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Author manuscript; available in PMC: 2026 Apr 11. Published in final edited form as: J Epidemiol Community Health. 2026 Jun 10;80(7):503–511. doi: 10.1136/jech-2025-225433 Search in PMC Search in PubMed View in NLM Catalog Add to search Association between migration and cardiovascular health in Mexicans: a binational analysis using the Hispanic Community Health Study (HCHS/SOL) and Mexican Family Life Survey (MxFLS) Aresha Martinez-Cardoso Aresha Martinez-Cardoso 1 Public Health Sciences, University of Chicago Biological Sciences Division, Chicago, Illinois, USA Find articles by Aresha Martinez-Cardoso 1 , Cal Chengqi Fang Cal Chengqi Fang 1 Public Health Sciences, University of Chicago Biological Sciences Division, Chicago, Illinois, USA Find articles by Cal Chengqi Fang 1 , Gabriela Leon-Perez Gabriela Leon-Perez 2 Sociology, Virginia Commonwealth University, Richmond, Virginia, USA Find articles by Gabriela Leon-Perez 2 , Linda C Gallo Linda C Gallo 3 Psychology, San Diego State University, San Diego, California, USA Find articles by Linda C Gallo 3 , Carmen Isasi Carmen Isasi 4 Department of Epidemiology, Population Health, and Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA Find articles by Carmen Isasi 4 , Stephanie R Potochnick Stephanie R Potochnick 5 Sociology, The University of North Carolina at Charlotte, Charlotte, North Carolina, USA Find articles by Stephanie R Potochnick 5 , Martha L Daviglus Martha L Daviglus 6 Institute of Minority Health Research, University of Illinois Chicago, Chicago, Illinois, USA Find articles by Martha L Daviglus 6 , Olga Garcia-Bedoya Olga Garcia-Bedoya 7 Medicine, University of Illinois Chicago, Chicago, Illinois, USA Find articles by Olga Garcia-Bedoya 7 , Gregory Talavera Gregory Talavera 8 San Diego State University, San Diego, California, USA Find articles by Gregory Talavera 8 , Jonathan Ross Jonathan Ross 9 Albert Einstein College of Medicine, New York, New York, USA Find articles by Jonathan Ross 9 , Krista Perreira Krista Perreira 10 Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Find articles by Krista Perreira 10 Author information Article notes Copyright and License information 1 Public Health Sciences, University of Chicago Biological Sciences Division, Chicago, Illinois, USA 2 Sociology, Virginia Commonwealth University, Richmond, Virginia, USA 3 Psychology, San Diego State University, San Diego, California, USA 4 Department of Epidemiology, Population Health, and Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA 5 Sociology, The University of North Carolina at Charlotte, Charlotte, North Carolina, USA 6 Institute of Minority Health Research, University of Illinois Chicago, Chicago, Illinois, USA 7 Medicine, University of Illinois Chicago, Chicago, Illinois, USA 8 San Diego State University, San Diego, California, USA 9 Albert Einstein College of Medicine, New York, New York, USA 10 Department of Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Contributors AM-C, GL-P and KP conceived of and designed the study. AM-C, GL-P and CCF led data cleaning, analysis and interpretation. AM-C and CCF drafted the manuscript. All authors reviewed the manuscript critically for important intellectual content and approved the final version. AM-C is the guarantor of the study. ✉ Correspondence to: Dr Aresha Martinez-Cardoso; [email protected] Collection date 2026 Jun 10. PMC Copyright notice PMCID: PMC13068288 NIHMSID: NIHMS2161942 PMID: 41741008 The publisher's version of this article is available at J Epidemiol Community Health Abstract Background Evolving migration patterns between the USA and Mexico may alter the traditional health advantages associated with Mexican immigrants in the USA. This study examines the relationship between migration status and health, comparing Mexican-origin individuals residing in the USA and Mexico. Methods We conducted a binational, population-based, cross-sectional analysis using the Hispanic