Related Chronic Disease Among Middle&#X02010

LIFESTYLE

Country of birth differences in lifestyle-related chronic disease among middle-aged and older adults of Lebanese ethnicity

Aymen El Masri,1 Gregory S. Kolt,1 Emma S. George1

hronic diseases, such as cardiovascular Abstract disease (CVD), cancer and diabetes, are Ca leading cause of mortality globally1 Objective: To examine country of birth differences in the odds of reporting chronic diseases and also a leading cause of illness, disability among those of Lebanese ethnicity in comparison to those of Australian ethnicity. and premature mortality in the Australian Methods: Participants were 41,940 Australians aged 45 years and older, sampled from the 2 context. The risk of developing such lifestyle- 45 and Up Study baseline dataset. Participants included those of Lebanese ethnicity born related chronic diseases can be reduced by in Lebanon (n=401), Australia (n=331) and other countries (n=73); and those of Australian 3,4 engaging in regular physical activity (PA). It ethnicity (n=41,135). Logistic regression models were conducted to examine differences in the has been reported that physical inactivity is odds of reporting chronic disease between those of Lebanese ethnicity and those of Australian responsible for 10.1% of all-cause mortality ethnicity. and 6–10% of chronic disease cases for CVD, Results: Those of Lebanese ethnicity had higher odds of reporting diabetes (OR 1.62; 95%CI type 2 diabetes mellitus (T2DM), and cancers 1.32-2.00) and lower odds of reporting hypertension (OR 0.82; 95%CI 0.70-0.96) when of the colon and breast in Australia.3 Further, compared with those of Australian ethnicity. After country of birth stratification, only those evidence suggests that higher volumes born in Lebanon had higher odds of reporting diabetes (OR 2.21; 95%CI 1.71-2.85) and also of sedentary behaviour (i.e. behaviours had lower odds of reporting cancer (OR 0.66; 95%CI 0.46-0.97), when compared with those of characterised by sitting) are associated Australian ethnicity. with an increased risk of all-cause and CVD mortality, increased risk of CVD, T2DM, and Conclusions: Country of birth differences in health exist among those of Lebanese ethnicity. some forms of cancer independent of PA Implications for public health: Country of birth is an important factor that could assist in levels.5 explaining differences in health among ethnic groups of the same origin. Australia is well known for being culturally Key words: culturally and linguistically diverse, chronic disease, migrants, Lebanese and linguistically diverse (CALD), with 26% of the population being first generation There is a large body of evidence supporting A study by Marmot and colleagues examined Australians.6 As such, it is important to these trends, with studies conducted in the the differences in chronic disease among examine the heath of CALD populations Australian context8,9 and other countries10 Japanese men in three different contexts to identify potential differences that could reporting that immigrants are less likely to (Japan, California, Hawaii) and found those be targeted through policy and health have a chronic condition in comparison to of Japanese origin living in California had interventions. The healthy migrant effect the host population, and that rates of chronic the highest prevalence of coronary heart suggests that immigrants tend to have conditions among immigrants converge to disease (CHD), with the lowest rates observed good health upon migration, which can that of the host population with increased among those living in Japan.12 These findings be attributed to the rigorous screening duration of residence. That said, a study may suggest that the prevalence of chronic checks associated with migrating to a new conducted in the Australian context among disease differs among ethnic groups of the country.7 However, with increased duration Asian immigrants examined the influence of same origin living in different contexts due of residence it has been suggested that nativity and duration of residence on a range to the unique exposures associated with immigrants usually undergo an acculturative of chronic conditions and reported that these each destination country.12 In another study, process, whereby their lifestyle behaviours trends may be dependent on the health Marmot et al. examined differences in CHD by and health tends to align more closely with condition.11 level of acculturation among men of Japanese those of the host population over time.7

1. School of Science and Health, Western Sydney University, New South Wales Correspondence to: Dr Emma S. George, School of Science and Health, Western Sydney University, Sydney, New South Wales; e-mail: [email protected] Submitted: January 2019; Revision requested: May 2019; Accepted: May 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:429-35; doi: 10.1111/1753-6405.12919

