Acculturation and hepatic steatosis among individuals of Hispanic ancestry

INTRODUCTION

Metabolic dysfunction–associated steatotic liver disease (MASLD) is a comprehensive term encompassing all disease stages, defined by ≥5% of hepatocytes exhibiting macrovesicular steatosis in individuals who consume minimal to no alcohol (<20 g/d for women and <30 g/d for men) and where alternative causes of steatosis are ruled out (eg, medications and genetic disorders).¹ This condition encompasses a spectrum of liver damage that ranges from simple steatosis to more severe forms, including metabolic dysfunction–associated steatohepatitis and cirrhosis, which carry the risks of liver failure and HCC.¹ The global prevalence of MASLD is significantly increasing. More precisely, MASLD prevalence has steadily risen from 25.5% before 2005 to a concerning 37.8% in 2016 and beyond.² MASLD prevalence is most pronounced among individuals of Hispanic ancestry in the current US population, standing at approximately ~44%.³

Acculturation, in its essence, represents a sociocultural phenomenon where individuals from one cultural background integrate the customs and norms of another group.⁴ This seemingly straightforward concept unfolds into a complex tapestry of interrelated factors. Today, acculturation is understood as a multidimensional journey, involving various stages of adaptation and transformation across diverse facets such as language acquisition, socioeconomic dynamics, and cultural alignment, encompassing shifts in values and attitudes.⁵ These transformations occur as individuals and communities acclimatize themselves to a novel cultural milieu.

The process of acculturation has been linked to a heightened risk of developing conditions such as hypertension, obesity, unhealthy dietary patterns, and a lack of physical activity. These factors are extensively documented as risk factors for MASLD.^1,6 Understanding how acculturation can influence dietary choices and physical activity levels can aid in developing targeted interventions to address the growing global prevalence of MASLD in diverse populations.

EXPLORING THE INTRICATE RELATIONSHIP BETWEEN ACCULTURATION AND MASLD

While researchers recognize the potential influence of cultural adaptation on dietary and lifestyle patterns, comprehensive studies exploring this link are relatively scarce. We conducted a study using cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) to investigate the association between acculturation, as indicated by language preference, and hepatic steatosis. Our sample consisted of all participants aged 18 and older who self-identified as Hispanic and completed surveys between 2017 and March 2020, before the COVID-19 pandemic. We excluded individuals with evidence of hepatitis B or C and those who engaged in significant alcohol consumption (>4 drinks/d for men and >3 drinks/d for women). To determine the presence of hepatic steatosis, we employed vibration-controlled transient elastography ultrasonographic findings, specifically controlled attenuation parameter (CAP) score. We used language preference as a surrogate measure of acculturation, as it is a key aspect of cultural adaptation and integration. To explore the relationship between hepatic steatosis and acculturation, we employed linear regression models controlled for age, sex, education, insurance, income, body mass index, diabetes, hypertension, total cholesterol, HDL, and waist circumference. These variables were selected due to their significant associations with disease progression among patients with MASLD.⁷

The Hispanic population was stratified into 2 categories: US-born and foreign-born and their characteristics are displayed in Table 1. The multivariable linear regression analysis found a significant association between language preference and the risk of hepatic steatosis among USA-born individuals of Hispanic ancestry (Table 2). Notably, individuals who were proficient in both Spanish and English, as well as those who favored English over Spanish, exhibited a heightened risk of steatosis. On the other hand, among foreign-born individuals, a marked association was observed between a preference for Spanish over English and the risk of hepatic steatosis (Table 3). However, no significant relationship was observed between language preference and fibrosis in either group. Our findings diverge from a prior study that similarly investigated the association between acculturation and hepatic steatosis among individuals of Hispanic ancestry using the NHANES 1999–2004 data. They did not identify a significant relationship between these variables.⁶ However, it is important to note that their characterization of hepatic steatosis differed, as they lacked available data on vibration-controlled transient elastography. This disparity in measurement methodology could account for the variance in results observed between the 2 studies. Alternatively, differences in population demographics over time could also contribute to the disparate findings.

TABLE 1.

Cohort characteristics (n=1640)

	USA-born	Foreign-born
	N=722	N=918
Age (mean±SD)	38±16	47±18
Sex, female, n (%)	369 (51)	496 (54)
BMI (mean±SD)	30±7	29±6
Waist circumference (mean±SD)	100±17	98±14
Total cholesterol (mean±SD)	179±39	189±44
HDL (mean±SD)	52±14	50±15
Diabetes mellitus, n (%)	72 (10)	119 (13)
Hypertension, n (%)	166 (23)	239 (26)
FibroScan
CAP (mean±SD)	265±66	270±69
kPa, (mean ±SD)	6±4	6±5
Insurance, n (%)
Medicare	36 (5)	101 (11)
Private insurance	455 (63)	441 (48)
Safety net insurance	173 (24)	303 (33)
Government insurance	58 (8)	73 (8)
Education, college graduate or above n (%)	173 (24)	199 (13)
Family Monthly Poverty Level Index, n (%)
≤1.30	188 (26)	459 (50)
>1.3 to ≤1.85	108 (15)	147 (16)
≥1.85	426 (59)	312 (34)
Language, n (%)
Only Spanish	14 (2)	459 (50)
More Spanish than English	51 (7)	239 (26)
Both equally	130 (18)	129 (14)
More English than Spanish	188 (26)	64 (7)
Only English	339 (47)	27 (4)

Abbreviations: BMI, body mass index; CAP, controlled attenuation parameter.

TABLE 2.

