The Association Between Acculturation and Diet and Physical Activity Among Pregnant Hispanic Women with Abnormal Glucose Tolerance

Abstract

Background:

Hispanic women are disproportionately affected by gestational diabetes mellitus (GDM), yet few studies have assessed the impact of acculturation on health behaviors that may reduce GDM risk.

Materials and Methods:

We assessed relationships between acculturation and meeting American Diabetes Association guidelines for macronutrient intake and American College of Obstetricians and Gynecologists guidelines for physical activity (PA) using baseline data from Estudio Project Aiming to Reduce Type twO diabetes, a randomized trial conducted in Massachusetts (2013–2017) among 255 Hispanic pregnant women with hyperglycemia. Acculturation was assessed via the Psychological Acculturation Scale, duration of time and generation in the continental United States, and language preference; diet with 24-hours dietary recalls; and PA with the Pregnancy Physical Activity Questionnaire (PPAQ).

Results:

The majority of participants who reported low psychological acculturation (74.9%), preferred English (78.4%), were continental U.S. born (58.0%), and lived in the continental United States ≥5 years (91.4%). A total of 44.8%, 81.8%, 22.9%, and 4.6% of women met guidelines for carbohydrate, protein, fat, and fiber intakes, respectively; 31.9% met guidelines for PA. Women with higher acculturation were less likely to meet carbohydrate guidelines (English preference: adjusted risk ratios [aRR] 0.45, 95% confidence intervals [CI] 0.23–0.75; U.S. born: aRR 0.60, 95% CI 0.36–0.91; duration of time in United States: aRR 0.96, 95% CI 0.92–0.99). Women with higher acculturation were more likely to meet PA guidelines (U.S. born: aRR 1.95, 95% CI 1.11–3.44).

Conclusions:

In summary, higher acculturation was associated with lower likelihood of meeting dietary guidelines but greater likelihood of meeting PA guidelines during pregnancy. Interventions aimed at reducing GDM in Hispanics should be culturally informed and incorporate acculturation. Clinical Trial Registration: clinicaltrials.gov NCT01679210.

Introduction

Acculturation and cultural factors play significant roles in health disparities among Hispanic women, compared with non-Hispanic White women.^1,2 Acculturation is defined as the process by which an individual's cultural behaviors and values may change due to acclimatizing to a new cultural setting. Higher acculturation has been associated with adverse pregnancy outcomes (e.g., preterm birth, preeclampsia, and gestational hypertension) regardless of self-described race or ethnicity, but little is known about why these disparities occur.³

More than 53 million Hispanics currently live in the United States, making up 17% of the total U.S. population and representing the fastest growing ethnic population; Hispanics are expected to constitute 30% of the total U.S. population by 2050.^4,5 Hispanics are a diverse ethnic population, varying in race, national origin, immigration status, and socioeconomic characteristics. The “Hispanic paradox” is a relevant concept from observational studies where Mexican immigrants have more favorable health status than anticipated relative to poor economic profiles.⁶ More recent findings have demonstrated that the “Hispanic paradox” does not apply to Puerto Ricans, consistent with the significant ethnic heterogeneity and health disparities observed among Hispanic subgroups.⁷

Puerto Ricans are the second largest U.S. Hispanic subgroup, with a population growth rate three times higher than the general U.S. population.⁸ Inequities in social and physical environmental conditions experienced by Puerto Ricans favor unhealthy nutrition and inactivity and are consistent with higher rates of diabetes and obesity observed in Puerto Ricans as compared with Mexicans and non-Hispanic Whites.^9,10

Hispanic women are disproportionately affected by gestational diabetes mellitus (GDM) and subsequent type 2 diabetes mellitus (T2DM), compared with non-Hispanic women.¹¹ In addition to subsequent increased T2DM, women experiencing GDM are prone to other pregnancy complications, including cesarean delivery, preeclampsia, and postpartum hemorrhage.^12

–16 Their offspring are at increased risk of developing obesity and T2DM later in life.¹⁷ Given these adverse maternal and infant outcomes, it is important to understand the role that risk factors such as acculturation play, yet its role in the development of GDM is sparse.¹¹

Among Hispanic populations in the United States, foreign-born women have higher risks of developing GDM that is not attributable to obesity alone.^18,19 Migrant women may be more prone to GDM due to dietary acculturation, lack of physical activity, and weight gain after migration to high-income countries.²⁰ Previous literature on associations between acculturation and dietary behaviors^21

–24 and physical activity^21,22,25 among Hispanic pregnant women is sparse and conflicting, and has largely been conducted among women of Mexican descent.^21

–25 Prior studies of acculturation and dietary behaviors in this population have focused primarily on vegetable and fruit consumption and total fat; few have examined protein or carbohydrate intake, nor measured adherence to meeting dietary guidelines.^21

–24 Similarly, the majority of studies of acculturation and physical activity have not assessed meeting physical activity guidelines.^21,22,25 Finally, studies have primarily focused on only one or two proxies of acculturation (e.g., length of time in the United States, birth place, or preferred language) and have not considered psychological acculturation.

Proxies treat acculturation as a concurrent movement away from culture of origin toward the new culture.²⁶ In contrast, the Psychological Acculturation Scale is a bidimensional scale that focuses on psychological attachment to both cultures,²⁷ and may be preferable, as it incorporates the individual's unique psychological response to cultural exposures and allows for identification with both cultures.

