Acculturation Factors Related to Obesity of Latino American Men Nationwide

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1 653182JMHXXX / American Journal of Men s HealthAi et al. research-article2016 Article Acculturation Factors Related to Obesity of Latino American Men Nationwide American Journal of Men s Health 1 10 The Author(s) 2016 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: / ajmh.sagepub.com Amy L. Ai, PhD 1, Hoa B. Appel, PhD, MPH 2, and Jungup Lee, MSW 1 Abstract Obesity is a public health epidemic, particularly among underrepresented populations. With a large proportion of immigrants, Latino Americans comprise the largest minority population in the United States. This study examined the association of acculturation factors with obesity among Latino American men (n = 1,127) using the National Latino and Asian American Study. The result identified two acculturation-related factors (being U.S.-born and living in the United States for the longest period/5-10 years) as positive correlates. In contrast, a different study on obesity in Latino American women demonstrated discrimination, but not the above factors, as significant correlates. The men s pattern suggests that the Hispanic/Latino paradox might have greater implications for men with respect to weight issues. Furthermore, Mexican American and Other Latino American men presented a greater likelihood of being obese than Cuban and Puerto Rican men. The findings, if replicated in prospective research, suggest the need for gender- and ethnic-specific intervention for obesity in Latino American men, particularly for the largest subgroup, Mexican Americans. Keywords sex differences, men of color, obesity, risk factors Introduction An estimated one third of adults (ages 20+ years) in the United States (U.S.) were obese in 2011 to 2012 (National Health and Nutrition Examination Survey, 2013). Obesity is a significant risk factor for major chronic conditions. The Hispanic Community Health Study/Study of Latinos identified that diabetes, a consequence of obesity, disproportionally affect Latino Americans (Latinos; Schneiderman et al., 2014). The rate of obesity among Latino men (40.1%), though slightly lower than that in Latino women, is higher than rates among non-hispanic White men (32.4%) and non-hispanic Black men (37.1%) in the United States (44.4%; National Health and Nutrition Examination Survey, 2013). Despite their higher rates of obesity, Latino men had considerably less weight concerns than other populations (Isasi et al., 2015). Partly due to the large-wave Latino migration of the past decade, Latinos will reach an estimated one third of the total population by 2060 (U.S. Census Bureau, 2014). Given this momentum, the prevalence of obesity in Latino men may have significant impacts on the nation s public health agenda because many of them comprise a rising low-wage workforce in the nation. It is therefore imperative for behavioral health researchers to investigate risk factors for this priority issue in this minority male population. The primary aim in the current study is to explore how acculturation was associated with the diagnostic criterion of obesity in Latino men. The underlying theoretical framework lies in an assumption; that is, the health status of Latino Americans is intertwined with their generations of acculturation process (Lorenzo-Blanco & Cortina, 2013). Most Latinos in the United States are foreign-born, while their acculturation process can uniquely play a key role in health conditions, including weight-related issues, in this largest minority male group in the US. Acculturation, in the view of a mainstream culture, refers to overtime experiences through which minorities acquire cultural elements from the culture of the majority (Healey & O Brien, 2014). Removed from their own cultural traditions, Latinos may become less collectivist, more independent, and closer to an American identity in this process (Schwartz, Unger, Zamboanga, & Szapocznik, 2010). The acculturation health link especially manifest in terms of 1 Florida State University, Tallahassee, FL, USA 2 University of Washington Bothell, Bothell, WA, USA Corresponding Author: Amy L. Ai, Florida State University, 296 Champions Way, 2570 University Center Building C, Tallahassee, FL 32306, USA. amyai8@gmail.com

