Acculturation and Healthy Lifestyle Among Latinos With Diabetes

INTRODUCTION

Diabetes has reached epidemic proportions in the United States.¹ The deleterious outcomes of this disease can be decreased through appropriate ongoing management and treatment.² Diabetes burden is not distributed equally throughout the population. In particular, Latinos have a higher prevalence of diabetes, more complications, and worse outcomes than non-Latino whites.^3–7 Quality of care for diabetes among Latinos continues to lag behind that for non-Latino whites.⁸ Moreover, recent projections continue to predict an increasing prevalence of diabetes, particularly for Latinos.⁹

The US Census indicates that 14.5% of adult US residents are foreign-born.¹⁰ These immigrants, particularly minorities, may require interventions and modifications to the standard health care delivery system that differ from those of their ethnic counterparts who are born in the United States. Differences in diabetes prevalence and care among ethnic subgroups are associated with degree of acculturation.^11,12 For example, Latinos who are less acculturated to the majority US culture tend to have a higher prevalence of diabetes and more complications.^11,13

One aspect of successful diabetes management takes place outside of the physician’s office and entails the patient adopting a healthy lifestyle. For patients with diabetes, a healthy lifestyle includes an appropriate diet and exercise.^14,15 These self-management behaviors related to lifestyle may be particularly influenced by culturally specific attitudes and beliefs.^16–18 In particular, some data suggest that acculturation for the general population of Latinos has been associated with suboptimal lifestyle choices, including a low intake of fruits and vegetables, a higher consumption of fats, and smoking.¹⁹ Acculturation among Latinos with diabetes to the mainstream US culture may thus influence the healthiness of their lifestyle, particularly depending on whether the mainstream society has a healthy lifestyle. The purpose of this study was to examine the association of acculturation with a healthy lifestyle among Latinos with diabetes in the United States.

METHODS

RESULTS

Depending on the measure used to assess acculturation, an estimated 36% to 69% of Latino individuals with diabetes nationally were more-acculturated (Table 1⇓).

Latinos with diabetes who were less-acculturated according to SAS score were predominantly female, and they were significantly more likely that their more-acculturated counterparts to have annual incomes of less than $20,000 and less likely to be high school graduates (Table 1⇑). Less-acculturated individuals were also less likely to have private health insurance or a usual place for health care. There were no significant differences between the groups in terms of current smoking or BMI, but less-acculturated individuals exercised much less during leisure time. When using the 1994 ADA dietary guidelines, in bivariate analyses, dietary fiber and cholesterol intakes were not significantly different between the groups, but less-acculturated individuals were significantly more likely to get fewer than 10% of their daily calories from saturated fats. When using the 2006 ADA dietary guidelines, there still was no difference between the more-acculturated and less-acculturated groups with regard to dietary cholesterol intake; however, less-acculturated individuals were significantly more likely to have diets high in fiber and low in saturated fat. This effect was also apparent for acculturation as assessed by country of birth.

The relationships between the lifestyle characteristics and socioeconomic measures are shown in Table 2⇓. The only significant differences were that compared with individuals who had graduated from high school, those who had not were less likely to exercise in their leisure time and more likely to have diets low in cholesterol and saturated fat.

The results of the logistic regression analyses indicated that when the SAS score was used as the indicator of acculturation, more-acculturated individuals were no more or less likely than less-acculturated individuals to be nonsmokers (odds ratio, 0.5; 95% confidence interval [CI], 0.17–1.72) or to engage in some leisure time exercise (odds ratio, 2.17; 95% CI, 0.85–5.53). When using the 1994 ADA dietary guidelines, more-acculturated individuals were significantly less likely to have diets low in saturated fats (Table 3⇓). When using the 2006 ADA dietary guidelines, however, they were significantly less likely to have diets both high in fiber and low in saturated fat.

When country of birth was used as the indicator of acculturation, the associations between acculturation and healthy lifestyle were not as strong (Table 4⇓). According to the 2006 criteria, acculturation was only associated with saturated fat intake, and that association indicated that individuals born outside the United States were more likely to have a diet low in saturated fat.

