Frailty in ethnic minority women

  • Natasha Reid
    Corresponding author at: Centre for Health Services Research, The University of Queensland, Level 2, Building 33, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba Queensland 4121, Australia
    Faculty of Medicine, The University of Queensland, Queensland, Australia
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  • Shavini Weerasekera
    Faculty of Medicine, The University of Queensland, Queensland, Australia

    Princess Alexandra Hospital, Metro South Health Hospital and Health Service, Queensland, Australia

    School of Medicine, Griffith University, Queensland, Australia
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  • Ruth E Hubbard
    Faculty of Medicine, The University of Queensland, Queensland, Australia

    Princess Alexandra Hospital, Metro South Health Hospital and Health Service, Queensland, Australia
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  • Emily H Gordon
    Faculty of Medicine, The University of Queensland, Queensland, Australia

    Princess Alexandra Hospital, Metro South Health Hospital and Health Service, Queensland, Australia
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      • A sex–frailty paradox exists, where females tend to be more frail but live longer than males.
      • Frailty in ethnic minority women is likely exacerbated by health inequalities and other factors.
      • While the evidence on frailty in ethnic minority women is sparse and mostly from cross-sectional and cohort studies, we conclude that ethnic minority women are an extremely vulnerable group.
      • The biopsychosocial factors that are most likely to be influential in the development of frailty in ethnic minority women are not immutable, and culturally appropriate and targeted strategies have the potential to positively impact outcomes.
      • Efforts to impact the trajectory of frailty and vulnerability in ethnic minorities need to have a global-level and population-level approaches, and should incorporate individual-level interventions.
      • Future research should focus on understanding the impact of interventions across races and ethnicities.


      In majority populations in high- and middle-income countries, women live longer yet experience higher levels of frailty than men of the same age. It is unclear whether this ‘sex–frailty paradox’ is present in ethnic minority populations. In this narrative review, we explore biological, behavioural and social factors associated with mortality, morbidity and frailty in women, particularly ethnic minority women. We ascertain that natural menopause occurs earlier in women of particular ethnicities. Ethnic minority women (living in high-income countries) have more children and higher rates of chronic disease and disability, all of which are associated with frailty. In some ethnic minorities, women are less likely to engage in deleterious health behaviours such as smoking and alcohol consumption. However, in others the reverse is true. Women from migrant ethnic minorities tend to have lower levels of physical activity. With time, they can also adopt adverse behavioural patterns of the majority population. Although the evidence is sparse, sex differences in health reporting and social assets, as well as gender roles, are likely to contribute to sex differences in frailty in ethnic minorities. Overall, ethnic minority women are a particularly vulnerable group, but the majority of risk factors for frailty appear to be mutable rather than fixed. Future research may examine interventions that target frailty in different races and ethnicities at individual, population and global levels.


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      1. Life expectancy & deaths, 2020.