2 2 American Journal of Men s Health an evident Hispanic/Mexican paradox : Latinos tended to report better health outcomes and lower mortality than mainstreamers despite having lower socioeconomic status (SES; Abraído-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999; Chung, 2006; Markides & Coreil, 1986; Vega et al., 1998). Yet lower SES is consistently related to poor public health and higher mortality globally (Franzini, Ribble, & Keddie, 2001). Over the past decades, the Hispanic paradox received national evidence underlining the role of acculturation in Latinos health status. Latino immigrants showed lower infant mortality rate compared with U.S.-born Latinos with better SES and health insurance (Smith & Bradshaw, 2006). Most middle-aged and the elderly Latinos, especially Mexicans, presented lower or equal levels of mortality than non-hispanic Whites, except Puerto Ricans (Turra & Goldman, 2007). Mortality rates in infants of Mexican immigrant mothers in the United States were considerably lower than those of non-hispanic White, U.S.-born mothers (Hummer et al., 2007). Other studies revealed an increasing morbidity and mortality burden in the U.S.-born Latinos compared with foreign-born Latinos (Cunningham, Ruben, & Narayan, 2008; Smith & Bradshaw, 2006). Foreign-born Latinos also live longer than members of other populations (Hayward, Hummer, Chin, González-González, & Wong, 2014). Albeit the increasing attention to the aforementioned paradox, there has been paucity of national evidence linking acculturation with obesity in Latinos, especially in Latino men (Chung, 2006). Emerging data on Latinos obesity suggest that the acculturation process may take certain protection in Latino culture away from this population. A regional agricultural study reported that certain acculturation factors (generational status and years staying in the United States) were stronger predictors for obesity than lifestyle factors (exercise and diet) among Latinos (Hubert, Snider, & Winkleby, 2005). A trend study also related generational status with obesity of all Latinos in the United States (Bates, Acevedo-Garcia, Alegría, & Krieger, 2007). Nevertheless, findings are not always consistent. The finding on obesity in Latino women did not converge with the Latino paradox (Ai, Pappas, & Lee, 2016). Rather, obesity in Latino women was associated with perceived discrimination that may co-occur with acculturation. To examine if acculturation took a part in obesity of Latino men, this parallel study was conducted. Based on the literature (Abraído-Lanza et al., 1999; Chung, 2006; Hayward et al., 2014; Markides & Coreil, 1986; Vega et al., 1998), it was hypothesized that risk of obesity in Latino men would increase with the status of acculturation. Following the women s study (Ai et al., 2016), the authors included acculturation-related critical factors, especially discrimination, showing the reality Latino men faced (Espino & Franz, 2002; Faught & Hunter, 2012; Pérez, Fortuna, & Alegrίa, 2008; Verissimo, Grella, Amaro, & Gee, 2014). The concept of discrimination refers to actions that individuals or institutions have taken to negatively affect disadvantaged social groups defined by SES and/or ethnic-cultural sectors (Jones, 2000). Furthermore, the secondary aim was to demonstrate ethnic-group differences in obesity of Latino Americans alongside the tested acculturation obesity link. Latino populations are heterogeneous, involving major ethnic subgroups such as Cubans, Mexicans, and Puerto Ricans (Brady, Ho, Kelley, & Clancy, 2007; Ennis, Ríos-Vargas, & Albert, 2011; Healey & O Brien, 2014). The Hispanic paradox was initially identified in the Southwestern United States where most Mexican descendants resided (Abraído-Lanza et al., 1999; Chung, 2006; Markides & Coreil, 1986). This paradox was also reported not to be applicable to Cubans (Pérez et al., 2008). A recent study presented considerable ethnic differences in overall health measures among Latino subgroups in the National Latino and Asian American Study (NLAAS). Mexican men reported the highest obesity rate (32.5%), whereas Cuban men had the highest overweight rate (50.4%; Ai, Noel, Appel, Huang, & Hefley, 2013). Mexican men are more likely to take dangerous agricultural and construction jobs that demand a migrant lifestyle (Healey & O Brien, 2014; World Bank, 2015). The unstable living conditions could deprive them of their traditional cultural resources (e.g., homemade meals) and expose them to unhealthy fast food and more soft drinks. Based on the literature and the Hispanic paradox assumption (Ai et al., 2013; Vega et