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. Author manuscript; available in PMC: 2014 Sep 1.
Published in final edited form as: J Cross Cult Gerontol. 2013 Sep;28(3):359–373. doi: 10.1007/s10823-013-9200-y

Diabetes Risk in Mexican Americans: Effects of Language Acculturation, Generation and Socioeconomic Status

Aimee Afable-Munsuz 1, Steven E Gregorich 2, Kyriakos S Markides 3, Eliseo J Pérez-Stable 2
PMCID: PMC3804224  NIHMSID: NIHMS520211  PMID: 23990075

Abstract

Background

The effect of language acculturation, socioeconomic status (SES), and immigrant generation on development of diabetes among Mexican Americans was evaluated in the Hispanic Established Population for the Epidemiologic Study of the Elderly (HEPESE).

Methods

HEPESE is a longitudinal cohort study of 3,050 non-institutionalized Mexican Americans aged 65 years at baseline (1993–1994) from 5 Southwestern states. Diabetes incidence was ascertained in 4 follow-up surveys to 2004–05 by respondent self-reported physician-diagnosis of diabetes, high blood glucose, or sugar in the urine. Language of interview, immigrant generation, gender, age, education, family history of diabetes, smoking status, alcohol use, health insurance type and self-reported height and weight were assessed. High socioeconomic status (SES) was defined by high school graduation and non-Medicaid insurance. Cox's proportional hazards models were fit to evaluate the effects of language acculturation, generation and SES on incident diabetes.

Results

845 of 3,050 (27.7%) Mexican Americans had diabetes at baseline and were younger, more educated, and more likely to have health insurance than those without diabetes. Risk of developing diabetes increased for Spanish-speaking respondents with low SES from 1st to 3rd generation (HR = 1.76, 95% CI = 1.02–3.03) and from 2nd to 3rd generation (HR = 2.15, 95% CI = 1.20–3.84). Among English-speaking, high SES participants, generation had a protective effect on developing diabetes: HR = 0.45 (95% CI = 0.22–0.91) when comparing 3rd versus 1st generation

Conclusion

The effect of language acculturation and immigrant generation on incident diabetes is moderated by SES status in HEPESE participants.

Keywords: acculturation, diabetes, Mexican Americans

Introduction

Diabetes is increasing in the US and in countries that are the biggest contributors of immigrants to the US such as Mexico (Villalpando S et al., 2010, Yang et al., 2010, Soria et al., 2009). Mexican immigrants to the US may provide a unique opportunity for studying the effect of immigration on incident diabetes especially considering their possible genetic predisposition (Gardner et al., 1984, Stern et al., 1991, Elbein, 2009, Haffner, 1998). Immigrants experience rapid change in exposures providing an efficient way to study the impact of migration and environmental change on the rate of diabetes. The foreign-born population in the US has increased at rate six times faster than the native population (Malone et al., 2003), and demographic projections indicate that 87% of the population growth to 2050 will be driven by immigrants and their children (Passel and Cohn, 2008).

It has been well documented that immigrants arrive in the US with a health advantage despite generally adverse social and economic factors. Although this observation was originally developed from studies of Latinos (Markides and Coreil, 1986), it has also been shown to apply to other immigrant groups (Singh and Siahpush, 2002). The most likely explanation for this immigrant health advantage is that immigrants may compose a selected group who are healthier than their counterparts who stay in the country of origin (Marmot et al., 1984). Another possible explanation is that the cultural orientation immigrants bring to the US is protective and provides a buffer from adverse health outcomes. It has been suggested that the protective culture of immigrants encourages healthy behaviors and strong social support systems, facilitates access to health information and health systems, and reinforces positive health norms (Cattell, 2001, Kawachi, 2000). For example, evidence suggests that the body mass index (BMI) of recent immigrants is lower, when compared to US natives (Antecol and Bedard, 2006, Oza-Frank and Cunningham) and other studies show higher fruit and vegetable intake (Ayala et al., 2008) and more frequent non-leisure time physical activity (Afable-Munsuz et al., 2010) among immigrants relative to US born. However, the predominant paradigm is that this initial health advantage is thought to erode over time and acculturation leads to adopting the unhealthy behaviors of the host country population leading to more chronic disease (Antecol and Bedard, 2006).

