with obesity or diabetes, individuals who drink excessively or smoke, and those who face occupational and environmental hazards.19 Many of these premature deaths may be preventable by changing lifestyles and maintaining healthy behaviors.
Overall, the Houston region has lower rates of premature death compared to the state and national average. Fort Bend County has the lowest premature death rate in the three-county region overall and for all racial/ethnic groups. Harris County has the highest premature death rate in the three-county region overall and for most racial/ethnic groups. Premature death rates for Black residents in Harris County are double the rate for Latinos and one-and-a-half times the rate for white residents.
Heart disease and cancer cause nearly half of all deaths in the region and nation
In 2020, the top 10 leading causes of death in the U.S. were heart disease, cancer, COVID-19, accidents (unintentional injuries), stroke, chronic lower respiratory diseases, Alzheimer’s disease, diabetes, influenza and pneumonia, and kidney disease. Cumulatively, these diseases accounted for 74% of all deaths.
The top 10 leading causes of death in Texas were slightly different from the nation as a whole. While heart disease, cancer, COVID-19 and accidents were the top four leading causes of death in both the U.S. and Texas, the remaining causes of death in Texas varied slightly. Alzheimer’s, stroke, chronic lower respiratory diseases, diabetes, chronic liver disease, and kidney disease make up the remainder of the top 10 list for Texas.
In 2020, the top 10 leading causes of death in the Houston three-county area were heart disease (20.5%), cancer (18.0%), COVID-19 (10.4%), accidents (6.4%), stroke (4.9%), Alzheimer disease (3.7%), chronic lower respiratory diseases (2.9%), diabetes (2.9%), blood infections (1.9%), kidney diseases (1.9%), and suicide (1.9%). There are slight differences by county.
Suicide is among the top 10 leading causes of death in the Houston three-county region. In 2020, 3.1% of deaths in Harris County were the result of suicide — double what we see at the state and national levels.
- Link, B. G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of health and social behavior, 80-94.
- Habans, R., Losh, J, Weinstein, R., and Teller, A. ( 2020). Placing Prosperity: Neighborhoods and Life Expectancy in the New Orleans Metro. Retrieved from https://www.datacenterresearch.org/placing-prosperity/
- Knight, J. A. (2012). Physical inactivity: associated diseases and disorders. Annals of Clinical & Laboratory Science, 42(3), 320-337.
- Rosenberger, R. S., Sneh, Y., Phipps, T. T., & Gurvitch, R. (2005). A spatial analysis of linkages between health care expenditures, physical inactivity, obesity and recreation supply. Journal of Leisure Research, 37(2), 216-235.
- Scholes, S., Bann, D. (2018) Education-related disparities in reported physical activity during leisure-time, active transportation, and work among US adults: repeated cross-sectional analysis from the National Health and Nutrition Examination Surveys, 2007 to 2016. BMC Public Health,18, 926. https://doi.org/10.1186/s12889-018-5857-z
- Harper, S., & Lynch, J. (2007). Trends in Socioeconomic Inequalities in Adult Health Behaviors among U.S. States, 1990–2004. Public Health Reports, 122(2), 177–189.
- Coleman-Jensen, A., Rabbitt, M.P., Gregory, C.A., and Singh, A. (2021) Household Food Security in the United States in 2020. ERR-298, U.S. Department of Agriculture, Economic Research Service. https://www.ers.usda.gov/webdocs/publications/102076/err-298.pdf?v=8785.8
- Idler, Ellen L., and Angel, Ronald J. (1990) “Self-Rated Health and Mortality in the NHANES-I Epidemiologic Follow-Up Study.” American Journal of Public Health, 80(4), 446-452.
- Jylhä, M. (2009). What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Social science & medicine, 69(3), 307-316.
- Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: a review of twenty-seven community studies. Journal of health and social behavior, 21-37.
- Jia, H., Muennig, P., Lubetkin, E. I., & Gold, M. R. (2004). Predicting geographical variations in behavioural risk factors: an analysis of physical and mental healthy days. Journal of Epidemiology & Community Health, 58(2), 150-155.
- Biener, A., Cawley, J., & Meyerhoefer, C. (2017). The high and rising costs of obesity to the US health care system. Journal of general internal medicine, 32(1), 6-8. https://doi.org/10.1007/s11606-016-3968-8.
- Habans, R., Losh, J, Weinstein, R., and Teller, A. (2020). Placing Prosperity: Neighborhoods and Life Expectancy in the New Orleans Metro. Retrieved from https://www.datacenterresearch.org/placing-prosperity/.
- Franzini, L., Ribble, J. C., & Keddie, A. M. (2001). Understanding the Hispanic paradox. Ethnicity & disease, 11(3), 496–518. https://pubmed.ncbi.nlm.nih.gov/11572416/.
- Palloni, A., & Arias, E. (2004). Paradox lost: explaining the Hispanic adult mortality advantage. Demography, 41(3), 385-415.
- Goldman N. (2016). Will the Latino Mortality Advantage Endure?. Research on aging, 38(3), 263–282. https://doi.org/10.1177/0164027515620242.
- Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., & Cutler, D. (2016). The association between income and life expectancy in the United States, 2001-2014. JAMA, 315(16), 1750-1766. doi:10.1001/jama.2016.4226.
- Galea, S., Tracy, M., Hoggatt, K. J., DiMaggio, C., & Karpati, A. (2011). Estimated deaths attributable to social factors in the United States. American journal of public health, 101(8), 1456-1465. https://doi.org/10.2105/AJPH.2010.300086.
- Di, Q., Dai, L., Wang, Y., Zanobetti, A., Choirat, C., Schwartz, J. D., & Dominici, F. (2017). Association of Short-term Exposure to Air Pollution With Mortality in Older Adults. JAMA, 318(24), 2446–2456. https://doi.org/10.1001/jama.2017.17923.