Associations between family functioning, acculturative stress, and sugar-sweetened beverage consumption in the Hispanic Community Children's Health Study/Study of Latino Youth CURRENT STATUS: REVIEW

Background. Maintaining a bond with one’s family as well coping with stress while acculturating to the US may protect Hispanic/Latino youth from increased sugar-sweetened beverages (SSB) consumption. This study aims to examine associations between acculturative stress, family functioning, and SSB consumption by acculturation status among U.S. Hispanic/Latino youth. Methods. With data on 1,465 youth 8-16y (49.6% females) participating in the Hispanic Community Children's Health Study/Study of Latino Youth, we classified youths into four acculturation groups – assimilated, integrated, marginalized/separated, and unclassified. SSB consumption was assessed through two 24-hour diet recalls and defined as intake frequency of soda, fruit juice, sweetened soft and fruit drinks. Multi-group path regression models were used to test associations of Hispanic/Latino youth’ acculturative stress and family functioning with SSB consumption, as well as the moderating role of acculturation status. Results. When controlling for age, sex, and study site, acculturative stress ( β = -0.13, p = 0.01) was inversely associated with SSB, and poor family functioning ( β = 0.11, p = 0.07) was only marginally associated with SSB consumption among youth classified as assimilated but not among youth classified as integrated, marginalized/separated, or unclassified. Conclusions. A socio-ecological perspective that incorporates the role of key acculturation-related factors across multiple levels may aid efforts to identify mechanisms that influence the relationship between acculturation status and diet among Hispanic/Latino youth and their families.

obesity by contributing to a high glycemic load and exacerbating insulin response. 11 SSB consumption, along with the daily calories sold per capita per day from all SSB, is highest in both North and Latin America, 4

and is prevalent among Hispanic/Latino children and youth in Latin
America and the United States (U.S.). 14,15 These numbers have pronounced implications for native and immigrant youth of Hispanic/Latino heritage living in the U.S., as they are disproportionally affected by obesity. 16 Existing disparities in SSB consumption and health outcomes such as obesity among Hispanic/Latino youth and their families living in the US may be associated with adoption of US customs and behaviors, versus maintenance of Latin American customs and behaviors. 17 Acculturation, broadly defined as the multidimensional process through which individuals economically, psychologically, and socio-culturally adapt from one cultural context to another due to migration or other life experiences, 18,19 has been associated with dietary behaviors and other obesity-related behaviors among Hispanic/Latino youth. 20 Research suggests that greater language-based acculturation to the U.S. among Hispanic/Latino families is associated with negative health outcomes and less healthful dietary behaviors, 17 including greater SSB consumption than their U.S.-born non-Hispanic white counterparts. 21 Recently, Arandia et al. (2018) examined associations between a multi-dimensional measure of acculturation, the Acculturation Habits, and Interests Multicultural Scale for Adolescents (AHIMSA), and Hispanic/Latino youth's eating behaviors. 22 They found no differences in consumption of empty calories by acculturation group. 22 However, the study did not specifically examine SSB consumption 23 .
Because acculturation tends to occur more rapidly among Hispanic/Latino youth than among their parents, 24 understanding the role of acculturation on SSB consumption patterns in youth is essential.
One plausible factor influencing SSB consumption through acculturation is acculturative stress.
Acculturative stress can be defined as the psychological impact of adaptation to a new culture. 25 For Hispanics who move to the U.S., there are a number of significant stressors (i.e., language conflict, family acculturation conflicts, perceived discrimination) that can be pervasive, intense, and lifelong due to acculturation. For example, rapid acculturation to the US among youth may lead to the adoption of unhealthy behaviors through increasing inter-generational stress within families (i.e., family acculturation conflicts), and subsequent loss of Hispanic/Latino customs and behaviors. 26 Thus, acculturative stress may play a significant role influencing health outcomes among Hispanic/Latino families.
The Hispanic/Latino family is a vital source of support, comprised of interdependent relationships that may cultivate cultural values and discourage family dysfunction. 27, 28 This is important as youth in more dysfunctional families engage in unhealthier behaviors. 29 However, the role of family functioning in influencing SSB consumption, moderated by acculturation, remains an untested hypothesis.
This study aimed to examine the associations of acculturative stress and family functioning with SSB consumption by acculturation status among U.S. Hispanic/Latino youth. We examined such associations under the assumption that on average, youth experience more rapid acculturation attainment, as well as youth adopt certain acculturation statuses on the basis of characteristics and experiences that are heterogenous across groups. We hypothesized that Hispanic/Latino youths' SSB consumption would differ by acculturation status and that acculturative stress and family functioning would be associated with Hispanic/Latino youth' SSB consumption across acculturation statuses. Between 2012 and 2014, SOL Youth recruited 1,465 youth aged 8-16 years whose parent or caregiver was part of HCHS/SOL. 31, 32 For these analyses, we included youth with complete and valid SSB consumption data, as well as complete and valid data for family functioning, socio-cultural factors, and demographics. Study questionnaires to collect these data were administered by bilingual staff and in the youth language of preference. We excluded 210 cases due to incomplete data across key study variables. The overarching goal of the SOL-Youth study was to evaluate the influence of youth acculturation, effects of intergenerational influence in acculturation between youth and parents, parenting practices, as well as psychosocial functioning on cardiometabolic risk in Hispanic/Latino youth. 31, 32 SOL-Youth had a cross-sectional design and included children who were assented to participate through voluntarily written informed consent. The study was conducted with approval of the Institutional Review Board at all study institutions, including the HCHS/SOL coordinating center and laboratory.