ethnicity in the US and found that those with line with the healthy migrant effect. Despite who were the comparison group. Ancestry higher levels of acculturation were more likely this, it has been reported that Lebanese- was used as an indicator of ethnicity.25,26 to have CHD in comparison to those with a born adults in Australia have higher rates Those of Lebanese ethnicity were identified lower level of acculturation.13 of various chronic diseases and associated based on their response to the question The Lebanese-Australian population is risk factors, which may contradict these ‘What is your ancestry?’ from the baseline the largest Middle Eastern CALD group in theories. The aim of this study was to examine questionnaire and participants had the Australia. This group has a long history of differences in the odds of reporting chronic option to select up to two ancestries that migration to Australia, with many arriving disease between those of Lebanese ethnicity they most identified with. All participants following the Lebanese civil war in 1975.14-16 and Australian ethnicity. This study first who reported Lebanese ethnicity, including Despite this, the health evidence on those examined the odds of reporting lifestyle- those who reported Lebanese ethnicity in of Lebanese ethnicity is limited. It has been related chronic diseases, CVD, T2DM, cancer, conjunction with another ancestry, were reported that chronic disease risk factors and hypertension among those of Lebanese categorised as being of Lebanese ethnicity. such as insufficient PA, hypercholesterolemia, ethnicity in comparison to those of Australian Responses to the question ‘In which country smoking, low vegetable consumption, and ethnicity. Secondly, this study examined were you born?’ was used to stratify those overweight and obesity were more prevalent country of birth differences in the odds of of Lebanese ethnicity into three distinct among Lebanese-born adults in New South reporting chronic disease by stratifying those groups based on country of birth (Lebanon, Wales (NSW) in comparison to Australian- of Lebanese ethnicity by country of birth (i.e. Australia, and other countries). An Australian- born adults in NSW.17 A recent study Lebanon, Australia, and other countries) in born Australian group (those who reported comparing middle-aged and older adults of comparison to those of Australian ethnicity Australian ancestry only and were born in Lebanese ethnicity born in Australia, Lebanon born in Australia. This provided information Australia) was used as a comparison group. and other countries with those of Australian as to whether or not the healthy migrant ethnicity has shown that those of Lebanese effect existed for the various chronic diseases Study variables ethnicity born in Lebanon had higher odds among those of Lebanese ethnicity born Chronic disease in Lebanon and other countries, and how of not meeting PA guidelines and suboptimal Chronic disease outcomes were ascertained chronic disease differed by country of birth sleep durations, those born in Australia had by asking participants to report whether between those of Lebanese origin. Finally, this higher odds of suboptimal sleep durations, a doctor has ever told them they had a study also examined the impact of PA and and those born in other countries had higher particular disease or illness. The following four 18 sitting time on the odds of chronic disease odds of not meeting PA guidelines. outcome variables were derived: CVD (heart among those of Lebanese ethnicity. It has been reported that Lebanese-born disease and stroke); diabetes (excluding adults in Australia had higher levels CVD gestational diabetes); cancer (including and T2DM attributable complications Methods breast, prostate and other forms of cancer, in comparison to the Australian-born and excluding skin cancer/melanoma); and population.19 Similarly, evidence from The 45 and Up Study high blood pressure (hypertension). A fifth Denmark suggests that Lebanese immigrants The Sax Institute’s 45 and Up Study is an outcome variable was created by summing had higher rates of T2DM when compared Australian cohort study of 267,153 residents those four chronic diseases to examine the with the general Danish population.20 from New South Wales (the most populous odds of reporting any of those diseases. Lebanese immigrants to Australia were state in Australia) aged 45 and older, and is reportedly more likely to develop different the largest study of healthy ageing in the Covariates 24 forms of cancer, such as prostate (male), Southern Hemisphere. The cohort was Variables adjusted for in this study included breast (female), kidney, and colon cancer, randomly sampled from the database of the sex, age, educational qualifications, smoking when compared with the Lebanese Department of Human Services, formerly status, body mass index, Socio-economic population in Lebanon.21 The available Medicare – Australia’s national healthcare Index for Areas (SEIFA), Accessibility/ 24 evidence on the health of those of Lebanese service provider, between February 2006 Remoteness Index of Australia (ARIA), PA, and ethnicity is limited and predominantly and December 2009 and had a response sitting time. focuses on those who were originally born in rate of approximately 18%. The 45 and Up Lebanon; however, evidence suggests that Study was approved by the University of NSW Analysis Human Ethics Committee. Reciprocal ethics differences in the health of CALD populations Data analysis was conducted using the approval from the Western Sydney University of the same ethnic origin differ by country of Statistical Package for the Social Sciences 22,23 Human Research Ethics Committee was birth. (SPSS 21, Chicago, IL USA). Descriptive obtained (H10930). In accordance with the theory of statistics were used to explore distribution acculturation, the odds of reporting chronic of key demographic, outcome, and exposure Sample disease for those of Lebanese ethnicity born variables of the sample. A series of binary in Australia may be more closely aligned A sample of 41,940 participants was logistic regression models were conducted to those of the host population, given that drawn from the baseline 45 and Up Study to examine the odds of reporting the they were all born in Australia. Whereas, dataset, comprising of those of Lebanese lifestyle-related chronic diseases among each those of Lebanese ethnicity born in Lebanon ethnicity born in Lebanon (n=401), Australia respective Lebanese group in comparison and other countries may have lower odds (n=331), and other countries (n=73), and to those of Australian ethnicity. Preliminary of reporting the various chronic diseases in those of Australian ethnicity (n=41,135), analyses were performed examining

