type 2 diabetes and prediabetes have emerged as significant health issues in overweight / obese african - american and latino - american pediatric populations in the united states ( us ) .
data from the search for diabetes in youth study indicate that incidence rates for type 2 diabetes were three times higher in african - americans and latino - americans aged 1519 years compared to non - latino whites . the studies to treat or prevent pediatric type
2 diabetes also reported a larger proportion of african - american and latino - american children and adolescents with high fasting insulin levels compared to their non - latino white counterparts ( 29.3% , 44.3% , and 20.5% , resp . ) .
this ethnic disparity in diabetes and prediabetes has been linked to more severe insulin resistance and pancreatic beta - cell dysfunction in these ethnic minority children and adolescents . while several behavioral mechanisms have been proposed to explain the increased diabetes risk in african - american and latino - american children and adolescents [ 4 , 5 ] , research investigating the role of sociocultural factors ( i.e. , cultural attitudes , beliefs , and behaviors ) is limited . with the rapid increase in cultural diversity of the us
, african - american and latino - american cultures are quickly becoming a part of mainstream american culture , evolving within the us , while simultaneously integrating aspects of different african and latin american cultures .
these alternative cultures have aspects that are uniquely shaped by historical , social , political , and economic forces present in the us .
consequently , african - american and latino - american children and adolescents who come of age in the us , a multicultural society , interact with people from different cultural backgrounds which can lead to an interchange of cultural attitudes , beliefs , and behaviors .
unger et al .   have argued that ethnic minority children and adolescents who interact with non - latino whites may chose to adopt one of four sociocultural orientation patterns : ( a ) integration  combining aspects of their family 's culture with aspects of mainstream american culture ; ( b ) assimilation  replacing their family 's culture with mainstream american culture ; ( c ) separation  retaining their family 's culture while rejecting mainstream american culture ; or ( d ) marginalization  becoming alienated from both cultures .
this approach to conceptualizing sociocultural orientation is unique in that it emphasizes the psychological aspects of culture rather than assessing proxy indicators such as language use , nativity , and time in the us .  
the limited number of studies assessing the influence of sociocultural orientation on type 2 diabetes risk suggests that , for african - americans , integrating into mainstream american culture while retaining aspects of their own family 's culture is inversely associated with diabetes risk through health - related behaviors .
with one notable exception , much research suggests integrating and/or assimilating into the mainstream american culture is positively associated with obesity [ 1214 ] and suboptimal dietary choices [ 5 , 1517 ] , whereas separation from mainstream american culture is positively associated with increased insulin resistance .
although the influence of sociocultural factors on subsequent diabetes risk in african - americans and latino - americans is striking , these findings may be confounded by socioeconomic position .
sociocultural attitudes , beliefs , and behaviors are heavily influenced by an individual 's socioeconomic environment .
ethnic minority children and adolescents who reside in low socioeconomic households may be more likely to be segregated from non - latino whites both at school and in their neighborhood   providing less exposure to a multicultural environment and limited sociocultural options . in contrast , ethnic minority children and adolescents living in middle - to - high socioeconomic households are more likely to live in racially mixed neighborhoods and/or attend predominantly white schools   thereby increasing interaction with individuals from different cultural backgrounds and expanding sociocultural orientation options . despite the well - characterized relationships between sociocultural orientation , socioeconomic position , and type 2 diabetes risk , few researchers have attempted to disentangle these associations to better understand the increased diabetes risk reported in minority children and adolescents .
therefore , the primary objective of this study was to examine the independent relationships between sociocultural orientation , household social position , and type 2 diabetes risk in overweight / obese african - american and latino - american children and adolescents .
it was hypothesized that , for both minority groups , low household social position would be associated with increased diabetes risk defined as decreased insulin sensitivity ( si ) , decreased acute insulin response ( airg ) , and decreased disposition index ( di ) derived from a frequently sampled intravenous glucose tolerance test .
independent of household social position , integration ( combining aspects of one 's family 's culture with aspects of mainstream american culture ) would be associated with lower diabetes risk in overweight / obese african - american children and adolescents , whereas this same sociocultural adaptive style would be associated with increased diabetes risk in latino - americans .
all participants met the following inclusion criteria : age- and gender - specific bmi  85th percentile , african - american or latino - american ethnicity ( self - report and based on all four grandparents being of the same ethnic group as the child in the study ) , and between the ages of 818 years . prior to any testing , informed written consent and assent were obtained from the participants and parents .
