The Role of Acculturation in Cardiovascular Disease in Hispanics: An Unrecognized Risk
Significant gaps exist in our understanding of the variability of cardiovascular disease (CVD) risk profiles in many Hispanic subgroups. The reasons for this are complex and the role of acculturation has emerged as a potential explanation.
US health and CVD data on Hispanics has consistently reported a higher prevalence of diabetes, obesity, metabolic syndrome and inactivity compared with whites, other ethnic minority groups and, in some instances, non-Hispanic blacks.1 However, this has been based almost exclusively on epidemiologic data obtained on Mexican Americans with little data on other Hispanic groups.
More recently, the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), the largest and most comprehensive population-based study of risk factors for chronic diseases, including CVD, has expanded the existing database on the health of other Hispanic subgroups. This study included over 16,000 self-identified Hispanics (ages 18-74) from randomly selected households in four major US city communities (NY, Miami, Chicago, San Diego) and has been pivotal in elucidating not only variability of risk profiles but highlighting that significant CVD burden exists among all major Hispanic subgroups in the US.2
Acculturation is the process by which new cultural elements and engagement in specific behaviors, including the lifestyle, diet, beliefs and values of a new country, are acquired. The cumulative experience of individuals with their environments to assimilate or adapt to change across their life cycle further shapes this process. Acculturation is thus multidimensional. Factors often analyzed in studies of acculturation include; demographics, socioeconomic status (SES), nativity, duration of residence in the US and language preference (Figure 1). The process may vary across different US communities and is directly related to an individual's permissive adaptation to change. The process can be slow or accelerated. When high native cultural maintenance predominates, the process is slow. Conversely, this acculturative process may accelerate if the host communities do not provide familiar cultural habits or lifestyle customs. This acceleration may not necessarily be a healthy one.
Figure 1: Factors of Acculturation
In Hispanics, the acculturation process has been associated with obesity-related behaviors, increased smoking, alcohol intake, hypertension, diabetes and worse birth outcomes. The 'health advantage' in foreign born Hispanics seems to dissipate the longer their duration of residence in the US.3-6
Variation of CVD Risks
Important differences in measurable major adverse CVD risk profiles among Hispanics by country or region of origin have been described. In the HCHS/SOL, Daviglus et al. showed that participants of Puerto Rican (PR) background had the highest percentage of self-reported CVD risks versus those of Central American (CA), and South American (SA) backgrounds who had the lowest percentages among all groups studied.7 Significant differences were seen in cardiovascular heart disease (4.9% P.R vs. 1.6% C.A, 2.6% S.A), stroke (2.3% P.R. vs. 1.5% C.A, 0.9% S.A), hypertension (31.5% P.R, 26.1% C.A, 20.3 % S.A), obesity (46.8% P.R vs. an average of 37.1% across all subgroups) and diabetes (19.2 P.R% vs. 17.8% C.A, 10.7% S.A) respectively. As U.S. citizens, Puerto Ricans are the group with the highest degree of acculturation when compared to other groups from Latin America. Thus, this may explain the observations seen in SOL.7
Educational level is tied to economic advancement and SES. The census data of 2016 indicated that foreign-born Hispanics had a higher proportion of adults with less than a high school education (28%) compared with native US born Hispanics (8%).8-9 In Hispanics of lower SES, a detrimental association of acculturation with increased smoking and alcohol consumption has been reported. Interestingly, less acculturated Mexican and Central Americans drank and smoked less often than more acculturated individuals in this study. Gender/sex differences have also been seen with regard to certain risk factors like smoking where age adjusted rates of smoking in more acculturated women were higher (22.3%) than less acculturated women (13.9%), but inconclusive in men.8-11
Daviglius (HCHS/SOL) and colleagues have shown a relatively lower adverse CVD risk profile (LR, denoting a better profile) in less acculturated Cuban and South American women. In age-adjusted analyses of these women, those who were foreign born (vs. US born), who had resided in the United States <10 years (vs. ≥10 years), and who preferred the use of Spanish (vs. English) had 1.64, 1.96, and 1.54 times higher odds, respectively, of having a LR profile, i.e., a "better profile."