Community Health Study/Study of Latinos (2008–2011) and the Mexican Family Life Survey (2009–2011). Our sample included 13 486 adults aged 18–65, categorised as US-born Mexican Americans, foreign-born Mexicans in the USA, return migrants in Mexico and non-migrants in Mexico. We analysed cardiovascular risk factors, including body mass index, waist-to-hip ratio, hypertension and self-reported health, using multivariable logistic regression, adjusting for socioeconomic and behavioural covariates. Results Compared with non-migrants in Mexico, foreign-born Mexicans in the USA had higher odds of overweight (OR=1.83, 95% CI 1.26 to 2.52) and elevated waist-to-hip ratio (OR=2.87, 95% CI 2.24 to 4.50) but lower odds of clinical hypertension (OR=0.49, 95% CI 0.34 to 0.68) and poor self-rated health (OR=0.26, 95% CI 0.19 to 0.33). US-born Mexican Americans exhibited similar patterns to the foreign-born in the USA. Return migrants had health profiles more aligned with non-migrants in Mexico. Increasing years in the USA for foreign-born migrants was associated with adverse health risks (OR=0.003–0.01, p≤0.001–0.02). Conclusions US residency for US-born Mexicans and foreign-born Mexicans is associated with both advantages and risks compared with remaining in Mexico. Return migrants exhibit mixed health outcomes, suggesting that migration trajectories shape long-term cardiovascular risk. These findings point to potential shifts in the Hispanic paradox among Mexicans. INTRODUCTION Migration between Mexico and the USA is one of the largest international migration flows in the world. More than 10 million Mexican immigrants reside in the USA, representing 23% of all US immigrants. 1 At the same time, the population of US-born Hispanic/Latinos of Mexican heritage has grown significantly and now exceeds Mexican immigrants: more than one in 10 US residents (11.2%) identify as Hispanic/Latino of Mexican heritage. 2 Over the past decade, USA–Mexico migration patterns have shifted significantly. Historically, migration between the USA and Mexico has been cyclical, with migrants both travelling to the USA and returning to Mexico. Before 2000, more people moved from Mexico to the USA than vice versa. 3 However, between 2005 and 2014, net migration approached zero, as roughly equal numbers left the USA for Mexico and entered from Mexico. 3 Since 2021, though, there has been a modest uptick in Mexican migration to the US Economic and political changes—such as stricter US immigration policies, the rising cost of living in the USA, and increasing economic opportunities within Mexico—have contributed to changes in the traditional USA–Mexico migration flows. Previous research has established that migration to the USA significantly influences health behaviours and outcomes among diverse Mexican-origin populations. However, it is unclear how evolving migration patterns complicate the long-standing relationship between Mexican migration and health. 4 5 For instance, early studies on the ‘Hispanic paradox’ suggested that Mexican immigrants were often healthier than US-born Mexicans and non-Hispanic whites, partly due to immigrant health selection. 4 However, more recent research on Mexican migrant cohorts presents mixed findings, revealing variations in immigrant health selection based on factors such as documentation status, sex, region of origin and other demographic characteristics. 5 – 10 Similarly, prior research also suggested that return Mexican migrants had worse health profiles than their counterparts who remained in the USA or never migrated. 11 12 The recent upticks in return migration and improvements in Mexican healthcare infrastructure, however, may be potentially reshaping or even reversing the health advantages historically associated with Mexican immigrants in the USA. 13 14 By examining health across different migration experiences, researchers can better capture these evolving trends and their implications for public health on both sides of the USA–Mexico border. However, binational studies with comparable health data on US and Mexican migration groups have been limited in several respects. 