Therefore, the objective of this study was to assess associations between acculturation (measured via psychological acculturation, duration of time and generation in the continental United States, language preference) and meeting American Diabetes Association (ADA) guidelines for macronutrient and fiber intakes and American College of Obstetricians and Gynecologists (ACOG) guidelines for physical activity among pregnant Hispanic women at risk for developing GDM. We hypothesized that women with higher acculturation to the U.S. culture would be (1) less likely to meet ADA guidelines for macronutrient intakes and (2) less likely to meet ACOG-recommended guidelines for physical activity, compared with women with lower levels of acculturation.

Materials and Methods

Study population and design

We used baseline data from the Estudio Project Aiming to Reduce Type twO (PARTO) diabetes, a randomized controlled trial conducted from January 2013 to December 2017 at Baystate Medical Center in Western Massachusetts. Estudio PARTO was designed to test the efficacy of a lifestyle intervention to reduce risk factors for the development of type 2 diabetes and cardiovascular disease in postpartum Hispanic (predominantly Puerto Rican) women with abnormal glucose tolerance during pregnancy and has been previously described.²⁸ Estudio PARTO did not collect information about study participant's specific country of origin, however, based on U.S. census data in Springfield, Massachusetts, the majority of women were of Puerto Rican ancestry.²⁹

Briefly, women were recruited by bilingual/bicultural health educators at the time of routine prenatal screening for GDM (24–28 weeks gestation). Hispanic women with a blood glucose ≥140 mg/dL on the nonfasting 50-g oral glucose tolerance test were eligible for inclusion. Hispanic ethnicity was self-reported by participants. Women were excluded if they had a history of type 1 or type 2 diabetes, heart disease, chronic renal disease, inability to consume low-fat/high-fiber diet, inability to engage in moderate physical activity, or were less than 18 years of age or greater than 45 years of age. Sociodemographic, behavioral, and clinical characteristics were abstracted from medical records and/or collected at the time of recruitment via standardized questionnaire. All women included in the study were required to sign written informed consent, as approved by the Institutional Review Board of the University of Massachusetts-Amherst and Baystate Medical Center.

Assessment of acculturation

Acculturation was assessed with several measures, including the Psychological Acculturation Scale (PAS),²⁷ duration of time in the continental United States, language preference, place of birth, and generation in the continental United States. PAS is a bidimensional scale that measures psychological attachment to both mainstream Anglo and Latino culture via 10 items using a Likert scale from 1 to 5, and allows for identification with both cultures. Example questions include “with which group of people do you feel you share most of your beliefs and values” and “which culture do you feel proud to be a part of.” Responses on each item were totaled and a mean overall acculturation score was calculated (possible range from 1 to 5). The PAS has high internal consistency in Spanish (0.90) and English (0.83) in Puerto Rican populations.²⁷

The mean overall acculturation score was considered as a continuous variable and also categorized as a 2-level and 3-level variable, respectively. For the 2-level variable, psychological acculturation score less than 3 was considered low acculturation, while scores of 3 or greater were considered high acculturation.²⁷

Generation in the continental United States was defined as first (participant born outside the continental United States), second (at least one parent born outside the continental United States), or third (at least two grandparents born outside the continental United States). Duration of time in the continental United States was considered as both a continuous and categorical (e.g., <5, 5–10, >10 years) variable.

Dietary intake

Dietary intake was assessed by trained bicultural/bilingual personnel via three unannounced 24-hour dietary recalls during the 2-week period after the baseline assessment by phone.³⁰ Meeting ADA guidelines for carbohydrate, protein, fat, and fiber intakes were defined as 50%–60% of daily energy from carbohydrate, 10%–20% from protein, 25%–30% from fat, and 28 g of fiber intake daily, respectively.

Physical activity

Physical activity was assessed using the PPAQ.³¹ The PPAQ is a semiquantitative instrument, previously shown to be valid and reliable in this population. The PPAQ measures duration and intensity of time spent in household/caregiving, occupational, transportation, and sports/exercise activities.²⁹ The number of minutes spent in each reported activity was multiplied by its metabolic equivalent of task (MET) level and summed to arrive at an estimate of average MET-hours per week.

Each activity was classified by intensity: sedentary (<1.5 MET), light (1.5–<3.0 MET), moderate (≥3–<6.0 MET), or vigorous (≥6.0 MET) and the average number of MET hours per week expended in each intensity level were calculated. Meeting ACOG guidelines was categorized as ≥7.5 MET hours per week of moderate–vigorous sports and exercise.³²

Assessment of covariates

We collected information on age, parity, marital status, insurance status, education level, and smoking status, at enrollment via standardized questionnaires. Prepregnancy body mass index (BMI), history of GDM diagnosis, and glucose tolerance in pregnancy were abstracted from the medical record. Glucose tolerance in pregnancy was categorized as blood glucose ≥140 mg/dL on the nonfasting oral glucose tolerance test with (1) isolated hyperglycemia (no abnormal result), (2) impaired glucose tolerance (one abnormal result), or (3) GDM (two or more abnormal results) as defined by the ADA.^33,34

Statistical analysis

Categorical variables are expressed as raw numbers and percentages, while continuous variables are expressed as mean ± standard deviation for data with normal distribution, and median ± interquartile range for nonparametric data. Fisher's Exact and Chi square tests were used to identify differences between categorical covariates, and two-sample t-tests or rank-sum tests were used to compare continuous variables. To assess the impact of acculturation on meeting ADA guidelines for macronutrient and fiber intake and ACOG guidelines for physical activity, unadjusted and multivariable logistic regression models were used. We considered potential confounders if they resulted in a greater than or equal to 10% change in the coefficients for acculturation, using the change-in-estimate approach,³⁵ as well as factors that were deemed clinically significant a priori, such as age and pregravid BMI.

