Culturally based health assumptions in Sub-Saharan African immigrants: Body mass index predicting self-reported health status

Abstract

This study examined whether Sub-Saharan African adult immigrants maintained cultural preferences for curvier/higher body size post-migration to the United States. Linear and multiple regression analyses were utilized to discern the predicting effects of Sub-Saharan African immigrants’ body mass index score on their self-reported health status at two post-migration data collection points. The initial assessment reveals that Sub-Saharan African immigrants’ overweight body mass index score predicted better self-reported health status. Four to six years later, higher body mass index score predicted a better self-reported health status and lower dietary acculturation moderated the predicting effect of body mass index on self-reported health status. Limitations of the study and implications for research and practice are explored.

Keywords

body mass index dietary acculturation immigrants self-reported health status Sub-Saharan African

Introduction

Approximately 40 million new immigrants reside in the United States (US Census Bureau, 2012). Studies on immigrant populations have primarily focused on newcomers originating from Latin America and Asia. Few have explored the experiences and acculturation processes of Sub-Saharan African immigrants (Shaw-Taylor and Tuch, 2007). African immigrants represent 3.6 percent of all US immigrant populations (Gambino and Trevelyan, 2014). The 2010 US Census revealed that the number of African immigrants doubled between 2000 and 2010 and that about three-quarters of African immigrants are of Black descent (US Census Bureau, 2012).

United States–based Sub-Saharan African immigrants are individuals residing in the United States who originate from the African geographical areas below the Sahara desert. Upon migration to the United States, Sub-Saharan African communities report being in excellent health (Jasso et al., 2005). This self-perception has been related to the healthy immigrant effect, which explains immigrants’ health amelioration immediately post-migration (Kruseman et al., 2005; Lee et al., 2013). For instance, Wen et al. (2013) reported that new immigrants had lower levels of obesity than US citizens. However, studies have noted the short-term duration of this healthy immigrant effect and the long-term health deterioration of Sub-Saharan African communities (Lee et al., 2013; Watroba et al., 2015). For instance, immigrants from a low-income country who settle in a high-income host culture experience an increase in weight post-migration (Gaillard, 2014; Watroba et al., 2015). Studies also reveal the elevated health concerns in African immigrant communities post-migration (Gong et al., 2006): prevalence of cardiometabolic diseases is found in African immigrants post-migration (O’Connor et al., 2014). Renzaho (2004) also reported that hypertension was a risk factor for Sub-Saharan African immigrants who settled in Western countries due to changes in lifestyle habits and food consumption. Gualdi-Russo et al. (2009) compared body mass index (BMI) scores and hypertension rates of 401 adult immigrants who resided in Italy and originated from Senegal, Morocco, Tunisia, Pakistan, and Southeastern Europe. Results revealed that hypertension was higher in Senegalese participants, Kosovar, and Gypsy participants than immigrants from other host countries.

Roshania et al. (2008) reported higher dietary acculturation of African immigrants than Latin American/Caribbean and Asian immigrant groups in the United States. Renzaho et al. (2008) found that consumption of an African-style diet was associated with decreased rates of obesity among African immigrant children in Australia. Similar findings emerged in a study of Ghanaian immigrants in the Netherlands: Dutch-Ghanaian migrants had higher levels of overweight and obesity than Ghanaian nationals (Agyemang et al., 2008). An equivalent US study found that African Americans had higher rates of colon cancer risk than individuals residing in rural African areas (O’Keefe et al., 2015); health risks significantly decreased upon African American participants’ temporary adoption of an African-style diet rich in resistant starch and low in fat intake. Finally, Okafor et al. (2014) demonstrated that greater dietary acculturation of African immigrants in the United States was associated with poorer self-reported health status.