Mexico is the largest contributor of immigrants to the US (Grieco, 2009), and has recently experienced rapid increases in both obesity and doubling of diabetes rate (Aguilar-Salinas et al., 2003, Jimenez-Cruz and Bacardi-Gascon, 2004, Rivera et al., 2002). This pattern is common in middle-income countries undergoing rapid urbanization leading to more sedentary lifestyles and greater consumption of processed foods and higher total energy intake, a process that has been labeled the “nutrition transition” (Popkin, 2004, Rivera et al., 2004). In the US, it is well known that relative to non-Latino Whites, Latinos and those of Mexican-origin in particular, bear a disproportionate burden of diabetes (Hamman et al., 1989, Flegal et al., 1991, Harris et al., 1998, Cowie et al., 2010, Stern et al., 1983). There has been interest in understanding whether acculturation to US lifestyles contributes to the heightened diabetes risk experienced by Mexican Americans. The evidence on whether the risk of diabetes in Latino immigrant populations increases with greater time in the US or with increased acculturation, however, is equivocal (Afable-Munsuz A et al., 2012, Oza-Frank et al., 2009b, Ahmed et al., 2009, Hazuda et al., 1988, Kandula et al., 2008, Mainous et al., 2006).

We considered the theoretical model of segmented assimilation and postulated that divergent assimilation paths may manifest in different diabetes risks. Segmented assimilation theory views immigrant generation as a central variable conceptualized broadly as a time dimension reflecting increasing exposure to US social and cultural norms (Portes and Zhou, 1993). The length of residence in the US may lead to the progressive narrowing of socioeconomic differences with the native-born population, and gradual adoption of the traits of the host culture with a loss of those from their home country (Alba and Nee, 1997). However, segmented assimilation theory proposes more diverse paths of incorporation into US society with one path characterized by economic advancement with deliberate preservation of the immigrant community's values and traditions. An alternative path of downward assimilation leads to greater identification with a minority subculture and increasing poverty (Portes and Zhou, 1993). Thus the central concepts of segmented assimilation theory are: 1) that the assimilation pattern of immigrants is dependent on which segment of the society they adapt to; and 2) that assimilation involves both cultural change or what health researchers often refer to as acculturation as well as a process of social mobility (both upward, achieving greater affluence or downward, stagnating in poverty).

Following previous work and those of others (Afable-Munsuz et al., 2010, Finch et al., 2007, Nagasawa et al., 2001), we asked whether differences in language acculturation and socioeconomic status (SES) might lead to differential risks for diabetes from first to third generations. First, we aimed to describe patterns of diabetes risk across generations among immigrants who preserve their tradition, as indicated by Spanish language preference. We expected that diabetes risk is lower in second and third generations, relative to immigrants, an observation that would be consistent with the notion that immigrant culture is protective. Second, we examined whether SES confounds observed language acculturation patterns in diabetes risk from first to third generations. Third, if SES confounds observed patterns described above, we aimed to examine the interactive influences of SES, language preference and immigrant generation on diabetes risk. These questions are motivated in part by previous commentaries that have proposed that SES confounds the relationship between language measures of acculturation and health (Hunt et al., 2004). Given that segments of society are likely to have different lifestyle patterns we expect that health behaviors of poor immigrants will differ from those of more affluent immigrants because opportunities and norms for major risk factors for diabetes are likely to differ. We examined these hypotheses and questions using data from a large population-based cohort study representative of aging Mexican-origin adults living in the southwestern US.