Odds ratios (OR) were used to approximate relative risk with accompanying 95% confidence intervals (CI), with the application of statistical correction if the incidence of the outcome was more than 10% and the OR was >2.5 or <0.5.³⁶ Statistical analysis was performed using STATA version 14.2 (StataCorp LP; College Station, TX, USA). All p-values were two sided, with a significance threshold of p < 0.05.

Results

A total of 255 women were eligible for inclusion. Participants were, on average, 27.6 years of age with mean BMI in the obese range (30.6 kg/m²). The majority were multiparous (72.7%) and publicly insured (81.6%). In terms of acculturation, three-quarters (74.9%) reported low psychological acculturation. The preferred language spoken was English (78.4%), and 58.0% were born in the continental United States. Approximately 8.6% of women in the study population had lived in the continental United States for <5 years.

Women with low psychological acculturation were more likely to list Spanish as their preferred language (28.3% vs. 15.6%, p < 0.001), to be born outside the continental United States (48.9% vs. 20.3%, p < 0.001), to have lived in the United States for a shorter period (19.7 vs. 26.4 years, p < 0.001), and to be first generation in the continental United States (48.9% vs. 20.3%, p < 0.001), than women with high psychological acculturation (Table 1).

Table 1.

Participant Characteristics According to Psychological Acculturation Status; Estudio Project Aiming to Reduce Type twO 2013–2017

Demographics	Low psychological acculturation (PAS <3), (n = 191)	High psychological acculturation (PAS ≥3), (n = 64)	p
Maternal age (mean ± SD)	27.4 (±5.8)	28.3 (±5.7)	0.29
Parity, n (%)
Nulliparous	52 (27.2)	19 (29.7)	0.70
Multiparous	139 (72.8)	45 (70.3)	0.70
Marital status, n (%)
Never married	136 (71.2)	41 (64.1)	0.72
Married	43 (22.5)	19 (29.7)
Separated	3 (1.6)	1 (1.6)
Divorced	7 (3.7)	3 (4.7)
Widowed	1 (0.5)	0 (0)
Insurance type, n (%)
No insurance	1 (0.5)	0 (0)	0.09
Private	19 (9.9)	13 (20.3)
Public	162 (84.8)	46 (71.9)
Both	8 (4.2)	5 (7.8)
Do not know/refused	1 (0.5)	0 (0)
Education level, n (%)
Less than high school	59 (30.9)	13 (20.3)	0.15
High school grad/GED	46 (24.1)	22 (34.4)
Post high school	86 (45.0)	29 (45.3)
Pregnancy smoking status, n (%)
None	145 (75.9)	47 (73.4)	0.82
≤10 cigarettes/day	41 (21.5)	16 (25.0)
>10 cigarettes/day	5 (2.6)	1 (1.6)
Prepregnancy BMI (mean ± SD)	30.6 (±8.1)	31.5 (±8.1)	0.42
History of diagnosis of GDM, n (%)	22 (11.5)	10 (15.6)	0.39
Glucose tolerance, n (%)
Normal glucose tolerance	6 (3.1)	0 (0)	0.24
IHG	86 (45.0)	26 (40.6)
IGT	39 (20.4)	11 (17.2)
GDM	57 (29.8)	27 (42.2)
Preferred language, n (%)
English	137 (71.7)	63 (98.4)	<0.001
Spanish	54 (28.3)	1 (15.6)	<0.001
Place of birth, n (%)
Continental United States	97 (51.1)	51 (79.7)	<0.001
Other	93 (48.9)	13 (20.3)	<0.001
Generation in the United States^a, n (%)
First generation	93 (48.9)	13 (20.3)	<0.001
Second generation	63 (33.2)	37 (57.8)
Third generation	34 (17.9)	14 (21.9)
Duration of time in the continental United States (years, Mean ± SD)	19.7 (±9.6)	26.4 (±6.9)	<0.001
Duration of time in the continental United States, years, n (%)
<5	21 (11.0)	0 (0)	0.002
5–<10	11 (5.8)	1 (1.6)
≥10	159 (83.2)	63 (98.4)

Values less than 0.05 were bolded to highlight statistical significance.

All data are presented as n (%) or mean (SD). PAS is defined as psychological acculturation.

Generation was defined as first (participant born outside the continental United States), second (at least one parent born outside the continental United States), or third (at least two grandparents born outside the continental United States).

BMI, body mass index; GDM, gestational diabetes mellitus; IGT, impaired glucose tolerance; IHG, isolated hyperglycemia; SD, standard deviation.

A total of 44.8%, 81.8%, 22.9%, and 4.6% met ADA guidelines for carbohydrate, protein, fat, and fiber intakes, respectively. In bivariable analyses, women with low psychological acculturation had lower average energy from fat than those with high acculturation (31.0 vs. 33.4, p = 0.04), but did not differ significantly by carbohydrate, protein, or fiber intake (Table 2). Similarly, there was no statistically significant difference in the percentage of women meeting ADA guidelines for macronutrient intake by psychological acculturation status (Table 2).