Maintenance of cultural values of health post-migration may influence Sub-Saharan African immigrants’ perception of their health condition. For example, a common African proverb, “if you are overweight, you are well nourished while if you are thinner, you are ill,” demonstrates African body image values that being overweight is an indication of satisfactory health, power, and status, while thinness is a sign of illness, impoverishment, and deprivation (Renzaho, 2004). In contrast, various cultural communities perceive thinness as ideal (Soh et al., 2006; Thompson and Stice, 2001). Internalization of thin ideals was found to be associated with body dissatisfaction as well as eating disturbance attitudes among a sample of Guatemalan girls (Vander Wal et al., 2008). Differences in thin idealization have been connected to the effects of westernization, particularly in changing gender roles among females (Witcomb et al., 2013). For example, studies have demonstrated that high exposure to Western cultural values increases the likelihood of preference for a thin-ideal and body dissatisfaction among Chinese (Lee and Lee, 2000), Saudi Arabian (Al-Subaie, 2000), and Singaporean (Wang et al., 1999) adolescent females, which have led to disordered eating and other negative health effects (Santoncini et al., 2012; Shin et al., 2017).

Studies with Sub-Saharan African populations have linked a preference for a rounder physical figure to the economic disparities in Sub-Saharan regions, presumably due to diminished access to food and/or healthy lifestyle (Renzaho, 2004; Olivieri et al., 2008). Frederick et al. (2008) found that the ideal and most attractive Ghanaian woman was curvier and heavier in body size than the ideal US and Ukrainian woman. Another study revealed that Gambian participants were more tolerant than White or Black US participants of individuals with an overweight/obese BMI (Siervo et al., 2006). Toselli et al. (2015) conducted a comprehensive review of 26 studies on the body image perception of African immigrants and African citizens. They concluded that African residents preferred rounder physical figures than African immigrants. Toselli and colleagues also reported preference for a high BMI among African immigrants in Europe.

Maintenance of cultural assumptions of dietary health post-migration may affect one’s likelihood to perceive oneself as healthy or to sustain well-being post-migration. This is particularly salient for Sub-Saharan African immigrants because of their low health care utilization (Chaumba, 2011) despite their report of health concerns post-migration (Ludwig and Reed, 2016).

Cultural assumptions and perceived health relate highly to levels of acculturation. For instance, the association between acculturation and BMI was found in a study of mothers of Puerto Rican descent. Wiley et al. (2014) discovered that mothers of Puerto Rican descent with higher level of acculturation were more likely to serve their children sugar-sweetened beverages and to consume less Latin American–oriented foods than lesser acculturated Puerto Rican mothers. Dietary acculturation was also related to higher BMI scores among Puerto Rican mothers. Moreover, increased length of time in the United States was associated with high BMI and elevated risk of obesity among Latin American immigrants (Bates et al., 2008). Higher BMI and obesity could be explained by increased acculturative stress levels experienced by immigrants post-migration as well as potential homeostasis imbalances created by over-consumption and rapid environmental changes (Marks, 2015).

Because no known studies have been conducted on the impact of cultural assumptions on the health status of African immigrants in the United States, this study seeks to investigate whether a factual health assessment is a predictor of Sub-Saharan African adult immigrants’ self-reported health status at two different points of time. With an emphasis on eating, this study hopes to determine whether BMI predicts the self-reported health status of Sub-Saharan African immigrants. Two research questions were developed:

What is the influence of Sub-Saharan African immigrants’ BMI score on their self-reported health status at two time intervals post-migration to the United States?

Do dietary acculturation and BMI scores influence self-reported health status at two time intervals post-migration to the United States?

The following hypotheses were generated:

Greater BMI score will significantly predict better self-reported health status post-migration (a) at the initial assessment and (b) 4–6 years later.

Unhealthy BMI score will predict better or worse self-reported health status (a) at the initial assessment and (b) 4–6 years later; more specifically, BMI scores in the overweight range will predict an increase in self-reported health status while BMI scores in the underweight range will predict a decrease in self-reported health status.

Greater BMI and lower dietary acculturation will predict better self-reported health status (a) at the initial assessment and (b) 4–6 years later.