al., 1998), the authors included ethnicity in this analysis and expected Mexican men to have highest likelihood for meeting a criterion of obesity. Moreover, coincide with Latinos ethnic backgrounds are many other complex health-related factors (e.g., demographics, social stratification, immigration history, and legal status that could affect their health outcomes; Aguilar-Gaxiola, Kramer, Resendez, & Magaña, 2008; Blendon et al., 2014; Derose, Bahney, Lurie, & Escarce, 2009; Ennis et al., 2011; Gonzalez-Barrera & Lopez, 2013; Guisepi, 2009; Lee & Rytina, 2008) to be controlled for. A trend study on the National Health Interview Surveys linked higher social stratification and acculturation statue with poor self-rated health particularly among Mexicans (Zsembik & Fennell, 2005). Mexicans constitute the largest Latino population in the United States, and among the more recent fast-growing waves, Mexicans top the numbers among all Latino immigrants (Ennis, 2011; U.S. Census Bureau, 2014). Whereas many Mexicans are undocumented immigrants, Puerto Ricans are born as U.S. citizens. Yet both Mexicans and Puerto Ricans have been viewed as less educated and to hold blue-collar occupations, thereby perceiving more

3 Ai et al. 3 discrimination than Cubans (Gonzalez-Barrera & Lopez, 2013; Passel & Cohn, 2009). Cuban-concentrated communities in Florida were established by well-educated and affluent immigrants as political refugees with intellectual and financial resources (Healey & O Brien, 2014). Whereas wealth was a strong predictor of distress for all Latino subgroups, the lack of wealth was especially detrimental for Cubans and Puerto Ricans (Xu, 2011). Finally, in interpretation of the Hispanic paradox, researchers assumed a barrio advantage. Eschbach, Ostir, Patel, Markides, and Goodwin (2004) hypothesized that lower mortality rates alongside reduced levels of chronic conditions (e.g., stroke, cancer, and hip fracture) among Mexicans may be attributable to their living in a highly concentrated Latino residential area in the United States. Other researchers also attributed the advantage in health status among all foreign-born Latinos to their context of traditional socialization, family resources, kinship network, and related Latino cultural environment and experiences, compared with their U.S.-born counterparts (Palloni & Arias, 2004; Smith & Bradshaw, 2006; Sorlie, Backlund, Johnson, & Rogot, 1993). Overall, these authors assumed the benefits of a stable cultural environment that may provide support resources and fend off adverse behavioral influence (e.g., substance abuse) of assimilation to the mainstream culture. To test this existing hypothesis, in a post hoc analysis interactions between social support from families and friends and acculturation status on obesity were tested. With a focus on obesity in relation to Hispanic/ Mexican paradox, the authors employed the data from the NLAAS. An advantage of using the NLAAS to address the primary lies in its rich data on acculturationrelated factors, including perceived discrimination. In addition, through address of the secondary aim and with the post hoc analyses, the present study may have potential to orient future research on mechanisms underlying the obesity-based Hispanic/Mexican paradox in Latino Americans health disparity. Method Study Design and Participants The original goals of the NLAAS included (a) attaining cultural relevance with attention to the fundamental cultural and contextual differences of Asian and Latino American populations as compared with the mainstream population, (b) developing the culturally equivalent standardized instruments to be used in the two minority populations, and (c) evaluating the generalizability of the measures (Alegría, et al., 2004). The NLAAS was part of the Collaborative Psychiatric Epidemiology Studies (CPES) and adopted the research design of the CPES from an earlier related representative study, the National Comorbidity Survey Replication (Kessler et al., 2004; Pennell et al., 2004). CPES examined the prevalence of mental disorders and service utilization in the general populations living in the United States, which had very small samples of minority groups. The NLAAS became the first nationally household representative survey on mental health and service utilization of Latino and Asian American populations, aged 18 years and older and living in the United States, to better represent their psychological disorders and service