Acculturation and Health

Acculturation is defined as the process by which a newcomer adopts the cultural behaviors common in the host country, which may lead to changes in diet, physical activity level, and environmental exposures. This process has a major impact on the long-term health of resettled refugees[1]. Most refugees enter the US with better health profiles in terms of chronic disease than native-born individuals. However, this health advantage decreases over time, largely due to changes in food and physical activity [2].

Diet and Nutrition
Adopting a Western diet is a significant indicator of resettled refugees making a cultural transition. Many refugees experienced periods of food insecurity prior to resettlement, which has been linked to increased intake of food after arrival in the US [3]. Some weight gain may be beneficial in refugees who were previously underweight or undernourished. However, acculturation may result in rapid and unhealthy weight gain, with some resettled refugees quickly becoming overweight and suffering the associated comorbidities. Resettled refugees may encounter barriers in preparing nutritious and culturally-appropriate foods such as difficulties with transportation, lack of familiar equipment for food preparation, and being unable to find foods that they are comfortable preparing [4]. In addition, financial constraints may necessitate the purchase of low-cost, high-energy foods or limit travel to markets that sell fresh produce.

Acculturation has been found to increase the risk of obesity and associated non-communicable diseases such as diabetes and hypertension due to weight gain and environmental and psychological stressors [5]. Studies have demonstrated significant rates of obesity/overweight (46.8%) and hypertension (22.6%), and lower, but still important rates of documented coronary artery disease and diabetes (3.7% and 3.1% respectively) among different refugee populations [6]. A more recent study on the large Iraqi population in California presented data on both infectious and non-communicable diseases[7]. Even though infectious disease has long been the focus of the domestic health assessment, this study provided evidence that the rates of chronic non-communicable diseases are higher than the rates of infectious diseases in this population (24.6% obese and 15.2% with hypertension compared to 14.1% with latent tuberculosis), thus highlighting the need for public health to address these concerns early.

Given the impact that acculturation has on the overall health status of resettled refugees over time, health care providers should incorporate a discussion of dietary behaviors into follow-up visits, including an exploration of culturally acceptable and nutritious diets. Developing partnerships with governmental organizations, resettlement agencies, and other local community groups may enhance healthcare providers’ capacity to address this important issue by connecting refugees to resources such as community gardens or farmers’ markets.

Mental Health
It is also important to note the impact of mental illness on successful resettlement and its relationship to acculturation. While short-term and self-limited adjustment disorder may be anticipated for most refugees, more significant and longer-lasting mental health concerns such as anxiety, post-traumatic stress disorder (PTSD), depression, and somatization may also be triggered or exacerbated by the acculturation process. Ten percent of refugees screened in Colorado presented with mental health diagnoses [8]. Moreover, significant changes in family roles may accompany resettlement, with faster acculturation occurring in younger refugees leading to intergenerational family conflict. Finally, in diagnosing and treating mental illness among refugees, significant barriers to accessing high-quality, culturally appropriate care for mental illness may exacerbate these issues.

Screening, early intervention to address mental health issues, and engendering support systems within refugee communities will also help mitigate the potential negative mental health consequences of acculturation. Therefore, as per CDC recommendations, healthcare providers are encouraged to conduct early screening, diagnosis, and treatment and then ongoing monitoring of refugees’ mental health as they transition to life in the US.

Contributed by:

Marc Altshuler, M.D., Kevin Scott, M.D., and Beth Careyva, M.D.

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