Materials and Methods

The Hispanic Established Population for the Epidemiologic Study of the Elderly (HEPESE) is a longitudinal cohort study of 3,050 non-institutionalized Mexican Americans aged 65 years and older at baseline (1993–1994) from five Southwestern states: Texas, California, Colorado, New Mexico, and Arizona.(Markides et al., 1996) The HEPESE participants are representative of approximately 500,000 older Mexican Americans over these five states. The baseline sample was selected using an area probability sample design involving a list of counties in the Southwestern states that contained approximately 90% of Mexican Americans residing in these states (Markides et al., 1996). The first follow-up of the baseline data (1995–1996) followed 2,438 of the original 3,050 respondents and the second follow-up (1998–99) followed 1,980 of these respondents. The third follow-up (2000–2001) followed 1,682 of the original respondents and the fourth follow-up (2004–2005) followed 1,167 of these respondents. Interviews were conducted in English and Spanish, depending on the participants' preference.

Diabetes ascertainment

Respondents were coded as having diabetes if they reported one of three criteria: told by a physician that they had definite diabetes, that they had sugar in their urine, or that they had a test showing high blood glucose. If respondents reported having diabetes they were also probed for month and year of diagnosis. We also included participants who were told by a physician that they had borderline diabetes. At the time of the baseline survey diabetes was defined by fasting blood glucose of ≥140 mg/dl and this subsequently decreased to ≥126 mg/dl (Diabetes Care, 1997). Because all participants were 65 years of age or older, we assumed that all diabetes was type 2 and refer to all as diabetes. Participants, who did not report diabetes at baseline, were classified as having incident diabetes in follow-up or as being censored; time to diabetes/censorship was recorded as age (in years) of the participant at diabetes diagnosis.

Acculturation and immigrant generation

Given that language preference is a powerful component of ethnic identity (Giles and Johnson, 1987, Tong et al., 1999), language of interview (English vs. Spanish) was assessed as a measure of acculturation to US society. Generation was assessed based on information on the respondent's and respondent's parents nativity. A foreign-born respondent was classified as a first-generation immigrant; a US-born respondent with at least one foreign-born parent was classified as second-generation; if the respondent and both parents were born in the US, he/she was classified as third-generation (Afable-Munsuz et al., 2010).

Other Factors and Socioeconomic Status

Demographic variables included gender, age and marital status (married or not). Family history was assessed based on whether parents have/had diabetes (yes/no). Other measures at baseline were selected according to their potential association with acculturation and because they were thought to be potential confounders or mediators on the causal pathway between acculturation and diabetes risk (Baron and Kenny, 1986). These included Body Mass Index (BMI) calculated from self-reported weight and height and categorized as 25 or less, >25 to 30, and > 30 kg/m2; educational attainment categorized as no high school, high school graduate, and college or more; any current consumption of alcoholic beverages (yes/no); ever smoker of cigarettes (yes/no) (Baliunas et al., 2009, Willi et al., 2007); and type of health insurance (no insurance, private insurance, Medicare, and Medicaid).

We operationalized socioeconomic status (SES) using the educational attainment and health insurance variables as a proxy of income/wealth. Participants with high school graduation or more years of education and with private or Medicare insurance were considered of high SES. Persons who 1) did not graduate from high school, or 2) had no insurance, or 3) had Medicaid insurance (in combination with Medicare or not) were categorized as low SES.

Data Analysis

Descriptive statistics detailing demographics and diabetes were generated for the aggregate study population and for the diabetes and the non-diabetes group respectively at the baseline. Chi-square tests and t-tests were computed to assess differences in covariate distributions across groups. Data management and all SAS procedures for statistical analyses were performed with SAS 9.22.(SAS Institute, 2002–2003) Statistical significance throughout was defined p< 0.05. All analyses were adjusted for HEPESE complex survey design.

