Mediating Role of Acculturation and Lifestyle Behaviors on Cardiometabolic Risk Among a National Sample of U.S. Asian Indians

  • Nitha Mathew JosephEmail author
  • Ranjita Misra
  • Jing Wang
Original Paper


Asian Indians are the third largest and fastest growing Asian subgroup in the U.S. and have high risks for diabetes and cardiovascular disease. This study explored the mediating role of lifestyle behaviors on the relationship between acculturation and cardiometabolic risk factors among Asian Indians using the Diabetes in Indian Americans national study. The cross-sectional study sample comprised 1038 randomly selected adult Asian Indians in seven U.S. sites. Acculturation was assessed using the Acculturation Scale for Southeast Asians. Diet and lifestyle behaviors were measured using the Health-Promoting Lifestyle Profile II subscales. Path analyses with bootstrap methods were conducted. Dietary behavior significantly mediated the relationship between acculturation and HbA1C (β = 0.004, p = 0.047), and physical activity mediated the relationship between acculturation and HDL (β = 0.08, p = 0.011). Other mediation models were not significant (p > 0.05). Mediating factors besides lifestyle behaviors should be explored in future studies.


Cardiovascular diseases Diabetes mellitus Physical activity Culture Dietary habits 



The authors thank Markeda Wade, BA, ELS, for editorial assistance. We would also like to thank Stanley Cron, MSPH for assistance with statistical analysis.


  1. 1.
    Ardeshna DR, Bob-Manuel T, Nanda A, Sharma A, Skelton WPT, Skelton M, et al. Asian-Indians: a review of coronary artery disease in this understudied cohort in the United States. Ann Transl Med. 2018;6(1):12. Scholar
  2. 2.
    Jonnalagadda SS, Diwan S. Health behaviors, chronic disease prevalence and self-rated health of older Asian Indian immigrants in the US. J Immigr Health. 2005;7(2):75–83. Scholar
  3. 3.
    Misra KB, Endemann SW, Ayer M. Leisure time physical activity and metabolic syndrome in Asian Indian immigrants residing in northern California. Ethn Dis. 2005;15(4):627–34.PubMedGoogle Scholar
  4. 4.
    Palaniappan LP, Araneta MR, Assimes TL, Barrett-Connor EL, Carnethon MR, Criqui MH, et al. Call to action: cardiovascular disease in Asian Americans: a science advisory from the American Heart Association. Circulation. 2010;122(12):1242–52. Scholar
  5. 5.
    Misra A, Vikram NK. Insulin resistance syndrome (metabolic syndrome) and obesity in Asian Indians: evidence and implications. Nutrition. 2004;20(5):482–91. Scholar
  6. 6.
    Misra A, Khurana L. Obesity-related non-communicable diseases: South Asians vs White Caucasians. Int J Obes (Lond). 2011;35(2):167–87. Scholar
  7. 7.
    Abate N, Chandalia M. Ethnicity, type 2 diabetes and migrant Asian Indians. Indian J Med Res. 2007;125(3):251–8.PubMedGoogle Scholar
  8. 8.
    Kanaya AM, Herrington D, Vittinghoff E, Ewing SK, Liu K, Blaha MJ, et al. Understanding the high prevalence of diabetes in U.S. south Asians compared with four racial/ethnic groups: the MASALA and MESA studies. Diabetes Care. 2014;37(6):1621–8. Scholar
  9. 9.
    Lee JW, Brancati FL, Yeh HC. Trends in the prevalence of type 2 diabetes in Asians versus whites: results from the United States National Health Interview Survey, 1997–2008. Diabetes Care. 2011;34(2):353–7. Scholar
  10. 10.
    Misra R, Patel T, Kotha P, Raji A, Ganda O, Banerji M, et al. Prevalence of diabetes, metabolic syndrome, and cardiovascular risk factors in US Asian Indians: results from a national study. J Diabetes Complicat. 2010;24(3):145–53. Scholar
  11. 11.
    Oza-Frank R, Ali MK, Vaccarino V, Narayan KM. Asian Americans: diabetes prevalence across US and World Health Organization weight classifications. Diabetes Care. 2009;32(9):1644–6. Scholar
  12. 12.