utilization (Heeringa et al., 2004; Kessler et al., 2004). Instruments in this survey primarily covered sociodemographics, acculturation factors, major physical conditions, mental health diagnoses (based on the World Mental Health Survey Initiative version of the World Mental Health Composite International Diagnostic Interview, equivalent to the criteria from the Diagnostic and Statistical Manual of Mental Disorders Fourth edition; American Psychiatric Association, 1994; ; Kessler & Üstün, 2004), and utilization of services. The questionnaire was available in six languages, including Spanish. Trained interviewers collected the self-reported data from 2002 to Eligibility criteria included age 18 years or older, ethnicity (self-identified as Cuban, Mexican, Puerto Rican, or Other Latinos), and language capability. From May 2002 to December 2003, self-reported data were collected in a total of 252 geographic areas across the United States. All Latino participants were interviewed by trained bilingual interviewers fluent in both English and Spanish. Institutionalized people and those living on military bases were excluded from the study population. To compensate for sampling bias for the total sample of the NLAAS, Bayesian methods were employed to produce weighted estimates in the NLAAS (e.g., interval estimates from other CPES studies; Heeringa et al., 2004). The weighted NLAAS sample resembled the U.S. Census 2000 in age, gender, education level, marital status, and living area, but was divergent in nativity (U.S.- vs. foreign-born) and included more Latino immigrants and lower income respondents, which is consistent with the reports of the underestimating of immigrants in the Census (Cook, Alegría, Lin, & Guo, 2009; Pagoto et al., 2012). The NLAAS used stratified area probability sampling design with special supplements for adults of Puerto Rican, Cuban, Mexican, and Asian American national origin. Among 27,026 sample housing units screened for the target population, 5,579 eligible respondents were identified, and, finally, 4,649 respondents completed interview. The NLAAS had a weighted response rate of 75.5% with the total sample composed of 2,554 Latina/o Americans, including 1,127 men in this analysis.

4 4 American Journal of Men s Health Measures and Variables The dependent variable was Obesity, dichotomized at the level of body mass index (BMI) 30 (0 = nonobesity, 1 = obesity) in this analysis. BMI was first computed from self-reported data on height and weight using the standard formula (weight in kilograms/height in meters squared) and included six categories in the CPES data sets (i.e., underweight: BMI 18.5; normal weight: BMI ; overweight: BMI ; Class I obesity: BMI ; Class II obesity: BMI ; and Class III obesity: BMI 40.0). The key independent variables included five acculturation-related factors: (a) English Proficiency (a sum of three items on how well respondents speak, read, and write English based on a scale: 1 = poor, 2 = fair, 3 = good, 4 = excellent; ranging from 3 to 12; α =.97); (b) Nativity/U.S.-born (0 = no,1 = yes); (c) Years in the United States (1 = less than 5 years, 2 = 5-10 years, 3 = years, and 4 = 20 years and above); (d) Acculturation Stress (an average of nine dichotomous variables measuring social and emotional stresses pertaining to moving from a known culture to a new one; Vega et al., 1998; e.g., Do you find it hard interacting with others because of difficulties you have with the English language?; α =.73); and (e) Discrimination (an average of nine questions on daily perception regarding the frequency of perceived discrimination; Gee, Spencer, Chen, & Takeuchi, 2007; e.g., You receive poorer services than other people at restaurants or stores, You are treated with less courtesy than other people from 1 = never to 6 = almost every day; α =.91). Sociodemographic characteristics comprised five variables: Age (years); Ethnicity (1 = Mexican, 2 = Cuban, 3 = Puerto Rican, and 4 = Other Latinos); Education (1 = 0-11 years, 2 = 12 years, 3 = years, and 4 = 16 years and above); Income (an index as the ratio to poverty threshold, range from 0 to 17); and Employment (0 = unemployed, 1 = employed). Statistical Analysis The authors used all statistical analyses with sample weights to provide measures that were representative of the U.S. Latino population. Frequency distributions and means were calculated with standard deviations to describe all variables. Kendall s tau was performed for