Diabetes risk in older Mexican Americans: effects of language acculturation, generation and socioeconomic status

Diabetes and Hypertension Risk Across Acculturation and Education Levels in Hispanic/Latino Adults: The Hispanic Community Health Study/Study of Latinos

Importance

Acculturation among Hispanic/Latino populations, defined as adaptation to US lifestyle and culture, is often assumed to lead to adverse health outcomes that will reduce the immigrant health advantage.

Objective

To evaluate the risks for incident diabetes and hypertension by levels of acculturation and educational attainment.

Design, Setting, and Participants

This study used data from the Hispanic Community Health Study/Study of Latinos, a population-based cohort study of men and women aged 18 to 74 years who identified as Central American, Cuban, Dominican, Mexican, Puerto Rican, or South American living in 4 urban locales in the US. Visit 1 spanned March 2008 to June 2011; visit 2 spanned October 2014 to December 2017.

Main Outcomes and Measures

Multivariable logistic regression was used to evaluate the association between language acculturation level defined by the Short Acculturation Scale for Hispanics (SASH) and educational attainment (less than high school graduate vs more than high school) and incident diabetes and hypertension by heritage group.

Results

Of 11 623 adult participants, 1207 (10.4%) were of Central American heritage, 1645 (14.2%) of Cuban heritage, 1021 (8.8%) of Dominican heritage, 11 623 (41.3%) of Mexican heritage, 1801 (15.5%) of Puerto Rican heritage, and 795 (6.8%) of South American heritage. The mean (SE) age of all participants was 43.1 (0.3) years, and 7345 (56.3%) were female. A total of 8697 (71.4%) were born outside the US, 4358 (32.5%) had less than a high school education, and 7475 (58.3%) were less acculturated (SASH score less than 2). Incident rates of diabetes (total cohort, 14.6% [95% CI, 13.6%-15.6%]) and hypertension (total cohort, 20.4% [95% CI, 19.0%-21.9%]) varied across heritages; Mexican individuals (17.2% [95% CI, 15.5%-19.0%]) had the highest diabetes incidence and Dominican individuals the highest hypertension incidence (27.1% [95% CI, 22.7%-31.4%]). Persons with more educational attainment were at lower risk for diabetes and hypertension independent of acculturation, and more acculturated participants had a lower risk for incident diabetes. Less acculturated with lower socioeconomic status (SES) were more likely to have incident diabetes (weighted predicted probability [WPP], 0.17 [95% CI, 0.14-0.19]), and more acculturated with lower SES had the highest predicted probability of hypertension (WPP, 0.19 [95% CI, 0.15-0.23]). More acculturated with higher SES were at lower risk of diabetes (WPP, 0.11 [95% CI, 0.09-0.13]) and had a lower predicted probability of hypertension (WPP, 0.10 [95% CI, 0.08-0.12]).

Conclusions and Relevance

In this cohort study, the association of acculturation with health outcomes is not unidirectional and interacts with educational attainment in determining incident diabetes and hypertension. The Hispanic and Latino paradox, in which immigrants have a health advantage, is influenced by more factors than acculturation and may persist with higher educational attainment. These observations may inform prevention and treatment strategies associated with cardiometabolic health in Hispanic/Latino populations.

The Impact of Primary Language Spoken on the Pain Experience of Children With Cancer

The purpose of the current prospective cohort study was to determine if acculturation, measured by primary language spoken, impacts the pain response of children being treated for cancer during an experimental pain task. Sixty-seven Spanish-speaking and English-speaking children ages 6 to 18 years being treated for cancer provided ratings of pain and upset severity during the completion of the cold pressor task (CPT). One week following the CPT, participants provided their recollection of average pain and upset during the CPT. Repeated measures analysis of variance revealed Spanish-speaking children reported significantly higher pain (F1,64=5.58, P=0.02) and upset (F1,64=7.69, P=0.007) ratings during the CPT compared with English-speaking children. Also, Spanish-speaking children were over 4 times as likely to remove their hands from the water before the CPT 4-minute uninformed ceiling compared with English-speaking children (P=0.002). These findings suggest that cultural and contextual factors, including the level of acculturation, are important considerations in the assessment and management of pain in children with cancer. Future research should continue to examine the mechanisms underlying the association between acculturation and the symptom experience for children receiving treatment for cancer.

Racial Disparities in Gestational Diabetes by Maternal Nativity and Length of US Residence in an Urban Low-income Population in the United States

Background

Gestational diabetes mellitus (GDM) is associated with increased risk of cardiovascular disease (CVD). Racial/ethnic differences in GDM prevalence have been described, but disparities by nativity and duration of US residence are not well studied.

Methods

We analyzed data from 6088 women (mean age: 27.5 years [standard deviation: 6.3 years]) from the Boston Birth Cohort who self-identified as non-Hispanic Black (NHB; n = 2697), Hispanic (n = 2395), or non-Hispanic White (NHW; n = 996). Using multivariable logistic regression, we examined the cross-sectional association of nativity and duration of US residence (< 10 vs ≥ 10 years) with GDM within each race/ethnicity group.