        • Thorslund M.
        • Wastesson J.W.
        • Agahi N.
        • Lagergren M.
        • Parker M.G.
        The rise and fall of women’s advantage: a comparison of national trends in life expectancy at age 65 years.
        Eur. J. Ageing. 2013; 10: 271-277
        • World Health Organization
        World Health Statistics 2019: Monitoring Health for the SDGs, Sustainable Development Goals.
        World Health Organization, Geneva2019
        • Verbrugge L.M.
        Gender and health: an update on hypotheses and evidence.
        J. Health Soc. Behav. 1985; 26: 156-182
        • Gordon E.H.
        • Peel N.M.
        • Samanta M.
        • Theou O.
        • Howlett S.E.
        • Hubbard R.E.
        Sex differences in frailty: a systematic review and meta-analysis.
        Exp. Gerontol. 2017; 89: 30-40
        • Siriwardhana D.D.
        • Hardoon S.
        • Rait G.
        • Weerasinghe M.C.
        • Walters K.R.
        Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: a systematic review and meta-analysis.
        BMJ Open. 2018; 8e018195
        • Hirsch C.
        • Anderson M.L.
        • Newman A.
        • Kop W.
        • Jackson S.
        • Gottdiener J.
        • Tracy R.
        • Fried L.P.
        • Group C.H.S.R.
        The association of race with frailty: the cardiovascular health study.
        Ann. Epidemiol. 2006; 16: 545-553
        • Majid Z.
        • Welch C.
        • Davies J.
        • Jackson T.
        Global frailty: the role of ethnicity, migration and socioeconomic factors.
        Maturitas. 2020; 139: 33-41
        • Hyde Z.
        • Flicker L.
        • Smith K.
        • Atkinson D.
        • Fenner S.
        • Skeaf L.
        • Malay R.
        • Lo Giudice D.
        Prevalence and incidence of frailty in Aboriginal Australians, and associations with mortality and disability.
        Maturitas. 2016; 87: 89-94
        • Gordon E.H.
        • Hubbard R.E.
        Differences in frailty in older men and women.
        Med. J. Aust. 2020; 212: 183-188
        • Haapanen M.J.
        • Perälä M.-M.
        • Salonen M.K.
        • Guzzardi M.A.
        • Iozzo P.
        • Kajantie E.
        • Rantanen T.
        • Simonen M.
        • Pohjolainen P.
        • Eriksson J.G.
        • von Bonsdorff M.B.
        Telomere length and frailty: The Helsinki birth cohort study.
        J. Am. Med. Dir. Assoc. 2018; 19: 658-662
        • Eskes T.
        • Haanen C.
        Why do women live longer than men?.
        Eur. J. Obstetr. Gynecol. Reprod. Biol. 2007; 133: 126-133
        • Young A.C.M.
        • Glaser K.
        • Spector T.D.
        • Steves C.J.
        The identification of hereditary and environmental determinants of frailty in a cohort of UK twins.
        Twin Res. Hum. Genet. 2016; 19: 600-609
        • Livshits G.
        • Ni Lochlainn M.
        • Malkin I.
        • Bowyer R.
        • Verdi S.
        • Steves C.J.
        • Williams F.M.K.
        Shared genetic influence on frailty and chronic widespread pain: a study from TwinsUK.
        Age Ageing. 2017; 47: 119-125
        • Gubbels Bupp M.R.
        Sex, the aging immune system, and chronic disease.
        Cell. Immunol. 2015; 294: 102-110
        • Carcaillon L.
        • García-García F.J.
        • Tresguerres J.A.F.
        • Gutiérrez Avila G.
        • Kireev R.
        • Rodríguez-Mañas L.
        Higher levels of endogenous estradiol are associated with frailty in postmenopausal women from the toledo study for healthy aging.
        J. Clin. Endocrinol. Metab. 2012; 97: 2898-2906
        • Lee Y.
        • Kim S.
        • Kim M.
        • Kim B.
        • Jeong E.
        • Shim H.
        • Won C.
        A later menopausal age is associated with a lower prevalence of physical frailty in community-dwelling older adults: the Korean Frailty and Aging Cohort Study (KFACS).
        Arch. Gerontol. Geriatr. 2020; 91104243
        • Verschoor C.P.
        • Tamim H.
        Frailty is inversely related to age at menopause and elevated in women who have had a hysterectomy: an analysis of the Canadian longitudinal study on aging.
        J. Gerontol.: Ser. A. 2019; 74: 675-682
        • Kim C.
        • Golden S.H.
        • Mather K.J.
        • Laughlin G.A.
        • Kong S.
        • Nan B.
        • Barrett-Connor E.
        • Randolph Jr., J.F.
        Racial/ethnic differences in sex hormone levels among postmenopausal women in the diabetes prevention program.
        J. Clin. Endocrinol. Metab. 2012; 97: 4051-4060
        • Gold E.B.
        The timing of the age at which natural menopause occurs.
        Obstet. Gynecol. Clin. North Am. 2011; 38: 425-440
        • Gold E.B.
        • Bromberger J.
        • Crawford S.
        • Samuels S.
        • Greendale G.A.
        • Harlow S.D.
        • Skurnick J.
        Factors associated with age at natural menopause in a multiethnic sample of midlife women.
        Am. J. Epidemiol. 2001; 153: 865-874
        • Australian Institue of Health and Welfare
        Maternal Deaths in Australia 2012-2014.
        AIHW, Canberra2017
      2. M. Knight, S. Kenyon, P. Brocklehurst, J. Neilson, J. Shakespeare, J.J. Kurinczuk, Saving lives, improving mothers' care: lessons learned to inform future maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009-2012, (2017).

        • Petersen E.E.
        • Davis N.L.
        • Goodman D.
        • Cox S.
        • Syverson C.
        • Seed K.
        • Shapiro-Mendoza C.
        • Callaghan W.M.
        • Barfield W.
        Racial/ethnic disparities in pregnancy-related deaths - United States, 2007-2016.
        MMWR. Morbidity Mortality Weekly Rep. 2019; 68: 762-765
      3. United Nations Department of Economic and Social Affairs, Population division (2020). World fertility and family planning 2020: Highlights (ST/ESA/SER.A/440), 2020.

      4. T. Mathews, B.E. Hamilton, Total fertility rates by state and race and Hispanic origin: United States, 2017, (2019).

      5. Births, Australia: Statistics about births and fertility rates for Australia, states and territories, and sub-state regions, 2019.,%20%202.316%20%207%20more%20rows.