    Mohanty SA, Woolhandler S, Himmelstein DU, Bor DH. Diabetes and cardiovascular disease among Asian Indians in the United States. J Gen Intern Med. 2005;20(5):474–8. Scholar
  13. 13.
    Kanaya AM, Wassel CL, Mathur D, Stewart A, Herrington D, Budoff MJ, et al. Prevalence and correlates of diabetes in South asian indians in the United States: findings from the metabolic syndrome and atherosclerosis in South asians living in america study and the multi-ethnic study of atherosclerosis. Metab Syndr Relat Disord. 2010;8(2):157–64. Scholar
  14. 14.
    Venkatesh S, Conner T, Song WO, Olson BH, Weatherspoon LJ. The relationship between dietary acculturation and Type 2 Diabetes risk among Asian Indians in the US. J Immigr Minor Health. 2017;19(2):294–301. Scholar
  15. 15.
    Raji A, Seely EW, Arky RA, Simonson DC. Body fat distribution and insulin resistance in healthy Asian Indians and Caucasians. J Clin Endocrinol Metab. 2001;86(11):5366–71. Scholar
  16. 16.
    Shah AD, Vittinghoff E, Kandula NR, Srivastava S, Kanaya AM. Correlates of prediabetes and type II diabetes in US South Asians: findings from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Ann Epidemiol. 2015;25(2):77–83. Scholar
  17. 17.
    Abate N, Chandalia M. Ethnicity and type 2 diabetes: focus on Asian Indians. J Diabetes Complicat. 2001;15(6):320–7.CrossRefGoogle Scholar
  18. 18.
    Abraido-Lanza AF, Armbrister AN, Florez KR, Aguirre AN. Toward a theory-driven model of acculturation in public health research. Am J Public Health. 2006;96(8):1342–6. Scholar
  19. 19.
    Allen JD, Caspi C, Yang M, Leyva B, Stoddard AM, Tamers S, et al. Pathways between acculturation and health behaviors among residents of low-income housing: the mediating role of social and contextual factors. Soc Sci Med. 2014;123:26–36. Scholar
  20. 20.
    Commodore-Mensah Y, Ukonu N, Cooper LA, Agyemang C, Himmelfarb CD. The association between acculturation and cardiovascular disease risk in Ghanaian and Nigerian-born African immigrants in the United States: the Afro-Cardiac Study. J Immigr Minor Health. 2018;20(5):1137–46. Scholar
  21. 21.
    Kalra P, Srinivasan S, Ivey S, Greenlund K. Knowledge and practice: the risk of cardiovascular disease among Asian Indians. Results from focus groups conducted in Asian Indian communities in Northern California. Ethn Dis. 2004;14(4):497–504.PubMedGoogle Scholar
  22. 22.
    Dodani S, Dong L. Acculturation, coronary artery disease and carotid intima media thickness in South Asian immigrants–unique population with increased risk. Ethn Dis. 2011;21(3):314–21.PubMedGoogle Scholar
  23. 23.
    Mooteri SN, Petersen F, Dagubati R, Pai RG. Duration of residence in the United States as a new risk factor for coronary artery disease (The Konkani Heart Study). Am J Cardiol. 2004;93(3):359–61. Scholar
  24. 24.
    Wu TY, Wang J, Chung S. Cardiovascular disease risk factors and diabetes in Asian Indians residing in Michigan. J Community Health. 2012;37(2):395–402. Scholar
  25. 25.
    Daniel M, Wilbur J, Marquez D, Farran C. Lifestyle physical activity behavior among South Asian Indian immigrants. J Immigr Minor Health. 2013;15(6):1082–9. Scholar
  26. 26.
    Venkatesh S, Weatherspoon LJ, Kaplowitz SA, Song WO. Acculturation and glycemic control of Asian Indian adults with type 2 diabetes. J Community Health. 2013;38(1):78–85. Scholar
  27. 27.
    Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation. 2008;117(23):3031–8. Scholar
  28. 28.
    Bhopal RS. A four-stage model explaining the higher risk of Type 2 diabetes mellitus in South Asians compared with European populations. Diabet Med. 2013;30(1):35–42. Scholar
  29. 29.
    Patel M, Phillips-Caesar E, Boutin-Foster C. Barriers to lifestyle behavioral change in migrant South Asian populations. J Immigr Minor Health. 2012;14(5):774–85.CrossRefGoogle Scholar
  30. 30.