Results

Foreign-born NHB, NHW, and Hispanic women with a duration of US residence of < 10 years had a lower prevalence of CVD risk factors than those with US residence of ≥ 10 years, respectively, as follows: smoking (NHB: 1.7% vs 3.1%; NHW: 5.7% vs 8.1%; Hispanic: 0.4% vs 2.6%); obesity (NHB: 17.1% vs 23.4%; NHW: 3.8% vs 15.6%; Hispanic: 10.9% vs 22.7%); and severe stress (NHB: 8.7% vs 11.9%; NHW: 5.7% vs 28.1%; Hispanic: 3.8% vs 7.3%). In analyses adjusting for sociodemographic characteristics and CVD risk factors, foreign-born NHB women with a duration of US residence of < 10 years had higher odds of having GDM (adjusted odds ratio: 1.60, 95% confidence interval: 0.99-2.60), compared with their US-born counterparts, whereas foreign-born Hispanic women with a duration of US residence of < 10 years had lower odds of having GDM (adjusted odds ratio: 0.54, 95% confidence interval: 0.32-0.91). The odds of having GDM in Hispanic and NHB women with a duration of US residence of ≥ 10 years were not significantly different from those of their US-born counterparts.

Conclusions

The “healthy immigrant effect” and its waning with longer duration of US residence apply to the prevalence of GDM among Hispanic women but not NHB women. Further research on the intersectionality of race and nativity-based disparities is needed.

A Systematic Review Exploring Acculturation and Type 2 Diabetes in Spanish-Speaking Populations

BACKGROUND

Acculturation to the United States has been previously studied in Spanish-speaking populations, but little is known about the potential relationship between acculturation and type 2 diabetes mellitus (T2DM).

OBJECTIVE

The purpose of this systematic review was to explore the relationship between acculturation and T2DM in Spanish-speaking populations in the United States.

METHODS

Selected studies collected from a review of literature were analyzed by population, ethnicity, acculturation scale, and significance.

RESULTS

Thirty-two eligible articles showed conflicting data between the effects of acculturation on T2DM.

CONCLUSION

Overall, studies yielded inconclusive results on the significance of the relationship between acculturation and diabetes in Spanish-speaking populations, which merit further investigation.

How Does Acculturation Influence Smoking Behavior Among Latinos? The Role of Education and National Background

Introduction

As Latinos acculturate, they are assumed to smoke at higher rates. This study investigated the relationship between acculturation level, educational attainment, and cigarette smoking by gender and national background among Latinos.

Methods

Data from the 2009-2012 National Health Interview Survey were analyzed and participants included 1,111 Cubans, 813 Dominicans, 13,281 Mexicans, and 2,197 Puerto Ricans. Multivariable logistic regression was used to model acculturation and educational predictors of current smoking, stratified by gender and national background. Acculturation level was categorized into less acculturated, bicultural, and more acculturated by combining birthplace and language preference. Current cigarette smoking was defined by self-reported use every day or some days among those who ever smoked at least 100 cigarettes.

Results

Most respondents were interviewed in English (62%) and had a high school education or less (60%), but only 39% were US-born. Overall, 17.8% of men and 9.6% of women reported current smoking. By national background, smoking prevalence was highest among Puerto Ricans (16% of women and 23% of men) and lowest among Dominicans (6% of women and 10% of men). More acculturated Mexican women and men had significantly higher odds of current smoking (OR=2.94; 95% CI=2.01, 4.31 and OR=1.88; 95% CI=1.39, 2.55; respectively). Mexican men who were more acculturated and had greater levels of educational attainment had lower odds of smoking (OR=.84; 95% CI=.74, .96).

Conclusions

The relationship between acculturation and health behaviors among Latinos is influenced by education and should be considered by public health and clinician stakeholders when developing or adapting tobacco control strategies.

Type 2 diabetes, depressive symptoms and disability over a 15-year follow-up period in older Mexican Americans living in the southwestern United States

AIMS

To evaluate how depression and diabetes severity impact disability progression among Mexican Americans over a 15-year period.

METHODS

We used seven waves of the Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE). Primary disability outcomes included the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales. Explanatory variables included time since diagnosis with diabetes (no type 2 diabetes, 1-10, 11-20, 21+), an indicator of disease severity, and depression. Longitudinal generalized estimating equation models were used to estimate the relationship between time since diabetes diagnosis, depressive symptoms and ADL and IADL disability progression over a 15-year time period.

RESULTS

Years since diabetes diagnosis was associated with more rapid ADL and IADL disability progression compared to those without type 2 diabetes. Depression accelerated the disabling process in participants who were diagnosed with diabetes 11years or more years ago.

CONCLUSIONS

Longer duration of diabetes and greater symptoms of depression increase vulnerability for disability among older Mexican American adults.

