Examining Dietary Acculturation in the Us Southern Food Environment: Determinants of Food Choice and Dietary Patterns Among West African Migrants in the Stroke Belt Region

Background: Each year, over 500,000 international students, including many from Sub-Saharan Africa, enroll in universities within the United States (US). Up to 90% of these students remain in the country after graduation, often gradually adopting American lifestyles. As they acculturate to US lifestyle and dietary practices, these students risk losing the health advantage they initially had upon arrival, a decline commonly referred to as the "healthy immigrant effect". Unfortunately, the Southeastern US is commonly referred to as the Stroke Belt and is associated with a 10% higher risk of cardiometabolic diseases (CMDs) compared to other regions of the US. As CMDs disproportionately affects Black populations, West African (WA) international graduate students who acculturate in the Stroke Belt food environment region may also face increased CMD risk. Purpose: This study examined dietary acculturation and diet quality of WA international graduate students in three adjacent US Stroke Belt states—Alabama (AL), Georgia (GA), and Mississippi (MS). It investigated potential factors influencing their level of dietary acculturation and diet quality including nutrition knowledge, perception of the food environment, and food security status. Methods: This study employed a quantitative, cross-sectional study design, utilizing the Contento Determinants of Food Choice Model. This involved a comprehensive literature review to identify appropriate data collection tools for measuring the constructs of interest. Expert panel reviews, pilot testing, and iterative modifications were performed to ensure both construct and face validity of the final survey instrument. Reliability was assessed using a test-retest method. Quantitative survey data were analyzed with descriptive analysis, ANOVA, and regression analyses whereas qualitative responses to open-ended questions were thematically analyzed. Results: A total of 156 eligible WA international students from AL, GA, and MS completed the survey. The mean dietary acculturation score was 2.5 on a scale of 0–5 (SD = 0.4; Range =1.7–3.7), indicating a balanced intake of both traditional and non–WA foods. Regression analysis identified self-rated health (β = –0.356, p < .001), remittance behavior (β = –0.259, p < .001), income (β = 0.224, p = .002), and length of residence in the US (β = 0.184, p = .011) as the strongest predictors of dietary acculturation in this population, explaining 33% of the adjusted variance. Diet quality overall was generally poor, with a mean score of 40.6 on a scale of 0-100 (SD = 8.1; Range = 22.1–61.9). Gender was a significant predictor of diet quality (β = 0.17, p < .001), with females reporting higher overall diet quality scores (p = .001). Knowledge about how to prepare WA foods was also a strong predictor of better diet quality (β = 0.29, p < .001). Participants rated their perception of a healthy food environment at 3.0 (SD = 0.8) and the unhealthy food environment at 3.7 (SD = 1.1) on a 1–5 scale. Key barriers reported to maintaining traditional diets included limited availability of traditional foods, high cost, transportation constraints, and compromised authenticity of traditional food ingredients. Facilitators included access to ethnic stores, social and community support, personal food preferences, and use of digital media for recipe adaptation and ingredient sourcing. Discussion and Conclusion: In this population of WA students residing in the Stroke Belt region, participants demonstrated bicultural dietary acculturation shaped by personal, cultural, and environmental factors. Remittance behavior emerged as a novel predictor of dietary acculturation by encouraging continuity of traditional dietary practices. The overall poor diet quality reported in this population also highlights the need for culturally tailored nutrition education that builds on existing culinary knowledge of traditional food. Perceptions of the food environment were complex as participants reported their food environment as being both healthy and unhealthy. These findings call for further research to better understand the intersecting roles of culture, economics, and environment in shaping dietary behaviors among WA international students.