To examine our hypotheses, plots of diabetes survival functions, adjusted for covariates, were explored to visually provide information on the interactive effects of generation, language of interview and socioeconomic status. We divided the sample into low acculturation (Spanish language interview) vs. high acculturation (English language interview) and into low SES vs. high SES. We then plotted adjusted diabetes survival curves by immigrant generation for each of these four groups. We modeled time free from diabetes (survival) based on retaining Spanish language across generations (from 1st to 3rd). As a comparison, we also modeled time free from diabetes by generation among those who had an English language interview. To examine whether socioeconomic status moderates the relationship between language acculturation and diabetes risk across first to third generations, we stratified analyses by SES so that the effect of language and generation on incident diabetes was estimated within each SES stratum.

Because 19% of cases were missing responses for family history of diabetes, 20 multiply imputed datasets were generated for the analyses predicting incident diabetes. All potential predictor and outcome variables were included in the imputation model. To reflect the differences by language preference, separate imputations were performed and recombined into a single dataset after excluding the participants whose diabetes was diagnosed prior to the baseline survey. All parameter estimates, standard errors and significance tests were estimated by combining results across the imputed data sets (Allison, 2002).

To investigate the relation between generation, language acculturation, socioeconomic status and time to incident diabetes in the population, Cox's proportional hazards models were fit (Allison, 1996). After selecting the main effects, candidate interactions such as language of interview by generation, and socioeconomic status by generation, were investigated, and then tested using Wald chi-square tests. To account for the cases of interval censoring, the PHREG procedure was specified with exact method for tied event times (Klein and Moeschberger, 2003).

Results

At baseline the 3,050 participants had a mean age of 73 years, 57% were women, 89% had not graduated from high school and nearly 73% responded to the interview in Spanish. There were 690 persons with definite diabetes and 155 with borderline diabetes for total of 845 or 27.7% with diabetes at the baseline interview. The baseline characteristics of the sample stratified by diabetes prevalence are presented in Table 1. Persons with diagnosed diabetes were younger, had more education, were more likely to have health insurance, and were more likely to be second generation immigrants but less likely to be first or third generation immigrants in comparison with those who did not have diabetes at the baseline. Those who reported diabetes also had higher BMI (Mean BMI 28.8 vs. 27.5; p<0.01); were more likely to have a family history of diabetes (32.6 % vs. 12.1%; p<0.01) and were more likely to be not consuming any alcohol.

Table 1.

Characteristics of Baseline Sample by Diabetes Prevalence, Mexican Americans in Southwestern US, HEPESE, 1993–1994

Total N=3050 Diabetes N=845 No Diabetes N=2205 P valuea
Age
 65–74 65.6 71.2 63.5
 75–84 27.3 23.9 28.6 <.0001
 85 or older 7.1 4.9 7.9
Gender
 Men 42.4 43.1 42.1 0.620
 Women 57.6 56.9 57.9
State
 Arizona 3.6 3.4 3.7
 California 27.2 26.8 27.3
 Colorado 2.3 2.1 2.4 0.210
 New Mexico 3.6 2.4 4.0
 Texas 63.3 65.3 62.6
Generation
 Third 13.8 12.7 14.2
 Second 41.6 45.5 40.1 0.025
 First (Mexico born) 44.6 41.8 45.7
Language of interview
 English 22.2 21.7 22.4 0.676
 Spanish 77.8 78.3 77.6
Education
 Less than high school 90.0 89.4 90.3
 High school graduate 6.9 7.2 6.8 0.712
 Some college or more 3.1 3.5 3.0
Insurance
 No insurance 7.7 5.7 8.5
 Private & Medicare 16.6 16.8 16.5 0.0003
 Medicare only 40.7 37.2 42.0
 Medicare & Medicaid 35.1 40.4 33.0
Ever Smoked at baseline
 Yes 41.6 39.8 42.2 0.224
Used alcohol at baseline
 Yes 15.6 9.3 18.0 <0.0001
 No 84.4 90.7 82.0
Body mass Index (kg/m2) b 0.002
 ≤25 37.2 33.5 38.6
 <25 to ≤30 36.2 35.7 36.4
 >30 26.6 30.8 25.0
Family history of diabetes c
 Yes 17.1 30.6 12.4 <0.0001
 No 82.9 69.4 87.6
Total sample size (N) 3050 845 2205
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a