participants arrived at the general clinical research center ( gcrc ) where a licensed pediatric health care provider conducted a medical / family history and physical examination which included an assessment of tanner stage [ 22 , 23 ] . body composition was measured by air displacement plethysmography ( bodpod ; life measurement instruments , concord , ca ) .
total dietary intake was assessed with three - day dietary records given to participants to complete at home , which were later returned to research staff for nutritional analysis .
three - day physical activity recall was used to assess self - reported physical activity .  
a frequently sampled insulin - modified intravenous glucose tolerance test ( fsigt ) was used to assess type 2 diabetes risk . fasting plasma insulin and glucose concentrations
were used to estimate insulin resistance using homeostasis model assessment ( homa - ir ) , which was calculated as homa - ir = [ ( fpi  fpg)/22.5 ] .
plasma collected during the fsigt was analyzed for glucose and insulin , and values were entered into the minmod millennium 2003 computer program ( version 5.16 , bergman , usc ) to calculate si , airg , and di .
si was defined as the net capacity for insulin to promote the disposal of glucose and to inhibit the endogenous production of glucose .
airg was defined as the area under the plasma insulin curve between 0 and 10 minutes .
di , an index of beta - cell function , was calculated as the product of airg and si .
detailed descriptions of the fsigt methods and protocols used in this study have been previously published [ 2628 ] . during the gcrc visit
, participants also completed a questionnaire regarding sociocultural orientation and parents of participants answered questions regarding parental educational attainment and occupational rank .
sociocultural orientation was assessed using the acculturation , habits , and interests multicultural scale for adolescents ( ahimsa ) questionnaire .
the eight items on the ahimsa as well as the four response items are listed in table 1 .
the ahimsa responses were divided into four sociocultural orientation subscales :  the us  was categorized as assimilation ( cronbach alpha : 0.79 ) ;  the country my family is from  was categorized as separation ( cronbach alpha : 0.68 ) ;  both  was categorized as integration ( cronbach alpha : 0.79 ) ; and  neither  was categorized as marginalization ( cronbach alpha : 0.50 ) . for the african - american participants ,
the ahimsa responses for assimilation and separation were modified to read  white - american culture  and  my family 's culture ,  respectively ( cronbach alphas : 0.680.79 ) .
scores on each orientation scale ranged from 0 to 8 and are presented as percentages of a total possible out of 8 . for example , 0 on the assimilation scale indicated that the respondent did not answer  the us  or  white - american culture  to any of the items which is the equivalent of 0% . an 8 indicated that the respondent answered  the us  or  white - american culture  to all eight items , which represents a score of 100% .
household social position was measured using the hollingshead 's two - factor index of social position .
the hollingshead scale was used because it is one of the most commonly used socioeconomic measures .
the hollingshead score is a composite measure of educational attainment and occupational rank and was computed in the following manner .
an education score ( 1 through 7 , with 1 equal to less than a seventh - grade education and 7 equal to graduate training ) and an occupation score ( 1 through 7 , with 1 equal to unskilled employee and 7 equal to higher executives , proprietors of large businesses , and major professionals ) were assigned for each parent / guardian based on information provided by them .
education and occupation scores were then weighted to obtain a single score for each parent / guardian ( range of 8 to 49 ) that reflects one of five social strata ( 1 through 5 , with 1 being a reference to unskilled laborers or low social position and 5 a reference to major professionals or high social position ) . for families with multiple caretakers , scores for each
individuals whose primary activities were homemaking , school , or who received state assistance did not have categorizable occupations according to the hollingshead method and were not included in the household social position score ( n = 42 ) .
the hollingshead method has relatively good interrater agreement ( 6796% )   and correlates well with other measures of social position ( r = 0.730.86 ) [ 30 , 31 ] .   data analysis included data summarization , spearman correlations , and multivariate regression modeling .
data were evaluated for normality before analysis and natural log transformations were made when necessary .
of the 156 participants , 20 participants were missing data for dietary intake , moderate - to - vigorous physical activity , and/or sedentary time and were not included in the multivariate regression analyses .
mean variable differences by ethnicity were analyzed by independent t - tests , chi - square , and ancova .
spearman correlations were used to explore the associations between sociocultural and socioeconomic variables ( i.e. , ahimsa subscales , household social position ) and fsigt parameters ( i.e. , si , airg , and di ) .
multivariate regression models were used to further explore the relationships between the independent variables ( i.e. , ahimsa subscales , household social position ) and dependent variables ( i.e. , si , airg , and di ) .
specifically , partial correlations and parameter estimates were used to describe the relationship between sociocultural and socioeconomic variables and fsigt variables after controlling for a priori covariates .
a priori covariates included sex , tanner stage , fat mass , fat - free mass , energy intake , moderate - to - vigorous physical activity , sedentary time , household social position ( for sociocultural variables only ) , and si ( for airg only ) . statistical analyses that addressed the objectives of this study
were stratified by ethnicity for the reason that both qualitative and quantitative variables were examined in this study with african - americans using a modified version of the ahimsa questionnaire ( i.e. , response items were modified for assimilation and separation ) and latino - americans using the standard version . a priori significance level was set at p < 0.05 .
all assumptions for multiple linear regression were satisfied and fsigt variables were log transformed in order to meet these assumptions .

