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. Author manuscript; available in PMC: 2021 Apr 1.
Published in final edited form as: J Behav Med. 2019 Jul 26;43(2):198–208. doi: 10.1007/s10865-019-00082-9

The Association Between Family Social Network Size and Healthy Lifestyle Factors: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Rosenda Murillo 1, Amber Pirzada 2, Donghong Wu 3, Linda C Gallo 4, Sonia Davis 5, Natania W Ostrovsky 6, Frank J Penedo 7, Krista Perreira 8, Samantha A Reina 9, Linda Van Horn 10, Jeremiah Stamler 11, Martha L Daviglus 12
PMCID: PMC7340005  NIHMSID: NIHMS1594886  PMID: 31350713

Abstract

We examined associations of central family (i.e., children, parents, in-laws) social network size with healthy lifestyle factors (i.e., favorable body mass index, physical activity, diet, alcohol use, smoking). Using data on 15,511 Hispanics/Latinos 18–74 years old from the Hispanic Community Health Study/Study, multivariable adjusted survey logistic regression was used to compute associations of social network size with healthy lifestyle factors. A one-unit higher total of central family size was associated with lower odds of healthy body mass index (OR: 0.90; 95% CI: 0.86–0.93) and having all five healthy lifestyle factors (OR: 0.90; 95% CI: 0.85–0.96). Findings suggest familial structural social support may contribute to healthy lifestyle factors and differ based on the type of relationship among Hispanics/Latinos.

Keywords: social support, healthy lifestyle, health behavior, Hispanic, Latino

Introduction

Social networks at the familial and community level have been found to be salient with regard to health (Alegría et al., 2011). Evidence suggests that strong social networks (e.g., frequent contact with individuals within a social network) are associated with favorable cardiovascular health outcomes (Barefoot et al., 2005; Holt-Lunstad et al., 2003; Kop et al., 2005), and high levels of social support provided through social networks has been associated with lower chronic disease mortality across gender and age groups (Uchino, 2006). In fact, previous research suggests that the influence of social relationships on mortality risk is comparable to that of well-established mortality risk factors, such as alcohol use and smoking (Holt-Lunstad et al., 2010), and that individuals lacking social connections are at high risk of premature mortality (Holt-Lunstad et al., 2015). Various healthy lifestyle behaviors such as being physically active, a non-smoker, and consuming a healthy diet, have been associated with a lower mortality risk (Ford et al., 2012; Micha et al., 2017; Thun et al., 2013; U.S. Department of Health and Human Services, 2018). Further, having a greater number of healthy lifestyle factors is associated with a lower risk of cardiovascular disease and mortality (Chiuve et al., 2008; Li et al., 2018; Liu et al., 2012; Stampfer et al., 2000; Van Dam et al., 2008). Therefore, examining associations between social networks and healthy lifestyle factors, which are related to mortality risk, may provide further insight into how social networks relate to mortality risk. Given the influence of social networks on health, it is important to obtain a better understanding of how social networks relate to the healthy lifestyle behaviors.

Social support that individuals receive from strong social networks has been shown to promote healthy lifestyle behaviors (Cohen, 2004; Kahn et al., 2002; Reblin & Uchino, 2008; Uchino, 2004, 2006). For example, previous research has shown that social support from friends and family can promote smoking cessation (Christakis & Fowler, 2008), physical activity (McNeill et al., 2006), and healthy diet (Shaikh et al., 2008; Tay et al., 2013). However, depending on its characteristics, a social network may also have an adverse influence on health. For instance, the obesity status and alcohol consumption of relatives and friends within a social network have been associated with an increased risk of obesity and alcohol consumption, respectively (Christakis & Fowler, 2007; Galea et al., 2004; Rosenquist et al., 2010). Additionally, having members within the family and social network that smoke has been associated with an increased likelihood of cigarette smoking (Galea et al., 2004). However, results from the literature on the association of number of social ties with health behaviors has been mixed. For example, individuals with a higher number of family ties are more likely to report a greater consumption of sugary drinks and fast food, not accounting for whether or not family members drink sugary drinks and consume fast food (Tamers et al., 2013), while having fewer than three friends has been associated with physical inactivity among adults (Willey et al., 2010). Further research is warranted to understand contradictory findings and obtain additional insight into how number of social ties within social networks relate to health behaviors. Although previous research has examined the associations between social network size and health lifestyle behaviors, there is a paucity of research on these associations among Hispanics/Latinos.

