a Stanford Center for Research in Disease Prevention, Stanford University School of Medicine, USA.
b Karolinska Institutet, Family Medicine Stockholm, Novum, 14157 Huddinge, Sweden.
Reprint requests to: Professor Jan Sundquist, Karolinska Institutet, Family Medicine Stockholm, Novum, 14157 Huddinge, Sweden. E-mail: jan.sundquist{at}klinvet.ki.se
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Abstract |
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Methods We analysed data for 1387 MexicanAmerican women and 1404 Mexican American men, ages 2564, from the third National Health and Nutrition Examination Survey (19881994). We examined whether waist circumference and abdominal obesity varied by country of birth and acculturation status (primary language spoken), and whether among those with abdominal obesity, number of associated cardiovascular disease (CVD) risk factors varied by country of birth and acculturation status.
Results Both country of birth and, to a lesser degree, acculturation status were significantly associated with waist circumference and abdominal obesity. Mexican-born women and men had the smallest waist circumference (90.4 cm, 94.0 cm respectively), US-born English-speaking women and men had intermediate waist circumference (93.6 cm, 97.3 cm), and US-born Spanish-speaking women and men had the largest waist circumference (96.9 cm, 97.7 cm), after accounting for age, education, per cent of energy from dietary fat, leisure-time physical activity, and smoking. All women had high prevalences of abdominal obesity, particularly US-born Spanish-speaking women (68.7%). In addition, US-born Spanish-speaking women with abdominal obesity were significantly more likely than their counterparts to have one or more of the following CVD risk factors: high serum insulin, non-insulin dependent diabetes, high blood lipids, and/or hypertension.
Conclusions These findings illustrate the heterogeneity of the MexicanAmerican population and suggest that country of birth and lack of acculturation to the majority culture, as well as secondary lifestyle changes, may explain the significant clinical differences observed in abdominal obesity within MexicanAmerican population subgroups.
Keywords Mexican, American, migration, acculturation, waist circumference, abdominal obesity
Accepted 15 October 1999
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Introduction |
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There are large differences in the prevalence of obesity across ethnic groups,1,11 with the problem being particularly important in the MexicanAmerican population,217 which it is increasing rapidly. Between 1980 and 1990 the Hispanic population, of whom 63% are MexicanAmerican, increased by 45% compared with 7% for the overall population, with projected increases in population size from 31.4 million people in 2000 to 96.5 million people in 2050.18,19
There are also differences in the prevalence of obesity within the MexicanAmerican population, indicating a heterogeneity that is important to examine further. For example, the San Antonio Heart Study showed that MexicanAmerican women living in more affluent suburbs had a mean BMI of 24.5 while those living in the most socioeconomically disadvantaged neighbourhoods had a mean BMI of 28.3.13 Corresponding BMI levels for MexicanAmerican men in these areas were 26.9 and 27.8, respectively.
There are additional variations in obesity among populations that have migrated to new countries, suggesting that factors associated with the migration process (e.g. change in diet, exercise, and stress) may adversely influence body weight. Prospective studies have shown significant BMI increases following immigration to a new country. A prospective study of 654 adult Tokelauans who migrated to New Zealand because of a natural disaster showed that their BMI levels increased from 24.1 to 28.7 between 1968 and 1982 compared with non-migrants whose BMI levels increased from 24.8 to 26.1.20 Moreover, an 8-year prospective study from Sweden showed a significant net increase in BMI levels among men who immigrated from South Europe to Sweden compared to a reference group of men who had not immigrated (BMI levels for immigrant men increased from 25.5 to 27.0 compared to 24.6 to 25.0 for non-immigrant men, after adjustment for age, leisure-time physical activity, smoking, education, and health status).5
In addition to the possible adverse effects of migration on body weight, several studies have suggested that the degree to which people acculturate to the majority culture following migration may influence weight. A cross-sectional analysis of MexicanAmerican women and men from the Hispanic Health and Nutrition Examination Survey (HHANES) showed that preference for speaking Spanish (indicating a lower level of acculturation) was associated with a significantly higher BMI in women but not in men.21 Hazuda et al.22,23 examined the multidimensional aspects of acculturation and its association with body weight by constructing the following three acculturation scales: functional integration with mainstream American culture, worth placed on conserving Mexican culture, and attitudes toward traditional family structure. The scales showed different associations with body weight, with the first scale (low functional integration) showing the strongest association, but only for women and not for men.23 In contrast, the well-known study on acculturation and weight, which involved a cohort of 4653 men of Japanese ancestry living in Hawaii, found that men who were most traditional had significantly lower levels of BMI (mean of 23) than those who were more acculturated (mean of 26).24
In this analysis we used data from the Third National Health and Nutrition Examination Survey (NHANES III), a large national sample of women and men living in the US. We examined whether abdominal obesity differed among three groups of MexicanAmerican women and men who reflect different stages of migration and acculturation: those born in Mexico, those born in the US whose primary language was Spanish, and those born in the US whose primary language was English. We also examined whether among those with abdominal obesity, risk of associated CVD risk factors (indicated by high serum insulin, NIDDM, high blood lipids, and hypertension)2527 varied according to the three migration/ acculturation groups.