the zero-order correlations among variables in the multivariate analyses. Two-step logistic regression models were conducted to estimate the association between variables of major interest and obesity. In Model 1, key sociodemographics factors were entered as controls (age, ethnicity, education level, household income, and employment). In Model 2, the authors investigated the role of acculturation factors as major interests in the likelihood of being diagnosed with obesity. In the multivariate logistic regression models, criteria for inclusion variables that are related to the independent and dependent variables are at p <.15, and those for retaining variables in the final model are at p <.05. Odds ratios and 95% confidence intervals were computed and are presented in the final table. Differences in the chi-square statistic between Models 1 and 2 indicated whether the newly added set of variables add to the power of the Model 1 predictors. Finally, post hoc analysis were performed for interactions between social support and acculturation status on obesity. All analyses were computed using STATA 13 and assessed for statistical significance at the 0.05 level of significance. Results Sample Demographics and Bivariate Correlations The descriptive statistics concerning the sociodemographic and acculturation-related information are presented in Table 1. As noted, approximately 27% of Latino men were obese. The average age of them was years (SD = 14.24, range = 18-97). The four major subethnic categories included Mexican (56.4%), Puerto Rican (10.1%), Cuban (4.7%), and Other Latinos (28.8%). Of the sample 43% was born in the United States and 20.3% had been living in the United States for more than 21 years. Nearly, two in five Latino men (43.1%) had less than 12 years of education but nearly three quarters were employed (74.9%). The average income index of the sample was 3.55 (SD = 3.59, range = 0-17). The mean score of English proficiency was 7.54 (SD = 3.45, range = 3-12). Finally, the mean scores of acculturation stress and discrimination were 0.18 (SD = 0.23, range = 0-1) and 1.91 (SD = 0.92, range = 1-6), respectively. Bivariate correlations among all variables are presented in Table 2. Obesity was positively correlated with U.S.-Born and Years in the United States but negatively correlated with Ethnicity (Mexican as the reference category) and Acculturation Stress. In addition, there were positive correlations among three acculturation factors (U.S.-Born, Years in the United States, and English Proficiency). Both Education and Income were also positively correlated with these three factors. Education was positively correlated with Discrimination that also correlated with Ethnicity, U.S.-Born, Years in the United States, and English Proficiency. Correlates of Obesity in Multivariate Analysis To test the research hypotheses, the authors investigated the association between acculturation factors

5 Ai et al. 5 Table 1. Weighted Descriptive Statistics for Latino Men: National Latino and Asian American Study, 2002 to Variables Latinos (N = 1,127) n (%) M (SD) Obesity 299 (26.6) Age (18-97 years) (14.24) Ethnicity Mexican a 398 (56.4) Cuban 276 (4.7) Puerto Rican 213 (10.1) Other Latinos 240 (28.8) Education 0-11 a 429 (43.1) (25.7) (21.0) (10.1) Income (0-17) 3.55 (3.59) Employed 825 (74.9) English Proficiency (3-12) 7.54 (3.45) U.S.-Born 403 (43.0) Years in the United States <5 a 101 (9.2) (9.4) (18.1) (20.3) Acculturation Stress (0-1) 0.18 (0.23) Discrimination (1-6) 1.91 (0.92) Note. Sample sizes are unweighted. The sampling weights for Latinos are created based on the Census and were previously utilized by Cook et al. (2009) and Heeringa et al. (2004). a Reference categories in regression models. *p <.05. **p <.01. ***p <.001. and obesity outcome, adjusting ethnicity and other socio-demographics, by performing two-step multivariate logistic regression analyses. The two models were specified as follows: Model 1 included the five sociodemographic variables and Model 2 included the five acculturation-related factors. The results from the two models are displayed in Table 3. In Model 1, Ethnicity was the only sociodemographic factor significantly and negatively associated with the likelihood of obesity. More specifically, Cuban (OR = 0.52, 95% CI [0.35, 0.77], p <.01) and Other Latinos (OR = 0.65, 95% CI [0.45, 0.94], p <.05) were 48% and 35% less likely to be obese compared with Mexican Latinos, consistent with the hypothesis in the secondary aim. The pattern, however, was somewhat altered by entry of acculturation factors, while age and SES remained not to be influential on obesity of Latino men. In Model 2, being Puerto Rican emerged as a significantly negative correlate, whereas the advantage of being Other Latinos vanished. In the Cuban subgroup, the likelihood of Obesity decreased by 39% (OR = 0.61, 95% CI [0.40, 0.92], p <.05), while in the Puerto Rican subgroup, the odds reduced by 33% (OR = 0.67, 95% CI [0.45, 0.99], p <.05) after entry of the five acculturation factors. Consistent with the hypothesis in the secondary aim, within the new set of independent variables U.S.