differences in the odds of reporting chronic Table 1: Demographic characteristics of sample. disease among those of Lebanese ethnicity Ancestry by country of birth relative to those of Australian ethnicity. This Australian ethnicity Lebanese ethnicity Lebanese Lebanese ethnicity was followed by a series of models stratifying (n=41,135) born in Lebanon ethnicity born in born in other those of Lebanese ethnicity by country of (n=401) Australia countries birth (Australia, Lebanon, and other countries) (n= 331) (n=73) to examine country of birth differences in N % N % N % N % the odds of reporting chronic disease in CVDa 5,802 13.6% 66 14.7% 47 13.5% 9 11.8% comparison to those of Australian ethnicity. Hypertension 15,165 35.6% 144 32.1% 101 28.9% 25 32.9% Further stratification by PA and sitting time Cancer 4,788 11.2% 31 6.9% 44 12.6% 6 7.9% was performed to examine the impact of Diabetes 3,618 8.5% 90 20.0% 21 6.0% 12 15.8% these variables on the odds of reporting Any of the four chronic diseases 21,126 49.5% 220 49.0% 153 43.8% 38 50.0% chronic disease among those of Lebanese Age ethnicity born in Lebanon, Australia, and 45-54 13,414 32.6% 143 35.7% 153 46.2% 19 26.0% other countries in comparison to those of 55-64 13,717 33.3% 149 37.2% 98 29.6% 32 43.8% Australian ethnicity. All results are presented 65-74 8,431 20.5% 60 15.0% 52 15.7% 12 16.4% as odds ratios (OR) with 95% Confidence 75+ 5,573 13.5% 49 12.2% 28 8.5% 10 13.7% Intervals (CI); missing data were excluded. Sex P-values of <0.05 were interpreted as Male 21,394 52.0% 248 61.8% 145 43.8% 43 58.9% statistically significant. Female 19,741 48.0% 153 38.2% 186 56.2% 30 41.1% Education No education 4,683 11.4% 111 27.7% 16 4.8% 10 13.7% Results School Certificateb 10,113 24.6% 89 22.2% 80 24.2% 13 17.8% HSCc 3,343 8.1% 82 20.4% 38 11.5% 16 21.9% Descriptive statistics Cert/Diploma/Appren 13,039 31.7% 65 16.2% 101 30.5% 8 11.0% The descriptive statistics for the sample are University 9,957 24.2% 54 13.5% 96 29.0% 26 35.6% presented in Table 1. The sample was 41,940 SEIFAd adults aged 45 years and older. Quartile 1 10,219 24.8% 147 36.7% 67 20.2% 14 19.2% Quartile 2 10,210 24.8% 111 27.7% 80 24.2% 13 17.8% Chronic disease among those of Quartile 3 10,335 25.1% 84 20.9% 79 23.9% 28 38.4% Lebanese ethnicity Quartile 4 10,371 25.2% 59 14.7% 105 31.7% 18 24.7% ARIAe Table 2 presents the odds of reporting chronic Major cities 21,111 51.3% 381 95.0% 206 62.2% 64 87.7% disease among those of Lebanese ethnicity in Rural/Remote 20,024 48.7% 20 5.0% 125 37.8% 9 12.3% comparison to those of Australian ethnicity. PAf In Model 1, those of Lebanese ethnicity had <150 min/wk 8,697 21.1% 156 38.9% 58 17.5% 27 37.0% significant higher odds of reporting diabetes ≥150 min/wk 32,438 78.9% 245 61.1% 273 82.5% 46 63.0% (OR 1.87; 95%CI 1.54-2.27) when compared Sitting with those of Australian ethnicity. There were 7 or less h/d 30,483 74.1% 310 77.3% 244 73.7% 54 74.0% no significant differences for CVD, cancer, >7 h/d 10,652 25.9% 91 22.7% 87 26.3% 19 26.0% hypertension, or combined chronic disease Smoking odds between those of Lebanese ethnicity Never 23,534 57.2% 200 49.9% 192 58.0% 32 43.8% and those of Australian ethnicity. In Model Ever 17,601 42.8% 201 50.1% 139 42.0% 41 56.2% 4, those of Lebanese ethnicity had higher BMIg odds of reporting diabetes (OR 1.62; 95%CI <25 kg/m2 14,551 35.4% 95 23.7% 127 38.4% 17 23.3% 1.32-2.00) and lower odds of reporting 25-29.99 kg/m2 16,745 40.7% 172 42.9% 114 34.4% 26 35.6% hypertension (OR 0.82; 95%CI 0.70-0.96) in ≥30.00 kg/m2 9,839 23.9% 134 33.4% 90 27.2% 30 41.1% comparison to those of Australian ethnicity. Notes: a: CVD = Cardiovascular disease b: School certificate = Year 10 schooling Chronic disease among those of c: HSC = Higher School Certificate (the final year of secondary of high school, Year 12) Lebanese ethnicity by country of birth d: SEIFA = Socioeconomic index for areas e: ARIA = Accessibility/remoteness index for Australia Table 3 presents the odds of reporting chronic f: PA = Physical activity disease among those of Lebanese ethnicity g: BMI = Body mass index born in Lebanon, Australia, and elsewhere in 0.44-0.92), while those born in Australia In Model 4, those of Lebanese ethnicity born comparison to those of Australian ethnicity. had lower odds of reporting hypertension in Lebanon had higher odds of reporting In Model 1, those of Lebanese ethnicity born (OR 0.75; 95%CI 0.59-0.95) and those born diabetes (OR 2.21; 95%CI 1.71-2.85) and lower in Lebanon had higher odds of reporting elsewhere had higher odds of reporting odds of reporting cancer (OR 0.66 95%CI 0.46- diabetes (OR 3.00; 95%CI 2.37-3.80) and lower diabetes (OR 2.04; 95%CI 1.10-3.79), when 0.97) in comparison to those of Australian odds of reporting cancer (OR 0.64; 95%CI compared with those of Australian ethnicity. ethnicity.