Among women, being less acculturated was positively associated with having a LR profile. In contrast, among men, those with a LR profile tended to be more acculturated and were least likely to prefer speaking Spanish compared with others and were more likely to be US born or had lived in the United States for ≥10 years. Prevalence of unfavorable or borderline CVD risk was relatively high and correlated with less acculturation among men only.12
Several specific risk factors have been shown to associate positively or negatively with the acculturation process. Higher levels of C-reactive protein (CRP levels >3 mg/L; p = 0.002), a marker of inflammation with strong predictive value on future CVD risk, was noted to be independently associated with a 52% higher likelihood (P= 0.003) for the more acculturated compared with less acculturated Hispanics.13
Among Hispanics from HCHS-SOL, 66% of the studied population exhibited some form of dyslipidemia with low HDL-C (41%) and elevated LDL-C (33%) being the most common types observed. Overall, women had a higher prevalence of undesirable cholesterol levels (total cholesterol >200 mg/dL) when compared to men in the 45-74 age group. In this target population, SES, lower educational attainment and Spanish-language preference were significantly related to dyslipidemia across all Hispanic subgroups. Duration of residence in the US was not. Similar to SOL, a correlation of acculturation and dyslipidemia was seen in the Multi-Ethnic Study of Atherosclerosis (MESA) where custom language retention was associated with significantly higher LDL–C than English preference. In MESA, those with longer period of residence in the US had significantly higher LDL-C than those who had fewer years in the US. US birth and longer US residence have also been associated with higher prevalence of diabetes, other types of dyslipidemia, and hypertension, but the presence and strength of these associations varies across studies. MESA investigators have shown that longer baseline time in US was associated with lower cardiovascular health (CVH) scores and higher CV event incidence.14-15
Acculturation may increase nutrition health disparities in Hispanics and has been consistently associated with less-healthy dietary patterns, poorer quality diet and obesity. Studies have shown that while foreign born Hispanic adolescents have a healthier dietary pattern, consuming more rice (Mexicans), fruits (Mexicans, Puerto Ricans) and vegetables (Mexicans, Cubans) than their US born counterparts, this reverses in Hispanic adults.16-17 Findings suggest it is important to protect the positive dietary behaviors of the Hispanic culture and to improve those of more acculturated Hispanics.
Low level of physical activity and/or inactivity (TV/video and computer/video game use) has been seen to increase with generation of US residence among Mexicans and Cubans.17,20 But while the evidence of the association of acculturation with dietary quality and obesity appears universally inverse, the one regarding acculturation and leisure-time physical activity has been positive. These associations appear to be modified by several socio-economic and demographic factors and may not always be linear.
A negative effect of acculturation on the rates of hypertension has been shown. However, positive effects on the rates of awareness, treatment and control of blood pressure have also emerged. Data of HCH/SOL indicates that the prevalence of HTN appears highest in Dominican men and Puerto Rican women with the impact of acculturation remaining unclear at this point.18 Table 1 summarizes associations of CVD risk factors with the acculturation process. It is important to note that the preponderance of this evidence has been derived from cross sectional samples and thus has inherent limitations.
Table 1: Summary of Associations of Acculturation with CVD Risk Factors
*Lower SES and Spanish preference
** >US 10 yrs residence
The Hispanic Paradox
Despite a higher prevalence of CV risk factors as well as greater socioeconomic disadvantage, Hispanics are less likely to die from CVD compared with non-Hispanic whites.19-20 This has led to the concept of the term 'Hispanic Paradox.'
This paradox is not well understood and may not apply equally to all Hispanic groups or across all types of heart disease as significant variability exists among subgroups as noted earlier. Recent data suggests that the term 'Hispanic Paradox' may be more fitting to foreign-born Hispanics than to US-born more acculturated Hispanics. Non-US born Hispanics migrating to the US tend to be younger and potentially healthier (the 'healthy migrant effect'). These groups are commonly underrepresented in epidemiologic studies thus skewing the assessment of risk profiles towards the more established Hispanic groups. This along with the reported inherent desire of many immigrants to return to their native land in their final years ('salmon hypothesis') may affect the accuracy of mortality statistics gathered and, to some extent, explain this paradox.19-20
This underscores the importance of the acculturation process as a potential vital modifier of the interaction of environment and biology and thus a factor in the development of CV risk factors in Hispanics in the US.
By 2060, one out of three Americans will be of Hispanic origin. Providers need to recognize the complex environmental and social factors that magnify or modify CV risks in this important segment of our population. It is paramount to find reliable, test-proven ways to better define and study acculturation. By studying patterns, associations and clusters much the same way we study syndromes, we may gain further insight into this process that seems to go beyond just diet, language and income. Tailoring interventions to the acculturation level of individuals is likely to help reduce CV health disparities in Hispanics.
- Perez-Escamilla R, Putnik P. The role of acculturation in nutrition, lifestyle, and incidence of type 2 diabetes among Latinos. J Nutr 2007;137:860-70.
