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Mexican immigrant health advantage in metabolic syndrome? Examining the contributions of demographic, socioeconomic, and health behavior characteristics

Authors:
  • University of Michigan School of Public Health

Abstract

Although Mexican immigrants to the United States (US) have historically held health and mortality advantages over US-born groups, evolving population dynamics in Mexico paired with shifts in Mexico-US immigration patterns and policy regimes have raised new concerns about the metabolic health of recent cohorts of Mexican immigrants. Using a nationally representative sample of adults aged 20-years and older (n = 10,833) from the National Health and Nutrition Examination Study (NHANES, 1999–2016), we assess and seek to explain differences in metabolic syndrome (MetS) risk by race-ethnicity, country of origin, and duration of residence in the US and evaluate whether recent Mexican immigrants continue to exhibit a metabolic health advantage. We decompose the difference in MetS prevalence between US-born whites (45.5%) and recent Mexican immigrants (29.5%) to determine how demographic, socioeconomic, and health behavior characteristics contribute to the patterning of metabolic health. Findings reveal that recent Mexican immigrants hold a metabolic health advantage over all groups, which is accounted for by their younger age structure. Yet recent Mexican immigrants would retain a sizable age-adjusted MetS advantage if they were to achieve parity with US-born whites on education, income, and food security. To ensure that newly-arrived Mexican immigrants continue to experience historically favorable health and mortality prospects, modest policy changes could offer health-promoting protections in the form of increased economic and food security, as well as improved educational opportunities for younger immigrants.
SSM - Population Health 16 (2021) 100932
Available online 1 October 2021
2352-8273/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Mexican immigrant health advantage in metabolic syndrome? Examining
the contributions of demographic, socioeconomic, and health
behavior characteristics
Maria Carabello
a
,
b
,
c
,
*
, Julia A. Wolfson
a
,
d
a
Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
b
Department of Sociology, University of Michigan, Ann Arbor, MI, USA
c
Population Studies Center, Institute of Social Research, University of Michigan, Ann Arbor, MI, USA
d
Center for Human Nutrition, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
ARTICLE INFO
Keywords:
Hispanic paradox
Immigrant health advantage
Metabolic syndrome
Mexico-US immigration
Decomposition
ABSTRACT
Although Mexican immigrants to the United States (US) have historically held health and mortality advantages
over US-born groups, evolving population dynamics in Mexico paired with shifts in Mexico-US immigration
patterns and policy regimes have raised new concerns about the metabolic health of recent cohorts of Mexican
immigrants. Using a nationally representative sample of adults aged 20-years and older (n =10,833) from the
National Health and Nutrition Examination Study (NHANES, 19992016), we assess and seek to explain dif-
ferences in metabolic syndrome (MetS) risk by race-ethnicity, country of origin, and duration of residence in the
US and evaluate whether recent Mexican immigrants continue to exhibit a metabolic health advantage. We
decompose the difference in MetS prevalence between US-born whites (45.5%) and recent Mexican immigrants
(29.5%) to determine how demographic, socioeconomic, and health behavior characteristics contribute to the
patterning of metabolic health. Findings reveal that recent Mexican immigrants hold a metabolic health
advantage over all groups, which is accounted for by their younger age structure. Yet recent Mexican immigrants
would retain a sizable age-adjusted MetS advantage if they were to achieve parity with US-born whites on ed-
ucation, income, and food security. To ensure that newly-arrived Mexican immigrants continue to experience
historically favorable health and mortality prospects, modest policy changes could offer health-promoting pro-
tections in the form of increased economic and food security, as well as improved educational opportunities for
younger immigrants.
1. Introduction
A large body of research examines racial-ethnic and immigrant-
native health disparities among the adult population in the United
States (US). Studies indicate that minoritized racial-ethnic groups such
as Blacks and Hispanics have worse health than the majority group of
non-Hispanic whites (Brown, 2018). Research also documents an
immigrant health advantage across various racial-ethnic backgrounds
and areas of origin with immigrants experiencing better health, partic-
ularly within their rst decade of relocation, and also outliving their
native US-born peers (Antecol & Bedard, 2006; Brown, 2018; Hummer
& Gutin, 2018). Hispanics also hold a puzzling yet persistent survival
advantage over non-Hispanic whites, termed the Hispanic paradox,
which is most pronounced among rst-generation Mexican immigrants
(Lariscy et al., 2015; Markides & Coreil, 1986; Markides & Eschbach,
2005).
Despite these consistently documented patterns, it is unclear
whether recent waves of Mexican immigrants will continue to enjoy a
health advantage in at least one key area, metabolic syndrome (MetS).
MetS captures several markers of dysregulationincluding obesity,
elevated blood glucose levels, and hypertensionand is a strong pre-
dictor of morbidity and mortality (Alberti et al., 2009; Eckel et al.,
2010). There are two key sources of concern about the future metabolic
health of recent cohorts of Mexican immigrants to the US. First, Mexicos
rapid nutrition and epidemiologic transitions have been followed by one
of the steepest increases in obesity observed in any country (Popkin
* Corresponding author. 426 Thompson Street, ISR 2080-2, University of Michigan, Institute of Social Research, Population Studies Center, Ann Arbor, MI, 48104,
USA.
E-mail address: mcarabel@umich.edu (M. Carabello).