We found no evidence of an interaction between any of the socioeconomic indicators (health insurance, poverty, and education) and the SAS score in the models.

DISCUSSION

The results of this study suggest that although acculturation of Latinos to the mainstream US culture may be somewhat beneficial in terms of access to care and socioeconomic status, less-acculturated Latinos with diabetes tend to have healthier diets than their more-acculturated counterparts. Specifically, more-acculturated Latinos with diabetes were less likely to have diets higher in fiber and lower in saturated fat; moreover, this effect was more apparent when using the stricter ADA dietary criteria put forth in 2006. These differences suggest that adopting an “American” diet may not be a desirable change in behavior. This finding is especially pertinent in light of previous studies demonstrating that Latinos have difficulty in maintaining healthy traditional habits while adapting to the mainstream culture, which may be due to a lack of perceived behavioral control, as they are unable to develop strategies to protect these beneficial traditional habits.^27–29

Acculturation has been linked to the likelihood of developing diabetes, as well as to quality of care, with more-acculturated individuals receiving better care.^8,13 Little research has focused on the impact of acculturation on diet among Latinos with diabetes, however. Delivery of culturally competent health care by professionals has been discussed at length, but evidence suggests that self-management of diabetes in modern US society may be difficult for Latino patients as they struggle to decide which traditional behaviors to retain and which new ones to adopt.²⁸

Our findings suggest that an understanding of the complexities in providing culturally competent care must include an understanding not just of where the patient is coming from culturally, but where they are now. Having a medical home with continuity of care may help to ensure that the patient-physician relationship is intact and that the physician can understand factors that may be changing in the patient’s ability to adhere to treatment or lifestyle recommendations. Consequently, an initial lack of health insurance or disruption of health insurance coverage is a big problem in socially disadvantaged populations because of its impact on this continuity and having a medical home, and corresponding delivery of quality care.³⁰

There are several limitations to this study. First, the data set is cross-sectional, which limits the ability to make inferences about causality. The NHANES data do, however, allow us to generate population estimates for Latinos with diabetes in the US population. Second, we used both a general measure of acculturation (being born in the United States) and a standard scale that represents acculturation based on language (SAS score), and the latter was significantly associated with several indicators of healthy lifestyle. It is possible, however, that because acculturation includes multiple factors regarding behaviors and beliefs, our measure was too crude and simplistic to appropriately capture nuances of culture. Third, the question regarding physician-diagnosed diabetes, which was the basis for including individuals in the study, does not discriminate between individuals told that they had type 1 diabetes and individuals told that they had type 2 diabetes; however, the lifestyle questions we used are applicable to individuals with either type of diabetes. Fourth, although the NHANES allowed us to look at the current behaviors and acculturation of Latinos generally, the survey questions were limited regarding background characteristics of the subset of Latino immigrants. Consequently, we were unable to investigate questions such as whether immigrants from rural areas of Mexico differ in their behaviors from those hailing from urban areas. Fifth, in the bivariate analyses, more-acculturated individuals were more likely to engage in leisure time exercise than their less-acculturated counterparts. This finding does not necessarily mean that less-acculturated individuals do not engage in exercise, but rather that they may not use their leisure time for exercise. Individuals working in more physical and manual labor occupations may seek out less vigorous leisure time pursuits. For many, the importance of exercising after work may take a lower priority than resting from a workday considerably longer than 8 hours that involves physical activity. Even though we could not measure exercise obtained during leisure time vs on the job, once we controlled for demographic characteristics, the relationship between acculturation and leisure time exercise was no longer significant.

In conclusion, the common assumption that ethnic minority populations will always benefit from acculturation to mainstream US society does not appear to hold true in the case of healthy lifestyle behaviors among Latinos with diabetes. This study adds to other evidence that aspects of acculturation may be maladaptive.¹⁹ Dietary habits of Latinos with diabetes who are less-acculturated to US society are healthier than those of Latinos who are more-acculturated. It is important to understand the complex process of acculturation as we focus on developing culturally sensitive health care programs, in order to encourage patients to maintain healthy traditional behaviors while simultaneously adopting beneficial aspects of the mainstream culture.