These results suggest that within-group differences in ethnic groups may need to be considered in efforts to alleviate health disparities. In this nationally representative survey, acculturation among Hispanics in the U.S., as measured via language, is associated with diabetes even after controlling for a variety of demographic characteristics including health insurance and education. Individuals with low acculturation, measured by language, who have been diagnosed with diabetes are at increased risk for having the complication of peripheral neuropathy. Despite having a higher prevalence of diabetes and a greater risk of complications, they were less likely to have a regular place of care or health insurance. Acculturation was not associated with several other indicators of diabetes control or risk for cardiovascular disease. When acculturation was measured by the crude assessment of being foreign born, no significant relationship was yielded with either diabetes or control among patients with diabetes.
Understanding diabetes, its symptoms, and treatments is particularly important for the patient and conveying this information to the patient is a crucial role for the physician. Poor health literacy is more common among patients with low educational attainment, immigrants, and racial and ethnic minorities.29
Poor health literacy among patients with diabetes has been shown to be associated with worse glycemic control and more frequently reported retinopathy.30
Hispanic patients with low language acculturation may be particularly at risk if their physician has poor Spanish skills and understanding of Hispanic culture.31
Our findings suggest that a substantial portion of Hispanics in the U.S. may be at risk and that focusing on culturally appropriate interventions to increase health literacy among this population may be warranted.
Our nationally representative finding that lower levels of acculturation among Hispanics is associated with diabetes is similar to a previous regional study conducted 20 years earlier.8
Although that study operationalized acculturation differently than the present study, had a more restrictive age range for participation, and included only Mexican Americans, both studies observed a relationship between acculturation and diabetes. However, the regional study did not find a relationship between acculturation and BMI like that found in our analysis. The last 20 years have seen substantial growth of the U.S. Hispanic population to the point where estimates for 2002 indicate that more than one in eight individuals in the U.S., or 37.4 million individuals, is Hispanic.32
The within-group differences found in this nationally representative study illustrate that health care interventions to address disparities should recognize that ethnic groups may need to be seen in more sophisticated ways than simply as homogenous wholes.
We must acknowledge several limitations to this study. First, the data set is cross-sectional, which limits the ability to make inferences about causality. The NHANES data do, however, allow us to make population estimates for conditions for subgroups of the U.S. population. Second, we included everyone who self-identified as Hispanic in our study, then stratified Mexican-Americans vs. Other Hispanics. We believed that in the development of nationally representative population estimates, this clumping would give the best representation of diabetes and acculturation among Hispanics in the U.S, particularly since the primary acculturation measures are based on language or U.S. birth. However, it is possible that differences in health beliefs and behaviors among Hispanic cultural groups may have affected the results when viewing Hispanics as a single culturally unified group.33
Third, the question regarding the assessment of physician-diagnosed diabetes does not discriminate between those told that they had type 1 and type 2 diabetes. Fourth, although the levels of HbA1c and blood pressure and HDL were consistent with recommendations present at the time of data collection, all of these measures had been revised by 2004 to be more stringent.34
Consequently, the findings of this study may not generalize to practice in 2005.
In conclusion, this study points to the importance of within-group differences among Hispanics that need to be understood when considering health care disparities. For ethnic groups that have language and cultural differences from the majority English speaking U.S. population, ensuring cultural competence among providers is warranted.