The relationship of acculturation to cardiovascular disease risk factors among U.S. South Asians: Findings from the MASALA study

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Abstract

Aim

We investigated the association between acculturation strategies and cardiometabolic risk among South Asian (SA) immigrants in the US.

Methods

In this cross-sectional analysis of data from 849 SA participants in the Mediators of Atherosclerosis in SAs Living in America (MASALA), we performed multidimensional measures of acculturation to categorize the participants into three acculturation classes: separation (preference for SA culture), assimilation (preference for US culture), and integration (similar preference for both cultures). Differences in glycemic indices, blood pressure, lipid parameters and body composition by acculturation strategy were examined.

Results

Women in the integration class had the lowest prevalence of diabetes (16.4%), prediabetes (29.7%), fasting and 2-h glucose compared to women in the separation class with the highest prevalence of diabetes (29.3%), prediabetes (31.5%), fasting and 2-h glucose and 2-hr insulin (all p < 0.05). Women in the assimilation class had significantly lower triglycerides, BMI, and waist circumference and higher HDL compared to women in the separation class after adjusting for age, study site, and years in the US. After additionally accounting for socioeconomic/lifestyle factors, women in the assimilation class had significantly lower triglyceride and higher HDL levels compared to women in the separation class (p < 0.01). There was no significant association between acculturation strategies and cardiometabolic risk in SA men.

Conclusion

SA women who employed an assimilation or integration strategy had a more favorable cardiometabolic profile compared to women using a separation strategy. Future research should investigate the behavioral and psychosocial pathways linking acculturation strategies with cardiometabolic health to inform preventive interventions among SAs living in America.

Introduction

The prevalence of cardiovascular disease (CVD) risk factors including diabetes, hypertension, dyslipidemia, and obesity is rising at alarming rates in South Asia [1], [2], [3]. Immigrants from South Asian (SA) countries (i.e. India, Pakistan, Bangladesh, Sri Lanka, and Nepal) became the fastest-growing ethnic group in the United States (US) between 2000 and 2010, and there are close to 4.9 million SAs in the US [4], [5]. South Asian immigrants have a higher prevalence of CVD risk factors and greater cardiovascular mortality compared to local populations and immigrants of other ethnic groups [6], [7], [8], [9], [10], [11]. Furthermore, SA immigrants develop cardiometabolic diseases at a younger age and a lower BMI than individuals of other ethnic groups [10], [12], [13].

Similar to other immigrants, South Asians experience a process of acculturation whereby changes in cultural and psychosocial behaviors take place as they interact with members of different cultural groups and social structures in the host country and adapt to a new culture and environment [14]. The impact of acculturation on cardiometabolic health has been examined among various ethnic groups, but prior work has been limited by its overreliance on simple unidimensional proxy measures of acculturation (e.g. English fluency and years in the US) which do not account for the multiple dimensions and complex nature of the impact of acculturation on health. Using these proxy measures, greater acculturation (i.e. assimilation) has been associated with an increased prevalence of various CVD risk factors in Japanese, Chinese, Hispanic, European, and Black immigrants in the US [15], [16], [17], [18], [19], [20], [21]. The worse cardiometabolic profile in those who migrated from low-income to high-income countries compared to those who remained in their low-income home countries has been attributed to possibly adopting unhealthy behaviors related to dietary pattern (e.g. high-carbohydrate and/or fat intake), physical activity (e.g. sedentary life), psychosocial factors (e.g. depression or chronic stress), or combination of more than one of these factors that are more prevalent in most high-income countries [22], [23], [24]. For example, a higher consumption of animal protein, animal and vegetable fat, and simple carbohydrates along with lower physical activity have been found in Japanese immigrants in the US compared to Japanese living in Hiroshima [21]. These lifestyle changes were associated with unfavorable changes in lipids, blood pressure, BMI, and carotid intima-media thickness in this study. Acculturation, however, is widely variable among immigrants and depends in part on the differences in health behaviors between the host country and country of origin. It is possible that some immigrants may adopt healthier behaviors from the host country that would lower their risk of CVD [25], [26], [27]. Hence, the use of a multidimensional model of acculturation is needed to better characterize the impact of acculturation on cardiometabolic health and capture domains of this process that may not be apparent with the use of the traditional proxy measures of acculturation. Moreover, sex differences in the degree of assimilation to the host culture after migration, as well as heterogeneity by sex in the association of acculturation and CVD risk factors have been reported in various ethnic groups [20], [28], [29], [30].

In this study, we sought to examine the association between acculturation strategies, using several cultural and behavioral indicators of acculturation, and CVD risk factors among SA immigrants in the US. We used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study that utilized twelve indicators of acculturation to identify three acculturation strategies: assimilation, integration, and separation [31]. We hypothesized that by potentially adopting unhealthy behaviors that are prevalent in the US, SA immigrants using the assimilation and integration strategies (i.e. stronger preference of US culture over SA culture) would have a higher prevalence of CVD risk factors than South Asians using the separation strategy (i.e. stronger preference of SA culture over US culture). We also hypothesized that the association between acculturation and CVD risk factors would vary by sex among SA immigrants.

Section snippets

Study design and participants

We conducted a cross-sectional analysis of data from the MASALA study, a community-based cohort of SA men and women from two clinical sites (San Francisco Bay Area at the University of California, San Francisco (UCSF) and the greater Chicago area at Northwestern University (NWU)). MASALA enrolled 906 participants (98% foreign-born) between October 2010 and March 2013. The detailed study design and objectives of the MASALA study have been previously described [32]. In brief, individuals were

Sociodemographic and lifestyle-related factors by acculturation class

The study population included 849 participants, of whom 45.8% were women and 23.0% were in the separation class, 54.4% in the integration class, and 22.6% in the assimilation class. Majority of the study participants spoke English well or very well (87.2%), were born in India (85.3%) and were employed (70.4%). Table 1 shows the characteristics of the study participants by sex and acculturation class. Compared to those in the separation class, men and women in the assimilation and integration

Cardiovascular disease risk factors by duration of residence in the US

With the exception of HDL and waist circumference, none of the differences seen in the CVD risk factors by acculturation class was seen when length of residence in the US was used as a proxy measure of acculturation (Supplementary Table 1). There were no significant differences in any of the glycemic indices, triglyceride or LDL levels, blood pressure, BMI, or body composition by length of residence in the US. However, women and men who lived in the US for 20 or more years had higher HDL levels

Discussion

In contrast to prior studies, we found a relatively higher degree of preference for US culture over SA culture– represented by the integration and assimilation classes– to be associated with an overall healthier cardiometabolic profile among SA women in the US; but the differences in CVD risk factors by acculturation strategy were not significant in men. Furthermore, we identified healthier behaviors and psychosocial factors in men and women who employ the assimilation strategy compared to

Acknowledgement

The authors thank the MASALA staff and participants for their valuable contributions. They also thank Dr. Diane M. Becker from the Division of General Internal Medicine at Johns Hopkins University for providing critical analysis and insightful comments on early versions of the manuscript.

Financial Support

The MASALA study was supported by NIH grants R01HL093009 and K24HL112827. Data collection at the University of California, San Francisco, was supported by NIH/NCRR grant UL1 RR024131. The Saudi Government Scholarship from King Saud University, Riyadh, Saudi Arabia provided fellowship training support to Dr. Al-Sofiani. None of the funders were involved in the design, conduct, or analysis of the study; collection, analysis, or interpretation of the data; preparation, review, or approval of the

Declaration of Competing Interest

No conflicts of interest relevant to this article were reported by the authors.

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