Studies suggest that Hispanics/Latinos tend to be highly family-oriented and place a strong emphasis on family (Campos & Kim, 2017; Katiria Perez & Cruess, 2014; Ramirez et al., 2004). Previous research has suggested that Hispanics/Latinos have large family networks, typically identify immediate and extended family as part of their sole network (de Leon Siantz, 1994; Katiria Perez & Cruess, 2014; Markides & Krause, 1986), and their family networks extend beyond relationships with family residing within the same household (Katiria Perez & Cruess, 2014). Both familism (i.e., placement of family needs above individual needs, strong connection to family) (Gallo et al., 2009; Marin & Marin, 1991) and degree of family support have been suggested as factors that could be associated with health outcomes (both mental and physical) among Hispanics/Latinos (Katiria Perez & Cruess, 2014; Mulvaney-Day et al., 2007; Page, 2004). Familism has been shown to have both positive and negative effects on health, which may occur through various ways, such as familism yielding perceived support (e.g., encouragement of physical activity) but also perceived obligations which may result in placing family needs before individual needs (Katiria Perez & Cruess, 2014). Given the cultural value placed on family in the Hispanic/Latino population, it is important to consider the role of family in social support. In particular, structural social support, which refers to the presence of relationships and interactions that occur within a network (e.g., social network size, frequency of contact) (Cohen et al., 2000) as it relates to health outcomes among Hispanics/Latinos, remains understudied, especially as it relates to family. Findings from a study conducted by Marquez et al. (2014) showed that having a larger network is associated with meeting physical activity recommendations among Hispanics/Latinos, but the study examined a heterogeneous network that included friends and family. Additionally, a recent study examined associations of structural social support and cardiovascular disease risk factors in Hispanics/Latinos and showed that greater central family network size was associated with higher odds of obesity, but focused on Hispanics/Latinos with diabetes, a subset of the HCHS/SOL participants (Hernandez et al., 2017). To our knowledge, no study has comprehensively examined associations of familial structural support and healthy lifestyle factors in a large, diverse sample of Hispanics/Latinos. Using data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) we examined the association of central family size (i.e., children, parents, in-laws) with individual and multiple healthy lifestyle factors (not overweight or obese, favorable moderate-to-vigorous physical activity, favorable dietary behaviors, moderate or no alcohol use, non-smoking). We also examined associations between number of central family members in regular contact and number of extended family members individual feels close with individual and multiple healthy lifestyle factors. We hypothesized that greater familial structural social support would be associated with the presence of individual healthy lifestyle factors, and a greater number of multiple healthy lifestyle factors.

Methods

Study Design

The HCHS/SOL is a multicenter community-based cohort study of chronic disease risk factors. HCHS/SOL examined 16,415 self-identified Hispanic/Latino adults ages 18 to 74 years, recruited from 4 cities (Bronx, New York; Chicago, Illinois; Miami, Florida; San Diego, California) from randomly selected households at baseline (2008 to 2011). A stratified 2-stage area probability sample design was used to select households for the study. The institutional review board from each participating institution approved the study and all participants provided written informed consent. The baseline examination protocol included interviewer-administered questionnaires, anthropometry, and a blood draw. Details regarding the cohort selection procedures, sampling design, and baseline examination measures have been published (LaVange et al., 2010; Sorlie et al., 2010).

Of the 16,415 participants ages 18 to 74 years, only those with complete data on the variables of interest were included into the analyses sample. We excluded those missing data on social networks (n=439), diet (n=163), physical activity (n=53), body mass index (n=40), cigarette use (n=17), alcohol data (n=9), and on other covariates (n=183). Thus, our analysis was based on data from 15,511 participants.

Measures

Social Networks.

Familial structural social support was assessed using seven select items from the Social Network Inventory (SNI), (Cohen et al., 1997), which were used to create three subscales. The subscale assessing size of the individual’s central family (i.e., number of living children, parents and parents-in-law) was created based on three items which asked participants how many children they had, if either parent were living (i.e., number of parents living), and if in-laws (or partner’s parents) were living (i.e., number of in-laws living). The number of central family members in regular contact (i.e., number in contact at least once every two weeks) was based on three items that asked participants how many of their children, parents, and in-laws they either saw or spoke to on the phone at least once every two weeks. The number of extended family members to whom the individual feels close (i.e., outside the central family) were based on an item that asked participants how many of their other relatives, other than their spouse, parents, and children, they feel close to. For the analysis, all measures of familial structural social support were assessed continuously.

Healthy Lifestyle Factors.