- born Latino men were more than twice as likely to have obesity (OR = 3.07, 95% CI [1.39, 6.80], p <.01) than their foreign-born counterparts. Those who lived in the United States more than 21 years were approximately 1.5 times (OR = 2.48, 95% CI [1.21, 5.10], p <.05) and those who lived in the United States for 5 to 10 years were nearly 1.2 times more likely to be obese (OR = 2.19, 95% CI [1.06, 4.53], p <.05) than those who lived in the United States less than 5 years. English Proficiency, Acculturation Stress, and Discrimination had no direct effect. The new set of variables in Model 2 yielded a significantly better model fit (Δχ 2 = 20.38, Δdf = 7, p <.01). Overall, Latino men who self-identified as Mexicans and Other Latinos, those who were U.S.-born, and those who had been in the United States for longest period or for 5 to 10 years presented a significantly greater likelihood to meet the criterion of obese. Finally, the post hoc analyses find no effect of social support from families and friends on obesity in Latino men (OR = 0.78, 95% CI [0.60, 1.02], p =.06) nor interaction of social support with acculturation. Discussion The present study extends the finding from a regional study on obesity of both Latino men and women (Hubert et al., 2005) to a national sample of Latino men (Ai, Appel, Huang, & Lee, 2012). Supporting the hypothesis in the primary aim, the authors demonstrate the new evidence of associations between greater acculturation status and the likelihood of obesity among Latino men at a national level. Reinforcing existing studies on major health indicators for the Hispanic paradox (Abraído- Lanza et al., 1999; Chung, 2006; Cunningham et al., 2008; Hayward et al., 2014; Hummer et al., 2007; Markides & Coreil, 1986; ; Smith & Bradshaw, 2006; Turra & Goldman, 2007; Vega et al., 1998), this innovative finding extends the literature to obesity as a risk factor for many chronic diseases and a major public health concern. More specifically, the authors identified that the more Latino men become acculturated with respect to the U.S.-born status and longer stay in the United States, the more likely they suffered from obesity, just as with mainstream American men. The current finding concurs with a national trend study that linked generational status with obesity in all Latinos (Bates et al., 2007). A regional study also revealed generational status and years staying

6 6 American Journal of Men s Health Table 2. Bivariate Correlation Coefficients Among All Variables for Latino Men: National Latino and Asian American Study, 2002 to Obesity 2. Age Ethnicity 0.06* Education ** 5. Income ** 0.32** 6. Employed ** ** 0.24** 7. English Proficiency ** 0.13** 0.39** 0.29** U.S.-Born 0.12** 0.19** ** 0.12** ** 9. Years in the United States 0.12** ** 0.15** 0.08** 0.50** 0.79** 10. Acculturation 0.09** 0.11** ** 0.16** ** 0.73** 0.67** Stress 11. Discrimination ** ** ** 0.24** 0.17** 0.10** Note. We conducted Kendall s tau-β statistics to examine bivariate relationships for nonparametric measures. *p <.05. **p <.01. Table 3. Logistic Regression Analyses Predicting Obesity for Latino Men: National Latino and Asian American Study, 2002 to Latinos (N = 1,088) Model 1, OR [95% CI] Model 2, OR [95% CI] Age 1.00 [0.99, 1.01] 1.00 [0.98, 1.01] Female Ethnicity Mexican (ref.) Cuban 0.52 [0.35, 0.77]** 0.61 [0.40, 0.92]* Puerto Rican 0.71 [0.48, 1.05] 0.67 [0.45, 0.99]* Other Latinos 0.65 [0.45, 0.94]* 0.73 [0.50, 1.06] Education <High school (ref.) High school graduate 0.88 [0.62, 1.26] 0.80 [0.55, 1.17] Some college 1.25 [0.86, 1.83] 1.14 [0.75, 1.72] University graduate 0.91 [0.57, 1.45] 0.89 [0.53, 1.49] Income 1.01 [0.97, 1.05] 1.00 [0.96, 1.04] Employed 0.98 [0.70, 1.36] 1.07 [0.76, 1.50] English Proficiency 0.97 [0.91, 1.03] U.S.-Born 3.07 [1.39, 6.80]** Years in the United States <5 (ref.) [1.06, 4.53]* [0.76, 3.19] [1.21, 5.10]* Acculturation Stress 0.66 [0.24, 1.84] Discrimination 1.06 [0.90, 1.26] χ 2 (df) (9)* (16)** Δχ 2 (Δdf) (7)** Note. OR = odds ratio; CI = confidence interval; df = degrees of freedom. Less than high school serving as the reference category under Education; <5 years serving as the reference category under Years in the United States, Mexican serving as the reference category under Ethnicity. *p <.05. **p <.01. ***p <.001.

