Health-Related Behavioral Risk Factors and Obesity Among American Indians and Alaska Natives of the United States

Assessing Variations by Indian Health Service Region

Guixiang Zhao, MD, PhD; Jason Hsia, PhD; Alexander Vigo-Valentín, PhD; William S. Garvin, BS; Machell Town, PhD, MS


Prev Chronic Dis. 2022;19(1):e05 

In This Article

Abstract and Introduction


Introduction: Health-related behavioral risk factors and obesity are linked to high risk for multiple chronic diseases. We examined the prevalence of these risk factors among American Indians and Alaska Natives (AI/ANs) compared with that of non-Hispanic Whites and across Indian Health Service (IHS) regions.

Methods: We used 2017 Behavioral Risk Factor Surveillance System data from participants in 50 states and the District of Columbia to assess 4 behavioral risk factors (current cigarette smoking, heavy drinking, binge drinking, and physical inactivity) and obesity. We analyzed disparities in these risk factors between AI/AN and non-Hispanic White participants, nationwide and by IHS region, by conducting log-linear regression analyses while controlling for potential confounders.

Results: Nationwide, crude prevalence of current smoking, physical inactivity, and obesity were significantly higher among AI/AN than non-Hispanic White participants. After adjustment for sociodemographic characteristics, AI/AN participants were 11% more likely to report current smoking (P < .05) and 23% more likely to report obesity (P < .001) than non-Hispanic White participants. These patterns persisted in most IHS regions with some exceptions. In the Southwest region, AI/AN participants were 39% less likely to report current smoking than non-Hispanic White participants (P < .001). In the Pacific Coast region, compared with non-Hispanic White participants, AI/AN participants were 54% less likely to report heavy drinking (P < .01) but 34% more likely to report physical inactivity (P < .05). Across IHS regions, AI/AN participants residing in Alaska and the Northern Plains regions had the highest prevalence of current smoking and binge drinking, and those in the Southwest and Pacific Coast regions had the lowest prevalence of current smoking. AI/AN participants in the Southwest region had the lowest prevalence of physical inactivity, and those in the Southern Plains region had the highest prevalence of obesity.

Conclusions: The findings of this study support the importance of public health efforts to address and improve behavioral risk factors related to chronic disease in AI/AN people, both nationwide and among IHS regions, through culturally appropriate interventions.


Behavioral risk factors, such as cigarette smoking or commercial tobacco use, excessive alcohol use (eg, heavy and binge drinking), and sedentary lifestyle, as well as obesity are linked to increased risk for multiple chronic diseases including heart disease, hypertension, stroke, diabetes, and cancer.[1–4] Improving lifestyle behaviors plays an important role in the prevention and control of these diseases.[4–6]

American Indian and Alaska Native (AI/AN) people comprise a population with distinctive sociohistorical characteristics.[7] In the US, the AI/AN population alone reached 3.7 million and the AI/AN population alone or in combination with other racial groups reached 7.1 million in 2020, which increased by 85.2% from 2010 to 2020.[8] The projected AI/AN population alone or in combination will reach 10.1 million in 2060.[8] AI/AN people have a higher burden of many chronic diseases including type 2 diabetes, hypertension, cardiovascular diseases, cancers, and mental illnesses.[9–12] A national survey of the US adult population in 2014–2018 reported that, compared with all US adults, AI/AN adults had a significantly higher prevalence of having a severe disability (16.3% vs 8.9%), diagnosed hypertension (33.7% vs 28.7%), diagnosed diabetes (15.0% vs 8.6%), and multiple chronic conditions (31.9% vs 24.2%).[12] Significant disparities in all-cause or cancer mortality also existed among AI/AN individuals, especially in comparison with non-Hispanic White individuals.[13] The high prevalence of these conditions may be linked to the health-related behaviors of AI/AN people; however, there is a growing consensus that historical trauma experienced by AI/AN communities as a consequence of the US federal policies of relocation, assimilation, and tribal termination are the underlying causes of many of these health behaviors and outcomes.[14,15]

The health-related risk factors of AI/AN individuals have been reported for the periods of 1997–2000,[16,17] 2000–2006,[18] and 2000–2010.[19] These studies were conducted either among AI/AN people nationwide[16–18] or among the AI/AN population living in the Indian Health Service (IHS) Contract Health Service Delivery Areas.[19] These studies have shown significantly higher prevalence of current smoking, excessive alcohol use, physical inactivity, and obesity among AI/AN people as compared with people from other racial and ethnic groups, especially non-Hispanic White people.[16–19] However, due to the limited sample size of AI/AN people, these studies reported estimates based on multiple-year combined data.[16–19] Consequently, the Office of Minority Health at the US Department Health and Human Services and the Centers for Disease Control and Prevention (CDC) launched an initiative in 2017 to oversample participants in states that have a high proportion of AI/AN people to improve understanding of the health status of AI/AN communities. The aim of this study was to expand knowledge of the health-related behaviors and obesity prevalence of AI/AN people. With an increased sample size of AI/AN individuals, we were able to examine these risk factors stratified by IHS region, which has not been done previously.