        • Lv H.
        • Wu H.
        • Yin J.
        • Qian J.
        • Ge J.
        Parity and cardiovascular disease mortality: a dose-response meta-analysis of cohort studies.
        Sci. Rep. 2015; 5: 13411
        • Yuen L.
        • Wong V.W.
        • Simmons D.
        Ethnic disparities in gestational diabetes.
        Curr. Diab. Rep. 2018; 18: 68
        • Johnson J.D.
        • Louis J.M.
        Does race or ethnicity play a role in the origin, pathophysiology, and outcomes of preeclampsia? An expert review of the literature.
        Am. J. Obstet. Gynecol. 2020;
        • Jasienska G.
        Reproduction and lifespan: trade-offs, overall energy budgets, intergenerational costs, and costs neglected by research.
        Am. J. Hum. Biol. 2009; 21: 524-532
        • Zhou H.-H.
        • Shu B.
        • Liu T.-Z.
        • Wang X.-H.
        • Yang Z.-H.
        • Guo Y.-L.
        Association between parity and the risk for urinary incontinence in women: a meta-analysis of case-control and cohort studies.
        Medicine (Baltimore). 2018; 97: e11443
        • Gordon E.H.
        • Peel N.M.
        • Chatfield M.D.
        • Lang I.A.
        • Hubbard R.E.
        Frailty: a cost incurred by reproduction?.
        Sci. Rep. 2020; 10 (10139-10139)
        • Gale C.R.
        • Baylis D.
        • Cooper C.
        • Sayer A.A.
        Inflammatory markers and incident frailty in men and women: the english longitudinal study of ageing.
        Age (Dordrecht, Netherlands). 2013; 35: 2493-2501
        • Kane A.E.
        • Keller K.M.
        • Heinze-Milne S.
        • Grandy S.A.
        • Howlett S.E.
        A murine frailty index based on clinical and laboratory measurements: links between frailty and pro-inflammatory cytokines differ in a sex-specific manner.
        J. Gerontol. A Biol. Sci. Med. Sci. 2019; 74: 275-282
        • Stepanikova I.
        • Bateman L.B.
        • Oates G.R.
        Systemic inflammation in midlife: race, socioeconomic status, and perceived discrimination.
        Am. J. Prev. Med. 2017; 52: S63-S76
        • Hubbard R.E.
        • Lang I.A.
        • Llewellyn D.J.
        • Rockwood K.
        Frailty, body mass index, and abdominal obesity in older people.
        J. Gerontol. A Biol. Sci. Med. Sci. 2010; 65: 377-381
        • Fougère B.
        • Boulanger E.
        • Nourhashémi F.
        • Guyonnet S.
        • Cesari M.
        Chronic inflammation: accelerator of biological aging.
        J. Gerontol. Ser. A, Biol. Sci. Med. Sci. 2017; 72: 1218-1225
        • Stevens J.
        • Katz E.G.
        • Huxley R.R.
        Associations between gender, age and waist circumference.
        Eur. J. Clin. Nutr. 2010; 64: 6-15
        • Lassek W.D.
        • Gaulin S.J.C.
        Changes in body fat distribution in relation to parity in American women: a covert form of maternal depletion.
        Am. J. Phys. Anthropol. 2006; 131: 295-302
        • Wen M.
        • Kowaleski-Jones L.
        • Fan J.X.
        Ethnic-immigrant disparities in total and abdominal obesity in the US.
        Am. J. Health Behav. 2013; 37: 807-818
        • M M.J.Avedano
        • et al.
        First results from the survey of health, ageing and retirement in Europe (2004-2007).
        in: B.A. Borsch-Supan A Jurges H Kapteyn A Mackenbach J Siegrist J Changes in physical health among older Europeans. Mannheim Research Institute for the Economics of Ageing, Mannheim2008: 118-124
        • Crimmins E.M.
        • Kim J.K.
        • Solé-Auró A.
        Gender differences in health: results from SHARE, ELSA and HRS.
        Eur. J. Public Health. 2011; 21: 81-91
        • Merrill S.S.
        • Seeman T.E.
        • Kasl S.V.
        • Berkman L.F.
        Gender differences in the comparison of self-reported disability and performance measures.
        J. Gerontol. Ser. A: Biol. Sci. Med. Sci. 1997; 52: M19-M26
        • Hardy S.E.
        • Allore H.G.
        • Guo Z.
        • Gill T.M.
        Explaining the effect of gender on functional transitions in older persons.
        Gerontology. 2008; 54: 79-86
        • Joo J.Y.
        • Liu M.F.
        Effectiveness of culturally tailored interventions for chronic illnesses among ethnic minorities.
        West. J. Nurs. Res. 2020; 43: 73-84
      6. H.P. Collins, Q. AM, D. Kalisch, Contribution of chronic disease to the gap in adult mortality between Aboriginal and Torres Strait Islander and other Australians.