Chronic disease after stratification by Physical activity and sitting time did not Discussion physical activity and sitting time substantially influence the odds of reporting chronic disease as those meeting PA The findings of this study do not consistently The odds of reporting chronic disease among guidelines did not consistently display lower support the healthy migrant effect, as those those of Lebanese ethnicity born in Lebanon, odds of reporting chronic disease or those of Lebanese ethnicity born in Lebanon had Australia, and elsewhere in comparison to with high sitting time did not consistently higher odds of reporting diabetes but lower those of Australian ethnicity, with further demonstrate higher odds of reporting chronic odds of reporting cancer in comparison to stratification for PA levels and sitting time, disease. those of Australian ethnicity. Moreover, this are reported in the Supplementary Material. study demonstrated that lifestyle-related Table 2: Chronic disease odds among those of Lebanese ethnicity in comparison to those of Australian ethnicity. chronic diseases differed by country of birth Any of the among those of Lebanese ethnicity, which CVDe Diabetes Cancer Hypertension four chronic supports previous research reporting on diseases country of birth differences in health among a Model 1 ethnic groups of the same origin.18,22,23 Australian ethnicity 1.00 1.00 1.00 1.00 1.00 Additional stratification by PA and sitting *** Lebanese ethnicity 1.09 (0.90-1.32) 1.87 (1.54-2.27) 0.85 (0.67-1.07) 0.86 (0.75-1.00) 0.99 (0.86-1.14) time did not appear to substantially influence b Model 2 the odds of chronic disease among those of Australian ethnicity 1.00 1.00 1.00 1.00 1.00 Lebanese ethnicity. Lebanese ethnicity 1.25 (1.01-1.53)* 2.05 (1.68-2.50)*** 0.94 (0.74-1.19) 0.93 (0.80-1.09) 1.12 (0.96-1.30) c Model 3 Country of birth differences Australian ethnicity 1.00 1.00 1.00 1.00 1.00 Lebanese ethnicity 1.19 (0.97-1.47) 1.79 (1.46-2.20)*** 0.95 (0.75-1.20) 0.89 (0.76-1.03) 1.05 (0.90-1.22) Prior to stratifying each group by country Model 4d of birth, it appeared that those of Lebanese Australian ethnicity 1.00 1.00 1.00 1.00 1.00 ethnicity, as a whole, had higher odds Lebanese ethnicity 1.14 (0.92-1.40) 1.62 (1.32-2.00)*** 0.93 (0.73-1.18) 0.82 (0.70-0.96)* 0.98 (0.84-1.15) of reporting diabetes and lower odds of Notes: reporting hypertension in comparison ***p<0.001; **p<0.01; *p<0.05 to those of Australian ethnicity, and no a: Model 1: Unadjusted differences were observed for other chronic b: Model 2: age and sex diseases. Upon country of birth stratification, c: Model 3: Model 2 + education, SEIFA, and ARIA d: Model 4: Model 3 + PA, sitting time, smoking status, and BMI however, the higher odds of reporting e: CVD = Cardiovascular disease

Table 3: Chronic disease odds among those of Lebanese ethnicity stratified by country of birth in comparison to those of Australian ethnicity. Any of the four chronic CVDe Diabetes Cancer Hypertension diseases Model 1a Australian ethnicity 1.00 1.00 1.00 1.00 1.00 Lebanese ethnicity born in Lebanon 1.20 (0.92-1.56) 3.00 (2.37-3.80)*** 0.64 (0.44-0.92)* 0.96 (0.78-1.18) 1.15 (0.94-1.40) Lebanese ethnicity born in Australia 1.01 (0.74-1.37) 0.70 (0.45-1.09) 1.16 (0.85-1.60) 0.75 (0.59-0.95)* 0.81 (0.66-1.01) Lebanese ethnicity born elsewhere 0.86 (0.43-1.72) 2.04 (1.10-3.79)* 0.68 (0.29-1.57) 0.89 (0.55-1.45) 1.03 (0.65-1.63) Model 2b Australian ethnicity 1.00 1.00 1.00 1.00 1.00 Lebanese ethnicity born in Lebanon 1.26 (0.95-1.68) 3.17 (2.49-4.05)*** 0.68 (0.47-0.99)* 1.00 (0.81-1.24) 1.25 (1.01-1.54)* Lebanese ethnicity born in Australia 1.36 (0.98-1.89) 0.82 (0.53-1.29) 1.38 (1.00-1.91) 0.87 (0.68-1.11) 1.00 (0.80-1.27) Lebanese ethnicity born elsewhere 0.80 (0.38-1.66) 2.00 (1.07-3.76)* 0.68 (0.29-1.57) 0.86 (0.52-1.41) 0.99 (0.61-1.62) Model 3c Australian ethnicity 1.00 1.00 1.00 1.00 1.00 Lebanese ethnicity born in Lebanon 1.14 (0.85-1.51) 2.44 (1.90-3.13)*** 0.68 (0.47-0.99)* 0.89 (0.72-1.10) 1.08 (0.87-1.33) Lebanese ethnicity born in Australia 1.40 (1.01-1.94)* 0.87 (0.55-1.36) 1.39 (1.00-1.92)* 0.89 (0.70-1.13) 1.03 (0.82-1.30) Lebanese ethnicity born elsewhere 0.81 (0.39-1.67) 1.94 (1.03-3.66)* 0.69 (0.30-1.62) 0.86 (0.52-1.41) 0.99 (0.61-1.61) Model 4d Australian ethnicity 1.00 1.00 1.00 1.00 1.00 Lebanese ethnicity born in Lebanon 1.07 (0.80-1.42) 2.21 (1.71-2.85)*** 0.66 (0.46-0.97)* 0.81 (0.65-1.01) 0.99 (0.80-1.24) Lebanese ethnicity born in Australia 1.39 (1.00-1.93) 0.83 (0.52-1.30) 1.38 (1.00-1.92) 0.86 (0.67-1.10) 1.01 (0.80-1.29) Lebanese ethnicity born elsewhere 0.71 (0.34-1.48) 1.47 (0.76-2.84) 0.66 (0.28-1.53) 0.69 (0.41-1.15) 0.80 (0.48-1.32) Notes: ***p<0.001; **p<0.01; *p<0.05 a: Model 1: Unadjusted b: Model 2: age and sex c: Model 3: Model 2 + education, SEIFA, and ARIA d: Model 4: Model 3 + PA, sitting time, smoking status, and BMI e: CVD = Cardiovascular disease

