In 2023, life expectancy was 75.8 years for men, and 81.8 years for women — a substantial difference. The five leading causes of death among men were heart disease (23%), cancer (20%), unintentional injuries (9%), stroke (4%), and chronic lower respiratory disease (4%). Among women, the corresponding causes were heart disease (21%), cancer (20%), stroke (6%), Alzheimer's disease (5%), and chronic lower respiratory disease (5%).
Francis et al,3 using NHANES data collected between 1999 and 2016 and linked through the National Center for Health Statistics to National Death Index records from 1999 to 2019, examined factors traditionally cited to account for sex-based mortality differences. Variables included age (continuous), self-reported race and ethnicity, educational level, marital status, health insurance coverage, occupational exposure (including hazardous work), poverty- income ratio, and lifestyle measures such as alcohol consumption, smoking intensity, physical activity, sedentary behavior, self-rated health, history of cardiovascular disease, diabetes, hypertension, cancer and body mass index. Participants younger than 20 were excluded.
After adjustment for sociodemographic factors, lifestyle variables, comorbid conditions, and access to care, men demonstrated a 63% higher risk of all-cause mortality compared with women. The authors conclude that intrinsic biological differences may contribute to this gap, citing potential influences including hormone levels, biological aging, epigenetic variation, telomere length, and immune response differences.
The second article,4 examined sex differences in the age of onset of premature cardiovascular disease. Historical data have suggested that men develop coronary heart disease approximately 10 years earlier than women. Freedman et al4 recruited 5,115 participants aged 18 to 30 across four US cities between March 1985 and June 1986. Follow up assessments occurred at years 2,5, 7, 10, 15, 20, 25, and 30.
Cumulative incidence analysis demonstrated that men reached a 5% incidence of total cardiovascular disease approximately 7 years earlier than women. By age 50, cumulative incidence was 4.7% in men compared with 2.9% in women. For coronary heart disease specifically, men reached a 2% cumulative incidence approximately 10 years earlier than women. In contrast, cumulative incidences of stroke and heart failure did not significantly differ. Ten-year cardiovascular event rates began to diverge statistically by age 35, with widening differences through middle adulthood.
The authors suggest that, since sex-based differences in 10-year cardiovascular disease rates are apparent by age 35 and risk equations are capable of predicting cardiovascular disease by age 30, earlier preventive engagement may represent an important opportunity to reduce long-term risk. These findings have important implications for clinical practice. The divergence in cardiovascular risk by the mid-30s suggests that preventive engagement in men should begin earlier than is often routine. Incorporating structured cardiovascular risk assessment and counseling in early adulthood — particularly among men presenting for other healthcare encounters — may represent an underutilized opportunity to narrow this mortality gap. While intrinsic biological factors may contribute, the data reinforce that earlier detection and proactive management of modifiable risk factors remain essential.
Written by: Alan Wein, MD, PhD, FACS, Professor of Clinical Urology, Department of Urology, Desai Sethi Urology Institute (DSUI), University of Miami Miller School of Medicine, University of Miami Health Systems, Miami, FL
References:
- Schweitzer, K. Study points to biology-not just behavior- in the mortality gap between males and females. JAMA, published online, February 20, 2026
- Anderer, S. Cardiovascular disease risk climbs earlier for men. JAMA, published online, February 20, 2026
- Francis J et al, Sex and all cause mortality in the US, 1999 to 2019, JAMA Network Open, 2026;9(1): e 2556299.doi:10.1001//jamanetworkopen.2025.56299
- Freedman A yet al, Sex differences In age of onset of premature cardiovascular disease and subtypes: the coronary artery risk development in young adult study, J Am Heart Assoc. 2026; 15:e O.DOI:10.1161/JAHA.125.04492244922