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Am J Public Health. 2008 November; 98(11): 1979–1986.
PMCID: PMC2575738

Individual and Area-Based Indicators of Acculturation and the Metabolic Syndrome Among Low-Income Mexican American Women Living in a Border Region


Objectives. We sought to examine the relationships between individual and area-based indicators of acculturation and metabolic syndrome (MetS) risk among a sample of Mexican American women living in the California–Baja California border region.

Methods. We examined data collected between October 2003 and December 2004 from 141 women (mean age = 47.07 years) who completed physical and psychosocial assessments. We reviewed medical records for laboratory values.

Results. Individual-level US acculturation was associated with a greater consumption of fruits, vegetables, and fiber; increased odds of engaging in health-enhancing levels of physical activity; and decreased odds of meeting the clinical criteria for MetS. Moreover, beyond the influence of individual-level factors, US neighborhood acculturation was associated with less fat intake.

Conclusions. These findings provide preliminary evidence for a relationship between acculturation and the development of MetS in this population. Such information may assist efforts aimed at understanding and eliminating ethnic disparities in MetS risk and related health conditions.

Metabolic syndrome (MetS) is a clustering of metabolic abnormalities that places individuals at an increased risk of developing cardiovascular disease (CVD), type 2 diabetes, and related complications.1 Although it has been variously defined,2 MetS generally refers to the presence of 3 or more of the following risk factors: central adiposity (large waist circumference), hypertriglyceridemia, reduced high-density lipoprotein cholesterol, elevated resting blood pressure, and hyperglycemia.3

Mexican Americans, and, particularly, Mexican American women,4,5 are at high risk for the development of MetS, with prevalence estimates of 51% to 54% in middle-aged Mexican American women, compared with 33% to 37% in non-Latino White women.6 Obesity (particularly abdominal obesity) and insulin resistance are believed to be the primary physiological mechanisms underlying the development of MetS.79 Notably, behavioral factors could also help explain the high rates of MetS observed among Mexican American women,10 given the central importance of an imbalance of nutrient intake and energy expenditure in understanding these interrelated states.8,11 Thus, research that examines factors predicting diet, exercise, and obesity among Mexican American women may be helpful in understanding their vulnerability to MetS and other related chronic diseases.

Attempts to understand the mechanisms that drive ethnic-specific vulnerabilities in MetS should consider cultural factors, which can shape health through a myriad of pathways.1214 Unfortunately, studying cultural effects on health is complex because of its multifaceted nature, which makes it difficult to adequately define or measure culture.15 This challenge is further compounded in regions of the United States near the border with Mexico, where Mexican cultural influences remain pervasive.

A common approach to assessing the health effects of culture is to examine the related construct of “acculturation.” Although variously defined, acculturation generally refers to changes in the behaviors and cultural values of an individual or group as a result of contact with another culture.16 Although acculturation to the United States has repeatedly been associated with health outcomes in this population, research findings are often conflicting.17 For example, several studies have found an association between US acculturation and poor nutritional choices.1820 However, other studies have reported mixed, beneficial, or no association between acculturation and diet.2123 Similarly conflicting patterns can be found in research exploring the association between US acculturation and physical activity levels,24,25 as well as obesity.2628 Thus, these mixed findings, as well as the paucity of research that has directly examined the association between acculturation and MetS, prohibit clear conclusions.

Finally, to date, most research has focused on individual acculturation indicators and their effects on health. However, extensive literature indicates that community or contextual factors (e.g., accessibility to sidewalks, heart-healthy foods, and recreational facilities) are associated with health outcomes in minority populations beyond the impact of individual influences.29,30 Few studies have explored the association between area-based proxies of acculturation and health. Although the limited research available suggests that heart-healthy resources are more accessible in neighborhoods with higher concentrations of non-Latino Whites,31 for Mexican Americans, ethnic enclaves could foster social and community integration, which may improve their resiliency to disease.29,32,33 Hence, a consideration of contextual factors may provide a more complete picture of the relationship between acculturation and health outcomes, including the MetS.

We examined the relationships between individual and area-based indicators of acculturation and the prevalence of MetS and related behavioral factors in low-income Mexican American women living in a border community. To our knowledge, this is the first study to examine the association between MetS prevalence and acculturation in Mexican Americans. In addition, we addressed some of the limitations that have been noted in relation to previous studies on acculturation and health.15,17 Specifically, we included multiple indicators of acculturation, focused on a specific high-risk Latino subgroup, controlled for differences in socioeconomic status (SES), and accounted for the influence of contextual factors on MetS risk and prevalence.