Previous studies have evaluated the prevalence and associations of healthy lifestyle factors with cardiovascular disease risk (Liu et al., 2012; Stampfer et al., 2000). In our study, similar criteria were used to define each of the five healthy lifestyle factors (HLF), consistent with the measurement of healthy lifestyle factors in previous studies (Chiuve et al., 2008; Liu et al., 2012; Stampfer et al., 2000) and based on current national guidelines. To assess overall adherence to a healthy lifestyle, participants were categorized as having 0–1, 2, 3, 4, or 5 [0 (none) to 5 (all of above)] healthy lifestyle factors, which is consistent with the categorization of healthy lifestyle factors in previous research (Chiuve et al., 2008; Liu et al., 2012; Stampfer et al., 2000). Previous studies have utilized this approach to categorize healthy lifestyle factors to examine the presence of multiple healthy lifestyle factors to obtain insight into cardiovascular disease risk and mortality (Chiuve et al., 2008; Liu et al., 2012; Stampfer et al., 2000). A higher number of healthy lifestyle factors has been associated with lower cardiovascular disease risk (Chiuve et al., 2008; Li et al., 2018; Liu et al., 2012; Stampfer et al., 2000). Below are the five healthy lifestyle factors assessed in our study.

Healthy diet.

Dietary data from two 24-hour dietary recalls (conducted at baseline and after 6 weeks) were used. Adherence to a healthy diet was based on criteria of the 2010 Alternate Healthy Eating Index (AHEI) (Chiuve et al., 2012). The AHEI assesses intake of the following 11 dietary components: 1) vegetables (save potatoes); 2) whole fruits; 3) whole grains; 4) sugar-sweetened beverages and fruit juice; 5) nuts and legumes; 6) red/processed meat; 7) trans-fats; 8) long-chain (n-3) fats (eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA)); 9) Polyunsaturated fatty acids (PUFA); 10) sodium; and 11) alcohol. Individual components were scored from 0 (worst) to 10 (best), and the total AHEI score was computed by summing individual component scores. In our analysis, a modified AHEI score (ranging 0–100) was computed from all components except alcohol, given that alcohol was measured as a separate HLF. The highest 40% of sex-specific AHEI scores were designated as a healthier diet, consistent with definitions used in previous HLF research (Chiuve et al., 2008; Liu et al., 2012).

Physical activity.

Physical activity intensity and duration were ascertained using participant self-reported responses to questions about vigorous and moderate activities from the HCHS/SOL Physical Activity Questionnaire based on the Global Physical Activity Questionnaire developed by the World Health Organization (World Health Organization, 2012). Participants were asked about aerobic activities performed at moderate- or vigorous-intensity in bouts of ≥10 minutes at work, for transportation, and during leisure-time. Information on moderate and vigorous physical activities was combined to create a moderate-vigorous physical activity (MVPA) variable. As suggested by the 2018 Physical Activity Guidelines for Americans, (U.S. Department of Health and Human Services, 2018) minutes of vigorous-intensity activity were assigned twice the credit of moderate-intensity activity minutes to calculate an equivalent combination when moderate and vigorous-intensity activity were combined. Healthy physical activity levels were based on the current national guidelines in the 2018 Physical Activity Guidelines for Americans (i.e., ≥150 minutes/week of moderate intensity activity, ≥75 minutes/week of vigorous intensity activity, or ≥150 minutes/week of moderate plus vigorous activity).

Smoking.

Favorable level of smoking was classified as currently being a non-smoker as determined from self-reported questionnaire data on tobacco use.

Alcohol Consumption.

Favorable alcohol consumption levels were classified as 0–14 grams/day for women and 0–28 grams/day for men (i.e., up to one and two standard drinks/day, respectively), based on national guidelines for moderate levels of alcohol intake (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015).

Body Mass Index.

A healthy body mass index (BMI) was classified as 18.5 to <25.0 kg/m2 (not underweight, overweight or obese).

Covariates.

Age, sex, education level, Hispanic/Latino background, study site, income, employment status, church attendance, marital status, acculturation, and language preferences were included in the multivariable models. Age was modeled continuously, and educational level was dichotomized as less than a high school diploma versus having a high school diploma or more education. Income was categorized as <$30,000 or $30,000 or more per year. Employment status was dichotomized as not employed versus employed. Acculturation was measured categorically based on nativity and years of residence as foreign-born with <10 years of residence in the US, foreign-born with ≥10 years in the US, and US-born. Hispanic/Latino background was categorized based on self-reported country of origin. Given that religiosity may be related to social network size and health outcomes, we also included a covariate related to church attendance. Church attendance was measured as at least once a week or more, a few times to less than once a year, and not at all.