We chose waist circumference as our measure of abdominal obesity for the following reasons. First, waist circumference is more strongly related to the metabolically active visceral adipose tissue and therefore more biologically interpretable than the more widely used measure of abdominal obesity, the waist to hip ratio (WHR).28,29 Second, several studies have concluded that waist circumference alone is more closely associated with the amount of abdominal, visceral obesity than the WHR, and recommend that waist circumference should be used to estimate risk of CVD28,30 and NIDDM.31 Third, a 7-year prospective study revealed that waist circumference was the best predictor of NIDDM compared to BMI, WHR, triceps and subscapular skinfolds in MexicanAmerican women and men.32
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Methods |
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The NHANES III data were collected via standardized questionnaires administered by bilingual interviewers and examiners at participants' homes, and laboratory tests conducted at NHANES mobile examination centres. Of the 40 600 people invited to participate, 86% completed the home questionnaire, and 78% completed both the medical examination and the home questionnaire (n = 33 994).
The sample for our analyses includes 1387 Mexican American women and 1404 MexicanAmerican men, 2564 years of age, who completed both the home questionnaire and medical examination. We used age 25 as our lower age cut-point because educational attainment (a covariate in our multivariate regression models) is often not completed before this age. We used age 64 as our upper age cut-point because of lifestyle changes associated with retirement and ageing after 65.36 We excluded data for pregnant women (n = 69) and surveys coded as unreliable (n = 3). Missing data were as follows for the outcome variables; waist (4.0%), BMI (0.4%), serum insulin (3.6%), NIDDM (0.2%), high-density lipoprotein cholesterol (4.3%), serum triglycerides (3.7%), and hypertension (4.4%).
Definition of variables
Migration and acculturation status were indicated by country of birth and primary language spoken at home. Race-ethnic groups were based upon combinations of the race and ethnicity reported by the participants. Respondents who chose Mexican or MexicanAmerican ethnicity are included in this analysis.
Waist circumference was measured with the person in the erect position, with an inelastic tape at the level of the natural waist (the most narrow part of the torso).37 Abdominal obesity was defined as a waist circumference of 102 cm for men and
88 cm for women, these cut-points representing a substantially increased risk of future adverse health outcomes and CVD risk factors.10,38 As a measure of general obesity, a risk factor associated with CVD, we used BMI.