Contents lists available at ScienceDirect
SSM - Population Health
journal homepage: www.elsevier.com/locate/ssmph
https://doi.org/10.1016/j.ssmph.2021.100932
Received 26 July 2021; Received in revised form 21 September 2021; Accepted 25 September 2021
SSM - Population Health 16 (2021) 100932
2
et al., 2012), with adult rates rising by 42.2% between 2000 and 2018
(Barquera et al., 2020). Second, a shift in Mexico-US immigration pat-
terns and policy regimes has left recent waves of immigrants more
vulnerable to the health deteriorating effects of heightened discrimi-
nation, hostility, and harsh work environments (Orrenius & Zavodny,
2009; Viruell-Fuentes et al., 2012).
Using nationally representative population health data, this study
examines the metabolic health of foreign-born Mexicans, stratied by
duration of residence in the US, relative to US-born Mexican Americans
and non-Hispanic whites. We also further assess how key demographic,
socioeconomic, and health behavior characteristics contribute to
observed population health disparities. This study advances scholarship
on racial-ethnic and immigrant-native health disparities, generally, and
also specically contributes new knowledge on the recent metabolic
health of the US Mexican-origin population in two key ways. First, we
leverage population level biomarker data to capture all the dimensions
of MetS that have been linked to increased morbidity and mortality.
Second, we focus on the role of social factors in population health dis-
paritiesincluding demographic, socioeconomic, and health behavior
characteristicsto generate evidence that can help inform policy solu-
tions. Generating a fuller understanding of how demographic, socio-
economic, and health behavior characteristics contribute to the recent
patterning of metabolic health across groups dened by race-ethnicity,
country of origin, and duration of residence can help researchers and
policymakers identify preventive strategies to slow the rising risk of
obesity and related metabolic conditions in the US and Mexico, and
ultimately help preserve the prolonged life expectancy of Mexican im-
migrants and their descendants living in the US.
2. Background
2.1. Racial-ethnic health disparities
Despite overall improvements in health and longevity over the past
century, signicant racial-ethnic health disparities rooted in social
inequality persist and continue to present the greatest impediment to
improving population health in the US (Gutin & Hummer, 2021; House,
2002). In racialized societies like the US (Bonilla-Silva, 1997), racism
structures how minoritized groups, currently and historically, face dif-
ferential access to resources, opportunities, and risks, making racism a
fundamental cause of health and health disparities (Phelan & Link,
2015). Historically, the predominant focus of health disparities research
in the US has been on Black-white health gaps, but disparities have also
been increasingly documented between whites and Hispanics. Research
in this area has emphasized Hispanics survival advantage (Elo et al.,
2004; Lariscy et al., 2015), but less attention has been dedicated to
understanding whether the Hispanic paradox in mortality extends to
other dimensions of health and wellbeing (Hayward et al., 2014). The
existing research is mixed, suggesting that, compared to whites, His-
panics have similar or more favorable rates of cardiovascular disease
and cancer (Crimmins et al., 2004), comparable or better psychological
wellbeing (Williams, 2018), but higher rates of diabetes and disability
(Crimmins et al., 2004; Hayward et al., 2014). These equivocal ndings
on the relative health standing of Hispanics are largely attributable to
the complexity and heterogeneous patterns introduced by intersecting
systems of discrimination and inequality by race, ethnicity, and immi-
grant status (Boen & Hummer, 2019).
2.2. Immigrant health advantage
Immigrants have lower mortality rates than US-born individuals
(Dupre et al., 2012), less disability during their working years (Lev-
chenko, 2021; Markides et al., 2007), and fewer chronic health condi-
tions, including cancer, diabetes, heart disease, hypertension, and stroke
(Brown, 2018; Gorman et al., 2010). In the US, this immigrant health
advantageis particularly well-documented amongst the Mexican-origin
population (Cho et al., 2004). Three explanations have been proposed to
account for this healthy immigrant effect, including migrant selection,
data issues, and differences in health behaviors and risk proles.
First, immigrants are selected on numerous characteristics positively
associated with health, and thus are generally healthier than the pop-
ulations they leave behind and often those they are joining (Riosmena
et al., 2013). The initial health advantage of the US immigrant popu-
lation may also be partially reinforced by a pattern of return migration
amongst migrants in poor health, commonly referred to as the salmon
bias(Abraído-Lanza et al., 1999; Palloni & Arias, 2004). While positive
selection on education and health have long characterized Mexican
immigration to the US (Akresh, 2008), there are signs that this pattern is
beginning to attenuate (Feliciano, 2005) and separate research also
shows that return migration plays a limited role in observed health and
mortality differences (Hummer et al., 2007; Riosmena et al., 2013; Turra
& Elo, 2008).
A second explanation considers possible data issues that may
disproportionately inuence the health and mortality records of His-
panic immigrants, such as misidentication of ethnicity and age on
death certicates and a higher probability of mismatched mortality re-
cords in population data sources. There is little empirical evidence that
data issues account for a signicant portion of Hispanic immigrant-
native disparities (Hummer et al., 2007; Palloni & Arias, 2004),
although differential linkage of mortality records has been found to
reduce the accuracy of mortality risk estimation for Hispanics in
nationally-based US data sources (Lariscy, 2011). Finally, a third
explanation focuses on differences in the health risk proles of immi-
grants compared to the US native-born population, specically less
intensive and lower rates of smoking, lower rates of excessive drinking,
and less obesity (Singh & Siahpush, 2002). Smoking behavior, in
particular, has been shown to explain the majority of Mexican immi-
grantshealth and mortality advantage over US-born whites (Blue &
Fenelon, 2011; Fenelon, 2013). While all three of these explanations
partially account for the health advantages previously observed among
US Hispanic immigrants, it is also important to consider recent changes
to the conditions immigrants experience in both sending and receiving
countries to make sense of contemporary health patterns and to predict
future trajectories.