Statistical Analysis

The distributions of the descriptive characteristics of the study sample were examined by computing weighted means or proportions and 95% confidence intervals. Survey-specific procedures were used to obtain 95% confidence intervals, which took into account the 2-stage sampling design, stratification, and clustering. Logistic regression was used to examine the association of social network dynamics (size of central family, number of central family members in regular contact, and number of extended family members individual feels close to) with each healthy lifestyle factor (presence of healthy lifestyle factor vs. absence of healthy lifestyle factor). With regard to size of central family, we examined the associations between social network size and healthy lifestyle factors by individual family roles (i.e., number of children, number of parental figures/in-laws) and among the family network as a whole (i.e., total number of children, parent, and in-laws). Models were adjusted for age, gender, ethnicity, study site, income, education, employment status, church attendance, marital status, acculturation, and language preferences. We also examined the association of size of central family, number of central family members in regular contact, and number of extended family members individual feels close to with number of healthy lifestyle factors (i.e., 0–1, any 2, any 3, any 4, and all 5 healthy lifestyle factors).

We adjusted analyses for sampling probability and nonresponse to account for the complex sampling design and sampling weights (LaVange et al., 2010; Sorlie et al., 2010). SAS 9.4 software (SAS Institute, Cary NC) was used to perform all analyses.

Results

Descriptive Statistics

Table 1 presents the unadjusted distribution of the descriptive characteristics. Participant age ranged from 18 to 75 years of age (Mean=41.1 years of age, 95% CI=40.6, 41.6). Approximately half of the sample was female (52.4%) and Mexican was the largest reported Hispanic/Latino background group (38.1%). The majority of the sample reported an annual income of less than $30,000 (61.1%), 32.1% of the sample did not have a high school diploma, and approximately half of participants reported being unemployed (49.0%). Church attendance of at least once a week or more was reported by 41.9% of the sample and 49.8% reported being married. Less than half of participants reported being born in the US (22.5%) and 75.4% reported Spanish as their language preference.

Table 1.

Descriptive Characteristics of HCHS/SOL Study Participants (n=15511)

Variable M or % (Range or 95% CI)
Sociodemographics
Age, y 41.1 (18, 76)
Female (%) 52.4 (51.3–53.6)
Hispanic/Latino group (%)
 Mexican 38.1 (34.8–41.4)
 Cuban 20.3 (17.0–23.7)
 Puerto-Rican 15.3 (13.8–16.9)
 Dominican 9.6 (8.2–11.0)
 Central American 7.4 (6.3–8.5)
 South American 5.0 (4.4–5.6)
 Other 4.2 (3.6–4.8)
Study Site (%)
 Bronx 27.3 (24.5–30.2)
 Chicago 16.1 (14.1–18.1)
 Miami 29.8 (25.6–34.1)
 San Diego 26.7 (23.2–30.3)
Income (%)
 Less than $30,000 61.1 (59.2–63.0)
 $30,000 or more 32.9 (30.8–34.9)
 Not reported 6.1 (5.4–6.7)
Education (%)
 No high school diploma 32.1 (30.7–33.6)
 High school or greater 67.9 (66.4–69.3)
Employment Status (%)
 Not employed 49.0 (47.6–50.3)
 Employed 51.0 (49.7–52.4)
Church Attendance (%)
 At least once a week or more 41.9 (40.4–43.4)
 Few times to less than once a year 37.6 (36.3–39.0)
 Not at all 20.5 (19.0–21.9)
Marital Status (%)
 Married 49.8 (48.2–51.4)
 Not Married 50.2 (48.6–51.8)
Acculturation (%)
 Foreign-born, <10 years in US 28.0 (26.1–29.9;
 Foreign-born, 10 ≤ years in US 49.4 (47.9–51.0)
 US born 22.5 (21.0–24.1)
Language Preference (%)
 Spanish 75.4 (73.6–77.2)
 English 24.6 (22.8–26.4)
Health Factors
 Cigarette Smoking (%)
  Never 61.6 (60.3–62.8)
  Former 17.3 (16.4–18.2)
  Current 21.1 (20.0–22.3)
 Body mass index, mean (kg/m2) 29.4 (13.8, 70.3)
 Total Physical Activity (minutes/week) 1229.9 (0, 13620.0)
 AHEI Diet Score 42.4 (24.1, 72.3)
 Alcohol Intake (g/day) among current drinkers 10.3 (0, 162.0)
Structural Social Support
 Total number of living children, parents, and in-laws 4.0 (0, 11)
  Number of Children 1.9 (0, 7)
  Number of Parents 1.3 (0, 2)
  Number of In-Laws 0.8 (0, 2)
 Total number of children, parents, and in-laws in regular contact 3.3 (0, 11)
  Number of Children 1.7 (0, 7)
  Number of Parents 1.1 (0, 2)
  Number of In-Laws 0.5 (0, 2)
 Number of extended family members perceived as close ties 3.7 (0, 7)
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Abbreviations: BMI, body mass index; CI, confidence interval. Note: Ranges displayed for means, and CI for %.