We examined archival data from South San Diego Women's Health Study (2003–2004), a study of socioemotional factors in CVD health disparities. A total of 145 participants were recruited from community health centers near the San Diego–Tijuana border—a region strongly influenced by both Mexican and US cultural elements.

Women were eligible if they were patients of the clinic, aged 35 to 65 years (which represents a time of increasing CVD risk for women), and able to read and write in Spanish or English. Exclusionary conditions included pregnancy; history of or current CVD; renal, liver, or serious mental disease; substance dependence; use of medications known to affect the autonomic nervous system; and living in a group home. Of the 201 women screened, 175 were eligible. Approximately 93% (n = 162) agreed to participate, with a drop-out rate of 9% (n = 16), resulting in an 83% participation rate. Reasons for dropping out included leaving the clinic before the completion of the survey and asking to return another day but failing to do so. Four women were excluded from the current study because they were not of Mexican origin, for a final sample of 141.

Because laboratory data were not available for all participants, the relationship between acculturation and MetS prevalence was examined in a subset of the sample (n = 67). Participants included in this aspect of the study did not differ from the remainder of the sample in regards to health care access, education, income, and acculturation level (all P > .10). However, women included in this aspect of the study were significantly older than the remainder of the sample (mean age = 48.45 ±8.77 years compared with 45.67 ±7.65 years; P < .05).


Patients were recruited from the clinic waiting rooms by a Mexican American community health worker, and interested women were then screened for eligibility by bilingual and bicultural research assistants. Standardized procedures were used to measure waist circumference and blood pressure. Next, participants completed a survey battery in their language of preference. The remaining physical risk factors were abstracted from patients’ medical charts. All participants provided written informed consent.



The acculturation rating scale for Mexican Americans, revised (ARSMA-II),34 measures orientation toward Mexican (17 items) and Anglo cultures (13 items), yielding 2 subscales. Respondents indicate their general feelings toward Anglo or Mexican culture on a 5-point Likert scale ranging from 1 (not at all) to 5 (extremely often). A mean score for each subscale is calculated, with higher scores indicating greater Mexican or Anglo acculturation. Internal consistency for both scales was adequate (α = 0.82 for the Mexican orientation scale and α = 0.89 for the Anglo orientation scale). Years since participants made the United States their permanent home was used to assess participants’ exposure to the United States (set equal to age for those born in the United States; n = 11). Geographic information systems data (census tract level) were used to create an area-based proxy of acculturation, based on census tract level variables that paralleled the information currently used in self-report acculturation measures. Extracted variables included percentage of foreign-born individuals, percentage of foreign-born individuals that arrived within 10 years prior to census, and percentage of Spanish-speaking households that reported speaking English less than very well. A principal components analysis (with direct oblimin rotation) showed that a single factor described the area-based items (Eigen value = 2.37; 79.14% of item variance explained; all factor loadings > 0.70). Thus, the items were standardized (i.e., mean = 0; SD = 1), summed, and reflected to represent neighborhood level of US acculturation. Bivariate associations among the items ranged from r at 0.60 to r at 0.78, and internal consistency was adequate (α = 0.87).

MetS components.

Systolic and diastolic blood pressure were measured with the Omron HEM-705CP, an oscillometric automatic measurement device (Omron, Vernon Hills, IL), via standard research procedures.35 Waist circumference was assessed with a flexible tape measure positioned in a horizontal plane on the patient's bare abdomen at the narrowest part of the torso. Medical records were reviewed for high-density lipoprotein cholesterol (HDL cholesterol), serum triglycerides, and plasma glucose, recorded within 3 years of the enrollment date. Some participants were seen only once at the clinic (e.g., for flu shots or pelvic exams; n = 31), and others did not have recent laboratory assessments. Thus, lipids and plasma glucose were only available for a subset of patients (n = 63 for triglycerides; n = 61 for HDL cholesterol; n = 74 for plasma glucose). On average, lipids and plasma glucose were assayed 6.16 months (SD = 9.28) and 6.29 months (SD = 8.93) prior to enrollment, respectively.

The Adult Treatment Panel III of the National Cholesterol Education Program's clinical criteria,3 with modifications set forth by the American Heart Association and the National Heart, Lung, and Blood Institute,2 were used to create a dichotomous MetS variable. Although it has been suggested that the presentation of the MetS may vary across ethnic groups,36 we did not use ethnic-specific cutoffs, because to our knowledge, such have not been established for Latino women.37 A code of 1 indicated the presence of 3 or more of the following: waist circumference over 88 cm, serum triglycerides at or above 150 mg/dL, HDL cholesterol less than 50 mg/dL, systolic blood pressure at or above 130 mm Hg or diastolic blood pressure at or above 85 mm Hg, and plasma glucose at or above 100 mg/dL. In addition, individuals who did not display high values for a component but were on drug treatment for a related condition (e.g., elevated glucose or hypertension) were presumed to meet criteria for the component in question. Finally, individuals were only included in this aspect of the study when sufficient data points were available to determine the presence or absence of the syndrome.