 table 2 displays the participant characteristics for the 43 african - american and 113 latino - american boys and girls included in this study . for household social position
, 60.4% of african - american households classified themselves in either the  middle  or  upper - middle  categories , compared to 17.7% for latino - american households .
for behavioral factors , african - american children and adolescents participated in significantly fewer minutes of moderate - to - vigorous physical activity per week , compared to latino - americans ( p < 0.05 ) ; however , dietary patterns were similar across ethnic groups . for biological factors ,
african - american adolescents were significantly taller and heavier than their latino - american counterparts , with higher bmis , volumes of fat mass and fat - free mass ( all p 's < 0.05 ) .
after controlling for sex , tanner stage , fat mass , fat - free mass , and si ( for airg only ) , fasting glucose and si were significantly lower in african - american children and adolescents compared to latino - americans ( both p 's < 0.01 ) . in addition , homa , airg , and di were significantly higher in african - americans compared to latino - americans ( all p 's < 0.05 ) .
ethnic differences were not observed in age , tanner stage , bmi percentile , total dietary intake , and sedentary time .  
spearman correlations revealed that , for african - american children and adolescents , assimilation was positively associated with log  si (  = 0.33 , p < 0.05 ) and marginalization was positively associated with log  airg (  = 0.39 , p < 0.05 ) .
however , these relationships were no longer significant in our multivariate regression analyses suggesting confounding of biological and behavioral covariates included in our model . for latino - american children and adolescents , spearman correlations revealed a negative association between integration and di (  = 0.20 , p < 0.05 ) ; again this relationship was no longer significant after controlling for biological and behavioral covariates in our regression analyses .
household social position was negatively associated with di (  = 0.37 , p < 0.05 ) in latino - americans ; this relationship remained significant in our regression analyses .  

table 3 displays the results of the multiple regression analysis for african - american children and adolescents .
we observed a positive parameter estimate and partial correlation between the ahimsa subscale integration , log  airg and log  di .
also , log  airg was positively associated with integration (  = 0.27  0.09 , r = 0.48 , p < 0.01 ) after controlling for sex , tanner stage , fat / fat - free mass , energy intake , moderate - to - vigorous physical activity , sedentary time , and si . additionally , log  di was also positively associated with integration (  = 0.28  0.09 , r = 0.55 , p < 0.01 ) , after controlling for covariates . from these results and with all confounding effects of covariates being equal , predicted mean airg was 92% higher for african - american children and adolescents at the 75th compared to 25th percentile of the ahimsa integration subscale . predicted mean di was 93% higher for african - american children and adolescents at the 75th compared to 25th percentile of the ahimsa integration subscale . although the bivariate analysis did not reveal a significant correlation between integration , log  airg , and log  di , once other variables were accounted for , these relationships became significant , suggesting negative confounding by covariates in our model .
there were no significant relationships between household social position , other ahimsa subscales ( i.e. , separation , assimilation , and marginalization ) , and fsigt parameters .  

table 4 displays the results of the multiple regression analysis for latino - american children and adolescents .
we observed a negative parameter estimate and partial correlation between household social position , log  airg , and di .
moreover , log  airg was inversely associated with household social position (  = 0.010  0.004 , r = 0.19 , p = 0.02 ) , after controlling for sex , tanner stage , fat / fat - free mass , energy intake , moderate - to - vigorous physical activity , sedentary time , and si .
in addition , di was inversely associated with household social position (  = 20.44  7.50 , r = 0.27 , p < 0.01 ) , after controlling for biological and behavioral covariates . to better understand which of the two socioeconomic indicators measured was driving the inverse relationship between household social position and diabetes risk , we also calculated parameter estimates and partial correlations for educational attainment , occupational rank , log  airg , and di . these analyses revealed that log  airg and di were significantly associated with parental educational attainment ( airg :  = 0.09  0.36 , r = 0.19 , p = 0.01 ; di :  = 189.56  61.72 , r = 0.29 , p < 0.01 ) , whereas the associations between parental occupational rank , log  airg , and di were nonsignificant ( data not shown ) .