More than half of the sample reported never smoking cigarettes (61.6%). Participants had a mean BMI of 29.4 kg/m2 and reported a mean of 1229.9 minutes per week of total physical activity. Participants had a mean AHEI diet score of 42.4 and mean alcohol intake of 10.3 grams per day among current drinkers.

Associations between social network size and individual healthy lifestyle factors

Table 2 displays the results from the multivariable adjusted analyses on the associations of social network size with individual healthy lifestyle factors. A one-unit higher total of number of children, parents, and in-laws was associated with 10% lower odds of a healthy BMI (OR: 0.90; 95% CI: 0.86, 0.93). Specifically, a greater number of children and in-laws was associated with lower odds of having a healthy BMI (ORs and 95% CIs were 0.84 [0.80, 0.88] and 0.91 [0.85, 0.98], respectively). Further, greater number of children was associated with lower odds of being a non-smoker (OR: 0.94; 95% CI: 0.89, 0.99), while greater number of parents was associated with higher odds of being a non-smoker (OR: 1.11; 95% CI: 1.01, 1.22). Greater number of parents was associated with lower odds of meeting physical activity recommendations (OR: 0.91; 95% CI: 0.84, 0.99).

Table 2.

Associations between Social Network Size and Individual Healthy Lifestyle Factors: HCHS/SOLa

Healthy Lifestyle Factorsb
Diet Physical Activity Tobacco Use Alcohol Use BMI
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Total number of living children, parents, and in-laws 0.98(0.95,1.02) 0.99(0.96,1.02) 0.97(0.93,1.00) 0.99(0.93,1.04) 0.90(0.86,0.93)
 Number of Children 1.00(0.96,1.04) 0.99(0.95,1.03) 0.94(0.89,0.99) 0.96(0.90,1.03) 0.84(0.80,0.88)
 Number of Parents 0.93(0.84,1.03) 0.91(0.84,0.99) 1.11(1.01,1.22) 1.17(0.98,1.39) 1.00(0.91,1.09)
 Number of In-Laws 0.96(0.89,1.04) 1.04(0.98,1.11) 0.95(0.88,1.04) 0.95(0.82,1.09) 0.91(0.85,0.98)
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Abbreviations: BMI, body mass index; OR odds ratio; CI, confidence interval

a

Adjusted for age, gender, background group, study site, income, education, employment status, attends church regularly, marital status, acculturation and language preferences.

b

Healthy lifestyle factors were: 1) Diet: healthy diet defined as the highest 40% of sex-specific Alternate Healthy Eating Index scores for the sample; 2) Physical activity: healthy physical activity was classified as ≥150 minutes/week of moderate intensity activity, ≥75 minutes/week of vigorous intensity activity, or ≥150 minutes/week of moderate plus vigorous activity; 3) Tobacco use: currently non-smoker; 4) Alcohol use: average alcohol consumption of 0–14 g/day for women and 0–28 g/day for men; 5) BMI 18.5 to <25.0 kg/m2.

Associations of number of central family members in regular contact and extended family members individual feels close to with healthy lifestyle factors

Table 3 presents the results from the multivariable adjusted analyses examining associations of number of central family members in regular contact and number of extended family members individual feels close to with each healthy lifestyle factor. A one-unit higher total number of living children, parents, and in-laws in regular contact was associated with 9% lower odds of a healthy BMI (OR: 0.91; 95% CI: 0.87, 0.94). Individuals with a greater number of extended family members who they perceived as having close ties with had greater odds of being a non-smoker and having a healthy BMI (ORs and 95% CIs were 1.03 [1.01, 1.06] and 1.03 [1.01, 1.06], respectively).

Table 3.

Associations of Number of Central Family Members in Regular Contact and Close Extended Family Members with Individual Healthy Lifestyle Factors: HCHS/SOLa

Healthy Lifestyle Factorsb
Diet Physical Activity Tobacco Use Alcohol Use BMI
OR (95%CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Total number of children, parents, and in-laws in regular contact 0.98(0.95,1.01) 0.98(0.95,1.01) 0.99(0.95,1.03) 1.01(0.95,1.08) 0.91(0.87,0.94)
 Number of Children 0.98(0.94,1.02) 0.99(0.95,1.03) 0.95(0.90,1.01) 0.97(0.90,1.05) 0.85(0.81,0.89)
 Number of Parents 0.94(0.85,1.03) 0.92(0.85,0.99) 1.14(1.05,1.25) 1.15(0.99,1.34) 0.99(0.91,1.07)
 Number of In-Laws 0.99(0.89,1.09) 1.00(0.93,1.09) 0.98(0.90,1.07) 1.03(0.88,1.21) 0.95(0.88,1.04)
Number of extended family members perceived as close ties 1.02(0.99,1.05) 1.00(0.98,1.02) 1.03(1.01,1.06) 1.00(0.96,1.05) 1.03(1.01,1.06)
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Abbreviations: BMI, body mass index; OR odds ratio; CI, confidence interval

a

Adjusted for age, gender, background group, study site, income, education, employment status, attends church regularly, marital status, acculturation and language preferences.