Independent Measures Acculturation
Hispanic/Latino youth' acculturation status was measured using the Acculturation, Habits, and Interests Multicultural Scale for Adolescents (AHIMSA). 33 Scale scores ranged from 1 to 8. Under the assumption that acculturation itself is a dynamic process and that AHIMSA contains correlated subscales, youth were grouped into categories based on their acculturation status: Both Countries Orientation (Integration), United States orientation (Assimilation), orientation to other or neither country (Marginalization or Separation), and Unclassified. This categorical variable was used as grouping variable for descriptive purposes as well as the moderator in the final analytical output.

Acculturative stress
Hispanic/Latino youth' acculturative stress was measured using the Acculturative Stress Index 34 through three indicators: language conflict, family acculturation conflicts, and discrimination. To denote acculturative stress in our study, we developed a latent construct of acculturative stress composed of the three indicators aforementioned. This approach was used given that it accounts for measurement error, and tests whether these sub-domains represent well the higher construct (acculturative stress). Each indicator used a 5-point scale and, collectively, showed good compatibility to denote acculturative stress as a latent construct (a > 0.61; r > 0.32; b > 0.41).

Family functioning
Hispanic/Latino youths' family functioning was measured using the 12-item General Functioning subscale of the McMaster Family Assessment Device, which measures overall health of the family. 35 Example of statements include: "Planning family activities is difficult because we misunderstand each other;" "We cannot talk to each other about the sadness we feel;" "Making decisions is a problem for our family." To denote family functioning in our study, the average of all of the items was used.
Family functioning scores ranged from 1 to 4, with greater scores indicating poorer family functioning.

Covariates
Demographic characteristics included as covariates in all models were youth age in years (8-16 years old), youth' sex (male or female), birthplace (mainland U.S. or outside U.S.), parental educational attainment (less than high school, high School/GED, four-year college or university or more), family income (less than $20,000, $20,000-$50,000, greater than $50,000), and household composition (continuous). The Healthy Eating Index (HEI-2010) was also used as a covariate to represent overall diet quality. 36

Statistical Analysis
We used descriptive statistics to summarize demographic characteristics and key study variables (dependent and independent variables). Multi-group path regression models were used to test our study hypotheses using Structural Equation Modelling (SEM). Hispanic/Latino youth' SSB consumption was used as the dependent variable in all models. Hispanic/Latino youth' acculturative stress and family functioning were used as independent variables on SSB consumption to test our main hypothesis. Hispanic/Latino youth' acculturation status was used as the categorical grouping variable.
Hispanic/Latino youth' age and sex were used as covariates in all models. We used 0.05 as the significance level. Model fit was assessed using the root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), and the Comparative Fit Index (CFI). 33 In order for our models to attain good fit to the data, the following criteria had to be met: RMSEA (≤ 0.08), SRMR (≤ 0.10), and CFI (≥ 0.90). 37 Statistical software STATA 14 was used to perform all analyses while accounting for the complex survey design, sampling weights, and clustered nature of the data.

