Question

From a Healthcare Administrator/Epidemiology perspective:

1. Explain the association of the American diet with immigrants to the United States and discuss your thoughts on how diabetes could be better managed in this population.

Answer 1

Changes in health status following immigration have been noted, with health advantages disappearing over time and increasing prevalence of obesity and associated metabolic diseases such as type 2 diabetes (T2D); this change over time is known as the “healthy immigrant effect.” This suggests that adaptation to the new environment and culture is a risk factor for diabetes. Immigrants may also face obstacles to optimized treatment of complex chronic diseases due to many factors; lack of optimization of interventions based on culture may be a major barrier.

As will be described further, the adaptation occurring following immigration is termed acculturation, which has been defined as “the process by which an ethnic group, usually a minority, adopts the cultural patterns including beliefs, religion, and language of a dominant group”. At the group level, the acculturating group (or society as a whole) adopts physical, economic, cultural, and political changes while at the individual level, change is manifested in attitudes, beliefs, values, and behaviors (for example dietary behaviors and eating patterns). It is proposed that acculturation is affected by personal factors such as age, gender, and socio-economic status, the duration of stay in the host country and the traditions of the original culture. As reviewed by Sanou et al. , significant knowledge gaps exist regarding the interrelationship between immigration, acculturation, and health status in Canada but acculturation may affect an individual’s ability to fully embrace treatment , which for T2D includes a complex regime of self-care activities such as managing diet, increasing physical activity, monitoring blood glucose, taking medication, and being vigilant for co-morbidities . Because diet is closely tied to culture, adhering to a prescribed nutrition regimen may be even more difficult than for the dominant culture.

A major immigrant group in Canada is ethnic Chinese. According to the 2011 census, first generation immigrants make up about 20% of Canada’s population. Ethnic Chinese are the second largest population of first-generation Canadians and are also the second largest visible minority in Canada overall, comprising 4.0% of the total population. Only five published papers regarding health of Chinese immigrants to Canada were found in the literature. However, several studies have examined the association between the prevalence of chronic diseases and acculturation among Asian immigrants to the United States. American-Chinese have a higher prevalence of diabetes compared with both native Americans and their peers in China.

The purpose of this review is first to describe general barriers to dietary adherence in people with T2D. We will then summarize what is known about the influence of several acculturation indicators (diet, language, length of stay in North America) on T2D management behaviors in Chinese immigrants to North America and the effects of acculturation on diabetic management in different genders and family context. Avenues for improving diabetes nutrition therapy for ethnic Chinese, as a model for immigrant populations to Canada, will be suggested.

Focus on Cultural and Social Acceptability of Prescribed Diets

The need to recognize cultural diversity in diabetes treatment is recognized by the International Diabetes Federation and countries with large immigrant populations and multi-cultural societies. When optimizing dietary patterns in order to treat disease, the food culture of the society and the individual should be considered in order to maximize the acceptability of the treatment. Choosing unfamiliar foods from a different ethnic heritage might make dietary adherence to diabetes guidelines more complicated and could contribute to low adherence rates, while acceptability of a recommended diet could increase adherence. Therefore, understanding the personal and cultural barriers that are associated with dietary adherence faced by people with diabetes could contribute to a future intervention program

Acculturation, Dietary Acculturation, and Diabetes Management

For an immigrant in North America, the degree of acculturation influences many aspects of life, such as access to health services organizations and physical activity facilities as well as healthy eating behaviors. Therefore, the degree to which individuals are acculturated into the host culture is predicted to influence their ability to adapt to the requirements of a therapeutic nutritional pattern upon diagnosis of a chronic disease like T2D. Acculturation can be quantified using instruments such as the Suinn-Lew Asian Self-Identity Acculturation (SL-ASIA) scale, which examines responses to statements in several dimensions including ethnic identity, social interactions, language and cultural preference, country of birth and pride for one’s culture . The term “dietary acculturation” specifically refers to the process of adopting the eating patterns and food choices of their new environment. Dietary acculturation is multidimensional, dynamic, and complex, and does not appear to be a linear process. Instead of moving predictably from traditional to acculturated, immigrants may “retain and find new ways to use traditional foods, exclude others, and/or consume new foods”

When Chinese people immigrate to North America, dietary patterns change as a result of acculturation and availability of specific foods. More than half of respondents changed their diet after immigration from China to the USA, with increased consumption of western and reduced consumption of traditional Chinese foods from all food groups, as well as increased consumption of sweets and soft drinks. Lack of availability of traditional Chinese food at competitive prices with western foods is an important factor. Of the three daily meals, breakfast is usually the first to be acculturated, with inclusion of foods such as oatmeal, milk, bagels, and cream cheese whereas noodles or rice remain staples of the lunch and supper meals. This dietary acculturation pattern is likely a risk factor for obesity and T2D. As acculturation progresses, intake of processed, ready-to-eat western foods increases because of lack of familiarity with western cooking methods.

There is an appreciation for the need to address cultural considerations when prescribing diets for the treatment of T2D to patients from ethnic minorities in North America in order to increase diet acceptability and adherence. Ethnic Chinese are a large minority population in North America. The degree of acculturation may impact dietary choices by ethnic Chinese but few studies have addressed this possibility directly, particularly in the segment of this population with T2D. In addition to diet, acculturation affects access to health care and the likelihood of engaging in other healthy behaviors such as physical activity. Furthermore, application of cultural considerations is complicated by the complexity of the acculturation process, which involves both personal and environmental factors. Social and family influences may be of particular importance in certain cultures.