b

Healthy lifestyle factors were: 1) Diet: healthy diet defined as the highest 40% of sex-specific Alternate Healthy Eating Index scores for the sample; 2) Physical activity: healthy physical activity was classified as ≥150 minutes/week of moderate intensity activity, ≥75 minutes/week of vigorous intensity activity, or ≥150 minutes/week of moderate plus vigorous activity; 3) Tobacco use: currently non-smoker; 4) Alcohol use: average alcohol consumption of 0–14 g/day for women and 0–28 g/day for men; 5) BMI 18.5 to <25.0 kg/m2.

Associations of social network size, number of central family members in regular contact, and close extended family members with number of healthy lifestyle factors

Table 4 displays the results from the multivariable adjusted analyses of the associations of social networks size, number of central family members in regular contact, and close extended family members with multiple healthy lifestyle factors. A one-unit higher total of number of children, parents, and in-laws was associated with 10% lower odds of displaying all 5 HLF (OR: 0.90; 95% CI: 0.85, 0.96). Our findings also indicated that greater number of children was associated with lower odds of having 5 healthy lifestyle factors (OR: 0.85; 95% CI: 0.78, 0.92), while greater number of in-laws was associated with higher odds of having 3 healthy lifestyle factors (OR: 1.08; 95% CI: 1.01, 1.14). Further, a one-unit higher total number of children, living parents, and in-laws in regular contact was associated with lower odds of having 5 healthy lifestyle factors (OR: 0.91; 95% CI: 0.85, 0.97). Participants with a greater number of extended family members with whom they perceived to have close ties had lower odds of having 0–1 healthy lifestyle factors (OR: 0.93; 95% CI: 0.89, 0.98), but higher odds of having 3 healthy lifestyle factors (OR: 1.02; 95% CI: 1.00, 1.04).

Table 4.

Associations of Social Network Size, Number of Central Family Members in Regular Contact, and Close Extended Family Members with Number of Healthy Lifestyle Factors: HCHS/SOLa

Number of Healthy Lifestyle Factorsb
0–1 HLF 2 HLF 3 HLF 4 HLF 5 HLF
OR (95% CI) OR (95% CI) OR (95% CI) OR(95%CI) OR (95% CI)
Social Network Size
Total number of living children, parents, and in-laws 1.05(0.99,1.11) 1.01(0.98,1.05) 1.02(0.99,1.04) 0.97(0.94,1.00) 0.90(0.85,0.96)
 Number of Children 1.07(1.00,1.15) 1.04(0.99,1.09) 1.00(0.97,1.04) 0.97(0.94,1.01) 0.85(0.78,0.92)
 Number of Parents 0.93(0.79,1.10) 1.05(0.96,1.16) 1.00(0.93,1.09) 0.97(0.89,1.05) 1.02(0.86,1.23)
 Number of In-Laws 1.11(0.95,1.30) 0.94(0.86,1.02) 1.08(1.01,1.14) 0.94(0.87,1.02) 0.93(0.81,1.08)
Number of Central Family Members in Regular Contact and Close Extended Family Members
Total number of children, parents, and in-laws in regular contact 1.03(0.97,1.09) 1.02(0.99,1.05) 1.01(0.99,1.04) 0.98(0.95,1.01) 0.91(0.85,0.97)
 Number of Children 1.05(0.98,1.13) 1.04(1.00,1.09) 1.00(0.97,1.03) 0.97(0.94,1.00) 0.86(0.79,0.94)
 Number of Parents 0.95(0.81,1.12) 1.03(0.95,1.13) 1.00(0.94,1.07) 0.97(0.90,1.04) 1.09(0.92,1.28)
 Number of In-Laws 1.03(0.87,1.21) 0.93(0.86,1.02) 1.05(0.99,1.13) 1.00(0.92,1.09) 0.88(0.75,1.03)
Number of extended family members perceived as close ties 0.93(0.89,0.98) 0.99(0.97,1.01) 1.02(1.00,1.04) 1.00(0.98,1.03) 1.04(0.99,1.09)
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Abbreviations: HLF, Healthy Lifestyle Factors; OR odds ratio; CI, confidence interval

a

Adjusted for age, gender, background group, study site, income, education, employment status, attends church regularly, marital status, acculturation and language preferences.