Results
Demographic characteristics are summarized in Table 1. The majority of children were 8-12 years old (57.5%), and males and females were equally represented. A vast majority were born in the mainland United States (77.5%), and half had low family income (52.9%). Most youth were categorized as integrated (46.0%), followed by assimilated (42.5%), and lastly marginalized or separated (11.3%).
Overall, youth consumed approximately one SSB per day (0.96 servings/day), although marginalized or separated youth consumed slightly less SSB compared to youth with a stronger U.S. orientation (not statistically significant). Prior to testing the path regression models, ANOVA tests indicated mean SSB intake was statistically different across acculturation groups (F (2,1301) = 3.43, p = 0.04) in unadjusted models. Chi-square tests also indicated statistical differences across acculturation groups in family functioning (X 2 = 15.30, p < 0.01).
Results from the path regression models are presented in Table 2. HEI and other demographic factors were excluded from models due to lack of preliminary correlation with key study variables (r < 0.20) and potential collinearity. Only youth' age, sex, and study site were the key covariates included in our final models. When controlling for age, sex, and study site, acculturative stress (β = -0.13, p = 0.01) was inversely associated with SSB among youth classified as assimilated, and poor family functioning (β = 0.11, p = 0.07) was only marginally associated with SSB consumption among youth classified as assimilated but not among youth classified as integrated, marginalized/separated, or unclassified.  Abbreviations: SSB, sugar-sweetened beverages; Accult. Stress, acculturative stress; Acculturative stress is a latent variable composed of three observed indicators in the data, acculturative conflicts, perceived discrimination, and language conflicts (a = .61; r > .33). Indicators of acculturative stress loaded significantly onto factor (b > .41; p < 0.01).
Prior to testing the regression models, ANOVA tests indicated mean SSB intake was statistically different across acculturation groups (F (2,1301) = 3.43, p = 0.04). Chi-square tests also indicated statistical differences across groups in poor family functioning (X 2 = 15.30, p < 0.01).

Discussion
Findings from our study suggest limited support for our hypothesis that Hispanic/Latino youth' SSB consumption differs by acculturation status and for the hypothesis that family functioning would be associated with increased SSB consumption among Hispanic/Latino youth across acculturating groups. Acculturation differed across Hispanic/Latino youth in our sample, but no significant associations were found between acculturation categories and SSB consumption. There was a significant inverse association between acculturative stress and increased SSB consumption among assimilated Hispanic/Latino youth, but not in other acculturating groups.

Conclusion
In conclusion, there is an inverse association between acculturative stress and SSB consumption, as well as a marginal but insignificant association between family functioning and SSB consumption among assimilated Hispanic/Latino youth. These preliminary results may support further research to inform preventive family-based approaches to help improve diet quality among Hispanic/Latino children by dissuading SSB intake. Future studies should assess these important interconnections more rigorously and longitudinally, accounting for theoretically relevant covariates. Specifically, examining the interplay between key cultural (i.e., acculturation), familial, and behavioral (i.e., dietary behaviors) risk factors of obesity while accounting for racial and ethnic-specific characteristics could inform future obesity research and programming tailored to minority groups disproportionally affected by obesity.

Ethics approval and consent to participate
This study included children who were assented to participate by parents through voluntarily written informed consent. The study was conducted with approval of the Institutional Review Board at universities in four cities (Bronx, NY; Chicago, IL; Miami, FL; and San Diego, CA), as well as the HCHS/SOL coordinating center and laboratory (Chapel Hill, NC).

Consent for publication
Not applicable.
Northwestern University (N01-HC65236), and San Diego State University (N01-HC65237). At the earlier stages of this study, RF received support through the NIH Training Grant Postdoctoral Fellowship (T32DK007703). The funders did not have a role in the development of this study.

Authors' contributions
RF conceptualized the study, analyzed the data, and wrote the manuscript. JM supported the development of study from initial stage to subsequent significant revisions. CRI, KMP, ACM, LCG, DS-A, AMD, MD, and LVH contributed to the study concept and the revision of the manuscript; and all authors: read and approved the final manuscript.