15 16 Existing binational analyses largely rely on self-reported or limited health indicators, 17 – 19 consist of non-representative samples in the USA or Mexico 20 21 or restrict to older age populations. 22 – 24 Bostean’s study linking data from Mexico and the USA, for example, finds evidence of both positive health selection into migration and salmon bias in self-reported activity limitations among Mexican migrants in the USA and return migrants in Mexico. 25 In a sample of older adults in Mexico, researchers also found that return migrants, especially those who were undocumented, had a higher risk of dementia than Mexican non-migrants, but a comparable sample of migrants who remained in the USA was not included. 22 Similarly, Beltran-Sanchez and colleagues document similar SES-health gradient profiles among Mexican migrants in the US and Mexicans in Mexico, but do not explore the health of return migrants. 26 In this population-based cross-sectional study, we help address these gaps by leveraging two complementary data sources: the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and the Mexican Family Life Survey (MxFLS). Combining these data allows us to compare validated health outcomes between representative samples of US-born Mexicans (SOL), foreign-born Mexicans in the USA (SOL), Mexican return migrants (MxFLS) and Mexican non-migrants (MxFLS). Our study provides new and robust evidence on contemporary Mexican migration flows and their health consequences, shedding light on how changing migration dynamics may challenge or reinforce existing paradigms of migration and health. METHODS Data We combined data on Mexican and Mexican-heritage adults from two sources to compare health outcomes by migration and nativity status ( online supplemental figure 1 ). The first source is Wave I (2008–2011) of the HCHS/SOL, an observational, population-based study designed to assess chronic diseases and risk factors among individuals of Hispanic/Latino ethnic descent in Chicago, Miami, New York and San Diego. 27 28 In the HCHS/SOL, 16 415 participants aged 18–74 years were recruited for an in-person exam and underwent comprehensive biological, behavioural and sociodemographic assessments. We restricted our sample to individuals aged 18–65 who self-identified as Mexican heritage (n=6040), comprising US-born individuals of Mexican heritage and Mexican-born immigrants residing in the USA. The second data source is the third wave (2009–2011) of the MxFLS, a longitudinal, nationally representative study of the well-being of individuals and families in Mexico. 29 30 This wave closely aligns with the data collection period of HCHS/SOL. Participants completed detailed sociodemographic and behavioural surveys and an in-home physical health assessment administered by trained staff. In addition, they reported any prior residence in the USA lasting at least 1 year since age 12, which allowed us to identify return migrants. We restricted the MxFLS sample to adults aged 18–65 with valid sample weights (n=7571). The original MxFLS dataset contained 20 205 records, of which 7571 were assigned sampling weights according to the survey design. The analysis uses these weighted observations. The remaining observations were excluded as they fall outside the target population frame for weighted population-representative estimation. Variables Migration-nativity group We categorised participants into four migration-nativity groups: (1) Foreign-born Mexican migrants in the USA (HCHS/SOL), (2) U.S.-born Hispanic/Latinos of Mexican heritage (HCHS/SOL), (3) Mexican-born non-migrants (MxFLS), and (4) Mexican-born return migrants (MxFLS). Within HCHS/SOL, birthplace indicated whether participants were Mexican-born immigrants or U.S.