2.3. Demographic, nutrition, and epidemiologic transitions and the rise of
metabolic health risks in Mexico and the US
Over the past two decades Mexico has experienced signicant de-
mographic, nutrition, and epidemiologic transitions (Rivera et al.,
2004). While all three transitions are interrelated, the demographic
transition has been marked by lowered risk of premature mortality and
population aging, the nutritional transition by a shift from prevalent
undernutrition to a predominance of diet-related chronic conditions,
and the epidemiologic transition by chronic conditions replacing in-
fectious disease as the primary source of premature morbidity and
mortality (Omran, 1971; Popkin, 2001). The drivers of evolving popu-
lation dynamics in Mexico are multifactorial, but the inuence of
globalization and trade liberalization, such as the passing of the North
American Free Trade Agreement (NAFTA) in 1992, has played an
outsized role in weakening the power and viability of domestic food
suppliers and yielding a food environment dominated by cheap and
abundant processed foods (Thow, 2009). This drastic overhaul of the
countrys domestic food environment helped lay the groundwork for the
rapid increase in obesity and related metabolic conditions that Mexico
has experienced over the past two decades (Barquera & Rivera, 2020).
For much of the early 21st century, the US had the highest recorded
adult obesity prevalence among OECD countries. Yet following these
rapid nutrition and epidemiologic transitions, adult obesity in Mexico
rose quickly and slightly surpassed that of the US in 2013 (Barquera &
Rivera, 2020). The US has since reclaimed the top ranking, although the
proportion of severely obese adults and the mortality risks associated
M. Carabello and J.A. Wolfson
SSM - Population Health 16 (2021) 100932
3
with obesity remain higher in Mexico (Barquera et al., 2020; Mon-
teverde et al., 2010; Ogden et al., 2020). Within the US, a similar dy-
namic exists with Hispanics, and Mexican Americans in particular,
exhibiting a higher obesity prevalence than whites (Flegal et al., 2012,
2016). In both countries today, the main causes of preventable mortality
are associated with obesity, including cardiovascular disease, diabetes,
chronic respiratory disease, and cancer (WHO, 2018a, 2018b). This
convergence in the nutritional and epidemiologic proles of Mexico and
the United States raises important questions about whether recent and
future generations of Mexican immigrants will continue to hold a
metabolic health advantage over the US-born population (Goldman,
2016), with some evidence suggesting that this advantage has already
begun to deteriorate among youth-aged Mexican immigrants in Cali-
fornia (Buttenheim et al., 2013).
2.4. Social determinants of immigrant health deterioration
Immigrants health tends to decline shortly after migration (Gold-
man et al., 2014), with evidence that initial health advantages erode
signicantly and can even disappear altogether within the rst decade of
relocation (Antecol & Bedard, 2006). One prominent explanation points
to the detrimental effects of acculturation on immigrant health behav-
iors through exposure to US society, which has been supported as a
leading explanation for the disability crossover (Levchenko, 2021),
whereby Mexican immigrants with an initial age-specic disability
advantage in their working years later have higher rates of disability
relative to US-born whites at older ages regardless of educational
achievement (Levchenko, 2021). However, more nuanced explanations
have also been offered, guided by segmented assimilation theory and
related frameworks from the immigrant integration literature (Portes &
Zhou, 1993). These explanations recognize both immigrantsaccultur-
ation to American preferences and norms and also the existence of
segmented pathways to immigrant inclusion based on socioeconomic
position and mobility (Goldman et al., 2014; Van Hook et al., 2016).
Thus, while the majority of Mexican immigrants facing socioeconomic
disadvantage might be expected to acculturate to the less healthy be-
haviors of lower-income groups in the US (Abraído-Lanza et al., 2006),
others will incorporate into more advantaged positions where they may
encounter health promoting behaviors and opportunities. Consistent
with this framework of multiple acculturative processes, research
comparing Mexican migrants to non-migrants remaining in Mexico
shows that those who migrate are more likely to experience signicant
short-term changes in health, whether positive or negative, with an
overall trend towards health deterioration for the majority of recent
Mexican immigrants (Goldman et al., 2014). However, evidence
consistent with various acculturative processes does not rule out the
possibility that discrimination and other structural forces may be
operating simultaneously to inuence patterns of immigrant health
deterioration regardless of socioeconomic standing and level of inte-
gration into US society (Levchenko, 2021). Thus, others have also
focused on social inequality as a root cause of immigrant health declines,
acknowledging that Mexican immigrants across the socioeconomic
spectrum may face varying levels of discrimination and chronic stress
due to how they are perceived and treated within US society (Viruell--
Fuentes et al., 2012). Taken together, it is clear that research on
racial-ethnic and nativity health disparities must consider not only the
effect of exposure to US society on immigrant health and health be-
haviors, but also the contribution of social factors and structural envi-
ronments that play a role in shaping immigrantsexperiences and
opportunities post-migration.
2.5. Research aims
In light of uncertainty over the current and future metabolic health of
the Mexican-origin population in the US, we pursue two aims in the
present study:
1. Compare the metabolic proles of adult-aged US-born whites, US-
born Mexican Americans, and recent and earlier Mexican immi-
grants to evaluate whether recent Mexican immigrants hold a
metabolic health advantage.
2. Assess the contribution of demographic, socioeconomic, and health
behavior characteristics to observed population health gaps by race-
ethnicity, country of origin, and duration of residence in the US.