    DeSalvo KB. Public Health 3.0: Applying the 2015–2020 Dietary Guidelines for Americans. Public Health Rep. 2016;131(4):518–21. Scholar
  31. 31.
    U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans; 2015.
  32. 32.
    Tehrani H, Majlessi F, Shojaeizadeh D, Sadeghi R, Hasani Kabootarkhani M. Applying socioecological model to improve women’s physical activity: a randomized control trial. Iran Red Crescent Med J. 2016;18(3):e21072.CrossRefGoogle Scholar
  33. 33.
    Fleury J, Lee SM. The social ecological model and physical activity in African American women. Am J Community Psychol. 2006;37(1–2):129–40.PubMedGoogle Scholar
  34. 34.
    Robinson T. Applying the socio-ecological model to improving fruit and vegetable intake among low-income African Americans. J Community Health. 2008;33(6):395–406.CrossRefGoogle Scholar
  35. 35.
    Glanz K, Rimer BK, Viswanath K. Health behavior and health education. San Francisco: Wiley; 2008.Google Scholar
  36. 36.
    Rovniak LS, Kong L, Hovell MF, Ding D, Sallis JF, Ray CA, et al. Engineering online and in-person social networks for physical activity: a randomized trial. Ann Behav Med. 2016;50(6):885–97.CrossRefGoogle Scholar
  37. 37.
    Breslow L. Social ecological strategies for promoting healthy lifestyles. Am J Health Promot. 1996;10:253–7.CrossRefGoogle Scholar
  38. 38.
    Emmons K. Health behaviors in social context. In: Berkman L, Kawachi I, editors. Social epidemiology. New York: Oxford Press; 2000. p. 242–66.Google Scholar
  39. 39.
    Stokols D. Translating social ecological theory into guidelines for community health promotion. Am J Health Promot. 1996;10:282–98.CrossRefGoogle Scholar
  40. 40.
    Centers for Disease Control and Prevention. Addressing Obesity Disparities: Social Ecological Model. 2017. Accessed 16 Dec 2018.
  41. 41.
    Anderson J, Moeschberger M, Chen MS Jr, Kunn P, Wewers ME, Guthrie R. An acculturation scale for Southeast Asians. Soc Psychiatry Psychiatr Epidemiol. 1993;28(3):134–41.CrossRefGoogle Scholar
  42. 42.
    Walker SN, Sechrist KR, Pender NJ. The health-promoting lifestyle profile: development and psychometric characteristics. Nurs Res. 1987;36(2):76–81.CrossRefGoogle Scholar
  43. 43.
    Misra A. Ethnic-specific criteria for classification of body mass index: a Perspective for Asian Indians and American Diabetes Association Position Statement. Diabetes Technol Ther. 2015;17(9):667–71. Scholar
  44. 44.
    WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363(9403):157–63. Scholar
  45. 45.
    World Health Organization. Regional Office for the Western Pacific IDI, International Association for the Study of Obesity IOTF. The Asia-Pacific perspective: Redefining obesity and its treatment. Sydney: Health Communications Australia. 2000.
  46. 46.
    Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behav Res Methods Instrum Comput. 2004;36(4):717–31.CrossRefGoogle Scholar
  47. 47.
    Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: NJ Lawrence Earlbaum Associates; 1988.Google Scholar
  48. 48.
    Zhao X, Lynch JG, Chen Q. Reconsidering Baron and Kenny: myths and truths about mediation analysis. J Consum Res. 2010;37(2):197–206. Scholar
  49. 49.
    Abraido-Lanza AF, Echeverria SE, Florez KR. Latino immigrants, acculturation, and health: promising new directions in research. Ann Rev Public Health. 2016;37:219–36. Scholar
  50. 50.
    Lesser IA, Gasevic D, Lear SA. The association between acculturation and dietary patterns of South Asian immigrants. PLoS ONE. 2014;9(2):e88495. Scholar
  51. 51.
    Kulkarni KD. Food, culture, and diabetes in the United States. Clin Diabetes. 2004;22(4):190–2.CrossRefGoogle Scholar
  52. 52.