        • Ali R.
        • Barnes I.
        • Cairns B.J.
        • Finlayson A.E.
        • Bhala N.
        • Mallath M.
        • Beral V.
        Incidence of gastrointestinal cancers by ethnic group in England, 2001–2007.
        Gut. 2013; 62: 1692-1703
        • Allen K.D.
        Racial and ethnic disparities in osteoarthritis phenotypes.
        Curr. Opin. Rheumatol. 2010; 22: 528-532
        • Moore L.
        • Jayaweera H.
        • Redshaw M.
        • Quigley M.
        Migration, ethnicity and mental health: evidence from mothers participating in the Millennium Cohort Study.
        Public Health. 2019; 171: 66-75
        • Bhugra D.
        Migration, distress and cultural identity.
        Br. Med. Bull. 2004; 69: 129-141
      7. Indegenous Health and wellbeing, 2020.

        • Courtney-Long E.A.
        • Romano S.D.
        • Carroll D.D.
        • Fox M.H.
        Socioeconomic factors at the intersection of race and ethnicity influencing health risks for people with disabilities.
        J. Racial Ethnic Health Disparities. 2017; 4: 213-222
      8. L.H. Anderson L, Garcia J., Sex differences in muscle wasting, in: Mauvais-Jarvis F (Ed.), Sex and Gender Factors Affecting Metablic Homeostasis, Diabetes and Obesity Springer 2017, pp. 153-97.

        • Cruz-Jentoft A.J.
        • Bahat G.
        • Bauer J.
        • Boirie Y.
        • Bruyere O.
        • Cederholm T.
        • Cooper C.
        • Landi F.
        • Rolland Y.
        • Sayer A.A.
        • Schneider S.M.
        • Sieber C.C.
        • Topinkova E.
        • Vandewoude M.
        • Visser M.
        • Zamboni M.
        • Schols J.
        Sarcopenia: revised European consensus on definition and diagnosis.
        Age Ageing. 2019; 48: 16-31
        • Mayhew A.J.
        • Amog K.
        • Phillips S.
        • Parise G.
        • McNicholas P.D.
        • de Souza R.J.
        • Thabane L.
        • Raina P.
        The prevalence of sarcopenia in community-dwelling older adults, an exploration of differences between studies and within definitions: a systematic review and meta-analyses.
        Age Ageing. 2019; 48: 48-56
        • Kruger H.S.
        • Micklesfield L.K.
        • Wright H.H.
        • Havemann-Nel L.
        • Goedecke J.H.
        Ethnic-specific cut-points for sarcopenia: evidence from black South African women.
        Eur. J. Clin. Nutr. 2015; 69: 843-849
        • Du K.
        • Goates S.
        • Arensberg M.B.
        • Pereira S.
        • Gaillard T.
        Prevalence of sarcopenia and sarcopenic obesity vary with race/ethnicity and advancing age.
        Divers Equal Health Care. 2018; 15: 175-183
        • Dorhout B.G.
        • Overdevest E.
        • Tieland M.
        • Nicolaou M.
        • Weijs P.J.M.
        • Snijder M.B.
        • Peters R.J.G.
        • van Valkengoed I.G.M.
        • Haveman-Nies A.
        • de Groot L.C.P.G.M.
        Sarcopenia and its relation to protein intake across older ethnic populations in the Netherlands: the HELIUS study.
        Ethn. Health. 2020; : 1-16
        • Oksuzyan A.
        • Juel K.
        • Vaupel J.W.
        • Christensen K.
        Men: good health and high mortality. Sex differences in health and aging.
        Aging Clin. Exp. Res. 2008; 20: 91-102
        • Hubbard R.
        • Searle S.
        • Mitnitski A.
        • Rockwood K.
        Effect of smoking on the accumulation of deficits, frailty and survival in older adults: a secondary analysis from the Canadian Study of Health and Aging.
        JNHA-J. Nutrition, Health Aging. 2009; 13: 468-472
        • Shah M.
        • Paulson D.
        • Nguyen V.
        Alcohol use and frailty risk among older adults over 12 years: the health and retirement study.
        Clin. Gerontol. 2018; 41: 315-325
        • Luthra R.
        • Nandi A.
        • Benzeval M.
        Unravelling the ‘immigrant health paradox’: ethnic maintenance, discrimination, and health behaviours of the foreign born and their children in England.
        J. Ethnic Migration Stud. 2020; 46: 980-1001
      9. Ministry of Health NZ Key Indicators, 2020.!/key-indicators.