from these results and with all covariates being equal , predicted mean airg was 129% lower for latino - american children and adolescents at the 75th compared to 25th percentile of parental education .
the model for di contained an intercept of 3600  10  min and a parameter estimate of 189.6  10  min for every one - unit increase in parental education .
from these results and with all covariates being equal , di was 31% lower for latino - american children and adolescents at the 75th compared to 25th percentile of parental education .
pancreatic beta - cells have the ability to increase insulin secretion ( via airg ) in response to insulin resistance .
this nonlinear hyperbolic relationship between sensitivity and secretion is best described as di [ 25 , 32 ] .
hence , higher airg and di typically represent an ability to compensate for insulin resistance in order to maintain normal glucose tolerance ( i.e. , lower diabetes risk ) .
in contrast , lower airg and di represent an inability of the pancreas to secrete enough insulin at a given level of insulin resistance where impaired glucose tolerance may arise ( i.e. , higher diabetes risk ) .
indeed , our laboratory has shown both increased airg and di as potential compensatory mechanisms for decreased si in minority children and adolescents [ 3 , 27 ] .
the underlying determinants that contribute to increased insulin resistance and pancreatic beta - cell dysfunction in overweight / obese african - american and latino - american children and adolescents are unknown ; however sociocultural and socioeconomic factors each play a unique role in shaping diabetes risk in ethnic minorities . in the present analysis , the sociocultural adaptive style of combining aspects of both mainstream white - american culture while retaining aspects of their own family 's culture was negatively associated with type 2 diabetes risk in overweight / obese african - american children and adolescents ( as reflected by higher airg and di ) .
these relationships remained significant after adjusting for household social position and other behavioral and biological covariates .
in contrast , household social position was positively associated with type 2 diabetes risk in latino - american children and adolescents ( via decreased airg and di ) . taken together
, these findings suggest that sociocultural factors may be important predictors of type 2 diabetes risk in overweight / obese african - american children and adolescents whereas socioeconomic factors , rather than culture , may be more important for latino - americans .
african - americans are a heterogeneous ethnic group who vary in the extent to which they both retain their black - american culture and also adopt aspects of white - american culture .
previous research on adults has documented the relevance of these adaptive cultural styles to health and health - related behaviors in african - american adults [ 10 , 34 ] .
dressler et al .   reported african - americans living in accordance with culturally constructed local community norms  or 
cultural consonance  in lifestyle  were a stronger independent predictor of smoking and hypertension than were indicators of socioeconomic position ( i.e. , occupation , income and education ) .
reported that positive identification with african - american culture and a self - perception of being successful in both the  black  and  white  ways of life were associated with healthy behaviors , including reduced fat consumption , more participation in leisure - time physical activity , reduced smoking , and , in women only , reduced alcohol consumption .
our results are generally consistent with these findings and suggest that the protective health effects of integrating two cultures also extend to overweight / obese african - american children and adolescents at increased risk for type 2 diabetes .
in essence , integrating aspects of both black - american and white - american cultures was associated with lower diabetes risk ( via increased airg and di ) , independent of household social position , physical activity , sedentary time , dietary intake , sex , tanner stage , and fat / fat - free mass .
an association between culture and type 2 diabetes risk , independent of physical activity and diet , is plausible , given what is known about the physiological mechanisms linking psychosocial stress to insulin resistance and subsequent type 2 diabetes risk via hypothalamic - pituitary - adrenal axis activation [ 35 , 36 ] .
in general , integration of two or more cultures is viewed as a less stressful , more adaptive process , because this orientation allows ethnic minorities to function effectively in a multicultural society while still maintaining supportive connections to their own family 's culture .
hence , integration may be associated with lower psychological stress in african - americans , thereby influencing type 2 diabetes risk independent of physical activity and diet .
additional research is needed to better understand the associations between integration , psychological stress , and diabetes risk in this ethnic minority group .
many more researchers have investigated the influence of sociocultural factors on diabetes risk in latino - americans .
the influence of culture on behavior and subsequent diabetes risk is inconsistent   and may be confounded by socioeconomic position . in the present study , household social position , not sociocultural orientation , was positively associated with type 2 diabetes risk in latino - american children and adolescents .
moreover , post hoc analyses revealed that , of the two socioeconomic indicators measured ( educational attainment and occupational rank ) , parental education was driving the relationship between household social position and diabetes risk .