Behavioral factors associated with energy imbalance.

Two brief screening instruments (27 total items) developed by Block et al.38 and culturally adapted and translated in previous studies31 were used to assess dietary patterns. These screeners were used to measure respondents’ consumption of fruit and vegetable servings and grams of fiber (fruit and vegetable screener), as well as total fat (meat and snack screener). Response choices ranged from 0 (less than once per week) to 5 ( ≥2 times per day) for the fruit and vegetable screener and 0 (less than once per month) to 4 ( ≥5 times per week) for the meat and snack screener. Alpha coefficients for the 2 screeners were 0.74 and 0.89, respectively. Physical activity was measured with the Spanish and English short versions of the International Physical Activity Questionnaire.39 The questionnaire assesses multiple domains of physical activity, including work-related activity. A dichotomous variable was created with guidelines from the European Network for the Promotion of Health-Enhancing Physical Activity (HEPA).40 Women categorized as “HEPA active” were those who met the following criteria: engaged in vigorous-intensity activity on at least 3 days per week (achieving ≥ 1500 standard metabolic equivalent [MET]-min/wk), or any combination of walking, moderate, and vigorous-intensity activity 7 days per week (accumulating ≥ 3000 MET-min/wk).


Self-reported date of birth was used to calculate age at assessment. Reported education level was coded as less than 8th grade or secondary education,1 8th grade or secondary education,2 high school or general educational development diploma,3 or college degree or higher.4 Reported household monthly income was coded into 9 categories, ranging from 1 ( < $700) to 9 ( ≥ $3500). A dichotomous variable (coded 0, 1) was created to indicate menopausal status (participants who had not menstruated in 12 months were considered postmenopausal). Finally, although place of birth is commonly used as a proxy of acculturation, only 8% of the total sample reported US nativity (n = 11); therefore, the variable was included as a covariate rather than an acculturation indicator.


Descriptive statistics were calculated, and all variables were examined for deviations from normality. The distribution for plasma glucose was positively skewed and kurtotic because of 4 extreme outliers (> 3 standard deviations above the mean). All other distributions approached normality. One participant was not included in analyses concerning weight circumferences because of inconsistencies between weight circumference and body mass index that suggested a measurement or coding error. Pearson product-moment and point-biserial correlations were calculated to examine relationships between acculturation indices and SES indicators.

Although hierarchical linear modeling is typically employed when working with multilevel data, preliminary analyses with HLM 6.04 (Scientific Software International, Inc, Lincolnwood, IL) indicated nonsignificant variability at the census-tract level and that, congruently, parameter estimates at this level were unreliable. This reflects the fact that sampling was not stratified, which resulted in inconsistent numbers of participants across census tracts. Therefore, multiple regression analyses (linear and binary logistic) with SPSS 15.0 (SPSS Inc, Chicago, IL) were used to test whether (1) individual-level indicators of acculturation were associated with behavioral factors and MetS prevalence, and (2) after accounting for individual-level acculturation, neighborhood acculturation related to these outcomes.2 Separate analyses were conducted for each outcome with predictors entered in blocks, as follows: (1) covariates, (2) individual-level acculturation indices, and (3) neighborhood acculturation.

Acculturation indices, age, and monthly household income were standardized (mean = 0; SD = 1), and education was centered (mean = 0) prior to analyses. Age, education level, monthly household income, and place of birth were included as covariates in all analyses. Menopausal status was included in analyses concerning MetS prevalence. The expectation maximization algorithm41 was used to impute missing data for key demographics (i.e., 8 values for household income, 4 values for place of birth, and 1 value for education). All other missing data were excluded on a pair-wise basis.


Participant Characteristics

Table 1 describes the demographic characteristics of the sample. The sample was low in SES, with almost 40% reporting monthly household incomes of less than $1099. Most women (92%) had immigrated to the United States, and fewer than 20% immigrated as children (i.e., before age 18 years). A majority (93%) completed the survey in Spanish.

Sample Sociodemographic Characteristics: South San Diego Women's Health Study, 2003–2004

Descriptive Statistics

Table 2 shows descriptive statistics for the primary independent and dependent variables. The mean Mexican orientation score was high (4.32 ±0.47), indicating solid ties to the Mexican culture, whereas the mean Anglo orientation scale score of 2.61 (±0.82) suggested that, overall, the sample did not identify strongly with the Anglo culture. The level of neighborhood acculturation was observed to vary among participants.