chi-square test for categorical variables;

b

excludes 281 missing cases;

c

excludes 591 missing cases

Immigrant Generation and Language of Interview

Diabetes was most prevalent in second generation, followed by third and first generation Mexican Americans (30.3%, 26.4% and 24.9%; p <0.05). There was no significant difference in diabetes prevalence by language of interview. The educational levels increased with each generation, with third generation Mexican Americans being most likely to have a high school diploma or some level of college education, when compared with previous immigrant generations (5.4% vs. 12.7% vs. 16.1%, p<0.05). Those who preferred English as the language of interview had higher education levels in comparison to those who responded in Spanish (22.2% vs. 6.5%. p<0.05). First generation Mexican Americans and those who responded in Spanish as a language of interview were most likely to be uninsured, while third generation Mexican Americans and those who responded in English as a language for interview were more likely to have both private and Medicare health insurance. Use of Spanish as a language of interview decreased in each subsequent generation from first to third: 88.2%, 66.1%, and 40.6%, respectively (p<0.05).

Time Without Diabetes after Baseline

Table 2 shows the respondents in each of the four HEPESE follow-surveys with the new cases of definite and borderline diabetes by year of survey. Cumulative rate of diabetes increased with each follow-up survey, but the proportions responding in Spanish, and of low SES did not vary significantly.

Table 2.

Follow-up Surveys and Diabetes Status among Mexican Americans, HEPESE 1993–2005

1995–96 1998–99 2000–01 2004–05
Total sample size (N) 2438 1980 1682 1167
Gender
 Men (%) 41.6 40.4 38.6 36.9
 Women (%) 58.4 59.7 61.4 63.2
Language
 Spanish (%) 78.7 78.7 78.0 79.7
 English (%) 21.3 21.3 22.0 20.3
Generation
 1st Generation (%) 45.3 43.9 42.9 44.2
 2nd Generation (%) 40.9 42.6 44.2 44.5
 3rd Generation (%) 13.9 13.5 12.9 11.3
Socioeconomic status
 Low SES (%) 39.6 38.7 38.4 38.1
 High SES (%) 60.4 61.3 61.6 61.9
Diabetes status
 New DM (N) 126 81 58 56
 New definitive diabetes (N) 91 64 44 56
 New borderline diabetes (N) 35 17 14 n/a**
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*

Among 845 participants who diagnosed diabetes at the baseline, 155 is the number of borderline and 690 is the number of definite.

**

Have you ever been told by a doctor that you have diabetes, sugar in your urine, or high blood sugar? (no longer have a borderline category)

Plots of survival curve functions provided visual interpretation on the interactive effects of generation and SES or language of interview on the effect of time without diabetes in follow-up interviews. Figures 1a and 1b and 2a and 2b show the adjusted probability of being diabetes-free among four groups stratified by immigrant generation: low language acculturation, high language acculturation, higher SES and lower SES. In Figure 1a, for example, among respondents classified as low language acculturation (Spanish language interview), the probability of remaining diabetes-free decreases with increasing generation. In contrast, among the more acculturated respondents (English language interview), we observed an opposite trend where the probability of remaining diabetes-free increases from first to third generation (Figure 1b). Figures 2a and 2b assess potential confounding between language acculturation and SES, with plotted survival curves (time diabetes-free) among low vs. high SES respondents. We found a pattern among high SES respondents similar to that among high language acculturation respondents where time free from diabetes increases with increasing generation (Figure 2a). However, among low SES individuals, time free from diabetes is lower in 2nd and 3rd generations relative to 1st generation (Figure 2b).