diabetes were only present among those decline in health through acculturation colleagues compared the odds of diabetes of Lebanese ethnicity who were born in varies and may be dependent on the health and associated risk factors between Iraqi- Lebanon. Additionally, those of Lebanese condition.11 The findings of the current born immigrants to Sweden with native ethnicity born in Lebanon also had lower study may support this previous research Swedes, and suggested that Middle Eastern odds of reporting cancer in comparison to with respect to the healthy migrant effect ethnicity may be an independent risk factor those of Australian ethnicity, a finding not being dependent on the health condition for diabetes.30 Their study, however, used observed prior to stratification. Furthermore, in question; however, the influence of country of birth as an indicator of ethnicity. the findings of this study support earlier acculturation on these outcomes was not Although there are differences between research suggesting that country of birth explored as duration of residence is a factor the Lebanese and Iraqi culture, Lebanese differences in health exist among ethnic not accounted for in this study. ethnicity in the current study may not be an 18,22,23 groups of the same origin. With respect to those of Lebanese ethnicity independent risk factor for diabetes, as higher Although this study used self-reported born in Australia, there were no statistically odds of diabetes were not observed for those ancestry to determine ethnicity, this approach significant differences in the odds of of Lebanese ethnicity born in Australia and is an accepted method of identifying reporting chronic diseases relative to those other countries. For CVD, previous descriptive ethnicity.25,26 It is important to note that of Australian ethnicity, possibly suggesting reports suggested that Lebanese-born adults participants in the 45 and Up Study were that they are the most acculturated group. in Australia experience higher rates of CVD- 19 only able to select two ancestries; this was This may be partly explained by their health related complications; however, there were to ensure that only ancestries they most behaviours being more closely aligned to no statistically significant differences in the identified with could be selected. Country those of Australian ethnicity 18, having been odds of reporting CVD for any of the groups of birth as a sole indicator of ethnicity has born in the same country. The influence of of Lebanese ethnicity when compared with been discussed and the limitations of this acculturation among this group could be those of Australian ethnicity in this study. have been previously noted.27,28 It is possible further explored by examining differences For cancer, although it has been reported that those born in the same country may be by generational status (e.g. first, second, that Lebanese immigrants to Australia are heterogeneous in terms of ethnic identity, third generation); however, information reportedly more likely to develop a form of 21 which in turn presents unique differences to distinguish those of Lebanese ethnicity cancer than those in their country of origin, that could potentially influence health.29 born in Australia by generational status those of Lebanese ethnicity born in Lebanon Using other indicators of ethnicity, such (e.g. potential second and third generation in the current study still had lower odds of as ancestry, in addition to country of birth Lebanese immigrants) was not collected reporting cancer in comparison to those of allows for differences in health among ethnic in the 45 and Up Study. There were no Australian ethnicity. groups of the same origin to be explored. differences in the odds of reporting chronic This information could be used to inform disease among those of Lebanese ethnicity Impact of physical activity and initiatives aimed at addressing the health born in other countries. However, the sedentary behaviour disparities of these specific groups. Based heterogeneity of the reported countries of The protective and preventative effects on the findings of this study it appears that birth for this group may have influenced the of PA towards health have been widely country of birth has a major impact on the results, as different countries of birth could reported31 and evidence on the deleterious odds of chronic disease among ethnic groups potentially result in different environmental impacts of sedentary behaviour is being of the same origin, which support the need and lifestyle exposures as well as