Table 2.

Dietary Intake by Acculturation; Estudio Project Aiming to Reduce Type twO 2013–2017

Dietary outcomes	Total (n = 192)	Low psychological acculturation (PAS <3), (n = 142)	High psychological acculturation (PAS ≥3), (n = 50)	p
Dietary intake by percentage of content
Percentage of energy from carbohydrate	52.2 ± 8.8	52.9 (±8.3)	50.1 (±10.1)	0.06
Percentage of energy from protein	16.2 ± 4.0	16.1 (±3.9)	16.4 (±4.4)	0.61
Percentage of energy from fat	31.6 ± 7.1	31.0 (±6.7)	33.4 (±8.1)	0.04
Meeting ADA recommendations for macronutrients; n (%)
Carbohydrate guideline: 50%–60% of energy from Carbohydrates
Met	86 (44.8)	69 (48.6)	17 (34.0)	0.07
Did not meet	106 (55.2)	73 (51.4)	33 (66.0)	0.07
Protein guideline: 10%–20% of energy from protein
Met	157 (81.8)	118 (83.1)	39 (78.0)	0.42
Did not meet	35 (18.2)	24 (16.9)	11 (22.0)	0.42
Fat guideline: 25%–30% of energy from fat
Met	44 (22.9)	34 (23.9)	10 (20.0)	0.60
Did not meet	148 (77.1)	108 (76.1)	40 (80.0)	0.60
Fiber intake guideline: 28 g daily
Met	9 (4.7)	8 (5.6)	1 (2.0)	0.45
Did not meet	183 (95.3)	134 (94.4)	49 (98.0)

Values less than 0.05 were bolded to highlight statistical significance.

All data are reported as mean (SD) or n (%). PAS is defined as psychological acculturation.

In logistic regression analyses, duration of time in the continental United States was inversely associated with meeting ADA guidelines for carbohydrate intake (adjusted risk ratios [aRR] 0.96, 95% CI 0.92–0.99; Table 3). Additionally, duration of time living in the continental United States between 5 and <10 years was inversely associated with meeting ADA guidelines for protein intake (aRR 0.14, 95% CI 0.03–0.79). Women who preferred English were less likely to meet ADA guidelines for carbohydrate intake than women that preferred Spanish (aRR 0.45, 95% CI 0.23–0.75). Women born in, versus outside, the continental United States were less likely to meet ADA guidelines for carbohydrate intake (aRR 0.60, 95% CI 0.36–0.91). Second-generation women were less likely to meet carbohydrate guidelines (aRR 0.45, 95% CI 0.24–0.87) compared with first-generation women (Table 3). There was no association between psychological acculturation (RR 0.55, 95% CI 0.28–1.10) and meeting ADA guidelines for carbohydrate intake. We did not observe significant associations between any of the acculturation variables and meeting ADA guidelines for protein, fat, or fiber intake.

Table 3.

Unadjusted and Adjusted Risk Ratios for Acculturation and Meeting American Diabetes Association Guidelines for Macronutrient Intake; Estudio Project Aiming to Reduce Type twO 2013–2017

	Meeting guidelines for macronutrient intake
	Cases, n (%)	Meeting carb goal RR (95% CI)	Meeting carb goal aRR (95% CI)	Cases, n (%)	Meeting protein goal, RR (95% CI)	Meeting protein goal, aRR (95% CI)	Cases n (%)	Meeting fat goal RR (95% CI)	Meeting fat goal aRR (95% CI)	Cases, n (%)	Meeting fiber goal RR (95% CI)	Meeting fiber goal aRR (95% CI)
Psychological acculturation (categorical)
Low (PAS <3)	69 (48.6)	Reference (1.0)	Reference (1.0)	118 (94.4)	Reference (1.0)	Reference (1.0)	34 (23.9)	Reference (1.0)	Reference (1.0)	8 (5.6)	Reference (1.0)	Reference (1.0)
High (PAS ≥3)	17 (34.0)	0.55 (0.28–1.07)	0.55 (0.28–1.10)	39 (97.5)	0.72 (0.32–1.61)	0.66 (0.28–1.52)	10 (20.0)	0.79 (0.36–1.75)	0.79 (0.35–1.75)	1 (2.0)	0.34 (0.04–2.80)	0.31 (0.04–2.59)
Psychological acculturation (continuous)
	192 (100)	0.74 (0.48–1.15)	0.71 (0.45–1.11)	192 (100)	1.19 (0.69–2.06)	1.20 (0.68–2.14)	192 (100)	1.47 (0.85–2.52)	1.45 (0.84–2.51)	192 (100)	0.51 (0.20–1.29)	0.57 (0.22–1.47)
Duration of time in continental United States
	192 (100)	0.95 (0.92–0.98)	0.96 (0.92–0.99)	192 (100)	0.99 (0.96–1.04)	1.01 (0.97–1.05)	192 (100)	1.00 (0.96–1.04)	1.00 (0.97–1.04)	192 (100)	0.98 (0.89–1.09)	0.99 (0.89–1.10)
Preferred language
English	59 (39.1)	0.61 (0.38–0.89)	0.45 (0.23–0.75)	124 (95.4)	1.11 (0.46–2.67)	1.04 (0.42–2.)	34 (22.5)	0.89 (0.41–1.95)	1.01 (0.44–2.31)	5 (3.3)	0.31 (0.08–1.22)	0.33 (0.08–1.36)
Spanish	27 (65.9)	Reference (1.0)	Reference (1.0)	33 (94.3)	Reference (1.0)	Reference (1.0)	10 (24.4)	Reference (1.0)	Reference (1.0)	4 (9.7)	Reference (1.0)	Reference (1.0)
Place of birth
Continental United States	42 (38.9)	0.69 (0.46–0.97)	0.60 (0.36–0.91)	89 (93.7)	1.12 (0.54–2.34)	0.95 (0.43–2.08)	25 (23.2)	0.93 (0.48–1.79)	1.15 (0.57–2.33)	3 (2.8)	0.37 (0.09–1.51)	0.41 (0.09–1.77)
Other	44 (53.0)	Reference (1.0)	Reference (1.0)	67 (97.1)	Reference (1.0)	Reference (1.0)	19 (22.9)	Reference (1.0)	Reference (1.0)	6 (7.2)	Reference (1.0)	Reference (1.0)
Generation in the continental United States^a
First	44 (53.0)	Reference (1.0)	Reference (1.0)	67 (97.1)	Reference (1.0)	Reference (1.0)	19 (22.9)	Reference (1.0)	Reference (1.0)	6 (7.2)	Reference (1.0)	Reference (1.0)
Second	31 (38.3)	0.55 (0.30–1.02)	0.45 (0.24–0.87)	67 (93.1)	1.14 (0.52–2.53)	1.00 (0.43–2.33)	18 (22.2)	0.96 (0.46–2.00)	1.01 (0.48–2.11)	2 (2.5)	0.32 (0.06–1.66)	0.36 (0.07–1.93)
Third	11 (40.7)	0.61 (0.25–1.47)	0.50 (0.20–1.23)	22 (95.7)	1.05 (0.35–3.20)	0.80 (0.25–2.56)	7 (25.9)	1.17 (0.43–3.21)	1.22 (0.44–3.39)	1 (3.7)	0.49 (0.06–4.29)	0.55 (0.06–5.06)