Method

Participants

Participants (N = 763; 57% = male, 43% = female) were new US immigrant adults from Nigeria (n = 172), Ethiopia (n = 199), and other Sub-Saharan African countries (n = 392). Participants who were between the ages of 18 and 77 years old (M_age = 34.31, mode = 28, standard deviation (SD) = 11.37) and participated in the Princeton University New Immigrant Survey (NIS, 2006), a 2001–2009 multi-cohort longitudinal study of new lawful permanent residence (LPR) grantees, sponsored by the US Immigration and Naturalization Services (presently the US Department of Homeland Security). The NIS project offered a comprehensive biopsychosocial assessment of new immigrants including critical background information, health measures, family dynamics, economic and financial factors, and housing environments. Participants were first assessed between May and November 2003 (Guillermina et al., 2006). A follow-up data collection was conducted from June 2007 to December 2009 in which 372 of the 763 sample participated (Guillermina et al., 2014). NIS public datasets reveal that 46 of the 763 participants reported residing in the United States for approximately 2 years (11 years to less than 1 year of time of residence in the United States). A prior publication of NIS dataset on Sub-Saharan African immigrants report average time in the United States for all participants to be 5 years (Okafor et al., 2014). The Institutional Research Board (IRB) Committee of the first author’s academic institution granted approval for the utilization of NIS public datasets for this study.

Measures

The following self-reported variables of participating Sub-Saharan African immigrants from 2003 and 2009 NIS data collection points were extracted for the purpose of this study: country of origin, age, sex, self-reported health status, weight, and height. The NIS data included coded responses −1 (i.e. “refusal to answer”) and −2 (i.e. “not sure”) from participants. For the purpose for this study, these responses were removed from the data. The 2003 data collection represented initial interviews of new legal permanent resident grantees (LPR) in the 2003–2004 fiscal years while the 2009 data collection included follow-up interviews of these LPR grantees, 4–6 years later.

Self-reported health status

Participants were asked in 2003 and in 2009 to rate their health perception in a 4-point scale as (1) excellent, (2) very good, (3) good, (4) fair, or (5) poor (i.e. Would you say that your health is excellent, very good, good, fair, or poor?).

BMI

The body mass index (BMI) is an equation of one’s weight divided by one’s height. Participants reported their weight in either kilograms or pounds and their height in centimeters/meters or foot/inches. The weight of participants provided in kilograms was converted into pounds while height listed in centimeters/meters was converted into inches to calculate their BMI score. Following the World Health Organization (2016)’s BMI coding, underweight/low BMI score was 18.5 and lower, normal/moderate BMI was deemed as in the range between 18.6 and 24.9, and high BMI (overweight and obese) was 25 and above.

Dietary acculturation

Dietary acculturation is defined as changes in one’s diet, from a native culture to the mainstream/host culture (Deslile, 2010). Dietary acculturation was captured with the question in which participants were asked to rate from 1 to 10, from completely different to exactly the same, the food they eat in the United States versus the one they ate in their home country (i.e. Using a scale from 1 to 10 where 10 indicates exactly the same and 1 means completely different, how would you compare the similarity in the food you now normally eat in the United States with the food you normally ate in your home country?). In accordance with prior NIS studies (Okafor et al., 2014; Roshania et al., 2008), the degree of dietary acculturation was rated from high (1; responses 1–4), moderate (0; responses 5 and 6), and low (−1; responses 7–10).

Results

Exploratory analyses

Descriptive and intercorrelation analyses were conducted to obtain preliminary information on the dependent (self-reported health status) and independent (BMI and dietary acculturation) variables (see Table 1).

Table 1.

Summary of intercorrelations, means, and standard deviations for BMI, self-reported health status, and dietary acculturation in 2003 and in 2009.

Variable	1	2	3	4	5	6	7	8
1. 2003 BMI	–
2. 2003 Low/high BMI	.52**	–
3. 2003 SRHS	.07	.11*	–
4. 2003 Dietary acculturation	−.05	.05	.04	–
5. 2009 BMI	.47**	.28**	.03	.04	–
6. 2009 Low/high BMI	.24**	.59**	.02	.05	.45**	–
7. 2009 SRHS	.11*	.02	.28**	−.04	.15**	−.04	–
8. 2009 Dietary acculturation	−.07	−.01	−.04	.06	.01	.03	−.10	–
n	690	438	762	734	347	213	365	338
M	24.49	0.79	1.70	0.01	26.34	0.94	1.99	−0.04
SD	5.30	0.61	0.91	0.84	4.66	0.33	0.99	0.87

BMI: body mass index; SRHS: self-reported health status; low/high BMI: BMI scores higher than 24.9 and BMI scores lower than 18.6; SD: standard deviation.

p < .05, **p < .01.