Figure 1a.

Figure 1a

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Estimated Time without Diabetes (Survival) for 2,205 Mexican Americans through Three Follow-Up Surveys among those who Interviewed in Spanish by Immigrant Generation, HEPESE, 1993–2005

Figure 1b.

Figure 1b

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Estimated Time without Diabetes (Survival) for Mexican Americans through Three Follow-Up Surveys among those who Interviewed in English by Immigrant Generation, HEPESE, 1993–2005

Figure 2a.

Figure 2a

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Estimated Time without Diabetes (Survival) for Mexican Americans through Three Follow-Up Surveys among High Socioeconomic Status (SES) by Immigrant Generation, HEPESE, 1993–2005

Figure 2b.

Figure 2b

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Estimated Time without Diabetes (Survival) for Mexican Americans through Three Follow-Up Surveys among Low Socioeconomic Status (SES) by Immigrant Generation, HEPESE, 1993–2005

Predictors of Incident Diabetes

Table 3 shows the results of adjusted hazard ratios for developing new diabetes (definite plus borderline) during the follow-up period. Third generation immigrants who responded in English and had higher SES had lower risk of developing diabetes compared to their first-generation counterparts, and even comparison of second to first generations had borderline statistical significance (Table 3). Among English speaking lower SES respondents, the adjusted risk was also significantly lower for second compared to first generation immigrants, but not for other comparisons across generations. Maintaining Spanish as the primary language did not affect diabetes risk among higher SES respondents from first to third generations. However, among respondents who maintain Spanish and were of lower SES, there was a significantly higher risk of diabetes among third generation immigrants compared to second or first generation Mexican Americans. BMI greater than 30 kg/m2 and parental history of diabetes was significantly associated with developing diabetes as would be expected.

Table 3.

Risk of Developing Diabetes by Language Acculturation, Immigrant Generation and Socioeconomic Status in Follow-up Surveys, Mexican Americans HEPESE 1992–2005

Hazard Ratio 95% CI P-value
English and High SES
 Generation: 2nd vs. 1st 0.57 0.31–1.02 0.06
 Generation: 3rd vs. 1st 0.45 0.22–0.91 0.03
 Generation: 3rd vs. 2nd 0.79 0.42–1.51 0.48
English and Low SES
 Generation: 2nd vs. 1st 0.47 0.23–0.96 0.04
 Generation: 3rd vs. 1st 0.84 0.38–1.88 0.68
 Generation: 3rd vs. 2nd 1.79 0.81–3.96 0.15
Spanish and High SES
 Generation: 2nd vs. 1st 0.99 0.72–1.36 0.95
 Generation: 3rd vs. 2nd 0.94 0.56–1.59 0.82
 Generation: 3rd vs. 2nd 0.95 0.56–1.61 0.85
Spanish and Low SES
 Generation: 2nd vs. 1st 0.82 0.53–1.27 0.37
 Generation: 3rd vs. 1st 1.76 1.02–3.03 0.04
 Generation: 3rd vs. 2nd 2.15 1.20–3.84 0.01
Body Mass Index ≥ 30 kg/m2 1.68 1.30–2.16 <0.001
Parental History of Diabetes 1.39 1.02–1.90 0.04
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High SES defined by being a high school graduate and having Medicare or private health insurance

All models adjusted for gender, age, BMI, smoking history, alcohol use and family history of diabetes.

