Perceived Multi-Level Diabetes Protective and Risk Factors Associated with Food and Dietary Acculturation Patterns Among East African Immigrants in the United States

Background: Upon arrival in a new country, immigrants have lower body mass index (BMI), and are less likely to be overweight and obese than natives. However, longer residence is associated with higher BMI, partly attributed to adoption of unhealthy diets and dietary habits. Overweight and obesity (primary risk factors for diabetes) have been associated with food acculturation—the process by which immigrants adopt food practices of their new country. In particular, unfamiliar food cultures and food purchasing environment, lack of knowledge on how to prepare and incorporate new foods in traditional diets, perceptions towards food in new countries, all limit immigrants’ food choices and access. However, very few food acculturation studies have focused on African immigrants, specifically from eastern Africa. Yet, this group reports high rates of overweight, obesity, and higher prevalence of diabetes and pre-diabetes. Using the socioecological framework, this study explored the multi-level facilitators and barriers associated with food and dietary acculturation patterns and perceived diabetes-related health risks among East African immigrants and refugees in the Twin Cities Metro Area, Minnesota, United States. Methods: Six semi-structured focus groups were conducted with 36 Somali and Ethiopian women in the summer and fall of 2025. Participants represented Somali, Oromo and Amharic speakers. Only women were recruited with the assumption that women are the primary food decision makers and preparers in these communities. Therefore, the 36 participants provided insight into their households’ dietary practices and food decision-making processes. All focus group discussions were audio recorded to ensure accuracy and authenticity of participants’ narratives, then directly translated into English within a few days of being conducted. Each transcript was cross-checked by at least two team members. Data were analyzed thematically using Braun and Clarke’s approach: codes, categories, themes, and subthemes were iteratively refined through collaborative team review and organized within the socioecological framework. Results: The analysis identified two overarching themes at the individual, family, community and structural levels. Attachment to traditional and ethnic foods functioned as important cultural and health-related anchors. Participants shared their preference for ethnic foods as healthier, more natural, tastier and central to identity and continuity after migration. Sustaining healthy dietary practices at the individual and family levels was shaped by complex factors such as: work and caregiving demands, stress, time constraints, and changing family dynamics and roles. Intergenerational differences were especially salient. Children adopted American foods faster, increasing reliance on fast and convenience foods, creating household tensions, and sometimes requiring separate meal preparations. Community and structural factors further shaped dietary choices. High costs, limited availability of cultural foods, distance to ethnic stores, and transportation barriers constrained access, while highly processed and sugary foods were easily accessible. Participants also described reduced routine physical activity and migration-related stress as contributors to perceived diabetes risk. Ethnic grocery stores, halal markets, community networks, recipe adaptation, and the continued consumption of traditional foods were perceived as protective resources amidst these challenges. Overall, the findings appear to demonstrate that food and dietary acculturation are not a linear process in which immigrants shift from a traditional to a Western-based diet. Rather, it is shaped by complex interactions across individual, family, community, and structural factors. The study limitations, and implications for practice and research are discussed in the paper.