b

Healthy lifestyle factors were: 1) Diet: healthy diet defined as the highest 40% of sex-specific Alternate Healthy Eating Index scores for the sample; 2) Physical activity: healthy physical activity was classified as ≥150 minutes/week of moderate intensity activity, ≥75 minutes/week of vigorous intensity activity, or ≥150 minutes/week of moderate plus vigorous activity; 3) Tobacco use: currently non-smoker; 4) Alcohol use: average alcohol consumption of 0–14 g/day for women and 0–28 g/day for men; 5) BMI 18.5 to <25.0 kg/m2. Participants were categorized into 5 HLF groups: presence of any 1 or none (0–1), any 2, any 3, any 4, and all 5 HLFs.

Conclusions

Our main findings suggest that central family social network size, number of central family members in regular contact, and number of extended family members individual feels close to are related primarily to BMI and tobacco use among Hispanic/Latinos adults living in the U.S. Specifically, greater central family size and greater regular contact with central family members were associated with lower odds of a healthy BMI, while greater number of extended family members an individual felt close to was associated with higher odds of having a healthy BMI and being a non-smoker. Our results also indicated that individuals reporting a greater central family size, and greater number of central family members in regular contact, were less likely to have all 5 HLF. Those with a greater number of extended family members they felt close to were less likely to have 0–1 healthy lifestyle factors, but more likely to have 3 healthy lifestyle factors. Further, our findings were inconsistent across aspects of the family network examined. To our knowledge, this is one of the first studies to examine the associations of familial structural social support with healthy lifestyle factors in a diverse Hispanic/Latino population. Given the importance of family in the Hispanic/Latino culture, our findings may provide meaningful insight into the contribution of family structural social support to healthy lifestyles among Hispanics/Latinos.

Our findings on the association of central family social network size and number of central family members in regular contact with BMI are generally consistent with previous research on the association of social networks, including family members, with obesity. Previous research has demonstrated that social networks have an influence on obesity outcomes and suggests that frequency of interaction between individuals may influence obesity in social networks (Christakis & Fowler, 2007). Specifically, among Hispanics/Latinos, a recent study examining associations of structural social support and cardiovascular disease risk factors in Hispanics/Latinos with diabetes, a subset of the HCHS/SOL participants, found that greater central family network size was associated with higher odds of obesity (Hernandez et al., 2017). Interestingly, our study findings also showed that individuals with a greater number of children and in-laws had lower odds of having a healthy BMI. This is consistent with findings from previous research showing an increase in obesity risk among men and women with each child that they have (Weng et al., 2004). Our study findings also indicated that those who had a greater number of extended family members they felt close to were more likely to report a healthy BMI. Few studies have examined the influence of extended family members on BMI, and the findings have been mixed. For example, research has shown that having an obese sibling increases the chances of being obese by 40% (Christakis & Fowler, 2007), while other research findings have indicated that siblings and other family members outside of the central family do not influence weight (Winston et al., 2015). Further research is warranted to obtain insight into the role of central and extended family members in promoting healthy weight status.

Our findings also showed that those with a greater number of parents (i.e., own parents and in-laws) were less likely to engage in healthy levels of physical activity. One possible explanation for our findings may be that an increased number of family ties may indicate a higher burden of obligations or responsibilities, which in turn may lead to limited time for engaging in healthy behaviors (Tamers et al., 2013). Previous research has shown that individuals, specifically women, with larger family networks engage in lower levels of physical activity (Dowda et al., 2003). Further, when accounting for the role of familism in Hispanic/Latino culture, a Hispanic/Latino individual may prioritize the family needs over their own needs or health (Caballero, 2011; Katiria Perez & Cruess, 2014). Future research should consider further examining how family networks, that include parents, may influence physical activity.

The current study also showed that those who had a greater number of children had lower odds of being a non-smoker, while those with a greater number of parents and extended family members the individual felt close to were more likely to be non-smokers. Previous research has demonstrated that social networks have an influence on smoking cessation, and that this association can vary by the role of a member within the social network (Christakis & Fowler, 2008). There is also evidence that having members within the family and social network that smoke increase the likelihood of cigarette smoking (Galea et al., 2004), and similarly, having family and friends that quit smoking increases the likelihood of smoking cessation (Christakis & Fowler, 2008). Thus, beyond the size of the family network, evidence suggests that smoking behaviors within a social network should be considered. The associations between familial structural support and smoking, may be explained by family cohesion. For example, in a study among Mexican-American women, women who reported a less cohesive family unit were more likely to be smokers (Coonrod et al., 1999). The perceived closeness with extended family may be indicative of dynamics within these relationships that provide the individual with positive social support. Future research should consider examining the quality and dynamics of the relationships between family members to understand how these relationships influence healthy lifestyle factors among Hispanics/Latinos.