- Gonzalez HM, Tarraf W, Rodriguez CJ, et al. Cardiovascular health among diverse Hispanics/Latinos: Hispanic Community Health Study/Study of Latinos (HCHS/SOL) results. Am Heart J 2016;176:134-44.
- Abraido-Lanza AF, Chao MT, Florez KR. Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox. Soc Sci Med 2005;61:1243-55.
- Eamranond PP, Wee CC, Legedza AT, Marcantonio ER, Leveille SG. Acculturation and cardiovascular risk factor control among Hispanic adults in the United States. Public Health Rep 2009;124:818-24.
- Jones SE, Pezzi C, Rodriguez-Lainz A, Whittle L. Healthy risk behaviors by length of time in the United States among high school students in five sites. J Immigr Minor Health 2016;18:150-60.
- Chang A, Kenya S, Ilangovan K, et al. Is greater acculturation associated with an increased prevalence of cardiovascular risk factors among Latinos in South Florida? Med Care 2015;53:417-22.
- Hispanic Community Health Study/Study of Latinos Data Book: A Report to the Communities (NIH Publication No. 13-7951). Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. September 2013.
- Alba R, Nee V. Rethinking assimilation theory for a new era of immigration. Int Migr Rev 1997;31:826-74.
- Ramirez RR, de la Cruz PG. The Hispanic population in the United States: population characteristics. Curr Pop Reports 2002.
- Dawson DA. Beyond black, white and Hispanic: race, ethnic origin and drinking patterns in the United States. J Subst Abuse 1998;10:321-39.
- Marin G, Perez-Stable EJ, Marin BV. Cigarette smoking among San Francisco Hispanics: the role of acculturation and gender. Am J Public Health 1989;79:196-8.
- Daviglus ML, Pirzada A, Durazo-Arvizu R, et al. Prevalence of low cardiovascular risk profile among diverse Hispanic/Latino adults in the United States by age, sex, and levels of acculturation: the Hispanic Community Health Study/Study of Latinos. J Am Heart Assoc 2016;5:e003929.
- Rodriguez F, Peralta CA, Green AR, Lopez L. Comparison of c-reactive protein levels in less versus more acculturated Hispanic adults in the United States (from the National Health and Nutrition Examination Survey 1999-2008). Am J Cardiol 2012;109:665-9.
- Rodriguez CJ, Daviglus ML, Swett K, et al. Dyslipidemia patterns among Hispanics/Latinos of diverse background in the United States. Am J Med 2014;127:1186-94.
- Goff DC Jr, Bertoni AG, Kramer H, et al. Dyslipidemia prevalence, treatment, and control in the Multi-Ethnic Study of Atherosclerosis (MESA): gender, ethnicity, and coronary artery calcium. Circulation 2006;113:647-56.
- Office of Disease Prevention and Health Promotion; Center of Disease Control and Prevention, National Institutes of Health. The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD; US Department of Health and Human Services, Public Health Service, Office of the Surgeon General: Washington DC, 2000.
- Caldera YM, Lindsey EW. Mexican American Children and Families: Multidisciplinary Perspectives. New York, NY: Routledge, Taylor & Francis Group 2015.
- Pabon-Nau LP, Cohen A, Meigs JB, Grant RW. Hypertension and diabetes prevalence among U.S. Hispanics by country of origin: the National Health Interview Survey 2000-2005. J Gen Intern Med 2010;25:847-52.
- Dominguez K, Penman-Aguilar A, Chang MH, et al. Vital signs: leading causes of death, prevalence of diseases and risk factors, and use of health services among Hispanics in the United States – 2009-2013. MMWR Morb Mortal Wkly Rep 2015;64:469-78.
- Hummer RA, Benjamins MR, Rogers RG. Racial and Ethnic Disparities in Health and Mortality Among the U.S. Elderly Population. Anderson NB, Bulatao RA, Cohen B (eds.), Critical Perspectives on Racial and Ethnic Differences in Health in Late Life. National Academies Press 2004;310-52.
Keywords: Primary Prevention, Secondary Prevention, Hispanic Americans, Acculturation, Mexican Americans, Metabolic Syndrome, C-Reactive Protein, Risk Factors, Prevalence, Latin America, Minority Groups, Factor XII, Diabetes Mellitus, Obesity, Atherosclerosis, Dyslipidemias, Cholesterol, Smoking, Social Class, Alcohol Drinking, Life Style, Hypertension, Stroke, Cardiovascular Diseases, Habits, Chronic Disease, Inflammation, Heart Diseases
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