Acculturation and Insulin Resistance among US Chinese Immigrant Women

OBJECTIVE

Chinese immigrants in the United States undergo a transition to increased chronic disease risk commonly attributed to acculturative changes. Longitudinal data to confirm this are lacking. We examined acculturation in relation to insulin resistance in a sample of Chinese immigrant women to determine differences by level of education and possible mediation by anthropometry and diet.

DESIGN

Longitudinal study.

SETTING

Philadelphia, Pennsylvania.

PARTICIPANTS

305 Chinese immigrant women recruited October 2005 to April 2008 and followed until April 2010.

MAIN OUTCOME MEASURES

Association of acculturation, measured using the General Ethnicity Questionnaire - American version (GEQA), with homeostasis model assessment (HOMA) score as an indicator of insulin resistance, modeled using generalized estimating equations to account for repeated measures over time.

RESULTS

GEQA was associated with log HOMA score, but only in women with <9 years of education (beta [SE] = .09 [.04], P=.02; interaction P=.02). The association persisted with adjustment for body mass index, waist circumference, and dietary variables.

CONCLUSIONS

These findings provide longitudinal evidence that insulin resistance increases with acculturation. However, the association was apparent only in less-educated immigrants and may be mediated by a pathway other than changes in anthropometry and diet.

The Quality of Diabetes Management Among Mexican Adults in California: Does Generational Status Matter?

BACKGROUND

Although there is increasing knowledge regarding the association between generational status on diabetes risk, less is known about the effects of generational status on diabetes management among Mexicans.

OBJECTIVES

We test whether generational status is associated with variations in diabetes processes of care among Mexican adults to optimize disease management.

RESEARCH DESIGN

Weighted multivariate logistic regression was used to test the association between generational status on the quality of diabetes care processes and health care utilization adjusting for socioeconomic/demographic factors. Four generational cohorts were constructed: first generation immigrant; second generation; generation 2.5; and third generation.

SUBJECTS

We conducted analyses of 3072 self-identified foreign and US-born Mexican adults with diabetes who participated in the 2005, 2007, 2009, and 2011/2012 California Health Interview Surveys.

MEASURES

Three diabetes process outcomes were measured, including receipt of at least 1 eye examination, 1 foot examination, or 1 hemoglobin A1C test (HbA1c) in the past year. One secondary prevention outcome was measured, receipt of an annual influenza vaccine. Finally, we measured whether an individual with diabetes received an annual doctor visit.

RESULTS

A gradient of progressively decreased odds of receiving an eye examination and HbA1c test were observed and significant for most of the higher generations. Higher generations also had significantly decreased odds of receiving an annual flu vaccine.

CONCLUSIONS

Data collection on generational granularity and a specific focus on mixed acculturation status can vitally inform health system improvements in diabetes care among Mexicans in the United States.

Acculturation, Gender, and Active Life Expectancy in the Mexican-Origin Population

OBJECTIVE

This study examines the potential effects of nativity and acculturation on active life expectancy (ALE) among Mexican-origin elders.

METHOD

We employ 17 years of data from the Hispanic Established Population for the Epidemiologic Study of the Elderly to calculate ALE at age 65 with and without disabilities.

RESULTS

Native-born males and foreign-born females spend a larger fraction of their elderly years with activities of daily living (ADL) disability. Conversely, both foreign-born males and females spend a larger fraction of their remaining years with instrumental activities of daily life (IADL) disability than the native-born. In descriptive analysis, women with low acculturation report higher ADL and IADL disability. Men manifest similar patterns for IADLs.

DISCUSSION

Although foreign-born elders live slightly longer lives, they do so with more years spent in a disabled state. Given the rapid aging of the Mexican-origin population, the prevention and treatment of disabilities, particularly among the foreign born, should be a major public health priority.

Older Latinos

Latinos/Hispanics are the largest and fastest growing ethnic minority group in the United States. By mid-century, older Hispanics may account for almost 20% of the older cohort. Yet while health disparities have garnered increased attention, little is known about older Hispanics and their overall health, social, and economic needs. This article presents an innovative Ethnocultural Gerontological Nursing Model that can serve as an overarching framework for exploring various salient macro- and micro-level factors that affect the lives of Latino elders, their families, and the communities that support them. By utilizing a life span perspective, the Ethnocultural Gerontological Nursing Model and attached questionnaire can assist nurses and other health providers in gaining a fuller assessment of older Latinos in order that we may improve our understanding and development of health service, program, and policy changes that address the needs of older Latinos and the nurses who care for them and their families.

Dietary Acculturation in Latinos/Hispanics in the United States

As a person acculturates into a new culture, dietary changes may occur. This is termed dietary acculturation and is a complex process that has been observed in the Hispanic population in the United States. As acculturation occurs, traditional dietary behaviors are shed, and behaviors representative of the US diet are adopted. Many diet-related psychological and environmental factors may influence this diet change in the Hispanic population. It is important for health professionals to identify factors that may be causing unhealthy dietary behaviors and determine the most appropriate forms to address them. By identifying and addressing negative dietary change and behaviors, certain diet-related health issues commonly seen in this population, such as obesity and diabetes, may be prevented or managed.