Less than 1% of Hispanic/Latino groups meet the ideal criteria of the biological and lifestyle factors related to cardiovascular health as defined by the American Heart Association, (González et al., 2016) which includes all the factors examined in our study, with the exception of alcohol consumption, warranting further research into the factors that contribute to a healthy lifestyle. Further, previous research has shown that a higher number of healthy lifestyle factors are associated with lower cardiovascular disease risk (Chiuve et al., 2008; Li et al., 2018; Liu et al., 2012; Stampfer et al., 2000). In our study, individuals that reported greater central family size and number of central family members in regular contact had lower odds of displaying all 5 healthy lifestyle factors, with variation in the associations between central family size and number of healthy lifestyle factors by family member role. Additionally, those with greater number of extended family members they perceived as close ties had lower odds of having 0–1 healthy lifestyle factors, but higher odds of displaying 3 healthy lifestyle factors. These findings suggest that the role of familial structural social support should be considered in the multiple healthy lifestyle factors that contribute to cardiovascular health. Given that findings from a previous HCHS/SOL study indicated that most Hispanic/Latino adults have at least one cardiovascular risk factor, (Daviglus et al., 2012) further research is warranted to learn more about how family-related social support can help to reduce the burden of cardiovascular disease among Hispanic/Latinos.

Strengths of our study include a large adult sample of diverse Hispanic/Latino background and the use of varied measures of structural social support, particularly those related to family. One limitation of our study was the cross-sectional nature of the analyses, which limits our causal inferences. Another was that participants were not asked about age of their family members who were in their family social network or questions about caregiving. Information about age and caregiving could provide insight into the extent to which their family member may require care or attention which in turn could limit the amount of time and energy individuals may have to take care of themselves. Another limitation of our study was that we did not have information about whether individuals within the extended family lived with them. Determining whether the associations between ties with extended family and HLF vary depending on the physical proximity of participants to their extended family members (e.g., in a household, neighborhood, or more remote geographic area) could provide further insight into these associations. Additionally, living with an obese individual has been shown to influence weight gain (Winston et al., 2015); however, our study did not measure whether family network members resided in the same home. Thus, determining whether central family members live within the same household in future studies may provide further information about how these relationships impact health. Lastly, the full SNI was not used in HCHS/SOL which limited the items available to assess familial structural support and did not include items assessing functional social support which could have provided further insight into the associations observed.

Our findings add to the current paucity of research on familial structural social support and healthy lifestyle behaviors in Hispanics/Latinos. Our study findings highlight that family social networks, can have both negative and positive effects on healthy lifestyle factors among Hispanics/Latinos, and can vary by family member role. Future research should consider the role of family social networks in health promotion efforts and interventions aimed in Hispanic/Latino adults.

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Acknowledgements

The Hispanic Community Health Study/Study of Latinos was carried out as a collaborative study supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) to the University of North Carolina (N01-HC65233), University of Miami (N01-HC65234), Albert Einstein College of Medicine (N01-HC65235), Northwestern University (N01-HC65236), and San Diego State University (N01-HC65237). The following Institutes/Centers/Offices contribute to the HCHS/SOL through a transfer of funds to the NHLBI: National Center on Minority Health and Health Disparities, the National Institute of Deafness and Other Communications Disorders, the National Institute of Dental and Craniofacial Research, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the Office of Dietary Supplements. The authors thank the staff and participants of HCHS/SOL for their important contributions. A complete list of staff and investigators has been provided by Sorlie P., et al. in Ann Epidemiol. 2010 Aug; 20:642-649 and is also available on the study website http://www.cscc.unc.edu/hchs/. Research reported in this publication was also supported by the National Cancer Institute of the National Institutes of Health under award number P20CA221697 and P20CA221696 (Murillo). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Funding:

This study was funded by the National Heart, Lung, and Blood Institute (NHLBI) to the University of North Carolina (N01-HC65233), University of Miami (N01-HC65234), Albert Einstein College of Medicine (N01-HC65235), Northwestern University (N01-HC65236), and San Diego State University (N01-HC65237). Research reported in this publication was also supported by the National Cancer Institute of the National Institutes of Health under award number P20CA221697 and P20CA221696 (Murillo).

Footnotes

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

Conflict of Interest: The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent was obtained from all individual participants included in the study.

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