Self-reported health status

Sub-Saharan African immigrants (n = 762) rated their self-reported health status in 2003 as primarily excellent (54.7%), followed by very good (24.8%), good (16.8%), fair (2.8%), and poor (.9%). In 2009, the self-reported health status of participating Sub-Saharan African immigrants (n = 364) was still primarily excellent (39.2%), very good (31.2%), good (22.5%), fair (5.5%), and poor (1.6%). Standard error of skewness and kurtosis were respectively .89 and .18 in 2003 and .13 and .26 in 2009. A paired t-test analysis revealed significant mean differences in self-reported health status (t(363) = −4.67, p = .000) between 2003 (M = 1.71, SD = 0.88) and 2009 (M = 1.98, SD = 0.98), which indicates that participants reported a significantly lower health status in 2009 than in 2003.

BMI

In 2003, the BMI score of participating Sub-Saharan African immigrants (n = 690) ranged from 9.8 to 78.2 (M = 24.49, SD = 5.30). The average BMI score of Sub-Saharan African immigrants was in the moderate/normal range. Standard error of skewness and of kurtosis for BMI score obtained in 2003 were respectively .93 and .19, which is in the range of a normal distribution. In the second data collection (2009), Sub-Saharan African immigrants’ BMI score ranged from 15 to 59 (M = 26.3, SD = 4.66) and reached the overweight range. Standard error of skewness and kurtosis remained within the normal range of distribution, respectively, .13 and .26. A paired t-test analysis was conducted to discern mean differences between the BMI scores in 2003 and in 2009. The result was significant and indicated that BMI scores in 2003 (M = 24.23, SD = 5.11) were significantly lower than the BMI scores in 2009 (M = 26.25, SD = 4.34, t(321) = −7.35, p = .000).

Dietary acculturation

In 2003, participating Sub-Saharan African immigrants primarily endorsed a high (36.1%) or low (35%) dietary acculturation, followed by moderate (28.9%) dietary acculturation. In the second data collection, in 2009, dietary acculturation still remained primarily low (40.2%), followed by high (35.8%) and moderate (24%) levels. Standard error of skewness was .09 in 2003 and .13 in 2009 while standard error of kurtosis was .18 in 2003 and .27 in 2009. No significant mean differences were found in dietary acculturation between 2003 and 2009 (p > .05), which indicate minimal change in Sub-Saharan African immigrants’ dietary acculturation style post-migration.

Primary analyses

Hypothesis 1. Greater BMI score will significantly predict better self-reported health status (a) at the initial assessment and (b) 4–6 years later

To test our hypothesis, linear regression analyses were conducted with BMI as an independent variable and self-reported health status as a dependent variable in the 2003 and in the 2009 data responses. Results showed that 2003 BMI score did not significantly predict 2003 self-reported health status (p = .07). Hypothesis 1a was rejected. In the 2009 data, greater BMI predicted a 2 percent increase in Sub-Saharan African immigrants’ self-reported health status, R = .15, R² = .02, F(1, 344) = 7.43, p = .007, β = .15, t = 2.73, tolerance = 1, variance inflation factor (VIF) = 1 (see Table 2). Hypothesis 1b was accepted.

Table 2.

Regression analyses summary for significant predictors of self-reported health status.

Variable	N	F	R ²	SE	B	β	t
1. 2003 Self-reported health status
2003 Low/high BMI	438	4.89*	.01	.07	.15	.11	2.21
2. 2009 Self-reported health status
2009 BMI	346	7.43**	.02	.01	.03	.15	2.73
2009 BMI × Dietary acculturation	325	6.68***	.04	.95
2009 BMI				.01	.04	.18	3.32***
2009 Dietary acculturation				.06	−.10	−.09	−1.58
2009 BMI x 2009 BMI×2009 high dietary acculturation	346	6.55**	.04	.96
2009 BMI				.01	.04	.17	3.15**
2009 BMI × 2009 high dietary acculturation				.00	−.01	−.12	−2.25*

SE: standard error; BMI: body mass index; low/high BMI: BMI scores higher than 24.9 and BMI scores lower than 18.6.

p < .05, **p < .01, ***p < .001.