        • Yu M.
        • Whitbeck L.B.
        A prospective, longitudinal study of cigarette smoking status among North American Indigenous adolescents.
        Addict. Behav. 2016; 58: 35
        • Twyman L.
        • Bonevski B.
        • Paul C.
        • Bryant J.
        Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature.
        BMJ Open. 2014; 4
        • Fischbacher C.M.
        • Hunt S.
        • Alexander L.
        How physically active are South Asians in the United Kingdom? A literature review.
        J. Public Health (Oxf). 2004; 26: 250-258
        • Ige-Elegbede J.
        • Pilkington P.
        • Gray S.
        • Powell J.
        Barriers and facilitators of physical activity among adults and older adults from Black and Minority Ethnic groups in the UK: a systematic review of qualitative studies.
        Prevent. Med. Rep. 2019; 15100952
        • Shivappa N.
        • Stubbs B.
        • Hébert J.R.
        • Cesari M.
        • Schofield P.
        • Soysal P.
        • Maggi S.
        • Veronese N.
        The relationship between the dietary inflammatory index and incident frailty: a longitudinal cohort study.
        J. Am. Med. Dir. Assoc. 2018; 19: 77-82
        • Baker A.H.
        • Wardle J.
        Sex differences in fruit and vegetable intake in older adults.
        Appetite. 2003; 40: 269-275
        • Perrig-Chiello P.
        • Hutchison S.
        Health and well-being in old age: the pertinence of a gender mainstreaming approach in research.
        Gerontology. 2010; 56: 208-213
        • August K.J.
        • August K.J.
        • Sorkin D.H.
        • Sorkin D.H.
        Racial/ethnic disparities in exercise and dietary behaviors of middle-aged and older adults.
        J. Gen. Internal Med.: JGIM. 2011; 26: 245-250
        • Orzech K.M.
        • Vivian J.
        • Huebner Torres C.
        • Armin J.
        • Shaw S.J.
        Diet and exercise adherence and practices among medically underserved patients with chronic disease: variation across four ethnic groups.
        Health Educ. Behav. 2013; 40: 56-66
        • Chauhan A.
        • Walton M.
        • Manias E.
        • Walpola R.L.
        • Seale H.
        • Latanik M.
        • Leone D.
        • Mears S.
        • Harrison R.
        The safety of health care for ethnic minority patients: a systematic review.
        Int. J. Equity Health. 2020; 19: 1-25
        • Szanton S.L.
        • Seplaki C.L.
        • Thorpe Jr., R.J.
        • Allen J.K.
        • Fried L.P.
        Socioeconomic status is associated with frailty: the Women’s Health and Aging Studies.
        J. Epidemiol. Community Health. 2010; 64: 63-67
        • Andrew M.K.
        • Mitnitski A.B.
        • Rockwood K.
        Social vulnerability, frailty and mortality in elderly people.
        PLoS One. 2008; 3: e2232
        • Woo J.
        • Goggins W.
        • Sham A.
        • Ho S.C.
        Social determinants of frailty.
        Gerontology. 2005; 51: 402-408
        • Trevisan C.
        • Veronese N.
        • Maggi S.
        • Baggio G.
        • De Rui M.
        • Bolzetta F.
        • Zambon S.
        • Sartori L.
        • Perissinotto E.
        • Crepaldi G.
        • Manzato E.
        • Sergi G.
        Marital status and frailty in older people: gender differences in the Progetto Veneto Anziani longitudinal study.
        J. Women’s Health. 2002; 25 (2016): 630-637
        • Andrew M.K.
        • Keefe J.M.
        Social vulnerability from a social ecology perspective: a cohort study of older adults from the National Population Health Survey of Canada.
        BMC Geriatr. 2014; 14: 90
        • Berges I.-M.
        • Graham J.E.
        • Ostir G.V.
        • Markides K.S.
        • Ottenbacher K.J.
        Sex differences in mortality among older frail Mexican Americans.
        J. Women’s Health. 2002; 18 (2009): 1647-1651
      10. Australian Bureau of Statistics 2016 Census, aboriginal and torres strait islander peoples profile table 106.

        • Kil T.
        • Neels K.
        • Wood J.
        • de Valk H.A.G.
        Employment after parenthood: women of migrant origin and natives compared.
        Eur. J. Population = Revue europeenne de demographie. 2017; 34: 413-440