Unadjusted RR (95% CI).

Adjusted RR for age, BMI, and glucose tolerance test results.

PAS is defined as psychological acculturation.

Generation defined as first (born outside the continental United States), second (at least one parent born outside the continental United States) or third (at least two grandparents born outside the continental United States). Participants born in the continental United States were not included in this question.

aRR, adjusted risk ratios; CI, confidence intervals.

A total of 31.9% of women met ACOG guidelines for physical activity (Table 4). The mean MET-hour per week in the sedentary category was 15.2 (±13.7), 127 (±58.5) in the light-intensity category, 70.3 (±70.1) in the moderate-intensity category, and 0.49 (±1.7) in the vigorous-intensity category. In bivariable analyses, there were no significant differences in physical activity or physical activity outcomes by psychological acculturation status (Table 4).

Table 4.

Physical Activity by Acculturation; Estudio Project Aiming to Reduce Type twO 2013–2017

Physical activity outcomes	Total (n = 254)	Low psychological acculturation (PAS <3), (n = 190)	High psychological acculturation (PAS ≥3), (n = 64)	p
ACOG guidelines for physical activity, n (%)
Met	81 (31.9)	57 (30.0)	24 (37.5)	0.27
Did not meet	173 (68.1)	133 (70.0)	40 (62.5)	0.27
Inactive MET-hour per week	17.9 (±25.2)	17.9 (±24.2)	17.9 (±32.8)	0.60
Sedentary MET-hour per week	14.9 (±13.4)	14.9 (±13.2)	7.4 (±13.4)	0.37
Nonsedentary MET-hour per week	182 (±125)	176 (±126)	197 (±102)	0.18
Moderate MET-hour per week	49.5 (±88.2)	47.6 (±93.5)	61.4 (±79.1)	0.17
Vigorous MET-hour per week	0 ± (0)	0 (±0)	0 (±0)	0.80
Total MET-hour per week^a	196 (±119)	188 (±125)	214 (±90.0)	0.18

All data are reported as median (±interquartile range) or n (%). PAS is psychological acculturation.

Defined as ≥7.5 MET-hour per week.³²

ACOG, American College of Obstetricians and Gynecologists; MET, metabolic equivalent of task.

In logistic regression analyses, women born in the continental United States were more likely to meet ACOG guidelines for physical activity than women born outside the continental United States (aRR 1.95, 95% CI 1.11–3.44; Table 5). Second-generation women in the continental United States were more likely to meet ACOG guidelines for physical activity than women who were born outside the continental United States (aRR 1.95, 95% CI 1.06–3.58; Table 5). There were no associations between psychological acculturation (aRR 1.42 for high vs. low acculturation, 95% CI 0.78–2.58), between preferred language preference (aRR for English vs. Spanish: 1.84, 95% CI 0.91–3.74), or between duration of time in the continental United States (aRR 1.02, 95% CI 0.99–1.05) and meeting ACOG guidelines for physical activity.

Table 5.

