Background

The goal of this systematic review was to determine whether acculturation is associated with risk of cardiovascular disease (CVD). Acculturation has been defined both as the “process by which immigrants adopt the attitudes, values, customs, beliefs and behaviors of a new culture”,¹ and as the “gradual exchange between immigrants’ original attitudes and behavior and those of the host culture”.¹ Acculturation is relevant for individual dietary behaviors because evidence suggests that the healthy lifestyles with which recent immigrants arrive deteriorate as they integrate or assimilate into mainstream American culture.² Moreover, evidence suggests that to be effective in helping immigrants retain their healthy lifestyles, nutrition education and food assistance programs must be tailored to their different levels of acculturation.²

Conclusion statement

No conclusion can be drawn regarding the relationship between acculturation to the United States and the risk of CVD. This is due to the small number of studies, wide variation in methodology used to assess acculturation, and limited representation of ethnic groups in the body of evidence. Very limited evidence from a small number of cross-sectional studies conducted in Latino/Hispanic populations suggest a positive relationship between language acculturation and elevation in low-density lipoprotein cholesterol (LDL-C) and no relationship between acculturation and blood pressure. Insufficient evidence is available for other race/ethnic populations and among children for these outcomes and other CVD outcomes.

2015 DGAC Grade: Not assignable

Methods

Literature searches were conducted using PubMed, Embase and Cochrane databases to identify studies that evaluated the association between acculturation and risk of cardiovascular disease (CVD). Studies that met the following criteria were included in the review: cross-sectional studies and cohort studies; human subjects aged two years and older who were healthy or at elevated chronic disease risk; studies conducted in the United States with participants residing within the United States and when available, participants residing in the country of origin; and studies published in English in peer-reviewed journals January 2004 to January 2014. The exposure was acculturation measured by acculturation scales, or more than one proxy for acculturation (e.g., time living in the United States, language preference, place of birth). The outcome was risk of cardiovascular disease and included the following outcomes: LDL-C, high-density lipoprotein cholesterol (HDL-C), (including total cholesterol (TC):HDL and LDL:HDL ratios), triglycerides, blood pressure (systolic and diastolic), incidence of coronary heart disease (CHD) or CVD, incidence of myocardial infarction (MI), incidence of stroke, CVD-related mortality and incidence of hypertension.

Data from each included article were extracted, and risk of bias was assessed. The evidence was qualitatively synthesized, a conclusion statement was developed and the strength of the evidence (grade) was assessed using pre-established criteria including evaluation of the quality and risk of bias, quantity, consistency, magnitude of effect and generalizability of available evidence.

Findings

• This systematic review includes six cross-sectional studies in adult men and women between the ages of 40 to 60 years. The study populations included five Latino/Hispanic and one multicultural population; the data were predominately derived from large, multi-state or national data sets
• Three studies found a positive relationship between language acculturation and elevated blood lipid levels, but results varied by acculturation indicator
• Two studies assessed the association between acculturation and blood pressure in Latino/Hispanic populations and no association was found
• Two studies assessed the relationship between acculturation and hypertension in Latino/Hispanic and a multicultural population, and found no association
• Two studies suggest a positive association between language acculturation and overall CVD risk, but results varied as a function of language acculturation indicator used.

Limitations

• The preponderance of the evidence is from cross-sectional studies, thus causality inferences cannot be made and it is unknown whether the relationship changes over time.
• Variations in the combination and methods used to assess acculturation proxies and application of differing multidimensional acculturation scales, made comparison of results across studies difficult.

References

1. Abraido-Lanza AF, White K, Vasques E. Immigrant populations and health. In: Anderson N, editor. Encyclopedia of Health and Behavior. Newbury Park, CA: Sage; 2004: p. 533-7.
2. Perez-Escamilla R. Food insecurity in children: impact on physical, psychoemotional and social development. In: Ross CA, Caballero RJ, Cousins RJ, Tucker KL, Ziegler TR, editors. Modern Nutrition in Health and Disease. Baltimore, MD: Lippincott Williams & Wilkins; 2013: p. 1006-15.