Univariate and multivariate models for LSM (kPa) in US-born population

	Univariate coeff B (95% CI)	p	Multivariate coeff B (95% CI)a	p
Only Spanish	Reference		Reference
More Spanish than English	−1.0 (−3.9 to 1.8)	0.474	1.3 (−0.9 to 3.6)	0.235
Both equally	−1.3 (−4.3 to 1.5)	0.338	1.6 (−0.4 to 3.6)	0.118
More English than Spanish	−1.1 (−4.1 to 1.8)	0.423	1.0 (−0.8 to 2.8)	0.261
Only English	−0.4 (−3.4 to 2.6)	0.774	1.4 (−0.6 to 3.6)	0.163
Univariate and multivariate models for CAP (dB/m) in US-born population
More Spanish than English	2.7 (−34.0 to 39.4)	0.880	19.8 (−9.1 to 48.9)	0.171
Both equally	0.4 (−30.4 to 31.2)	0.978	49.0 (25.8 to 72.3)	<0.001
More English than Spanish	7.4 (−24.6 to 39.4)	0.638	40.9 (18.7 to 63.1)	0.001
Only English	16.7 (−10.7 to 44.3)	0.221	34.9 (14.5 to 55.4)	0.002

^aAdjusted for age, sex, education, insurance, income, BMI, diabetes, hypertension, total cholesterol, HDL, and waist circumference.

Abbreviations: BMI, body mass index; CAP, controlled attenuation parameter; LSM, Liver stiffness measurement.

TABLE 3.

Univariate and multivariate models for LSM (kPa) in foreign-born population

	Univariate coeff B (95% CI)	p	Multivariate coeff B (95% CI)a	p
Only Spanish	Reference		Reference
More Spanish than English	0.2 (−0.6 to 1.1)	0.580	1.0 (−0.1 to 2.2)	0.074
Both equally	0.06 (−0.6 to 0.8)	0.866	0.2 (−0.5 to 1.0)	0.518
More English than Spanish	−0.1 (−0.9 to 0.5)	0.623	−0.2 (−1.1 to 0.5)	0.496
Only English	−0.4 (−1.4 to 0.4)	0.327	−1.0 (−2.5 to 0.3)	0.124
Univariate and multivariate models for CAP (dB/m) in foreign-born population
More Spanish than English	−3.9 (−18.1 to 10.3)	0.574	17.5 (2.1 to 32.9)	0.027
Both equally	3.7 (−13.3 to 20.8)	0.657	17.5 (−1.6–36.7)	0.072
More English than Spanish	−6.1 (−27.2 to 14.8)	0.550	6.3 (−12.5 to 25.1)	0.498
Only English	−17.5 (−49.0 to 13.9)	0.261	7.5 (−24.6 to 39.6)	0.635

^aAdjusted for age, sex, education, insurance, income, BMI, diabetes, hypertension, total cholesterol, HDL, and waist circumference.

Abbreviations: BMI, body mass index; CAP, controlled attenuation parameter; LSM, Liver stiffness measurement.

Our research findings suggest that exposure to new lifestyles, diets, beliefs, and environments is associated with the development of hepatic steatosis among US-born individuals of Hispanic ancestry. This association could be attributed to the fact that their diet varies based on their level of acculturation. Although there are mixed findings regarding the effects of acculturation on diet, the overall impact appears to be negative. For instance, a study that focused on younger Mexican American women found that the use of traditional foods decreased over time after immigration to the United States, with second-generation women consuming fewer traditional foods than their first-generation counterparts. This change in diet was found to have a negative impact.⁸ However, our findings did not observe a relationship between lower acculturation and hepatic steatosis in US-born individuals. While living in a new society can introduce behavioral, social, and environmental changes that could adversely influence health, there may be benefits such as gaining new occupational skills, exposure to public health information, and access to preventive medicine which could explain the lack of association.⁹

In contrast, we identified a correlation between foreign-born individuals with low acculturation and an increased risk of hepatic steatosis. We could attribute this finding to the fact that foreign-born participants tended to have lower family monthly poverty levels compared to those born in the United States. Socioeconomic factors are known to impact the development of MASLD, as individuals with lower incomes tend to consume more low-cost foods such as sugar-rich snacks, or soft drinks, which have been linked to diabetes and obesity—known risk factors for MASLD.^10,11 Moreover, it is worth noting that individuals with Hispanic ancestry have a higher prevalence of steatohepatitis and cirrhosis compared to other ethnic groups. This higher prevalence may be attributed to the 148M variant in PNPLA3, which is associated with over 2-fold increase in hepatic fat content compared to noncarriers and occurs most frequently in individuals of Hispanic ancestry.¹²

CONCLUSIONS

Conducting targeted and well-designed research has the potential to result in interventions that are both timely and effective, ultimately improving health outcomes throughout an individual’s life. Our findings suggest that interventions targeting dietary choices may be effective in reducing the risk of hepatic steatosis among individuals of Hispanic ancestry. For less acculturated and first-generation Hispanics, encouraging traditional dietary choices with some modifications, such as increasing the amount of vegetables and incorporating traditional foods like beans, corn, and chiles, may be beneficial. For more acculturated individuals of Hispanic ancestry, health education strategies similar to those used among non-Hispanics may be more appropriate, such as the introduction of a Mediterranean diet which includes foods like fruits, vegetables, whole grains, fish, and olive oil. Furthermore, it is crucial that medical care is provided in a culturally and linguistically appropriate manner. One approach to this could be to make dietary information available to patients of Hispanic ancestry that utilizes traditional cooking ingredients and provides recipe adaptations to promote healthy eating habits.