• Immigration is a complex process, during which immigrants face barriers in communication, in accepting new cultures and new physical environments, adopting new values, and adapting to a new health care system. Cultural factors have both positive and negative influences on one’s health and behavior, so understanding the cultural backgrounds of immigrants is imperative for delivering good and culturally appropriate immigrant health care.1
  • The main reasons for immigrating to a western country include seeking a better quality of life and better futures for their families, as well as to reunite with the family members and close friends.2
  • Research has shown that, upon arrival to a western country, immigrants’ health is better than that of the native-born population (termed as “healthy immigrant effect”). This happens mostly due to a selective immigration process in which only people who have passed a medical screening exam are granted entry to that particular country.2
  • However, the healthy immigrant phenomenon has not shown to be lasting, as immigrants’ health tends to deteriorate with increases in time since immigration. Along with physically relocating to a new country, immigrants experience transitions in many segments of their life that result in cultural, psychosocial, socio-economic, lifestyle, and social support network changes.2
  • With increases in time since immigration, these changes and perturbations in the life of immigrants may result in an increased number of risk factors for CVD (cardiovascular disease).3, 4  The healthy immigrant effect decreases over time while measures of silent heart disease (subclinical atherosclerosis) increases.5
  • The Multi-Ethnic Study of Atherosclerosis (MESA) research group also reported a significant positive relationship between the prevalence of CAC (coronary artery calcification) score and time since immigration among Chinese and black immigrants in the US.6
  • After adjusting for socio-demographics, ethnicity, lifestyle characteristics, and cardio-metabolic risk factors, time since immigration was shown to be a significant predictor of carotid (IMT) intimal medial thickness, a measure of silent heart disease.4 The MESA study results showed that there was a 2% increase in IMT for every ten years since immigration in addition to the 7% increase in IMT for every 10 years of age. 4
  • Importantly, although immigrants as a whole were shown to have a lower burden of silent heart disease the burden among immigrants was shown to increase with time since immigration and eventually surpassed that of non-immigrants.
  • Similar conclusions come from the Konkani study where it was found that the duration of residence was an independent predictor of self-reported CAD (coronary artery disease) among South Asian immigrants in the US.5
  • Other studies have shown that immigration to a western country is, however, associated with the adoption of healthy behaviors and practices. Leisure time physical activity tends to increase among immigrants, while smoking rates tend to decrease among immigrant men with time since immigration.7
  • Compared to the practices in their country of birth, Chinese immigrants reported a greater consumption of fruits and vegetables and a decrease in preparing deep-fried food since immigrating to Canada. Furthermore, they reported greater awareness and knowledge about the healthy foods as well as the ability to read and understand food labels better.7
  • The adoption of healthy or unhealthy behaviors/practices is driven by the differences in behaviors and risk factors between the country of birth and that of immigration. However, it has been shown that settling in a community with people from the same cultural background helps immigrants adjust better and cope easier with the changes associated with acculturation to a western society.2
  • Most commonly, immigration takes place from a country with low risk levels for CVD to a country where CVD is a leading cause of death such as the US.8 However, the opposite has been shown as well. Emigrating from a country with a higher prevalence of CVD prevalence to one with a lower prevalence of CVD has been shown to be associated with more favorable CVD risk profile among immigrants.9
  • In order to strengthen positive and decrease negative cultural influences on health, it is important to develop culturally appropriate educational programs related to health promotion and health care. Recent research indicates that immigrants represent a high-risk and vulnerable population for CVD for which targeted and appropriate health promotion strategies should be developed.1

Migration within the country

  • In low-income countries such as India, migration from rural-to-urban areas is associated with increased cardiometabolic risk factors such as obesity, abdominal obesity, diabetes, hypertension, high cholesterol and diabetes.(see Figure 114) These changes are influenced by changes in physical activity, dietary fat intake, obesity and duration of migration.10 The high rate of heart disease observed in urban India is due to high prevalence of risk factors described above. On a brighter side tobacco use is lowered with urban migration.
  • The heightened risk of heart disease with migration to urban areas has huge impact on the CVD burden of India because of rapid increase in the urban population. Between 1901 and 2000, the proportion of people living in urban areas has tripled to 27% and is projected to reach 50% by 2030. The absolute number of people residing in urban areas has increased from 26 million in 1901 to 288 million in 2001.


1. Enas EA. How to Beat the Heart Disease Epidemic among South Asians: A Prevention and Management Guide for Asian Indians and their Doctors. Downers Grove: Advanced Heart Lipid Clinic  USA; 2011.

2. Lassetter JH, Callister LC. The impact of migration on the health of voluntary migrants in western societies. J Transcult Nurs. Jan 2009;20(1):93-104.

3. Lauderdale DS, Rathouz PJ. Body mass index in a US national sample of Asian Americans: effects of nativity, years since immigration and socioeconomic status. Int J Obes Relat Metab Disord. Sep 2000;24(9):1188-1194.

4. Lear SA, Humphries KH, Hage-Moussa S, Chockalingam A, Mancini GB. Immigration presents a potential increased risk for atherosclerosis. Atherosclerosis. Aug 2009;205(2):584-589.

5. Mooteri SN, Petersen F, Dagubati R, Pai RG. Duration of residence in the United States as a new risk factor for coronary artery disease (The Konkani Heart Study). Am J Cardiol. Feb 1 2004;93(3):359-361.

6. Diez Roux AV, Detrano R, Jackson S, et al. Acculturation and socioeconomic position as predictors of coronary calcification in a multiethnic sample. Circulation. Sep 13 2005;112(11):1557-1565.

7. Choi S, Rankin S, Stewart A, Oka R. Effects of acculturation on smoking behavior in Asian Americans: a meta-analysis. J Cardiovasc Nurs. Jan-Feb 2008;23(1):67-73.

8. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation. 2001;104(23):2855-2864.

9. Jartti L, Ronnemaa T, Kaprio J, et al. Population-based twin study of the effects of migration from Finland to Sweden on endothelial function and intima-media thickness. Arterioscler Thromb Vasc Biol. May 1 2002;22(5):832-837.

10. Gupta R, Agrawal A, Misra A, et al. Migrating husbands and changing cardiovascular risk factors in the wife: a cross sectional study in Asian Indian women. J Epidemiol Community Health. Dec 6 2011.

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