The CVD risk factors were defined as follows. Non-insulin dependent diabetes mellitus was defined as having an 8-hour fast and plasma glucose levels
126 mg/dl and/or a medical history of diabetes (other than during pregnancy) with an age of onset >25 years.39 Non-high-density lipoprotein cholesterol (non-HDL-C) was calculated as the difference between total cholesterol and high-density lipoprotein cholesterol. Non-HDL-C, which may be a better indicator of atherogenic lipoprotein particles than indirectly estimated low-density lipoprotein cholesterol,40 does not require fasting blood samples and therefore allowed the use of the entire NHANES III sample. Non-HDL-C (mmol/l), insulin (µU/ml), and triglycerides (mmol/l) were measured from serum specimens. All blood specimens were obtained by a venipuncture. High insulin levels were defined as
mean + 2 standard deviations (SD) for the entire NHANES III sample. High non-HDL-C cholesterol and high triglyceride levels were defined as
4.0 mmol/l and
2.26 mmol/l, respectively.41 Blood pressure was measured on the right arm by health examiners or physicians while the participant was seated during the medical examination; the mean of the second and third of three blood pressure readings was used. Hypertension was defined as systolic blood pressure
140 mmHg and/or diastolic blood pressure
90 mmHg and/or current use of antihypertensive medications.42
Data analysis
Primary analyses, using linear models, were carried out in SUDAAN, to adjust for the complex sample design of NHANES III.43 All analyses incorporated sampling weights that adjusted for unequal probabilities of selection. Sample weights were also adjusted for non-respondents' characteristics. Analyses were run separately for women and men. The primary outcome variable was waist circumference; the predictor variables were country of birth and acculturation status (three groupsborn in Mexico and used as the reference group, born in the US and Spanish-speaking, born in the US and English-speaking). The following potential confounding factors were included as covariates in the linear models: age (in years, centred at the sample mean to aid in the interpretation of the regression coefficients), years of education (continuous and centred), per cent of energy from dietary fat (based on a single 24-hour dietary recall and administered by trained dietary interviewers); no leisure-time physical activity (based on whether individuals had engaged in any leisure time physical activity in the past month, including exercises, sports, or physically active hobbiesthose who reported no leisure-time activities were considered physically inactive); and current cigarette smoker (determined by self-report and based on whether individuals had smoked 100 cigarettes during their lifetime and whether they were current smokers). We validated self-reported smoking by examining a biochemical measure, serum cotinine, and found that underreporting did not differ significantly between the three groups for either women or men. We included all first order interactions between predictor variables in the linear models.
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Results |
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Table 3 presents the unadjusted and adjusted means for waist circumference and BMI by country of birth and acculturation status. After adjustment for age, education, dietary fat, leisure-time physical activity, and smoking, Mexican-born women and men had the smallest waist circumference (90.4 cm, 94.0 cm respectively), US-born English-speaking women and men had intermediate waist circumference (93.6 cm, 97.3 cm), and US-born Spanish-speaking women and men had the largest waist circumference (96.9 cm, 97.7 cm). The corresponding adjusted levels for white women and men (presented for reference only) were 87.9 cm for women and 96.8 cm for men.
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Discussion |
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It is well-known that obesity is strongly associated with behavioural, cultural, and societal factors.5,4548 This association has been established, in part, by migration studies that have shown increasing levels of obesity among populations that migrate, as well as those that have low levels of acculturation to the majority culture.5,20,49 Mechanisms proposed as possible explanations are lifestyle changes,5,50 dietary changes,51,52 lack of educational or occupational opportunities,47,48,53 and/or other structural inequalities.50
Our findings of an association between country of birth and abdominal obesity (waist circumference) are consistent with findings from the Hispanic HANES that showed that BMI was larger for second and third generation MexicanAmericans than for first generation MexicanAmericans.21 In addition, Hispanic HANES found that MexicanAmerican women with a preference for the English language had significantly lower levels of BMI than those with a preference for the Spanish language, a finding which agrees with the present study. The San Antonio Heart Study also demonstrated that MexicanAmerican women with lower acculturation levels (low functional integration) had higher levels of central obesity (subscapular-to-triceps skinfold-thickness ratio) than women with higher acculturation levels.23
Underlying mechanisms
It is possible that the biological pathway between migration, acculturation, and abdominal obesity may be mediated by a long-term stress reaction.5456 Stress can result in either an acute fight or flight reaction, the first leading to control and the second leading to a long-term defeat reaction, characterized by depression or helplessness.57,58 Abdominal obesity has been shown to be associated with the long-term defeat reaction, in which the hypothalamic-pituitary-adrenal axis is activated with an increase of cortisol levels, which changes fat metabolism and can result in a central distribution of fat.26,5961 Migration, whether forced by poverty or persecution, leading to settlement in a different social, political and cultural context, might result in a long-term defeat reaction regardless of previous health. In addition to migration stress, not speaking the language of the majority culture may indicate a separation from the majority culture and create long-term acculturative stress.