Sample (N = 141) Descriptive Statistics of Primary Independent and Dependent Variables: South San Diego Women's Health Study, 2003–2004 ...

Associations Between Acculturation Indices and Socioeconomic Indicators

Bivariate associations between acculturation indices were small to moderate, with r ranging from 0.12 to 0.47, suggesting nonredundancy of variables. Anglo orientation scale scores were also significantly associated with education (r = 0.28) and household income (0.20; both P < .05). No other significant associations were observed between SES and acculturation indices.

Acculturation and Behavioral Factors Associated With Energy Imbalance

Tables 3 and and44 show the results from analyses regressing behavioral factors related to energy imbalance on individual-and neighborhood-level acculturation. After adjusting for covariates, higher Anglo orientation scale scores were significantly associated with the consumption of more fruits and vegetables (P < .01), and the individual-level acculturation indices in aggregate accounted for 7.6% of the variance in fruit and vegetable servings per day (ΔF[1133] = 3.83; P < .01). Higher Anglo orientation scale scores were also related to consumption of more fiber (P < .05). However, as a group, the individual-level acculturation indices did not contribute significantly to the model for fiber (ΔR2 = 0.04; ΔF[1133] = 2.02; P > .10). This likely arises from the fact that the Mexican orientation scale and US exposure variable were not statistically significant predictors. Beyond the influence of individual indicators of acculturation, US neighborhood acculturation was associated with decreased consumption of fat (ΔR2 = 0.05; ΔF [1132] = 8.01; P < .01), accounting for 5% of the total variance in this outcome.

Results From Hierarchical Multiple Linear Regression Analyses Regressing Dietary Factors on Socioeconomic Status And Individual- And Neighborhood-Level Acculturation: ...
Results From Hierarchical Multiple Logistic Regression Analyses Regressing Physical Activity and Metabolic Syndrome Prevalence On Socioeconomic and Individual ...

Finally, higher Anglo orientation scale scores were significantly associated with a greater likelihood of engaging in health-enhancing physical activity. Specifically, the odds of meeting HEPA criteria increased by a factor of 1.57 for every standard deviation increase on the Anglo orientation scale (P = .05). However, in the aggregate, the individual-level acculturation indices did not contribute significantly to the model (ΔR2 = 0.07; χ2 = 6.45; df = 3; P > .05), and consistent with the analyses of diet, neither Mexican orientation scale scores nor US exposure were statistically significant predictors. Neighborhood acculturation did not contribute significantly to physical activity levels.

Acculturation and the Prevalence of MetS

As shown in Table 4, after accounting for covariates, higher Anglo orientation scale scores were associated with decreased likelihood of meeting clinical criteria for the MetS (P < .05). Specifically, the odds of meeting Adult Treatment Panel III criteria for the MetS increased by a factor of 2.61 for every standard deviation decrease on the Anglo orientation scale. In the aggregate, individual-level acculturation indicators accounted for 13.2% of the variance in prevalence of the MetS (χ2 = 8.51; df = 1; P < .05). US neighborhood acculturation did not contribute significantly to the model.


In this sample of low-SES, middle-aged women living along the California–Mexico border, individual-level US acculturation (i.e., Anglo cultural orientation) was associated with increased consumption of fruits, vegetables, and fiber; increased odds of engaging in health-enhancing levels of physical activity; and decreased odds of meeting clinical criteria for MetS. Moreover, beyond the influence of individual-level factors, women living in more-US-acculturated neighborhoods reported lower fat consumption.

To our knowledge, this is the first study to address the association between acculturation and MetS in Mexican American women. More generally, few studies to date have examined the association between psychosocial variables and MetS risk.42 Among those that have,43,44 including a study in the current cohort,45 low SES has at times been associated with higher MetS risk. Given the positive association between US acculturation and SES,46 upward socioeconomic mobility may help explain the protective relationships suggested by this study. However, acculturation effects were shown to be independent of education and income, suggesting the presence of additional pathways. Such pathways may include English language acquisition,4749 increased access to heart-healthy food options,21 as well as recreational facilities.50 Moreover, US acculturation may represent a reduction in exposure to certain types of stress that may impact MetS risk more directly through physiological mechanisms.51 The significance of these pathways in explaining the observed relationships remains to be tested.