3. Materials and methods
3.1. Data and sample
Data were acquired from the National Health and Nutrition Exami-
nation Survey (NHANES), a cross-sectional, nationally representative,
population-based survey conducted by the Centers for Disease Control
and Prevention that uses a complex, multistage probability sampling
strategy designed to be representative of the civilian, non-
institutionalized US population (NCHS, 2013; NCHS, 2018). We com-
bined eight waves of data (19992016) for adults aged 20 or older. We
excluded respondents who were pregnant (n =1029), did not complete
the physical examination (n =1480), were not included in the morning
laboratory examination that was restricted to the fasting subsample (n
=16,076) or had their age top-coded in NHANES (n =790), leaving an
eligible sample of 11,559 individuals. The sample was further restricted
to those with complete information on all study outcomes, creating a
nal analytic sample of 10,833 individuals (93.7% of eligible sample):
foreign-born Mexican (n =1799), US-born Mexican American (n =
1334), US-born non-Hispanic white (n =7700).
3.2. Measures
Metabolic syndrome (MetS) was the primary outcome. We con-
structed the MetS measure using the six individual risk factors included
in the most recently harmonized denition of MetS (Alberti et al., 2009).
MetS encapsulates several health conditions that epidemiological
studies have found to co-occur in patients with a high risk of cardio-
vascular disease and type-2 diabetes. The six indicators of metabolic
dysregulation include: elevated fasting glucose (100 mg/dL), elevated
triglycerides (150 mg/dL), lowered HDL cholesterol (<40 mg/dL for
males, <50 mg/dL for females), elevated blood pressure (systolic 130
mmHg, diastolic 85 mmHg), obesity (BMI 30 kg/m
2
), and an
increased waistline (102 cm for males, 88 cm for females) (Alberti
et al., 2009; Eckel et al., 2005). Respondents were classied as having
MetS if they possessed three or more of the individual health risks based
on NHANES laboratory and physical examinations, or self-reported
taking medications to control them (Alberti et al., 2009; Eckel et al.,
2005). We created dichotomous measures (0/1) for each component as
well as a summary indicator of MetS (0/1).
We divided the sample into four groups to examine differences in
MetS by race-ethnicity, country of origin, and duration of residence in
the US. The two US-born groups, non-Hispanic whites (hereafter, US-
born whites) and Mexican Americans, were each dened based on
self-reported responses to a single race-ethnicity question. In order to
analyze expected changes in health status with increasing time spent in
the US, we sub-classied the foreign-born Mexicans (Mexican immi-
grants) into two additional groups (recent and earlier immigrants) based
on their self-reported duration of residence in the US: less than ten years
(n =493), or ten years or more (n =1250).
Three categories of independent variables were used to explain
prevalence differences in MetS: demographic characteristics, socioeco-
nomic factors, and health behaviors. Demographic characteristics
included age and gender. Socioeconomic factors included education
(less than high school, high school or GED, and some college/college
graduate), employment (not employed, part-time under 35 h/week, and
full-time over 35 h/week), and income (income-to poverty ratio). Given
the cross-sectional nature of the data, we selected three health behaviors
M. Carabello and J.A. Wolfson
SSM - Population Health 16 (2021) 100932
4
that would be difcult for respondents to alter in response to a diagnosis
of MetS in effort to minimize reverse causation bias. These included
three-category measures of alcohol consumption (never or former
drinker, moderate drinker [1 drink/day for females, 2 drinks/day
for males], and heavy or binge drinker [>1 drink/day for females, >2
drinks/day for males]) and food security (full, marginal, and low/very
low), as well as a continuous measure of years spent smoking. We also
included a survey wave indicator in all analyses to adjust for trends in
MetS over the study period.
3.3. Analysis
All analyses were weighted and conducted in Stata/MP-2 17.0 using
the svy command prex (StataCorp, College Station, Texas, USA).
Within the analytic sample, 15.3% had missing data on one or more
covariates (education, employment, income-to-poverty ratio, years
smoking, alcohol, and/or food security), with no more than 6.3% of the
sample missing on any single covariate. In order to preserve cases and to
avoid introducing bias through listwise deletion (Allison, 2001), we
employed multiple imputation separately for each study population. We
estimated unadjusted proportions and means for all demographic, so-
cioeconomic, and health behavior characteristics, as well as all meta-
bolic health outcomes. To account for major differences in the age
structure of each of our four study populations, we then estimated
18-year age-standardized prevalence rates using direct standardization
to the 2000 US Census population age distribution (Klein & Schoenborn,
2001). We also determined the prevalence rate for each study group at
every two-year survey wave, and then imposed a GLM smoothing
function to graph the group trends in MetS over the full study period.
For the main analysis, we decomposed the MetS prevalence differ-
ence between US-born whites and recent Mexican immigrants, in order
to assess how key demographic, socioeconomic, and health behavior
characteristics contribute to a possible immigrant health advantage. The
decomposition divides between-group differences in the dependent
variable into a component due to differences in population character-
istics (i.e., the explainedor endowmentportion) and a component
due to differential returns to those characteristics (i.e., the unex-
plained or coefcientportion). The unexplained portion represents
the between group disparity that would theoretically remain if the two
groups were matched on identical levels for all model variables.
This techniquerst introduced by sociologist and demographer
Kitagawa (Kitagawa, 1955), and further popularized by economists
Blinder and Oaxaca (Blinder, 1973; Oaxaca, 1973)has been increas-
ingly recognized as a preferred approach for analyzing and explaining
racial-ethnic disparities in health (Jackson & VanderWeele, 2018;
VanderWeele & Robinson, 2014). An age
2
term was also included to
account for the curvilinear association between age and MetS.