    Balasubramanyam A, Rao S, Misra R, Sekhar RV, Ballantyne CM. Prevalence of metabolic syndrome and associated risk factors in Asian Indians. J Immigr Minor Health. 2008;10(4):313–23. Scholar
  53. 53.
    Perez-Escamilla R, Putnik P. The role of acculturation in nutrition, lifestyle, and incidence of type 2 diabetes among Latinos. J Nutr. 2007;137(4):860–70.CrossRefGoogle Scholar
  54. 54.
    Gray VB, Cossman JS, Dodson WL, Byrd SH. Dietary acculturation of Hispanic immigrants in Mississippi. Salud Publica Mex. 2005;47(5):351–60.CrossRefGoogle Scholar
  55. 55.
    Satia JA. Dietary acculturation and the nutrition transition: an overview. Appl Physiol Nutr Metab. 2010;35(2):219–23. Scholar
  56. 56.
    Satia-Abouta J, Patterson RE, Neuhouser ML, Elder J. Dietary acculturation: applications to nutrition research and dietetics. J Am Diet Assoc. 2002;102(8):1105–18.CrossRefGoogle Scholar
  57. 57.
    Kandula NR, Lauderdale DS. Leisure time, non-leisure time, and occupational physical activity in Asian Americans. Ann Epidemiol. 2005;15(4):257–65. Scholar
  58. 58.
    Gallegos DN. Exploring weight status, dietary intake and acculturation in South Asian women living in Brisbane, Queensland. Nutr Diet. 2011;68:285–90.CrossRefGoogle Scholar
  59. 59.
    Mathew N. Exploring the Relationship between Physical Activity and Acculturation in U.S. Asian Indian Women Galveston. United States University of Texas Medical Branch: Texas; 2014.Google Scholar
  60. 60.
    Mathew Joseph N, Hanneman SK, Bishop SL. Physical activity, acculturation, and immigrant status of Asian Indian women living in the United States. Appl Nurs Res. 2019;47:52–6.CrossRefGoogle Scholar
  61. 61.
    Yi SS, Beasley JM, Kwon SC, Huang KY, Trinh-Shevrin C, Wylie-Rosett J. Acculturation and activity behaviors in Chinese American immigrants in New York City. Prev Med Rep. 2016;4:404–9.CrossRefGoogle Scholar
  62. 62.
    Kodama S, Tanaka S, Saito K, Shu M, Sone Y, Onitake F, et al. Effect of aerobic exercise training on serum levels of high-density lipoprotein cholesterol: a meta-analysis. Arch Intern Med. 2007;167(10):999–1008.CrossRefGoogle Scholar
  63. 63.
    Monda KL, Ballantyne CM, North KE. Longitudinal impact of physical activity on lipid profiles in middle-aged adults: the Atherosclerosis Risk in Communities Study. J Lipid Res. 2009;50(8):1685–91.CrossRefGoogle Scholar
  64. 64.
    Lucke-Wold B, Misra R, Patel TG. Risk factors for low high-density lipoprotein among Asian Indians in the United States. World J Diabetes. 2017;8(6):297–303.CrossRefGoogle Scholar
  65. 65.
    Eamranond PP, Wee CC, Legedza AT, Marcantonio ER, Leveille SG. Acculturation and cardiovascular risk factor control among Hispanic adults in the United States. Public Health Rep. 2009;124(6):818–24.CrossRefGoogle Scholar
  66. 66.
    Jin K, Gullick J, Neubeck L, Koo F, Ding D. Acculturation is associated with higher prevalence of cardiovascular disease risk-factors among Chinese immigrants in Australia: evidence from a large population-based cohort. Eur J Prev Cardiol. 2017;24(18):2000–8.CrossRefGoogle Scholar
  67. 67.
    Maxwell SE, Cole DA. Bias in cross-sectional analyses of longitudinal mediation. Psychol Methods. 2007;12(1):23–44.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Undergraduate Studies, Cizik School of NursingThe University of Texas Health Science Center at HoustonHoustonUSA
  2. 2.Department of Social and Behavioral Sciences, Robert C. Byrd Health Sciences Center, School of Public HealthWest Virginia UniversityMorgantownUSA
  3. 3.School of NursingThe University of Texas Health Science Center at San AntonioSan AntonioUSA

Personalised recommendations