Notably, our findings conflict somewhat with the dominant trends in the literature, which have tended to associate US acculturation with deleterious health effects. It has been theorized (but not always demonstrated) that US acculturation diminishes protective cultural practices and fosters the adoption of unhealthful behaviors.17 We addressed some of the inconsistencies that have contributed to mixed findings in this area by focusing on a discrete population, controlling for SES, and including a more comprehensive assessment of acculturation.15 However, given the exponential rise in deleterious health behaviors, obesity, and related-health conditions in urbanized areas of Latin America,5254 the specific characteristics of the migrant's region of origin may play a more prominent role in the acculturation–health dynamic. Whether the characteristics of communities from which immigrants originate moderate the relationship between acculturation and MetS risk is an additional direction for future research.

It is also important to note that our study was conducted in a border community in which mainstream culture represents an amalgamation of Mexican and Anglo cultural characteristics.25 The acculturation process may be very different for individuals residing in border communities compared with those settling into communities more distant from Mexico. Thus, in addition to the characteristics of sending communities, the social context of settlement regions should also be considered when interpreting the health implications of acculturation. Supporting this theory, studies that have explored the association between acculturation and diet in similar geographic regions as that sampled in this study also reported health-protective effects of acculturation.21,55

Finally, although the study included various indicators of acculturation, only the ARSMA-II's Anglo cultural orientation scale and the area-based index of US acculturation were significantly associated with outcomes of interest. It should be noted that the current sample's high identification with Mexican culture might have limited the ability to capture health effects of this aspect of cultural orientation. However, the findings provide some important information regarding the measurement of acculturation. First, measures of acculturation that are designed to capture multiple dimensions of the construct have higher predictive utility than do proxy indicators, which may be limited in their ability to capture the processes underlying the relationships between acculturation and health.25 Second, beyond the influence of individual-level factors, area-based measures of acculturation may provide valuable information regarding the role of contextual factors in explaining this population's vulnerability to the MetS.


Causation cannot be established because of the cross-sectional nature of this study. However, the probability of reverse causation is not likely, given the nature of the variables studied (i.e., MetS risk is not likely to influence acculturation). Other limitations to the generalizibility of this study's findings include the use of a nonrandom sample, the exclusion of males, and the fact that laboratory tests were not available for the entire sample. Notably, women who were referred for laboratory tests were older, and hence, may have been perceived to be at greater risk by their physician. Furthermore, the use of stratification during sampling would have enabled the use of analytic methods designed to analyze clustered data, which could have produced a more powerful examination of contextual effects.

Future Directions and Conclusions

Our study suggests that, among low-income Mexican American women living in a border region, US acculturation is associated with decreased risk for MetS via behavioral and physiological pathways. Although only preliminary because of the methodological limitations, these findings warrant further exploration of the influence of acculturation on MetS risk on this and other vulnerable populations (e.g., Mexican American males, non-Mexican Latinos). In addition, research is needed to identify the pathways by which acculturation may yield its influence on MetS risk. Finally, these results highlight the importance of accounting for differences in social context (e.g., proximity to country of origin and neighborhood acculturation level) in future explorations of the relationship between acculturation and health. Such efforts are warranted in attempts to understand and eliminate ethnic disparities in MetS and related health outcomes.


K. Espinosa de los Monteros is supported by a Ruth L. Kirschstein National Research Service Award (1 F31 HL087732-02) from the National Institutes of Health (NIH). This study was supported by San Diego State University's Minority Research Infrastructure Support Program, funded by NIH (grant 1 R24 MH065515), and by NIH (grants 1 R01 HL081604 and HHSN268200625237C). All authors were partially supported by a grant (P60 MD0020) from the San Diego EXPORT Center, National Center of Minority Health and Health Disparities, National Institutes of Health, during preparation of this article.

We are grateful to the staff at San Ysidro Health Center, and particularly Patricia Quintana and Maria Luisa Hernandez for their assistance and ongoing support of our research efforts. We are thankful to Marisol Arroyo, Daniela Barajas, Gabriel Crosthwaite, Iran Garcia, Betania Guerra, Sjouke Liem, Gissele Lopez, Maria-Elena Montellano, Mabel Ribas, Alexis Romero, Nadia Salas, Martha Solorzano, Hilda de la Torre, Virgina Ferent, and Jorge Urbina for their assistance with data collection, entry, and processing. Finally, we are thankful to Luis H. Favela for his detailed review of the article and constructive criticism.

Human Participant Protection

All procedures were approved by the San Diego State University and University of California, San Diego, institutional review boards.


Peer Reviewed


K. Espinosa de los Monteros conceptualized the study, led the writing, and completed the analyses. L. C. Gallo supervised the study and assisted in all areas, including the study design, analyses, and writing and editing of the article. J. P. Elder and G. A. Talavera assisted with writing and editing the article.


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