We subsequently estimated associations between independent vari-
ables and MetS in each study population using Poisson regression with a
log link function and robust standard errors to directly estimate the
prevalence rate ratio (PRR) between groups (Barros & Hirakata, 2003).
This model also included interactions of gender x race-ethnicity/country
of origin/duration of residence group and education x
race-ethnicity/country of origin/duration of residence group to account
for expected differences in associations by study population. An age
2
term was also included in our regression model. We then estimated the
predicted prevalence of MetS associated with a specied value of each
covariate with age held at the overall sample mean (46.5), and all other
covariates xed at their observed levels for each individual and then
averaged within each group. All tests were two-sided and signicance
was considered at P <0.05 for all analyses.
4. Results
4.1. Descriptive statistics
Table 1 summarizes the weighted demographic, socioeconomic, and
health behavior characteristics, of the four study groups. Recent
Mexican immigrants were the youngest group, with a mean age of 32.2
years for those residing in the US less than ten years. Mexican immi-
grants residing in the US for ten years or more were closer in age to US-
born Mexican Americans, with mean ages for these groups of 42.1 and
40.2 years, respectively. US-born whites were the oldest population,
with a mean age of 47.2 years. Both groups of foreign-born Mexicans
were composed of more males compared to US-born Mexican Americans
and US-born whites. Both groups of foreign-born Mexicans had signi-
cantly lower educational attainment and income, but had higher levels
of full-time employment than US-born groups. In terms of health be-
haviors, both the US-born and foreign-born Mexicans had smoked fewer
years than US-born whites on average. The foreign-born Mexican groups
had the highest share of non- and former-drinkers, but also the highest
levels of heavy alcohol drinkers, while US-born whites and Mexican
Americans had higher shares of moderate drinkers. US-born whites were
the most food secure of all the groups, with signicantly higher levels of
full food security and the lowest levels of food insecurity (i.e., low/very
low food security), while both groups of foreign-born Mexicans had
lower levels of food security and higher levels of food insecurity relative
to the US-born groups.
Table 1 also presents the unadjusted and age-standardized health
outcomes by study group. Prior to age-standardization, recent Mexican
immigrants hold a clear and signicant advantage in metabolic health,
with lower prevalence rates of low HDL cholesterol, high blood pressure,
high waist circumference, obesity, and MetS overall as compared to the
other three groups. US-born Mexican Americans and foreign-born
Mexicans residing in the US for ten years or more had the highest un-
adjusted prevalence rates of MetS overall, along with high levels of
many of the individual high-risk metabolic health indicators. Upon
standardizing all of the study groups to the 2000 US Census age distri-
bution, the recent immigrant health advantage in MetS over US-born
whites disappears. However, a signicant advantage remains for
recent Mexican immigrants over earlier Mexican immigrants and US-
born Mexican Americans. Fig. 1 portrays these age-standardized
trends in MetS over the eighteen-year study period, with recent
Mexican immigrants and US-born whites holding lower prevalence rates
of MetS at the beginning of the period, but a less distinct advantage over
the other two groups by the end of the period. This gure also reveals
that both US-born groups held trajectories of increasing MetS prevalence
over the study period, while both groups of Mexican immigrants are seen
to follow relatively at overall trends.
4.2. Decomposition
The results of the decomposition analysis are summarized in Fig. 2.
Panel A depicts the unadjusted MetS prevalence rates for US-born whites
(45.5%) and recent Mexican immigrants (29.5%), as well the prevalence
difference between the two groups (16.0%). The explained portion in
Panel A indicates that nearly 40% of the prevalence difference (i.e., 6.1
prevalence points) would be eliminated if associations were causal and
the two groups had the same mean level on all model variables.
Conversely, the remaining ~60% of the gap (9.9 prevalence points)
would theoretically remain under these same conditions. Panel B sum-
marizes the contribution of each study variable to the explained portion
of the MetS prevalence difference between US-born whites and recent
Mexican immigrants. While the full prevalence difference is accounted
for by the younger age structure of recent Mexican immigrants as
compared to US-born whites (i.e., statistically-explaining 17.4 preva-
lence points), this group would retain a sizable metabolic health
advantage of roughly 11.6 prevalence points, even after adjusting for
M. Carabello and J.A. Wolfson
SSM - Population Health 16 (2021) 100932
5
age differences, if they were to achieve parity with US-born whites on
education (3.2 prevalence points), income levels (4.5 prevalence
points), drinking behavior (0.7 prevalence points), and levels of food
security (3.2 prevalence points).
4.3. Multivariate and predictive models
Fig. 3 presents the predicted prevalence rate of MetS associated with
specied levels of the three social factors found to have the greatest
potential to improve recent Mexican immigrantsmetabolic health:
education, income, and food security. Consistent with the results of the
decomposition, recent Mexican immigrants are shown to retain a
metabolic health advantage over US-born whites when both groups are
assigned the same xed level on each of these measures. Of note, while
US-born Mexican Americans and foreign-born Mexicans residing in the
US for ten or more years also receive relative improvements in their
metabolic health risk from increasing education, income, and food se-
curity, these gains are not sufcient to overcome their metabolic health
disadvantage relative to US-born whites and recent Mexican immi-
grants. The underlying Poisson regression model from which the pre-
dicted prevalence rates were derived is summarized in Table A.1 of the
supplemental online les and the full set of predicted prevalence rates
associated with all study measures is summarized in Table A.2.