Hypothesis 2. Unhealthy BMI score will predict better or worse self-reported health status (a) at the initial assessment and (b) 4–6 years later

Two variables consisting respectively of the 2003 and 2009 responses of participants who endorsed high (above 24.9) and low (below 18.5) BMI were developed, with a score of 1 denoting overweight/high BMI score and −1 signifying underweight/low BMI score. A linear regression analysis was then conducted to determine whether unhealthy BMI scores (the variable 2003 high/low BMI) predicted an increase/decrease in 2003 self-reported health status. Our regression equation was significant and revealed that overweight BMI score significantly predicted an increase in 2003 self-reported health status, R = .11, R² = .01, F(1, 436) = 4.89, p = .03, β = .11, t = 2.21, tolerance = 1, VIF = 1. Hypothesis 2a was accepted. In 2009, high/low BMI did not significantly predict self-reported health status (p > .05). Hypothesis 2b was then rejected.

Hypothesis 3. Greater BMI and lower dietary acculturation will predict better self-reported health status (a) at the initial assessment and (b) 4–6 years later

The multiple regression analysis of 2003 BMI and 2003 dietary acculturation as independent variables and 2003 self-reported health status as dependent variable was not significant (p = .10). Hypothesis 3a was rejected. A multiple regression analysis was then conducted with 2009 BMI and 2009 dietary acculturation as independent variables and 2009 self-reported health status as the dependent variable. The result was significant (R = .20, R² = .04, F(2, 322) = 6.68, p = .001). The regression equation revealed that higher BMI score in 2009 (β = .18, t = 3.32, p = .001, tolerance = 1, VIF = 1) significantly predicted a 4 percent increase in self-reported health status when 2009 dietary acculturation was held constant and did not significantly contribute to the prediction (p = .12). Hypothesis 3b was rejected. Post hoc analyses were conducted to discern the influence of low or high 2009 dietary acculturation on the relationship between 2009 BMI and 2009 self-reported health status. Results revealed that high 2009 dietary acculturation (β = −.12, t = −2.25, p = .03, tolerance = .96, VIF = 1.04) negatively moderates the predicting effect of greater 2009 BMI (β = .17, t = 3.15, p = .002, tolerance = .96, VIF = 1.04) on better 2009 self-reported health status (R = .19, R² = .04, F(2, 343) = 6.29, p = .002).

Discussion

The purpose of this study was to examine the impact of cultural assumptions of dietary health on Sub-Saharan African immigrants’ self-reported health status, more specifically whether Sub-Saharan African immigrants’ greater BMI score would significantly predict their better self-reported health status. Our findings reveal that Sub-Saharan African immigrants’ overweight BMI score predicted better self-reported health statuses at the initial data collection point time. Four to six years later, greater BMI score was found to predict better self-reported health status. Post hoc analyses further supported our hypothesis by revealing a relationship between greater BMI scores and better self-reported health statuses moderated by lower dietary acculturation.

This study is one of the first to attend to cultural assumptions of Sub-Saharan African immigrants’ dietary health in the United States. Our findings confirm previously reported perceptions of Sub-Saharan Africans’ value for curvier/higher body mass (Oloruntoba-Oju, 2007; Renzaho, 2004). It also indicates that Sub-Saharan African immigrants seem to maintain cultural assumptions of health many years post-migration. Similar research of other ethnic groups in the United States reports that the value of thinner body size and decreased preference for curvier body shape is endorsed among African American and Latin American communities with lower ethnic identification (Rakhkovskaya and Warren, 2014). Considering that most participating Sub-Saharan African immigrants endorsed minimal dietary acculturation post-migration, their maintenance of their cultural assumptions of health may explain our findings.