Discussion

The immigrant health advantage is predicted to attenuate or disappear with increasing time living in the US. There is empirical evidence that acculturation has adverse health effects behavioral risk factors such as cigarette smoking and obesity (Oza-Frank et al., 2009a, Antecol and Bedard, 2006) (Pérez-Stable EJ et al., 2001); (Kaplan MS et al., 2004) as well as increased risk of diabetes (Oza-Frank et al, 2012). Our findings highlight the importance of consideration of socioeconomic status when interpreting the relationships between language acculturation, immigrant generation and incident diabetes risk. Our findings provide empirical support for the idea that the effects of acculturation on health outcomes are dependent on the segment of society to which the immigrant group adapts, a key theme of segmented assimilation theory. The idea that assimilation's association with health might be moderated or influenced by socioeconomic status has been studied previously with regard to obesity.(Sanchez-Vaznaugh et al., 2008, Kaushal, 2009) This is one of the only studies that have evaluated inter-related influences of SES, language acculturation and immigrant generation on the development of a major health outcome: incident diabetes in a high-risk population.

In this study, we do not find evidence that preservation on immigrant culture, measured by Spanish language preference, was protective against developing diabetes. On the contrary, we observed a tendency to increasing diabetes risk from first to third generation among participants interviewed in Spanish that was only statistically significant among participants of lower SES. This would potentially imply that behavioral or environmental exposures among less acculturated second and third generation Mexican immigrants increase risk of developing diabetes. Furthermore, we observed that among those who responded in English to the interview, there was a lower subsequent risk of incident diabetes in the second and third generation HEPESE participants. This protective effect from diabetes among English responding, higher SES participants, however, was absent in English interviewed participants of lower SES. Overall evidence on the divergent relationships between language acculturation and immigrant generation and diabetes risk is consistent with past studies on obesity, which have found a higher obesity risk in adults with increasing years in the US and low SES but no association among higher SES individuals by years in the US (Sanchez-Vaznaugh et al., 2008, Kaushal, 2009). These data provide some support for the “unhealthy assimilation” perspective for those with low levels of language acculturation and lower levels of SES and these findings are consistent with past studies on immigrant generation and diabetes risk (Ahmed et al., 2009, Oza-Frank et al., 2009b).

Despite the known higher risk of diabetes among Mexican Americans, the HEPESE offered an opportunity to expand on this knowledge by identifying possible contributions of SES, immigrant generation and language acculturation in the development of incident diabetes in this population in a prospective cohort. Previous studies of diabetes in HEPESE participants have focused on cross-sectional analyses and incidence of cardiovascular complications among those identified as having diabetes, but none had evaluated risk factors for developing incident diabetes (Beard HA et al., 2009); (Black SA et al., 1999).

Our study has important limitations. First, we do not have laboratory measures to further define diabetes risk among those without reported diabetes at baseline. In our study, diabetes is based on self-report only so it is possible that this study under-estimated prevalence at baseline and incidence in subsequent surveys (Margolis et al., 2008). Over this time period awareness and detection of pre-diabetes and diabetes has increased and thus differential use of health services by language preference and immigrant generation may lead to differences in undiagnosed diabetes rates. By including persons with self-reported “borderline” diabetes we do partially address the under-diagnosis problem. Second, because we have a cross-section of different immigrant generations in our study, each generation may come from a different migration cohort, and thus have a different migration experience (Antecol and Bedard, 2006). Third, first generation immigrants compared to US-born participants in our study may come from different ancestral and regional groups in Mexico, who are diverse in genetic admixture (Gonzalez Burchard et al., 2005, Martinez-Marignac et al., 2007) and social characteristics, and as a result, potentially vary in diabetes risk (Barquera et al., 2003). Family inter-generational studies and prospective cohort studies of new immigrants followed at regular intervals would allow us to control for heterogeneity by place of origin and to study adaptation over time (Jasso et al., 2000). Fourth, our measure of acculturation was a one-item proxy language of interview that performed as well as the longer language-based scale included in HEPESE. Although acculturation is a complex process, it remains unclear whether more extensive measures add explanatory power over the shorter scales or even one-item language proxies in health studies (Alegria, 2009). Finally, HEPESE did not collect complete physical activity or dietary measures. Thus, we were unable to examine the potential role these factors played in the relationship between acculturation, generation, SES and development of diabetes.