-born. Within MxFLS, respondents were asked about places they had lived for more than 1 year since age 12. Those who had spent at least 1 year in the USA were classified as return migrants; all others were classified as non-migrants. Dependent variables We focus on health outcomes that were comparable in the HCHS/SOL and MxFLS and associated with cardiovascular disease, one of the leading causes of morbidity and mortality in Mexican heritage individuals in the USA and Mexico. Outcomes were measured via clinical height, weight and blood pressure: overweight status (BMI ≥25); elevated waist-to-hip ratio (> 0.9 for male, > 0.85 for female); clinical hypertension (systolic ≥130 or diastolic ≥80, average of two blood pressure measurements). We also include hypertension based on self-report (eg, has a doctor ever told you that you have hypertension), and self-reported health (SRH) (excellent/very good/good vs bad/very bad/fair/poor). Covariates We controlled for a range of demographic, socioeconomic and behavioural factors, including age (in years), sex, educational attainment (less than high school/high school equivalent in Mexico versus high school/high school equivalent in Mexico); marital status (ever married/married/civil union vs never married/single/widowed/divorced), employment status (employed full vs part-time or unemployed), health insurance coverage, homeownership, subjective socioeconomic status (SES) (low, middle, high SES), current smoking status (never/former vs current smoker) and physical activity (met vs unmet 2008 physical activity recommendations). Models for SRH additionally controlled for self-reported diagnoses of chronic conditions such as cancer, hypertension and diabetes. We included these covariates because they vary systematically across migrant groups and are strongly associated with cardiometabolic risk, making them essential for reducing confounding when estimating associations with health. Adjusting for these characteristics allows us to better isolate the association between migration status and health outcomes. Data analysis To ensure comparability, we cleaned and harmonised variables across the HCHS/SOL and MxFLS datasets. Descriptive analysis revealed varying degrees of missingness in variables in both samples (<0.25% in HCHS/SOL; 0–13.92% in MxFLS; see online supplemental table 1 ). We employed multiple imputation with chained equations separately in each dataset before merging for analysis. Fully conditional specification was used given that categorical and continuous variables were both imputed. Imputation was performed by predictive mean matching for continuous data, logistic regression for binary variables and polytomous regression for other categorical variables. All imputations were performed with the mice package in R. Bivariable associations between migration-nativity groups and key demographic or health variables were assessed using one-way analysis of variance tests (ANOVA) for continuous measures and χ 2 tests for categorical measures. Tests were performed on each imputed dataset, and results were pooled using the moment-based D 1 statistics developed by Rubin 31 and Reiter. 32 Rubin’s p value was reported for all tables as our sample size exceeded Reiter’s small sample adjustment threshold (n>50). The estimates and p values are detailed in table 1 . Table 1. Sociodemographic and health characteristics of Mexicans living in Mexico and the USA by nativity and migration status, HCHS/SOL and MxFLS (n=13 611) MxFLS HCHS/SOL Return migrants in Mexico (n=276) Non-migrants in Mexico (n=7295) Foreign-born Mexicans in the USA (n=5002) US-born Mexicans in the USA (n=1038) Variable Mean (SD)/% Mean (SD)/% P value Age (years) 35.78 (12.42) 40.91 (12.39) 39.35 (11.36) 29.58 (13.65) <0.001 Female 50.8 72.1 54.7 47 <0.001 Education <0.001 <High school 79 72.9 40.6 17.9 High school/GED or more 21 27.1 59.4 82.1 Marital status: <0.001 Ever married/married 71.7 74.8 67.8 33.6 Employed 62.3 54.7 60.6 53.3 <0.001 Any health insurance 47.9 62.8 34.6 58.9 <0.001 Home ownership 76.5 80.9 31.4 44.4 <0.001 SES ladder—ordinal <0.001 