Past studies have noted the beneficial effect of the continuation of an African diet post-migration (Lee et al., 2013; Venters and Gany, 2011). However, in consideration of our findings that overweight BMI scores initially predicted better self-reported health status, adherence to an African diet and conformity with African cultural perceptions of health may be of concern for overweight Sub-Saharan African individuals. Nonetheless, Africans’ consumption of a Western-style diet, consisting of common US staple food (US Department of Agriculture (USDA), 2014) of low resistant starch, high animal protein, and fat food intake, is linked with colon cancer risk whereas African Americans’ consumption of an African-style diet, a high fiber/resistant starch and low fat intake, is associated with a decrease in color cancer risk (O’Keefe et al., 2015). Health professionals are then strongly encouraged to recommend, in conjunction with regular physical activity, an African diet to African immigrants and to also counsel them to incorporate healthiest African nutrition, with an emphasis on quantity, frequency, and type of African food consumed (Renzaho et al., 2015).

The primary limitation of the study is the utilization of self-reports of participants particularly regarding their health statuses, which has the potential for mono-method bias occurrence. The significant predictions found were also relatively small, which may infer the plausibility of multiple cultural factors in Sub-Saharan African immigrants’ discernment of their health status. Although critical in our understanding of health risk factors, BMI may not be the sole indicator of dietary health of Sub-Saharan African immigrants. For example, Meyer et al. (2011) reported that Ethiopian participants with lower BMI still had higher percentage body fat than immigrants from other ethnic groups. In addition, De Hoog et al. (2012) found that African mothers underestimated their child’s weight by 22 percent, which was more than mothers of Dutch ethnic background. Van Valkengoed et al. (2010) also reported differences between self-reported and measured weight and BMI among African women participants. Therefore, inclusion of other health screening such as blood testing, a body fat test, detailed pre- and post-migration food intake, and a measured BMI may provide a fuller understanding of dietary health of Sub-Saharan African immigrants.

It is also critical to note that other demographic characteristics of the sample may relate to dietary outcomes such as health conditions at the time of interview or geographical regions of residence at the time of migration. For example, 34 percent of participants lived in the Middle Atlantic and South Atlantic regions of the United States during the time of interview. Given the prevalence in variations of weight factors such as obesity by geographical location (Centers for Disease Control, 2014), future studies could explore moderating effects of specific geographical region on dietary health outcomes post-migration. Furthermore, approximately 48 percent fewer participants reported their self-reported status in 2009 than in 2003, although participant drop off is rather representative of longitudinal studies.

In addition, this study focused on participants who obtained legal permanent residence with varied length of stay in the United States which may influence their dietary acculturation and self-reported health status. Future studies are encouraged to attempt to collect data from immigrants with relatively similar duration of time in the United States.

This study pinpoints the importance of developing more research on the cultural perceptions related to Sub-Saharan African immigrants’ dietary health. Future studies may utilize a longitudinal methodological approach of the measured and perceived dietary health of Sub-Saharan African immigrants post-migration, with an emphasis on multiple cultural factors of salience to these communities. City of residence (Jasso et al., 2005), food accessibility (Lee et al., 2013; Venters and Gany, 2011), community belongingness, financial status, time in host country (Akresh, 2007), and post-migration health education (Venters and Gany, 2011) may impact Sub-Saharan African immigrants’ self-reported dietary health status.

With changing global climates and the estimation of increased Sub-Saharan African immigrant groups in the United States (Capps et al., 2011), health professionals are strongly encouraged to become aware of the biopsychosocial variables that may lead to better dietary health outcomes of Sub-Saharan African immigrants in the United States. Although studies have noted the critical salience of English-speaking language (Okafor et al., 2013) and spirituality (Jasso et al., 2003; Kamya, 1996) post-migration, the findings of this study propel further understanding on all the psychosocial factors related to the overall health status of Sub-Saharan African immigrants which may facilitate the development of adequate dietary health preventions and interventions in these communities.

Footnotes

Acknowledgements

The authors thank Lexa Watroba, Carol Hecht, and Kayla Barnoski for their assistance in the initial data analysis of the research study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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