5. Discussion
In this paper we rst aimed to determine whether the Hispanic
advantage in mortality extends to a lower risk of the major chronic
conditions which constitute metabolic syndrome among recent Mexican
immigrants to the US. We nd that recent Mexican immigrants do
exhibit an overall metabolic health advantage, which is largely attrib-
uted to their younger age structure compared to earlier Mexican
Table 1
Weighted demographic, socioeconomic, health behavior characteristics, and outcomes by race-ethnicity, country of origin, and duration of residence: US-residing
adults in the National Health and Nutrition Examination Survey (NHANES, 19992016) (N =10,833).
US-born Foreign-born Mexicans (FBM)
Non-Hispanic whites (NHW)
(N =7700)
Mexican Americans (MA)
(N =1334)
In US <10 years (N =491) In US 10+years (N =1308)
Demographic characteristics
Age, [mean (SE)] 47.2
†‡§
(0.277) 40.2*
‡§
(0.462) 32.2*
†§
(0.552) 42.1*
†‡
(0.553)
Gender, male [%] 49.9
‡§
50.9
‡§
59.1*
54.9*
Socioeconomic characteristics
Education [%]
Less than high school 11.7
†‡§
24.1*
‡§
66.5*
67.5*
High school or GED 24.5
§
24.1
§
20.7 16.4*
Some college or college graduate 63.7
†‡§
51.8*
‡§
12.8*
16.2*
Income-to-poverty ratio (PIR), [mean (SE)] 3.3
†‡§
(0.044) 2.5*
‡§
(0.085) 1.3*
†§
(0.064) 1.6*
†‡
(0.048)
Employment [%]
Not employed 32.3
31.6
24.8*
29.0
Part time (134 h/week) 14.3 14.5 13.3 12.8
Full time (35 h/week) 53.4
‡§
53.9
61.9*
58.2*
Health behaviors
Smoking, years spent [mean (SE)] 10.7
†‡§
(0.257) 6.8*
(0.371) 4.8*
†§
(0.428) 6.5*
(0.383)
Alcohol [%]
Never or former drinker 23.7
‡§
25.3
§
30.8* 35.7*
Current moderate drinker 38.8
†‡§
26.1*
‡§
19.2*
20.4*
Current heavy or binge drinker 37.5
†‡§
48.6* 50.0* 43.8*
Food security [%]
Full food security 85.4
†‡§
65.7*
‡§
45.1*
†§
53.6*
†‡
Marginal food security 5.4
†‡§
15.1*
23.5*
†§
17.5*
Low/very low food security 9.2
†‡§
19.2*
‡§
31.4*
†§
28.9*
Outcomes, unadjusted 18-year prevalence
High-risk metabolic health indicators [%]
Pre-diabetes 43.2
§
44.8
§
41.9
§
55.5*
†‡
High triglycerides 29.5
§
31.5 29.2 34.4*
Low HDL cholesterol 40.3
41.6
34.4*
†§
40.7
High blood pressure 38.5
†‡§
32.0*
‡§
13.2*
†§
26.5*
†‡
High waist circumference 54.6
†‡
60.8*
‡§
36.9*
†§
54.8
†‡
Obesity 33.5
†‡§
45.5
†‡§
23.2*
†§
39.8
†‡§
Metabolic syndrome,
3 high-risk health indicators
45.5
†‡
50.9*
29.5*
†§
49.6
Outcomes, age-standardized 18-year prevalence
a
High-risk metabolic health indicators [%]
Pre-diabetes 40.5
†‡§
49.8*
§
50.7*
§
56.9*
†‡
High triglycerides 28.6
†‡§
33.7* 37.6* 34.3*
Low HDL cholesterol 39.0
†§
43.2* 38.2 42.3*
High blood pressure 34.9
†‡§
38.5*
‡§
28.8*
30.8*
High waist circumference 52.6
63.5*
‡§
50.7
55.5
Obesity 32.7
†‡§
46.2*
‡§
28.1*
†§
40.1*
†‡
Metabolic syndrome,
3 high-risk health indicators
42.9
†§
55.4*
‡§
43.0
†§
50.7*
†‡
Notes. Weighted descriptive statistics. Symbols indicate a statistically signicant difference at the
α
=0.05 level in proportions/means between the respective group in
each column and US-born non-Hispanic whites (*), US-born Mexican Americans (
), foreign-born Mexicans in the US <10 years (
), and foreign-born Mexicans in the
US 10 or more years (
§
).
a
Prevalence rates for the eighteen-year study period are age-standardized to the US population distribution according to the 2000 US Census and incorporate survey
weights to generate nationally representative estimates.
M. Carabello and J.A. Wolfson
SSM - Population Health 16 (2021) 100932
6
immigrants, US-born Mexican Americans, and US-born whites. We then
explored how key demographic, socioeconomic, and health behavior
characteristics contribute to the prevalence of MetS among foreign-born
and US-born Mexican Americans relative to US-born whites. The in-
sights from this analysis advance our knowledge of how key character-
istics relate to the metabolic health of Mexican immigrants and
Fig. 1. Age-standardized metabolic syndrome (MetS)
prevalence by race-ethnicity, country of origin, and
duration of residence: US-residing adults in the Na-
tional Health and Nutrition Examination Survey
(NHANES, 19992016) (N =10,833)
Notes. Prevalence rates for each two-year study
period (presented as point estimates) are age-
standardized to the US population distribution ac-
cording to the 2000 US Census and incorporate sur-
vey weights to generate nationally representative
estimates. A GLM smoothing function is applied to
overlay the trends in metabolic syndrome for each
group over the eighteen-year study period. The study
populations are abbreviated as follows: US-born non-
Hispanic whites (NHW), US-born Mexican Americans
(MA), foreign-born Mexicans residing in the US for
less than ten years (FBM <10 yrs), and foreign-born
Mexicans residing in the US for ten years or more
(FBM 10 yrs).
