Obesity markedly increases risk for cardiovascular diseases, hypertension, type 2 diabetes, stroke, and some type of cancers, costing billions of dollars in healthcare expenses [1]. In 2016, over 70% of adults aged 20 and older in the United States (US) were overweight or obese [2]. The estimated direct medical care cost to the US healthcare system ranges from $147 billion to $210 billion per year for preventive and treatment services, and an additional $4.3 billion is estimated in lost productivity due to job absenteeism [3]. Unfortunately, rates of obesity and overweight are expected to increase, with minority populations disproportionately affected [1]. Of the obese or overweight US adult population, 42% are Hispanic compared to 34.5% for non-Hispanic whites [1].
In 2018, immigrants made up over 13% of the nation’s population, with about half of the immigrant population from Mexico (25%) and other Latin American countries (25%) [4]. This population is less likely to understand English, have lower educational attainment and income and are more likely to be uninsured [5], increasing their risk for adverse health outcomes. The persistent disparity in social determinants is exacerbated by inequities in the physical environment [6]. For example, lower income usually dictates the consumption of cheaper foods, usually containing high levels of fats and sugar, thereby increasing risks for unhealthy weight gain and diabetes [7]. The current food environment is also one that allows for abundant, cheaper food served in large portions, with many fast-food locations concentrated in lower-income and minority communities [6]. Meeting physical activity recommendations is also inversely related to income, that is, lower income communities have the least percentage of people engaging in physical activity [8]. The built environment, such as poor infrastructure or neighborhood safety, may also limit a persons’ ability to engage in physical activity safely and regularly. Adults with limited access to parks or walking trails are two times less likely to meet physical activity guidelines compared to other communities that are more walkable or have recreational facilities [9, 10]. In addition to socioeconomical and environmental factors increasing risk for obesity, Hispanic immigrants experience other barriers to accessing health care and preventive services that could minimize poor health outcomes, such as poor English proficiency and fear of deportation [5].
Despite barriers, several health measures among Hispanic immigrants reflect outcomes contrary to what may be expected considering common socioeconomic characteristics of Hispanic communities. That is, Hispanics tend to have better health outcomes and longer life expectancy compared to their non-Hispanic white counterparts despite having lower income and less access to health care resources [11]. This Hispanic paradox observably diminishes among later generations and as first-generation immigrants become more acculturated to US behaviors and beliefs, such as transitioning to a Western-typical diet [12]. For example, US-born Hispanics have a higher prevalence of obesity, hypertension, smoking, heart disease, and some types of cancer compared to foreign-born Hispanics [13]. These findings may be due to the Healthy Immigrant Effect (HIE), which suggests that new immigrants are in better health due to practicing healthier behaviors in their origin country or by self-selection, where only the healthiest immigrate to find work in the US [14, 15]. Research suggests this health advantage also dissipates with more time living in the US [15]. The nutritional transition theory also explains diminished health outcomes as a result of immigrants transitioning from a diet high in fruit and vegetable intake to a high-calorie, high-fat diet [16].
Acculturation, which is the process of immigrants adopting behaviors and attitudes of the new culture, increases risk for obesity in the US [15]. For example, immigrants who resided in the US for 10 or more years, and were thus more acculturated, had a higher Body Mass Index (BMI) compared to immigrants in the US for less than 10 years [17]. BMI among foreign-born immigrants approached US-born counterparts’ BMI as time living in the US increased [17, 18]. Less acculturated individuals possess several unique characteristics that may influence their response to weight related interventions, including low rates of correct weight perception, weight dissatisfaction, weight loss intention, and weight loss success, along with higher fruit and vegetable consumption [19, 20]. Individuals who accurately perceive their weight as overweight or obese are more likely to pursue and maintain weight loss in comparison to those who do not recognize themselves as such [20, 21]. Correct weight perception is also influenced by a healthcare provider, highlighting the importance of language in being able to effectively navigate the healthcare system, understand health recommendations, and engage in resources [21]. Since less acculturated individuals are less likely to proficiently speak English, language also serves as a factor in the success of weight loss interventions.
Since acculturation influences cognitions and behaviors related to weight, it is important to consider when developing interventions targeting immigrant communities. Cultural tailoring, modifying an intervention to appropriately incorporate elements of a population’s culture, improves the efficacy of behavior change interventions [22]. However, culturally appropriate interventions and preventive programs for Hispanics, specifically with low English proficiency, are lacking [20]. Promising methods of cultural tailoring for Hispanic populations include the use of community health workers (CHWs) and fotonovelas [23]. CHWs are members of the community that have been trained on health education delivery and available community resources. They are successful in reaching underserved communities and ethnic minority groups because they often relate to the lived experience of the target population [24]. CHWs advocate for the community’s health and empower individuals to make healthy behavior changes, in addition to linking disadvantaged communities to resources [24]. Interventions that are tailored to match the cultural identity and language of target communities are more likely to lead to positive health outcomes [22].
Fotonovelas, comic-like educational books, have been used to increase awareness and promote healthy habits in Hispanic populations [23]. This creative narrative approach allows participants to self-identify with characters and is easily understood, allowing participants with limited literacy to effectively engage in the educational material [24]. The fotonovelas used for Healthy Fit are a series of comic-books that were developed with the help of CHWs as part of Project HEART (Health Education Awareness Research Team) study [25]. These fotonovelas follow a Hispanic family, the Ramirez’s, through their struggle with chronic disease management and prevention. The fotonovelas, “An Ounce of Prevention” and “How to Control Your Blood Pressure”, use Hispanic values such as family, respect, and spirituality to promote health behaviors; for example, the use of spirituality to reduce stress for hypertension prevention. CHWs who are less acculturated are better able to explain the Ramirez family and make it relatable to the participant to point out common unhealthy behaviors and the importance of changing these with support from the family. Community intervention programs utilizing CHWs and similar fotonovelas improve access to health care, knowledge, and promote positive health outcomes [24].
Healthy Fit, the intervention examined here, is strengthened by its culturally and linguistically competent use of fotonovelas and low acculturated CHWs. Therefore, we expect Healthy Fit to be more effective at promoting weight loss among Hispanic individuals, specifically those with lower levels of acculturation. The purpose of this study is to evaluate the health outcomes of Healthy Fit participants 12 months after the initial intervention. Results from the 6-month follow-up suggest Healthy Fit improved exercise and nutrition, but did not include measures of body composition [26]. As part of this analysis, we examine changes in body composition in relation to acculturation status.
Based on the previously reviewed acculturation research, our first hypothesis is that more acculturated participants will have a higher body mass index (BMI) and body fat percentage (BFP) at baseline. Secondly, acculturation will significantly predict changes in body composition measures over time. Lastly, among participants, we expect less acculturated participants to experience greater reductions in body composition relative to more acculturated individuals, since Healthy Fit utilizes CHWs with low acculturation to deliver education and fotonovelas designed for less acculturated immigrants.