Unadjusted and Adjusted Risk Ratios and 95% Confidence Intervals for Acculturation and Meeting American College of Obstetricians and Gynecologists Guidelines for Physical Activity; Estudio Project Aiming to Reduce Type twO 2013–2017

	Meeting ACOG guidelines for physical activity
	Cases, n (%)	Unadjusted RR (95% CI)	Adjusted RR (95% CI)^a
Psychological acculturation (categorical)
Low (PAS <3)	57 (30.0)	Reference (1.0)	Reference (1.0)
High (PAS ≥3)	24 (37.5)	1.40 (0.77–2.53)	1.42 (0.78–2.58)
Psychological acculturation (continuous)
		1.12 (0.75–1.67)	1.11 (0.74–1.68)
Duration of time in continental United States (years; continuous)
		1.02 (0.99–1.05)	1.03 (0.99–1.07)
Duration of time in continental United States (years; categorical)
<5	5 (23.8)	Reference (1.0)	Reference (1.0)
5–<10	2 (16.7)	0.64 (0.10–3.95)	0.66 (0.11–4.15)
≥10	74 (33.5)	1.61 (0.57–4.57)	1.59 (0.56–4.56)
Preferred language
English	69 (34.7)	1.90 (0.94–3.84)	1.84 (0.91–3.74)
Spanish	12 (21.8)	Reference (1.0)	Reference (1.0)
Place of birth
Continental United States	56 (38.1)	1.99 (1.14–3.49)	1.95 (1.11–3.44)
Other	25 (23.6)	Reference (1.0)	Reference (1.0)
Generation in the continental United States^b
First generation	25 (23.6)	Reference (1.0)	Reference (1.0)
Second generation	38 (38.0)	1.99 (1.09–3.63)	1.95 (1.06–3.58)
Third generation	18 (38.3)	2.01 (0.96–4.21)	1.96 (0.92–4.15)

Adjusted for age and BMI.

Generation was defined as first (born outside the continental United States), second (at least one parent born outside the continental United States) or third (at least two grandparents born outside the continental United States). Participants born in the continental United States were not included in this question.

Discussion

In this secondary analysis of baseline data from a randomized controlled trial among predominantly pregnant Puerto Rican Hispanic women at risk for developing GDM, more acculturated women, defined by place of birth, duration of time in the continental United States, and preferred language, were less likely to meet carbohydrate guidelines for daily intake. In contrast, more acculturated women, defined by place of birth and generation in the continental United States, were more likely to meet guidelines for physical activity. We also observed inverse associations between increasing acculturation and meeting fiber goals, which were not statistically significant due to insufficient power for this endpoint. We did not observe associations between psychological acculturation and meeting dietary or physical activity guidelines. Similarly, we did not observe associations with any acculturation variables and meeting protein, fat, or fiber guidelines.

Our findings for the association between acculturation and dietary intake are consistent with prior studies.^21

–24 For example, in their cross-sectional analysis of mid pregnancy data among 568 women of predominantly Mexican descent, Harley and Eskenazi found that those with longer time in the United States were significantly less likely to have high dietary quality, as measured by the Diet Quality Index for Pregnancy (DQI-P; RR = 0.04, 95% CI 0.2–0.9 for the entire life in United States vs. <5 years).²³ Similarly, in their cross-sectional analysis of mid pregnancy data among 240 predominantly Mexican–American women, Brown et al found that each unit increase in ethnic identity score (i.e., less acculturation to the U.S. culture) was associated with an 8% (95% CI 1%–14%) increase in total energy intake, but there was no association with fiber intake.²¹

In the only study to focus on women of predominantly Puerto Rican descent (n = 1231), Gollenberg et al found no significant association between language preference nor birthplace and meeting guidelines for fruit and vegetable consumption.²² We found that women with higher acculturation as assessed by place of birth and preferred language were less likely to meet carbohydrate guidelines.

Our findings for the association between acculturation and physical activity are consistent with most of the few prior studies on this topic.^21,22,25 In a cross-sectional analysis among predominantly Puerto Rican women, Gollenberg et al found that both Spanish preference (adjusted OR 0.6, 95% CI 0.3–1.0) and foreign birth place (OR 0.7, 95% CI 0.4–1.0) were associated with lower odds of meeting physical activity guidelines, relative to women with English preference and birth in the continental United States, respectively.²² Similarly, in the same study population, Chasan-Taber et al found that Spanish language preference was significantly associated with lower sports/exercise activity (P _trend 0.02).²⁵ Similarly, in the current study, we found that continental U.S. birth and higher generation in the continental United States were significantly associated with meeting physical activity guidelines.

Our observations of a different direction of association between acculturation and meeting dietary goals (i.e., more acculturated women were less likely to meet carbohydrate guidelines) as compared with the direction of association between acculturation and physical activity goals (i.e., more acculturated women were more likely to meet physical activity guidelines) may have several explanations. First, it suggests that physical activity may not be as strongly held as a cultural belief, whereas food and dietary choices are a larger part of one's self-identity.³⁷ Findings on physical activity may be explained by cultural norms related to expected behaviors of pregnant women, as U.S. cultural norms often encourage physical activity in pregnancy, while this has been discouraged in Hispanic culture.³⁸

An alternative explanation may be that medical providers spend more time focusing on counseling related to physical activity in pregnancy rather than diet, given the intricacies and time consumption of proper nutrition counseling.³⁹ Pregnant women may be influenced by advertisements of low-carbohydrate diets for diabetes, which may lead to lack of proper nutrition counseling with a focus on carbohydrate intake rather than balanced assessment of macronutrients.⁴⁰ Patients may also perceive nutrition counseling as more complicated and confusing than physical activity.³⁹

Our study has several strengths. Our study provides information on acculturation in a pregnant population for which previous literature is sparse. We assessed acculturation through multiple domains, including psychological acculturation, preferred language, place of birth, and generation in the continental United States. Data were collected by bicultural/bilingual trained health educators.