social and documented.32,33 Findings from this study to examine country of birth differences in cultural norms. did not demonstrate consistent trends in the health among ethnic groups of the same odds of chronic disease by differences in PA origin.18,22,23 Chronic disease among those of and sitting time. For example, those meeting Lebanese ethnicity PA guidelines did not consistently display Healthy migrant effect and The higher odds of reporting diabetes lower odds of chronic disease, and those acculturation observed among those of Lebanese ethnicity with high sitting time did not consistently Many studies have reported that immigrants born in Lebanon are supported by existing demonstrate higher odds of reporting chronic are less likely to have a chronic condition literature in which higher rates of T2DM have disease. Although low levels of PA and high in comparison to the host population; been previously reported among Lebanese levels of sitting time can increase chronic however, this health advantage deteriorates born adults in Australia19 and Denmark.20 disease risk, they may not be the major or converges to that of the host population Although these studies used medical contributors to the odds of reporting chronic with increased duration of residence.8-10 The diagnoses to ascertain T2DM (as opposed disease experienced among the groups in this findings of this study may not consistently to self-report), they were only descriptive, study. An alternative explanation, however, support the healthy migrant effect, as those and used country of birth as an indicator is that the absence of differences in the odds of Lebanese ethnicity born in Lebanon had of ethnicity, of which the limitations are of reporting chronic disease by PA and sitting higher odds of reporting diabetes but lower noted.27,28 Adults born in Lebanon reportedly time could be due to the dichotomisation odds of reporting cancer in comparison have high rates of chronic disease risk factors, of PA and sitting time (i.e. meeting or not to those of Australian ethnicity. Previous such as insufficient PA, hypercholesterolemia, meeting guidelines and low sitting vs. high research conducted among Asian immigrants smoking, and overweight and obesity, which sitting), which could have resulted in the loss to Australia, however, has suggested that could potentially contribute to the higher of valuable information. Moreover, this is a healthy migrant effect and subsequent odds of diabetes.17 A study by Bennet and further complicated by the fact that most of

the sample reported low levels of sitting and and Australian ethnicity. Moreover, those This research was completed using data higher levels of PA, which could potentially be of Lebanese ethnicity in this study had collected through the 45 and Up Study (www. explained by over- and under-reporting that the option to claim up to two ancestries; saxinstitute.org.au). The 45 and Up Study is is associated with self-reported measures. however, due to the small sample of those managed by the Sax Institute in collaboration of Lebanese ethnicity, those who claimed with major partner Cancer Council NSW; Strengths and limitations Lebanese ethnicity in addition to another and partners: the National Heart Foundation A strength of this study is that its findings were considered to be of Lebanese ethnicity. of Australia (NSW Division); NSW Ministry contribute to the limited documented A limitation of this is that they could have of Health; NSW Government Family & evidence on the health of those of Lebanese other ancestral backgrounds that could Community Services – Ageing, Carers and the ethnicity, providing an insight into the be influencing the odds of reporting Disability Council NSW; and the Australian health of one of the larger CALD groups in chronic disease among those of Lebanese Red Cross Blood Service. We thank the many NSW, Australia. The findings of this study ethnicity that were not accounted for. The thousands of people participating in the 45 could be used to target key health messages low response rate (18%) of the 45 and Up and Up Study. towards those of Lebanese ethnicity through Study may limit the generalisability of the health interventions or initiatives. Another findings of this study. Furthermore, given References strength of this study was that a diverse the influence of acculturation on health outcomes and behaviours as well as the 1. World Health Organization. Noncommunicable Diseases range of chronic diseases was explored, Progress Monitor, 2017. Geneva (CH): WHO; 2017. which included CVD, diabetes, cancer, time it takes for chronic diseases to develop, 2. Willcox S. Chronic Diseases in Australia: The Case for duration of residence in Australia for those of Changing Course. Melbourne (AUST: Australian Health and hypertension, all of which – except Policy Collaboration; 2014. for hypertension – are key national health Lebanese ethnicity who were born overseas 3. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, is an important factor that was not accounted Katzmarzyk PT, et al. Effect of physical inactivity on priority areas. Furthermore, this study major non-communicable diseases worldwide: An examined country of birth differences in for in this study, and this could potentially be analysis of burden of disease and life expectancy. the odds of chronic disease among those of contributing to the odds of reporting chronic Lancet. 2012;380(9838):219-29. disease. 4. World Health Organization. Physical Activity. Geneva Lebanese ethnicity, which provides an insight (CHE): WHO; 2015 [cited 2018 Dec 1] Available from: into how health differs by country of birth https://www.who.int/dietphysicalactivity/pa/en/ 5. Physical Activity Guidelines Advisory Committee. 2018 among ethnic groups of the same origin. Conclusion Physical Activity Guidelines Advisory Committee Scientific Despite several strengths of this study, the Report. Washington (DC): United States of America The findings of this study support previous Department of Health and Human Services; 2018. findings must be considered in light of the 6. Australian Bureau of Statistics. 2071.0 – Census of cross-sectional design, which does not allow research that report country of birth Population and Housing: Reflecting Australia – Stories differences in health exist among ethnic from the Census, 2016. Canberra (AUST): ABS: 2017. for causal inferences to be determined. 7. Anikeeva O, Bi P, Hiller JE, Ryan P, Roder D, Han GS. The Although self-report questionnaires, as groups of the same origin and research, health status of migrants in Australia: A review. Asia Pac which suggests that a healthy migrant J Public Health. 2010;22(2):159-93. used in the 45 and Up Study, are useful for 8. Biddle N, Kennedy S, McDonald JT. Health assimilation collecting data for large population-based effect may be dependent on the health patterns amongst Australian immigrants. Econ Rec. studies, inherent limitations of this approach condition. As the Lebanese population is 2007;83(260):16-30. the largest Arabic-speaking population in 9. Jatrana S, Pasupuleti SSR, Richardson K. Nativity, include the social desirability bias, recall, duration of residence and chronic health conditions in and over- or under-reporting.34 Additionally, Australia, this study provides much-needed Australia: Do trends converge towards the native-born evidence on the health of this group and population? Soc Sci Med. 2014;119:53-63. the method used to determine chronic 10. Newbold KB. Chronic conditions and the healthy disease diagnosis was from participants highlights how chronic disease outcomes immigrant effect: Evidence from Canadian immigrants. may differ between first and later generation J Ethn Migr Stud. 2006;32(5):765-84. reporting if they had ever been told by a 11. Pasupuleti SSR, Jatrana S, Richardson K. Effect of nativity doctor that they had the specific condition, immigrants. However, as duration of and duration of residence on chronic health conditions which relied on participant recall. Given the residence is an important factor influencing among Asian immigrants in Australia: A longitudinal the health of immigrants and given the time investigation. J Biosoc Sci. 2016;48(3):322-41. documented issues and lack of engagement 12. Marmot MG, Syme SL, Kagan A, Kato H, Cohen JB, with healthcare services encountered by it takes for chronic conditions to develop, Belsky J. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, 35 future research should aim to examine the CALD groups, and lower levels of health Hawaii and California: Prevalence of coronary and literacy among those from non-English impact of acculturation on these chronic hypertensive heart disease and associated risk factors. 36 disease outcomes among those of Lebanese Am J Epidemiol. 1975;102(6):514-25. speaking backgrounds, there could be 13. Marmot MG, Syme SL. Acculturation and coronary a greater degree of under-reporting on ethnicity. Such research could help justify the heart disease in Japanese-Americans. J Epidemiol. the chronic disease rates among those of need for targeted health promotion programs 1976;104(3):225-47. and may be of relevance to policy makers 14. Department of Immigrant and Citizenship. Community Lebanese ethnicity when compared with Information Summary - Lebanon-born. Canberra (AUST): those of Australian ethnicity. A consequence or organisations targeting the health of Government of Australia; 2014. Lebanese immigrants. 