Heterogeneity in Acculturation Patterns Among Asian Ethnicities: A Call to Action

Abstract

We read with great interest the article titled, “Nativity and prevalence of cardiometabolic diseases among U.S. Asian immigrants” by Lee et al. that found odds of Type II diabetes and prediabetes to be higher in foreign-born Asian immigrants who lived ≥15 years in the US compared to US-born Whites. While the authors duly addressed the wide heterogeneity among Asian subgroups, we further this discussion by providing key insights into modifiable risk factors across subgroups and potential limitations associated with age-related confounding. Current age and age at migration in foreign-born Asians may confound the associations between nativity and diabetes. Indeed, in this study we observe across all Asian subgroups and Whites that those with higher mean age have higher diabetes prevalence. Furthermore, we observe differences in the age distributions across Asian subgroups (e.g. Chinese have a higher proportion of ≥65 participants than Asian Indians, who on average are younger as well). This may blurry odds ratio interpretations as adjustment for continuous age may not capture differences in age distribution and possible interaction between age and number of years in the US. Other well-established confounders include neighborhood culture, geographic location, and psychosocial stress, which may need to be accounted for in further studies. Among Asians overall, the authors showed that the proportion of those consuming alcohol and/or smoking, two modifiable cardiovascular risk factors, increased in US-born Asians and acculturated foreign-born Asians compared to recently arrived foreign-born Asians. In fact, there was a significant 24.7% increase in those consuming alcohol and 5.4% increase in those smoking. Although this increase is also seen among individual Asian subgroups, the magnitudes differ substantially, from an 18.1% increase in alcohol consumption in the US-born Chinese subgroup to a 31.8% increase in the US-born Asian Indian subgroup, compared to their recently-arrived foreign-born counterparts. Such heterogeneity is similarly present for smoking habits. Previous literature seems to also suggest an increase in these habits. Furthermore, despite the increase in physical activity in US and more acculturated foreign-born Asians, there has been a concomitant increase in overweight BMI and obesity, suggesting a dietary component to increases in BMI. Current interventions aimed at increasing physical activity and/or diet have been only modestly effective. While smoking, alcohol consumption, dietary habits, and physical activity are intuitively risk factors for any patient, targeted, culturally tailored efforts for acculturated Asians may attenuate the negative impacts of these risk factors.