This study has also several limitations. This was a secondary analysis of a study aimed at a lifestyle intervention among at-risk women, so women who chose to enroll in the randomized trial may be more concerned about their overall health and, therefore, have different behaviors related to dietary intake and physical activity than the general Hispanic pregnant population. Dietary intake and physical activity were self-reported, which may impact their accuracy, although validation studies of these self-report instruments provide reassurance that this was not a substantial source of misclassification.³¹ Finally, our power for certain associations (i.e., meeting fiber goals) was low. Specifically, the number of participants meeting fiber goals was small, which led to strata with a small number of “cases” when examining the association between particular subgroups and meeting fiber goals. Therefore, although we observed an inverse association between increasing acculturation and meeting fiber goals, this was not, however, statistically significant.

In contrast, our power was stronger for meeting carbohydrate and protein goals, which was reflected in our observation of statistically and clinically significant associations for our measures of acculturation and meeting these dietary goals. Overall, given the lack of research in this area within a predominantly Puerto Rican population, our findings can be seen as identifying directions for future research and highlighting areas of dietary insufficiency.

Our findings have implications for both individual-level and structural-level interventions. In terms of the former, our findings highlight the need to incorporate acculturation assessment via multiple measures when designing interventions, which focus on physical activity and dietary behaviors in pregnancy. More broadly, however, racial and ethnic differences exist among pregnant women with diabetes, including differences in social determinants of health, disparities in maternity and perinatal care, and maternal and neonatal health outcomes.⁴¹ Therefore, future interventions should take into account differences in maternal social determinants of health and personal history among women of different races and ethnicities. Additional research is needed in disadvantaged groups who are less likely to access perinatal care services and to be screened for T2DM after pregnancy. For example, implementation of immediate postpartum diabetes screening is needed to optimize long-term health outcomes and reduce obstacles related to access to care in at-risk populations.

In conclusion, we observed that higher acculturation to the U.S. culture, as defined by birthplace and generation in the continental United States, was associated with lower odds of meeting ADA guidelines for carbohydrate intake, but with higher odds of meeting physical activity guidelines in this population of high-risk Hispanic pregnant women. Interventions aimed at reducing gestational diabetes in Hispanic women should be culturally informed, and acculturation should be considered when addressing these modifiable behaviors. Further investigation into acculturation and its impacts on health behaviors and disease progression are needed, especially among pregnant, high-risk populations.

Footnotes

Authors' Contributions

L.-C.T. and G.W. developed research ideas and statistical plan. G.W. and K.L. analyzed data. G.W. and L.-C.T. wrote the initial draft of the article, and T.A.M.S. and K.L.T. assisted with article revision. All authors read and approved the final article.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was funded by NIH/NIDDK (Grant No. DK064902).

References

Thomson

, Hoffman-Goetz

. Defining and measuring acculturation: A systematic review of public health studies with Hispanic populations in the United States. Soc Sci Med, 2009; 69:983–991.

Alegria

, Shrout

, Woo

, et al. Understanding differences in past year psychiatric disorders for Latinos living in the US. Soc Sci Med, 2007; 65:214–230.

Premkumar

, Debbink

, Silver

, et al. Association of acculturation with adverse pregnancy outcomes. Obstet Gynecol, 2020; 135:301–309.

Tucker

, Mattei

, Noel

, et al. The Boston Puerto Rican Health Study, a longitudinal cohort study on health disparities in Puerto Rican adults: Challenges and opportunities. BMC Public Health, 2010; 10:107.

Flores

. How the U.S. Hispanic population is changing, 2017. Pew Research Center. Available at: http://www.pewresearch.org/fact-tank/2017/09/18/how-the-u-s-Hispanic-population-is-changing/ Accessed April 1, 2022 .

Cervantes

, Gattamorta

, Berger Cardoso

. Examining difference in immigration stress, acculturation stress and mental health outcomes in six Hispanic/Latino nativity and regional groups. J Immigr Minor Health, 2019; 21:14–20.

Rodriguez

, Allison

, Daviglus

, et al. Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: A science advisory from the American Heart Association. Circulation, 2014; 130:593–625.

Ross

, Guardino

, Dunkel Schetter

, et al. Interactions between race/ethnicity, poverty status, and pregnancy cardio-metabolic diseases in prediction of postpartum cardio-metabolic health. Ethn Heal, 2020; 25:1145–1160.

Van Rompay

, Castaneda-Sceppa

, McKeown

, et al. Prevalence of cardiovascular disease risk factors among older Puerto Rican adults living in Massachusetts. J Immigr Minor Heal, 2011; 13:825–833.

10.

Daviglus

, Talavera

, Avilés-Santa

, et al. Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States. JAMA, 2012; 308:1775–1784.

11.

Casagrande

, Linder

, Cowie

. Prevalence of gestational diabetes and subsequent type 2 diabetes among U.S. women. Diabetes Res Clin Pract, 2018; 141:200–208.

12.

Yogev

, Xenakis

, Langer

. The association between preeclampsia and the severity of gestational diabetes: The impact of glycemic control. Am J Obstet Gynecol, 2004; 191:1655–1660.