Low SES 49.4 49 27.3 22.7 Middle SES 43 41.3 48.5 48 High SES 7.7 9.6 24.2 29.3 Physical activity (MVPA/week) <0.001 Inactive (0 min/week) 77.7 84 17.2 15.8 Insufficient Active (0–150/week) 8.6 4.5 49 50.7 Met guidelines (≥150/week) 13.6 11.5 33.8 33.5 Current smoker 17.6 10.9 17.4 20.9 <0.001 Anthropometric measures BMI (kg/m 2 ) 28.40 (5.35) 28.62 (5.56) 29.06 (5.62) 29.63 (7.47) 0.01 Obesity (BMI criteria) 74.2 74.3 78.8 72.5 0.01 Elevated waist-hip ratio 69.9 72.7 80.2 73.3 <0.001 Hypertension (criteria) 44.7 47.5 22.6 21.1 <0.001 Mean arterial pressure 105.64 (15.06) 106.83 (16.27) 100.75 (13.62) 99.16 (12.52) <0.001 Self-reported health <0.001 Very good or good 55.4 48 78.3 81.1 Regular, bad or very bad 44.6 52 21.7 18.9 Self-reported health conditions Self-reported diabetes 6.4 8.6 8.9 5.9 0.03 Self-reported hypertension 9.1 12.3 17.3 16.5 <0.001 Self-reported CVD event 1.6 1.9 4.8 4.4 <0.001 Open in a new tab This table presents the descriptive analysis results using the multiple-imputed data. Samples from the HCHC/SOL and MxFLS studies were pooled, and all variables were cleaned and harmonised. Multiple imputation using chained equations was employed to impute missing values. Migration-nativity status was imputed for 936 observations. Continuous outcomes were analysed using ANOVA tests, while categorical outcomes were assessed using χ 2 tests. To account for the survey design, survey weights were incorporated in all tests. Final estimates were pooled using Rubin’s rules 31 to ensure accurate inferences from the imputed datasets. ANOVA, analysis of variance; BMI, body mass index; CVD, cardiovascular disease; GED, General Educational Development,; HCHS/SOL, Hispanic Community Health Study/Study of Latinos; MxFLS, Mexican Family Life Survey; SES, socioeconomic status. We next conducted multivariable logistic regression models to examine the association between migration-nativity status and health outcomes, while adjusting for covariates. For each outcome, we estimated (a) a minimally adjusted model including only age and sex, and (b) a fully adjusted model including demographic, socioeconomic and behavioural characteristics ( online supplemental table 1 ). Age and sex are essential demographic confounders that differ across migrant groups and are associated with cardiometabolic health. The fully adjusted models incorporate additional demographic, socioeconomic and behavioural factors that also vary systematically by migration–nativity status and are known predictors of cardiometabolic outcomes. However, some of these variables, particularly socioeconomic position, smoking and physical activity, can plausibly lie on the causal pathway through which migration affects health. For this reason, presenting both minimally adjusted and fully adjusted models allows us to evaluate how these factors shape the observed associations and potentially bias estimates. Two sets of models were estimated: Comparison to non-migrants: outcome i = β 0 + β 1 return i + β 2 usborn i + β 3 mxinus i + covars i ,where return i indicates return migration, usborn i indicates US-born Mexican Americans and mxinus i indicates Mexican-born immigrants in the USA. The reference group in this model was Mexican-born non-migrants ( table 2 ). Table 2. Association of US–Mexico migration and nativity with cardiovascular disease risk factors and outcomes, HCHS/SOL and MxFLS (n=13 611) Health outcomes Overweight Elevated waist-hip ratio Hypertension Self-reported hypertension Self-reported health Variables OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Return migrant vs non-migrants 1.23 (0.72 to 1.69) 1.12 (0.91 to 2.22) 1.05 (0.83 to 1.84) 1.09 (0.55 to 1.84) 1.16 (0.93 to 1.99) US-born in USA vs non-migrants 1.83 (1.26 to 2.52) ** 2.87 (2.24 to 4.50) *** 0.49 (0.34 to 0.68) *** 3.21 (1.92 to 4.92) *** 2.46 (1.81 to 3.69) *** Foreign-born in USA vs non-migrants 1.40 (1.07 to 1.86) * 2.34 (1.95 to 3.49) *** 0.35 (0.28 to 0.46) *** 1.85 (1.24 to 2.57) ** 3.79 (3.07 to 