Commentary: Important Advances in Understanding the Relationship Between Acculturation and Risk for Obesity

Understanding risk factors related to acculturation and the risk of developing obesity is important, given the increasing number of immigrants in the United States. A summary of key findings from the “Generation of Immigration and Body Mass Index (BMI) in Canadian Youth” article in this issue are presented, and the implications for future research and health promotion efforts are discussed in this commentary. An emphasis is placed on the importance of understanding cultural issues and linking social factors to better understand the barriers and facilitators of obesity risk in immigrants. Recommendations for developing culturally tailored weight-control programs matched to the ethnicity of immigrant populations are provided. The study investigating the role of acculturation, as measured by generational status, on BMI in Canadian youth reported that first-generation immigration was significantly related to higher BMI z-scores in adolescents as compared to second and third generations. Specifically, first-generation immigrants had more weight gain compared to other generation groups in adolescence. These findings expand on a growing literature demonstrating that generational timing of immigration may be a risk factor for obesity, and that maintaining traditional cultural orientation is associated with lower rates of obesity (Renzaho, Swinburn, & Burns, 2008). Although the relationship between first-generation immigration and higher prevalence of overweight has shown mixed results in some previous studies, findings in the article in this issue showed that race and ethnicity were also important factors to consider in understanding these complex relationships. Specifically, analyses stratified by race showed that this relationship tended to be stronger in Black, South Asian, and other first-generation immigrant groups. These findings suggest that first-generation youth may be at greater risk for developing unhealthy lifestyle patterns, such as poor dietary and physical activity habits. However, further research should explore how acculturation and race may be related to barriers for engaging in healthy lifestyle habits. For example, a recent qualitative study by Shelton and colleagues (2011) showed that both African American and Latina women reported having many stressors, including economic hardships, demanding caretaking relationships, inflexible work policies, and mistrust of health care providers. Those who were immigrants also reported that they experienced social isolation and were experiencing high levels of stress in general. Thus, health promotion efforts should take into account the additional stressors experienced by ethnic minority women and their families, and how immigration challenges may further impact these difficulties. The study on acculturation and obesity reported in this issue is also one of the first to examine longitudinal patterns of overweight status across generational status in children and adolescents. Overtime, BMI change for first-generation immigrants was associated with greater weight gain, but no direct measures of acculturation were integrated into the study measures, making it difficult to know exactly what the mechanisms are by which generational status is related to the development of obesity in young immigrants. As noted in a growing body of literature, more qualitative studies that address longitudinal and developmental issues related to engaging in healthy lifestyles are needed in underserved and ethnic minority populations (Wilson, Zarrett, & Kitzman-Ulrich, 2011). In particular, research on intergenerational effects of culture may provide important insights into family and generational issues that are protective or which may increase the risk for developing obesity. For example, in a qualitative study by Renzaho, Green, Mellor, and Swinburn (2011), Somali and Ethiopian migrant families indicated that intergeneration themes related to immigration included challenges with maintaining traditional parenting, family functioning, and family relations. In addition, these families reported that maintaining a healthy lifestyle of physical activity and diet was challenging, and that parents were more restrictive in controlling their youth’s behaviors and discouraged autonomy. Thus, future efforts to develop policies and health promotion programs among immigrant populations should integrate a parenting focus to better assist parents with how to communicate with their youth about the importance of engaging in healthy lifestyles, given the transition to a new cultural environment. Recently, investigators have argued for an ecological approach to understanding lifestyle factors that relate to obesity in underserved and ethnic minority populations that incorporates a stronger focus on social factors, including social context (Sallis, Owen, & Fisher, 2008; Wilson, 2009; Wilson, Ellerb, Kugler et al., 2012). Recent studies demonstrate that social factors are important for improving health behaviors in underserved low income, ethnic minority populations (Sallis et al. 2008; Wilson et al, 2012). In particular, research is needed to better understand social interactions and parent-related supports specific to acculturation of young immigrants who may be at increased risk for developing obesity. Understanding the socialization and cultural integration of immigrants may increase our understanding of how to address the barriers and create more positive social environments that encourage increased activity, healthy eating, and supportive climates for engaging in healthy lifestyles. There is an increasing body of literature that indicates that parent support and positive neighborhood conditions are both important for buffering the negative effects of poverty and poor environmental conditions on the development of obesity in youth (Lawman & Wilson, 2012). In a recent study by Sussner, Lindsay, Greaney, and Peterson (2008), immigrant Latina mothers reported that beliefs about feeding practices, lack of physical activity, lack of social support, and increased social isolation all contributed to a lifestyle that was prone to developing obesity. Taken together, these studies reviewed highlight the need for health promotion efforts that address the specific barriers related to parental beliefs and understanding of how to build social relationships that could reinforce health behaviors for engaging in physical activity and healthy eating. Health promotion efforts among immigrants need to address multiple systems within the family’s environment, including the neighborhood, schools, and religious and cultural affiliations. Health promotion programs for obesity prevention in culturally diverse populations have focused on incorporating cultural tailoring approaches that address the specific needs of the target population with respect to promoting healthy lifestyles. The most successful health promotion interventions for underserved and ethnic minorities have incorporated culturally targeted and culturally tailored intervention components using multisystemic approaches, and these approaches could be applied to young immigrants (Wilson, 2009). Furthermore, in a recent qualitative study by Lindberg and Stevens (2011), Mexican-American women indicated that they wanted more opportunities to engage in behavioral interventions that provided culturally centered behavioral strategies for improving nutrition and food choices within the family context. Kreuter and colleagues (2003) have provided an overview of cultural tailoring for improving health behaviors. They propose that interventions can incorporate peripheral strategies that give program materials the appearance of cultural appropriateness by using certain images and pictures of group members. In addition, linguistic strategies have also been used to develop program materials that are dominant to the native culture of the ethnic minorities. Interventions that have “socio-cultural” or “deep structures,” typically integrate cultural values and norms into the intervention programming and have been demonstrated to be effective tailoring approaches for health behavior change (Resnicow, Davis, Zhang, et al. 2008; Resnicow, Davis, Zhang, et al. 2009). Deep structures or socio-cultural strategies have also been shown to be successful, when integrated within the health-related context of interventions that target culturally diverse ethnic populations (Resnicow, Braithwaite, Ahluwalia, & Dilorio, 2001). All of these tailoring strategies could be implemented within immigrant families for promoting healthy lifestyles and obesity prevention. In summary, the article on acculturation and risk of obesity in this issue raises important questions about why and how immigration may lead to greater prevalence of risk for developing obesity in youth. Obtaining contextual information (i.e., via qualitative studies) for understanding the social and environmental processes will continue to inform future research for developing effective culturally tailored health promotion approaches in these high-risk populations of immigrants. In addition, developing culturally tailored approaches for improving parent support and social integration, as well as broader environmental supports for healthy lifestyles will be critical to reversing and preventing these trends in childhood obesity among immigrants. Future research should replicate these findings presented in this issue and explore the mechanisms across different ethnic and cultural groups to better understand how to best tailor obesity prevention efforts for immigrant youth. This article was supported in part by a grant (R01 DK067615) funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) to Dawn K. Wilson, PhD. Conflicts of interest: None declared.

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