Fig. 2. Decomposition of the prevalence difference in metabolic syndrome
(MetS) between US-born non-Hispanic whites and foreign-born Mexicans
residing in the US <10 years (NHANES, 19992016) (N =8191)
Notes. Panel A summarizes the explained and unexplained portions of a two-
way, logistic regression-based Oaxaca-Blinder decomposition of the preva-
lence difference in metabolic syndrome between non-Hispanic whites (NHW)
and recent Mexican immigrants (FBM <10 yrs). Panel B portrays the individual
contribution of each study variable to the explained portion of the
decomposition.
Fig. 3. Predicted prevalence rates of metabolic syndrome (MetS) associated
with select demographic, socioeconomic, and health behavior characteristics by
race-ethnicity, country of origin, and duration of residence: US-residing adults
in the National Health and Nutrition Examination Survey (NHANES,
19992016) (N =10,833)
Notes. Predicted prevalence rate (PPR) associated with key independent vari-
ables (holding age at the sample mean of 46.5 and all other covariates at their
observed levels for each individual) by race-ethnicity/country of origin/dura-
tion of residence group. Predicted rates are based on an underlying Poisson
regression model with a log link function and robust standard errors, used to
directly estimate the prevalence rate ratio between groups.
M. Carabello and J.A. Wolfson
SSM - Population Health 16 (2021) 100932
7
illuminate areas of policy intervention that may help to preserve their
health, and that of their descendants, with increasing time spent in the
United States.
A small number of nationally-representative studies have previously
explored whether the Hispanic advantage in mortality extends to a
lower risk of the major chronic conditions which constitute MetS and
related syndromes (Boen & Hummer, 2019; Crimmins et al., 2007;
Zhang et al., 2012), all reporting no signicant Hispanic metabolic
health advantage after adjusting for basic demographic factors, such as
age, gender, and/or marital status. Yet given sample size and data
constraints, each of these earlier studies was prevented from further
stratifying by country of origin and duration of residence, which are
notable limitations given that foreign-born Mexicans residing in the US
for less than a decade typically hold the greatest overall health and
mortality advantages (Antecol & Bedard, 2006; Markides & Eschbach,
2005). The present study improves on these limitations, yet reaches a
similar conclusion, as we found that the full prevalence difference in
MetS between recent Mexican immigrants and US-born whites was more
than accounted for by the immigrantsyounger age structure. However,
our results also reveal that recent Mexican immigrants would retain a
sizable metabolic health advantage, regardless of age structure, if they
were to achieve parity with US-born whites in terms of educational
attainment, income levels, and food security. This nding aligns with
prior research suggesting that Hispanicsmortality levels would be even
more favorable if not for their socioeconomic disadvantage (Lariscy
et al., 2015). Additionally, though not sufcient to overcome their sig-
nicant metabolic health disadvantage, US-born Mexican Americans
and earlier Mexican immigrants were also predicted to see relative im-
provements in their MetS risk from higher levels of education, income,
and food security. These results highlight the need to take a preventive,
social determinants focused approach in supporting newly-arrived im-
migrants in maintaining their health upon migrating to the US.
Policy solutions are needed to help resolve many of the socioeco-
nomic inequalities immigrants face. Our results support focusing on
policies that would help to resolve immigrant-native disparities in in-
come, food security, and education, such as equitable pathways to citi-
zenship and robust worker protections. A path to citizenship has already
been proposed for undocumented agricultural workers under the House-
approved, Senate-pending Farm Workforce Modernization Act of 2021
(H.R.1603) (Lofgren, 2021). Additional legislation could also help to
ensure all undocumented workers, whose labor currently upholds mul-
tiple sectors of the US economy, are able to receive livable wages, safe
and humane work and living conditions, and robust enforcement of
these protections. Short of providing a pathway to citizenship and
extending additional protections for migrant workers, both the food
insecurity and immediate nancial precarity faced by newly-arrived
immigrants could be partially addressed by de-coupling the eligibility
for federal and state-based welfare programssuch as SNAP benets,
housing assistance, disability and unemployment, Medicaid, and
SSIfrom documentation status, especially since undocumented im-
migrants already pay billions of dollars into these programs annually
(Southern Poverty Law Center, 2010). The expected impact on meta-
bolic health from this proposed shift in policy is further supported by
recent research showing that unauthorized Hispanic immigrants face
signicantly heightened risks of weight gain and obesity with time spent
in the US relative to their co-ethnic peers who hold legal residence status
(Altman & Bachmeier, 2021).
Improving the educational attainment of adult immigrants will likely
prove difcult under any policy regime, but opportunities to pursue
higher education should be safeguarded and expanded for those who
migrate as children or teenagers. While young immigrants are currently
able to seek protections under the Deferred Action for Childhood Ar-
rivals (DACA) policy, as a temporary work permit program, DACA has
been shown to present barriers to higher education by incentivizing
work over educational investment (Hsin & Ortega, 2018). In a recent
session of Congress the House approved the American Dream and
Progress Act of 2019 before it stalled in the Senate, which would have
offered young immigrants permanent legal status (H.R.6) (Royba-
l-Allard, 2019). The passage of this more expansive legislation would be
expected to have a signicant impact on reducing barriers to educational
attainment for young immigrants (Francesc et al., 2019). Our ndings
suggest that policy solutions are needed to address socioeconomic
inequality and support immigrant health, and a variety of recent legis-
lative efforts have been aligned with this goal; what is needed now is the
political will to pass them.