a protective effect of socioeconomic position and educational attainment in particular on type 2 diabetes risk has been well established among adults and non - latino whites ; however , in the present study , this relationship was not present in either ethnic group .
the rationale for the absent relationship in african - americans and paradoxical relationship in latino - americans is unclear .
nevertheless similar findings have been previously reported between socioeconomic position and other metabolic outcomes in minority children and adolescents . using data from the national health and nutrition examination survey and national health interview survey ,
sobal and stunkard   reported that ethnic minority children from higher socioeconomic households were just as likely to be overweight and obese as compared to children residing in lower socioeconomic households .
these findings taken together with those in the present study suggest that residing in higher socioeconomic households may not be protective against obesity and subsequent type 2 diabetes risk in ethnic minority children and adolescents as has been previously reported in non - latino whites .
moreover , parental education may be a stronger independent predictor of type 2 diabetes risk than culture in latino - americans ; additional research is warranted .
first , data limitations precluded analysis of other factors known to influence diabetes risk in this analysis including genetic admixture , smoking status and alcohol consumption , social desirability , and self - reported psychological stress .
similarly , proxy indicators of acculturation such as language use , nativity , and time in the us were not available for our participants .
second , although prior research suggests that household social position and sociocultural orientation are predictors rather than consequences of diabetes risk [ 10 , 21 , 34 ] , the cross - sectional nature of this study impeded our ability to make causal inferences .
third , these findings in a small sample of overweight / obese african - american and latino - american children and adolescents living in the greater los angeles area can not necessarily be generalized to all adolescents living in the us .
finally , post hoc power calculations revealed that some of our analyses were underpowered given the large variability in fsigt - derived insulin and glucose indices . despite being underpowered
, we were able to detect significant associations between the ahimsa subscale integration , airg , and di in african - americans as well as significant associations between household social position , airg , and di in latino - americans .
thus , our findings may be an underestimation of the true effect of sociocultural orientation and household social position on type 2 diabetes risk in overweight / obese african - american and latino - american children and adolescents .
nevertheless , additional research examining these relationships in a larger , more homogenous sample may better elucidate the role of sociocultural and socioeconomic factors in shaping type 2 diabetes risk in overweight / obese ethnic minority pediatric populations . in summary ,
sociocultural orientation and household social position appear to play distinct and opposing roles in type 2 diabetes risk in overweight / obese african - american and latino - american children and adolescents . for african - americans , maintaining a sense of their own family 's culture while integrating into mainstream white - american society was independently associated with decreased diabetes risk ( as represented by increased airg and di ) . for latino - americans ,
increased diabetes risk was independently associated with increased household social position , higher parental education in particular , via decreased airg and di .
future research should continue to examine these factors over time to better understand the relationships between the sociocultural orientation , household social position , and type 2 diabetes risk in overweight / obese african - american and latino - american children and adolescents .
moreover , behavioral interventions and public policies are needed to better address sociocultural and socioeconomic factors associated with type 2 diabetes risk in ethnic minority pediatric populations .
 
 purpose . it is unclear whether sociocultural and socioeconomic factors are directly linked to type 2 diabetes risk in overweight / obese ethnic minority children and adolescents . 
 this study examines the relationships between sociocultural orientation , household social position , and type 2 diabetes risk in overweight / obese african - american ( n = 43 ) and latino - american ( n = 113 ) children and adolescents . methods . 
 sociocultural orientation was assessed using the acculturation , habits , and interests multicultural scale for adolescents ( ahimsa ) questionnaire . 
 household social position was calculated using the hollingshead two - factor index of social position . 
 insulin sensitivity ( si ) , acute insulin response ( airg ) and disposition index ( di ) were derived from a frequently sampled intravenous glucose tolerance test ( fsigt ) . 
 the relationships between ahimsa subscales ( i.e. , integration , assimilation , separation , and marginalization ) , household social position and fsigt parameters were assessed using multiple linear regression . 
 results . for african - americans , 
 integration ( integrating their family 's culture with those of mainstream white - american culture ) was positively associated with airg (  = 0.27  0.09 , r = 0.48 , p < 0.01 ) and di (  = 0.28  0.09 , r = 0.55 , p < 0.01 ) . for latino - americans , 
 household social position was inversely associated with airg (  = 0.010  0.004 , r = 0.19 , p = 0.02 ) and di (  = 20.44  7.50 , r = 0.27 , p < 0.01 ) . conclusions . 
 sociocultural orientation and household social position play distinct and opposing roles in shaping type 2 diabetes risk in african - american and latino - american children and adolescents . 
1. Introduction
2. Methods
3. Results
4. Conclusions