It is unlikely that the differences in abdominal obesity that we found between the three migration/acculturation groups can be explained solely by genetic differences. Although it is estimated that genetic factors may explain from 30% to 70% of cases of obesity in the US, the rapid increase in the prevalence of obesity over the last two decades is likely due to environmental factors since the gene pool has been stable over the same time interval.62 Furthermore, in a population of MexicanAmerican adults from the San Antonio Heart Study, it was estimated that genes accounted for only 15% to 30% of the phenotypic variation in measures of obesity.63 Although genes may play an important role in the metabolism of adipose tissue, the large differences in weight-related outcomes that we observed within a single ethnic group of MexicanAmericans suggests that the current epidemic of obesity is largely environmental, either directly or via an interaction with genetic influences.
Our findings that a high proportion of women and men have abdominal obesity suggest that many MexicanAmericans may be at risk for additional CVD risk factors and metabolic complications.64 Björntorp26 suggested that the primary factors in the syndrome of visceral obesity or the metabolic syndrome, are overeating, physical inactivity, smoking, and stress. These may act via neuroendocrine pathways to induce insulin resistance, increased serum insulin and abdominal obesity, which can lead to diseases such as diabetes. The Metabolic Syndrome could be called a Civilization Syndrome because of its strong relationship with an urban sedentary lifestyle and a positive energy balance (overeating and lack of leisure-time physical activity).10 We suggest that the severe stress that can be associated with lack of acculturation to the majority culture and secondary lifestyle changes may induce an increase in weight, consistent with the findings in the present study.
Strengths and limitations
The NHANES III study is one of the most comprehensive national surveys to date. Extensive and complete data are available from both the home survey and medical examination, including standardized measures of waist circumference. As noted previously, response rates were high and there was minimal missing data. Unlike many surveys, NHANES III represents a sample of the US population and therefore results are generalizable to the population of MexicanAmericans living in the US. It also included an oversampling of MexicanAmericans to ensure that large numbers would be available for analyses. In addition, NHANES III assessed BMI as well as waist circumference, which may be a stronger predictor of obesity complications than BMI.65
Despite these strengths, there are several limitations to the NHANES III survey. First, it is based on a cross-sectional survey design that does not allow one to draw inferences about causal pathways. Second, there were limitations to several of the variables we used, including our outcome measure, waist circumference. Although exact methods exist for measuring the visceral adipose tissue accumulation, such as magnetic resonance imaging and computerized tomography, NHANES III did not use these more exact methods. However, studies of anthropometric correlates have found that waist circumference is the preferred clinical and epidemiological method to use because of its association with visceral adiposity, low cost and ease of measurement.10,28,38
In addition, NHANES III lacks measures of physical activity at work, which may influence the gender differences that we found for leisure-time physical inactivity (significant for women but not for men, Table 2). Finally, our measure of acculturation, indicated by primary language spoken at home, is a static factor that does not measure core beliefs and practices in relation to specific CVD risk factors or medical conditions, and does not consider the social context of behaviour.66,67
In summary, we found substantial variation in waist circumference and abdominal obesity among three subgroups of MexicanAmericans living in the US, distinguished by country of birth and acculturation status. All women, but in particular US-born Spanish-speaking women (68.7%), had high prevalence of abdominal obesity. The variation we found in abdominal obesity illustrates the heterogeneity of the MexicanAmerican population and suggests that both country of birth and acculturation status influence indicators of obesity. To address these variations, social and economic interventions are needed as well as lifestyle and public health policy interventions, such as those that influence food consumption patterns and stimulate physical activity.66,67 As with all interventions, there is a need for primary prevention efforts that begin early in life that are linguistically and culturally appropriate.
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Acknowledgments |
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