5.33) *** Age 1.04 (1.03 to 1.05) *** 1.05 (1.04 to 1.05) *** 1.05 (1.04 to 1.06) *** 1.07 (1.06 to 1.08) *** 0.98 (0.97 to 0.98) *** Female 1.17 (0.95 to 1.47) 0.70 (0.55 to 0.88) ** 0.54 (0.44 to 0.66) *** 1.62 (1.18 to 2.32) ** 0.67 (0.54 to 0.81) Insurance status 0.99 (0.85 to 1.24) 0.98 (0.83 to 1.21) 0.96 (0.82 to 1.14) 1.70 (1.26 to 2.18) 1.06 (0.91 to 1.28) High school graduate 0.77 (0.66 to 0.98) * 0.67 (0.55 to 0.84) ** 0.92 (0.80 to 1.17) 0.99 (0.80 to 1.45) 2.24 (1.84 to 2.67) *** Employed 1.17 (0.97 to 1.45) 0.93 (0.78 to 1.19) 0.90 (0.72 to 1.05) 0.76 (0.59 to 1.01) 1.09 (0.90 to 1.30) Married 1.47 (1.20 to 1.81) *** 1.45 (1.19 to 1.80) ** 0.87 (0.70 to 1.04) 1.24 (0.93 to 1.63) 0.91 (0.75 to 1.11) Homeownership 0.84 (0.70 to 1.08) 1.12 (0.86 to 1.33) 0.98 (0.86 to 1.27) 0.83 (0.63 to 1.21) 1.34 (1.13 to 1.69) Ever smoke 0.89 (0.62 to 1.09) 0.72 (0.49 to 0.87) 0.84 (0.61 to 1.03) 1.08 (0.63 to 1.58) 1.11 (0.88 to 1.51) Physical activity level Medium 1.20 (0.72 to 1.66) 0.86 (0.48 to 1.07) 0.69 (0.47 to 1.02) 1.12 (0.70 to 1.98) 1.03 (0.69 to 1.46) High 0.90 (0.70 to 1.19) 0.74 (0.54 to 0.89) 0.83 (0.73 to 1.17) 1.14 (0.82 to 1.70) 1.41 (1.11 to 1.81) ** Self-reported disease Cancer 0.65 (0.19 to 1.22) Heart disease 0.43 (0.21 to 0.86) * Diabetes 0.38 (0.28 to 0.59) *** Hypertension 0.50 (0.36 to 0.63) *** Open in a new tab This table presents the regression estimates with a categorical variable of migration-nativity status as the main independent variable; Mexican non-migrant is used as the reference group. Samples from the HCHC/SOL and MxFLS studies were pooled, and all variables were cleaned and harmonised. Multiple imputation using chained equations was employed to impute missing values. Multivariate logistic regression models were used to examine the association between migration-nativity status and health outcomes. All models accounted for age, gender and behavioural factors, including current smoking status and physical activity level, as well as socioeconomic factors such as insurance status, high school degree attainment, employment status, marital status and homeownership. Self-reported diseases including cancer, heart disease, diabetes and hypertension were also controlled for when examining the association between migration-nativity status and self-reported health. To account for the survey design, survey weights were incorporated in all tests. Final estimates were pooled using Rubin’s rules 18 to ensure accurate inferences from the imputed datasets. *** p<0.001; ** p<0.01, * p<0.05. HCHS/SOL, Hispanic Community Health Study/Study of Latinos; MxFLS, Mexican Family Life Survey. Years in the USA: outcome i = β 0 + β 1 return i + β 2 usborn i + β 3 yrsus i + covars i ,where yrsus i denotes the number of years living in the USA for Mexican-born immigrants ( online supplemental table 3 ). Models were performed on each imputed dataset; coefficients and SEs were pooled using Rubin’s rule. 31 We also ran additional models to conduct pairwise comparisons between return migrants, US-born Mexican Americans and foreign-born Mexican immigrants directly ( online supplemental table 5 ). Multiple-imputed samples corresponding to each immigration/nativity category were separated, and models were estimated for six pairwise comparisons with the corresponding sample sets: non-migrant versus foreign-born in the USA; US-born versus non-migrant; return migrant versus non-migrant; US-born versus return migrant; return migrant versus foreign-born in the USA; and US-born versus foreign-born in the USA. These models were estimated for each outcome and controlled for sociodemographic and behavioural factors. All models were performed on each imputed dataset and results were pooled using Rubin’s rule. 31 For each outcome, the six p values obtained from the pairwise comparisons were adjusted using the Holm–Bonferroni method to account for multiple comparisons. 