While this study offers signicant contributions to the current liter-
ature on the health of Mexican immigrants to the US, it also presents
limitations. First, our study faces a number of possible selection issues.
Given that we do not have access to data from the counterfactual pop-
ulation of Mexicans who did not migrate to the US, we cannot assess
healthy migrant selection effects as part of the explanation for recent
Mexican immigrantsinitial metabolic health advantage relative to the
other groups in our sample. This is notable since other researchers able
to combine data from NHANES (19992010) with data from the
Mexican National Health and Nutrition Survey (2006) have found evi-
dence of a modest migrant selection effect contributing to foreign-born
Mexicansmetabolic health advantage relative to non-Hispanic whites
(Beltr´
an-S´
anchez et al., 2016). Related to this, we also cannot rule out
the presence of selection bias into the NHANES sample, as it is possible
that immigrants selected and willing to respond may differ in systematic
and consequential ways from those not selected or not willing to respond
to survey administrators. However, even in the presence of unmeasured
migrant selection effects, our results offer valuable insight into key
factors that inuence the health of those who did migrate and now
reside in the US.
The second area of limitation relates to the cross-sectional nature of
our data source, which prevents causal conclusions from being drawn
from our analysis. In attempt to minimize likely sources of reverse
causation bias, we included measures that would be difcult for re-
spondents to alter in response to a change in health status or diagnosis.
However, this precaution also prevented us from including certain
measures known to have strong associations with metabolic health, such
as dietary intake and physical activity, which may have introduced
possible omitted variable bias. The cross-sectional nature of our data
also prevented us from directly assessing how the metabolic health of
the immigrants in our sample might be affected by the accumulated
stresses and opportunities encountered through the process of migration
and acculturation. Finally, given our limited sample of foreign-born
Mexicans, we were unable to model our outcomes separately for each
gender.
6. Conclusion
This study lls a critical gap in our knowledge of how key social and
behavioral characteristics inuence the metabolic health of rst- and
later-generation Mexican immigrants, at a time when the prevalence of
major chronic metabolic conditions like obesity and diabetes are
continuing to rise in both Mexico and the United States. To ensure that
newly-arrived Mexican immigrants and their descendants continue to
enjoy historically-documented health and mortality advantages in the
future, modest changes in US immigration and social policy could help
to offer health-promoting protections in the form of increased economic
and food security, as well as improved educational opportunities for
younger immigrants.
Credit author statement
Maria Carabello: Conceptualization, Data Curation, Formal Analysis,
Funding Acquisition, Methodology, Writing Original Draft, Writing
Review & Editing, Visualization. Julia A. Wolfson: Conceptualization,
Data Curation, Funding Acquisition, Supervision, Writing Review &
Editing.
M. Carabello and J.A. Wolfson
SSM - Population Health 16 (2021) 100932
8
Ethical statement
This research was conducted using publicly available data from the
National Health and Nutritional Examination Survey (NHANES), a de-
identied population health data source maintained by the National
Center of Health Statistics (NCHS). Our secondary analysis of this data
was ruled exempt from regulation by the Health Sciences and Behavioral
Sciences Institutional Review Board at the University of Michigan
(HUM00154839).
Declaration of competing interest
None.
Acknowledgments
Maria Carabellos research on this project was supported by the
National Institute on Aging of the National Institutes of Health (Award
#T32AG000221 and #T32AG027708). Julia A. Wolfson was supported
by the National Institutes of Diabetes and Digestive and Kidney Diseases
of the National Institutes of Health (Award #K01DK119166). The con-
tent is solely the responsibility of the authors and does not necessarily
represent the views of the National Institute on Aging or the National
Institutes of Diabetes and Digestive and Kidney Diseases. The authors
would like to thank participants of the Inequality and Social Demog-
raphy Workshop at the University of Michigan for their comments on an
earlier version of this paper.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ssmph.2021.100932.
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M. Carabello and J.A. Wolfson
... Mexican migrants in the US and their descendants have increased risk of diabetes and cardiovascular disease when compared to non-Hispanic whites [80]. There is a positive association between length of time in the US and negative health indicators, e.g., ageadjusted data for prevalence of obesity of Mexican migrants in the US was 28.1% for those in the US less for than 10 years, 40.1% for those in the US for more than 10 years, and 46.2% for Mexican Americans born in the US [81]. By maintaining a healthy and balanced diet, these NCDs can be prevented, and public health programs and interventions have expanded communication strategies to be accessible to Spanish-speaking communities and have been modestly effective [82]. ...
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... The KBO decomposition is a statistical method developed in Downloaded from http://ahajournals.org by on November 6, 2022 the economics literature to explain inequalities between groups. [17][18][19] It has been used in public health research to understand and identify potential intervention targets to reduce health inequities [20][21][22] such as to identify the contribution of social determinants to diabetes health disparities in Hispanic and Latinx populations, 23,24 and to characterize factors that explain the racial and ethnic differences in CVD risk factors among mid-life women. 25 Here, we applied the KBO decomposition to statistically quantify the amount of the difference in mean CVH between racial and ethnic groups that is associated with (1) "explained differences," which are the between-group differences in the levels of the factors of interest (i.e., differences based on the observable factors as included in the statistical regression models), and (2) "unexplained differences," which are differences due unobserved factors (e.g., discrimination) that result in differential magnitudes of association (i.e., differences in regression coefficients, or slope of regression line) of the individual-level factors with CVH within each racial and ethnic group. ...
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