15. Jupp J. The Australian People: An Encyclopedia of the of the survey being only administered in Nation, its People and their Origins. New York (NY): English is that more newly arrived immigrants Cambridge University Press; 2001. 16. Australian Bureau of Statistics. 3416.0 - Perspectives on of Lebanese ethnicity who might not have Acknowledgements Migrants, 2008. Canberra (AUST): ABS; 2008. a proficient level of English literacy may 17. Centre for Epidemiology and Research. Report on not have been able to participate in the Aymen El Masri was supported by an Adult Health by Country of Birth from New South Wales Population Health Survey. Sydney (AUST): New South 45 and Up Study, which could potentially Australian Government Research Training Wales Department of Health; 2010. mask the true extent of the differences in Program Scholarship. chronic disease between those of Lebanese

18. El Masri A, Kolt GS, Astell-Burt T, George ES. Lifestyle behaviours of Lebanese-Australians: cross-sectional Supporting Information findings from The 45 and Up Study. PLoS One. 2017;12(7). Additional supporting information may be 19. New South Wales Department of Health. The Health of found in the online version of this article: the People of New South Wales Report of the Chief Health Officer 2008. Sydney (AUST): State Government of NSW; Supplementary Table 1: Chronic disease 2008. odds among those of Lebanese ethnicity 20. Kristensen JK, Bak JF, Wittrup I, Lauritzen T. Diabetes prevalence and quality of diabetes care among stratified by country of birth and physical Lebanese or Turkish immigrants compared to a native activity in comparison to those of Australian Danish population. Prim Care Diabetes. 2007;1(3):159- 65. ethnicity. 21. Supramaniam R, O’Connell DL, Tracey EA, Sitas F. Cancer Incidence in New South Wales Migrants 1991 to 2001. Supplementary Table 2: Chronic disease Sydney (AUST): Cancer Council New South Wales; 2006. odds among Lebanese ethnicity stratified 22. Astell-Burt T, Feng X, Croteau K, Kolt GS. Influence by country of birth and sitting time in of neighbourhood ethnic density, diet and physical activity on ethnic differences in weight status: A study comparison to those of Australian ethnicity. of 214,807 adults in Australia. Soc Sci Med. 2013;90:70-7. 23. Feng X, Astell-Burt T, Kolt GS. Do social interactions explain ethnic differences in psychological distress and the protective effects of local ethnic density? A cross-sectional study of 226,487 adults in Australia. BMJ Open. 2013;3(e002713). 24. 45 and Up Collaborators. Cohort profile: The 45 and Up Study. Int J Epidemiol. 2008;37(5):941-7. 25. Fenton S, Charsley K. Epidemiology and sociology as incommensurate games: Accounts from the study of health and ethnicity. Health. 2000;4(4):403-25. 26. Villarroel N, Davidson E, Pereyra-Zamora P, Krasnik A, Bhopal RS. Heterogeneity/granularity in ethnicity classifications project: The need for refining assessment of health status. Eur J Public Health. 2019;29(2):260-6. 27. Bhopal R. Glossary of terms relating to ethnicity and race: For reflection and debate. J Epidemiol Community Health. 2004;58:441-5. 28. Stronks K, Kulu-Glasgow I, Agyemang C. The utility of ‘country of birth’ for the classification of ethnic groups in health research: The Dutch experience. Ethn Health. 2009;14(3):255-69. 29. Gill PS, Bhopal R, Wild S, Kai J. Limitations and potential of country of birth as proxy for ethnic group. BMJ. 2005;330(7484):196. 30. Bennet L, Groop L, Lindblad U, Agardh C-D, Franks PW. Ethnicity is an independent risk indicator when estimating diabetes risk with FINDRISC scores: A cross sectional study comparing immigrants from the Middle East and native Swedes. Prim Care Diabetes. 2014;8(3):231-8. 31. Reiner M, Niermann C, Jekauc D, Woll A. Long-term benefits of physical activity: A systematic review of longitudinal studies. BMC Public Health. 2013;13:813. 32. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: A systematic review and meta-analysis. Ann Intern Med. 2015;162(2):123-32. 33. Van der Ploeg HP, Chey T, Korda RJ, Banks E, Bauman A. Sitting time and all-cause mortality risk in 222 497 Australian adults. Arch Intern Med. 2012;172(6):494-500. 34. Prince SA, Adamo KB, Hamel ME, Hardt J, Gorber SC, Tremblay M. A comparison of direct versus self-report measures for assessing physical activity in adults: A systematic review. Int J Behav Nutr Phys Act. 2008;5:56. 35. Henderson S, Kendall E. Culturally and linguistically diverse peoples’ knowledge of accessibility and utilisation of health services: Exploring the need for improvement in health service delivery. Aust J Prim Health. 2011;17(2):195-201. 36. Australian Bureau of Statistics. 4233.0 - Health Literacy, Australia, 2006. Canberra (AUST): ABS; 2008.