13.

Ehrenberg

, Durnwald

, Catalano

, et al. The influence of obesity and diabetes on the risk of cesarean delivery. Am J Obstet Gynecol, 2004; 191:969–974.

14.

Bellamy

, Casas

, Hingorani

, et al. Type 2 diabetes mellitus after gestational diabetes: A systematic review and meta-analysis. Lancet, 2009; 373:1773–1779.

15.

England

, Dietz

, Njoroge

, et al. Preventing type 2 diabetes: Public health implications for women with a history of gestational diabetes mellitus. Am J Obstet Gynecol, 2009; 200:365.e1–8.

16.

Kim

, Newtom

, Knopp

. Gestational diabetes and the incidence of type 2 diabetes: A systematic review. Diabetes Care, 2002; 25:1862–1868.

17.

Bianco

, Josefson

. Hyperglycemia during pregnancy and long-term offspring outcomes. Curr Diab Rep, 2019; 19:143.

18.

Lara

, Gamboa

, Kahramanian

, et al. Acculturation and Latino health in the United States: A review of the literature and its sociopolitical context. Annu Rev Public Health, 2005; 26:367–397.

19.

Janevic

, Zeitlin

, Egorova

, et al. The role of obesity in the risk of gestational diabetes among immigrant and U.S.-born women in New York City. Ann Epidemiol, 2018; 28:242–248.

20.

Renzaho

, Skouteris

, Oldroyd

. Preventing gestational diabetes mellitus among migrant women and reducing obesity and type 2 diabetes in their offspring: A call for culturally competent lifestyle interventions in pregnancy. J Am Diet Assoc, 2010; 110:1814–1817.

21.

Brown

, Ehrlich

, Kubo

, et al. Lifestyle behaviors and ethnic identity among diverse women at high risk for type 2 diabetes. Soc Sci Med, 2016; 160:87–93.

22.

Gollenberg

, Pekow

, Markenson

, et al. Dietary behaviors, physical activity, and cigarette smoking among pregnant Puerto Rican women. Am J Clin Nutr, 2008; 87:1844–1851.

23.

Harley

, Eskenazi

. Time in the United States, social support and health behaviors during pregnancy among women of Mexican descent. Soc Sci Med, 2006; 62:3048–3061.

24.

Kieffer

, Welmerink

, Sinco

, et al. Dietary outcomes in a Spanish-language randomized controlled diabetes prevention trial with pregnant Latinas. Am J Public Health, 2014; 104:526–533.

25.

Chasan-Taber

, Schmidt

, Pekow

, et al. Correlates of physical activity in pregnancy among Latina women. Matern Child Health J, 2007; 11:353–363.

26.

Chasan-Taber

, Kini

, Harvey

, et al. The association between acculturation and prenatal psychosocial stress among Latinas. J Immigr Mino Health, 2020; 22:534–544.

27.

Tropp

, Erkut

, Garcia Coll

, et al. Psychological acculturation: Development of a new measure for Puerto Ricans on the U.S. Mainland. Educ Psychol Meas, 1999; 59:351–367.

28.

Chasan-Taber

, Marcus

, Rosal

, et al. Estudio PARTO: Postpartum diabetes prevention program for Hispanic women with abnormal glucose tolerance in pregnancy: A randomized controlled trial- study protocol. BMC Pregnancy Childbirth, 2014; 14:100.

29.

United States Census Bureau (2009–2013). American Community Survey. Available at: http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_5YR_B03001&prodType=table Accessed August 27, 2015 .

30.

Dao

, Subar

, Warthon-Medina

, et al. Dietary assessment toolkits: An overview. Public Health Nutr, 2019; 22:404–418.

31.

Chasan-Taber

, Schmidt

, Roberts

, et al. Development and validation of a pregnancy physical activity questionnaires. Med Sci Sports Exercise, 2004; 36:1750–1760.

32.

ACOG committee opinion No. 650: Physical activity and exercise during pregnancy and the postpartum period. Obstet Gynecol, 2015; 126:e135–e142.

33.

American Diabetes Association. Lifestyle management: Standards of medical care in diabetes-2019. Diabetes Care, 2019; 42(S1):S46–S60.

34.

American Diabetes Association. Gestational diabetes mellitus. Diabetes Care, 2003; 26(Suppl 1):s103–s105.

35.

Maldonado

, Greenland

. Simulation study of confounder- selection strategies. Am J Epidemiol, 1993; 138:923–936.

36.

Zhang

, Yu

. What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA, 1998; 280:1690–1691.

37.

Reddy

, van Dam

. Food, culture, and identify in multicultural societies: Insights from Singapore. Appetite, 2020; 149:104633.

38.

Kieffer

, Willis

, Arellano

, et al. Perspectives of pregnant and postpartum Latino women on diabetes, physical activity, and health. Health Educ Behav, 2002; 29:542–556.

39.

Ferrari

, Siega-Riz

, Evenson

, et al. A qualitative study of women's perceptions of provider advice about diet and physical activity during pregnancy. Patient Educ Couns, 2013; 91:372–377.

40.

Feinman

, Pogozelski

, Astrip

, et al. Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base. Nutrition, 2015; 31:1–13.

41.

Phonyiam

, Berry

. Racial and Ethnic Disparities in Health Care and Health Outcomes for Pregnant Women with Diabetes. Nurs Womens Health, 2021; 25:437–449.