7 Ai et al. 7 in the United States as stronger predictors for obesity than lifestyle factors (e.g., exercise and diet) among Latino agricultural workers (Hubert et al., 2005). The most interesting finding of the current study is its male-specific contributor to obesity. Whereas, the current finding spotlights acculturation status as a risk for Latino men, existing evidence suggests that this was not to be the case for Latino women (Ai et al., 2016; Ro & Bostean, 2015). Gender differences revealed in obesity risk factors may challenge the barrio advantage assumption that took the culturally support system within a stable Latino environment to interpret the Hispanic paradox (Eschbach et al., 2004). In terms of obesity, this paradox appears to be Latino men s case, even though Latino women may draw more advantage from their cohesive networks. For Latino women, previous authors have alternatively argued that discrimination and lower household income may be key factors, making them more vulnerable to weight gain (Ai et al., 2016; Ro & Bostean, 2015). Because the current Latino men s case corroborate with the Hispanic paradox, the data allow us to test the hypothesis made for the barrio advantage assumption (Eschbach et al., 2004). Nevertheless, the post hoc analyses lend no support for it with null findings on neither the role of social support, the culturally supportive system, on obesity in either Latino men or women, nor interaction of social support and acculturation on obesity. Accordingly, the interpretation should be sought beyond social support, concerning other factors with the acculturation process as the risk for obesity of Latino men. Regarding the male-specific finding in the current study, it is likely that in the process of acculturation, Latino men may have to sacrifice their traditional healthy lifestyle, such as homemade fresh and healthy meals that offered protection from diseases and increased longevity (Palloni & Arias, 2004). Interestingly, one small-scale study identified that among postpartum women, those who were foreign-born and had lived in the United States for 4 or fewer years consumed more fruit and vegetable servings daily than native-born women, and White women consumed less than Latino women (Dubowitz, Smith-Warner, Acevedo-Garcia, Subramanian, & Peterson, 2007). However, to the authors knowledge there has been no similar research conducted on Latino men s diet choice in relation to acculturation. Existing research has revealed other increased risks in their lives that could have indirect influences on Latino men s health conditions. Hayward et al. (2014) reported that secondgeneration Latino men become more acculturated and adopt behaviors such as smoking, which may have diminished life expectancy. Future studies are warranted to explore diet change patterns that pertain to obesity of Latino men to prevent more chronic conditions for saving health costs. Regarding the secondary aim, the current finding documents the disadvantage facing Mexican and Other Latino American men in obesity, which is consistent with the earlier analysis (Ai et al., 2013). The finding also dovetails with the literature that the Latino/Hispanic paradox did not apply to Cubans (Pérez et al., 2008). Taken together, the current and previous studies may specifically suggest that the Latino/Mexican paradox apply more to men than to women with respect to overweight issues. Due to their poverty and migrating working condition (Healey & O Brien, 2014; World Bank, 2015), these Latino men could be more sensitive to health risks from moving to a postindustrial individualistic cultural environment. Furthermore, consistent with the Hispanic Community Health Study, the authors reported no age effect in obesity of Latino men though it was demonstrated among Latino women (National Heart, Lung, and Blood Institute, 2013). The current analyses also did not identify any effect of education and family income on obesity of men. Some limitations