Relationships between assimilation, acculturation and health are complex (Markides, 2001) and both negative and positive associations between assimilation, acculturation indicators and diabetes and its risk factors have been observed. (Mainous et al., 2006, Ahmed et al., 2009, Ayala et al., 2008, Oza-Frank et al., 2009b, Lara et al., 2005, Afable-Munsuz et al., 2010, Hazuda et al., 1988, Kandula et al., 2008, Antecol and Bedard, 2006). This is not surprising given the heterogeneity of acculturation and assimilation processes in US immigrants as described by scholars of migration (Portes and Zhou, 1993). Our study suggests that the effects of acculturation on health are not uniform among Mexican Americans and are modified by SES and possibly explained by assimilation pattern. We found divergent associations between immigrant generation and diabetes risk. On the one hand, we add to the evidence that increased exposure to the US environment leads to higher risk of diabetes in immigrants to the US who remain predominantly Spanish speaking and are of lower SES background. But the study also demonstrates that this pattern does not apply to all segments of the population studied and that higher SES individuals may benefit from increased exposure to the US to the point of having a decreased risk of developing diabetes. Thus in these data increased acculturation as measured by language preference was protective from developing incident diabetes among higher SES Mexican Americans. This would be evidence that increased acculturation may actually be good for health in selected situations.

Our findings suggest the need to examine more closely the causal mechanisms linking acculturation to health and suggest that such examinations would benefit when considering the socioeconomic changes occurring as immigrants assimilate to US society. Because upward social mobility affords wider access and range of opportunities for different lifestyle options we also argue that need to examine more closely the environmental and lifestyle changes occurring among immigrants.

These findings can be applied to advance the health of older Mexican Americans by intensifying efforts to increase access to education for all immigrants given that more education can facilitate upward social mobility and better health. Public health education also needs to be directed at Spanish speaking Latinos with low levels of education so they eat healthier food, increase leisure time physical activity and do not gain excess weight. Overall, we need to intensify prevention efforts among Latinos of low SES especially in second and subsequent generations in the US.

Table 4.

Risk of Developing Diabetes by Language Acculturation, Immigrant Generation and Socioeconomic Status in Follow-up Surveys, Mexican Americans HEPESE 1992–2005

Hazard Ratio 95% CI P-value
English and High SES
 Generation: 2nd vs. 1st 0.57 0.31–1.02 0.06
 Generation: 3rd vs. 1st 0.45 0.22–0.91 0.03
 Generation: 3rd vs. 2nd 0.79 0.42–1.51 0.48
English and Low SES
 Generation: 2nd vs 1st 0.47 0.23–0.96 0.04
 Generation: 3rd vs 1st 0.84 0.38–1.88 0.68
 Generation: 3rd vs. 2nd 1.79 0.81–3.96 0.15
Spanish and High SES
 Generation: 2nd vs 1st 0.99 0.72–1.36 0.95
 Generation: 3rd vs. 2nd 0.94 0.56–1.59 0.82
 Generation: 3rd vs. 2nd 0.95 0.56–1.61 0.85
Spanish and Low SES
 Generation: 2nd vs 1st 0.82 0.53–1.27 0.37
 Generation: 3rd vs 1st 1.76 1.02–3.03 0.04
 Generation: 3rd vs 2nd 2.15 1.20–3.84 0.01
Body Mass Index ≥ 30 kg/m2 1.68 1.30–2.16 <0.001
Parental History of Diabetes 1.39 1.02–1.90 0.04
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High SES defined by being a high school graduate or having Medicare or private health insurance

Acknowledgements

This study was supported by Grant P30-AG15272 under the Resource Centers for Minority Aging Research program by the National Institute on Aging, National Institutes of Health. Dr. Afable-Munsuz received a Diversity Supplement to this grant. We thank Juliette Hong, MS for conducting data analyses.

References

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