of the study should be acknowledged. The study is a correlational based on the one-wave data in the NLAAS. There is a lack of obesity-related lifestyle and biological factors in this national survey. The self-reported information might not adequately reflect status detectable through medical and psychological diagnosis. The public version NLAAS does not contain geographic locations and other information which limited the authors knowledge about respondents backgrounds. Not all Mexicans and Puerto Ricans are disadvantaged in terms of SES and acculturation experiences. Although early Cuban immigrants tended to be more affluent and educated, hold more resources, and own businesses, those in more recent immigrant waves may be worse financially (Healey & O Brien, 2014). The indicators for acculturation could be overly simplified and not updated (Schwartz et al., 2010). Compared with Cubans, Mexicans and Puerto Ricans may be more acculturated in the English language but less acculturated in terms of business experiences and resources in a postindustrialized society. Although the data were collected by bilingual interviewers, it remains unclear how dialect differences among different ethnic subgroups (e.g., Cubans vs. Mexicans) were handled. Importantly, the NLAAS data have been one decade old. Still, the new finding about the detrimental aspect of acculturation in Latino men remains relevant, because the cohort investigated has approach to their average middle age and beyond with greater vulnerability to obesity-related chronic conditions. The tested association in this study needs to be replaced via prospective design, if the NLAAS can have a follow-up wave with updated information. Despite these caveats, the findings from gender-specific analyses are worth noting, given the role that Latino men, especially Mexican American men, are taking in the

8 8 American Journal of Men s Health low-wage U.S. labor market today. An earlier report explained why discrimination was associated with obesity in Latino women at biological, physiological, psychological, cultural, and societal levels (Ai et al., 2016). The current finding on the acculturation obesity pattern revealed for Latino men suggests that more in-depth and prospective studies should explore the underlying mechanisms of their obesity. Specifically, future investigation should take a translational approach and prospective design to integrate biological, behavioral, and socioenvironmental factors in understanding obesity developed across generations of Latino men and women. New studies should address questions such as Does acculturation into the mainstream culture especially means a negative adaptation to certain unhealthy lifestyles for Mexican and Other Latino men? and How acculturation factors interact with biobehavioral, SES, and migration factors on obesity development among blue-collar Latino labors? More clinical research should examine the culturally appropriated and effective interventions for obesity and related chronic conditions, such as diabetes, especially in the largest subgroup Mexican men, and cardiovascular diseases, especially in Cuban and Puerto Rican men. If future longitudinal studies report that this trend of susceptibility to obesity for acculturated Latino men continues, its public health impact, including diabetes (Schneiderman et al., 2014), must be addressed in the form of preventive care so as to avoid additional burden on the U.S. health care system. In particular, public health policy attention should be paid to the critical role of the sociocultural and environmental transition in their obesity and other-related health problems. Both previous and the current findings imply the need to develop more gender-specific approaches to obesity in Latino men and women. If more solid evidence can be established, such culturally appropriate approach should be established as a valuable vanguard for the future U.S. public health agenda. For example, healthy diet and lifestyle training (e.g., exercise, stress reduction) may help prevent obesity for more acculturated Latino men labors. Education for their employers should also be endorsed to reduce the harmful impact of acculturation on their Latino men employees for mutual benefits in a long run. Health providers should pay attention the strength within Latino cultural environment and help preserve these traditional resources for care of Latino men. 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