33 All analyses incorporated survey weights to account for the complex sampling design of each study. Determination of exempt status was granted by the University of Chicago Biological Sciences/UCMC IRB (IRB20–0186). RESULTS Descriptive statistics and bivariable comparisons Table 1 displays the descriptive statistics and bivariable analysis comparing the nativity-migrant groups across sociodemographic and health variables using the weighted and imputed data (n=13, 486). Compared with all other groups, non-migrants in Mexico were significantly more likely to be women (72% vs 47–55%), had higher rates of homeownership (81% vs 31–71%) and were more likely to be insured (62.8% vs 34–59%). Foreign-born Mexican immigrants in the USA had higher levels of high school (or equivalent) completion than non-migrants and return migrants (59% vs 21%–27%). Compared with foreign-born Mexicans, US-born individuals of Mexican heritage were younger on average (29.58 vs 36–4), had the highest rate of high school completion (82% vs 21–59) and were relatively well insured (58.9% vs 34–47.9%). Migrant groups were comparable on marital status, employment and perceived SES ranking based on the bivariable analysis. Results using complete cases were mostly consistent with the results from the imputed data ( online supplemental table 2 ). In terms of health, all migrant groups had low levels of physical activity, but Mexican immigrants in the USA and US-born individuals of Mexican heritage had higher rates of meeting recommended physical activity guidelines compared with those in Mexico (33% vs 11%–18%). Mexican immigrants in the USA also had slightly higher levels of BMI (29%–30% vs 28%–29%), but lower levels of mean arterial pressure (99–100 vs 106–107) than their counterparts living in Mexico. Groups were comparable on smoking, obesity, elevated waist-to-hip ratio, hypertension and self-reported chronic conditions based on the bivariable analysis. Multivariable associations Table 2 provides full model outputs comparing the health outcomes across nativity-migrant groups, with non-migrants in Mexico as the reference group, while online supplemental table 1 includes the unadjusted model results. Online supplemental table 3 and figure 1 present the association between years in the USA for foreign-born Mexicans in the USA with each outcome. Online supplemental table 4 shows the pairwise-comparison models comparing health outcomes across nativity-migrant groups. Figure 1. Open in a new tab Marginal effects of years of living in the USA as an immigrant on cardiovascular disease risk factors and health outcomes. Overweight Relative to non-migrants in Mexico, both foreign-born Mexican immigrants (OR 1.83, 95% CI 1.26 to 2.52) and US-born individuals of Mexican heritage (OR 1.40, 95% CI 1.07 to 1.86) had higher odds of being overweight after adjusting for demographic, socioeconomic and behavioural characteristics ( table 2 ). Every additional year spent in the USA by foreign-born Mexicans was linked to a 0.3 percentage-point increase in the probability of being overweight (95% CI 0.001 to 0.01) ( figure 1 , online supplemental table 3 ). No significant differences in overweight status were observed between US-born individuals of Mexican heritage, foreign-born Mexican immigrants and return migrants when these three groups were compared with each other ( online supplemental table 2 ). Elevated waist-hip ratio Findings were consistent with overweight status. Foreign-born Mexican immigrants in the USA (OR 2.87, 95% CI 2.24 to 4.50) and US-born individuals of Mexican heritage (OR 2.34, 95% CI 1.95 to 3.49) had higher odds of elevated waist-to-hip ratio relative to non-migrants ( table 2 ). In contrast, return migrants and non-migrants in Mexico did not differ significantly (OR 1.12, 95% CI 0.91 to 2.22) ( table 2 ). Each additional year in the USA among foreign-born Mexican immigrants was associated with a 1%-point increase in the probability of having an elevated waist-to-hip ratio (95% CI 1% to 1%) ( figure 1 , online supplemental table 3 ). Moreover, our pairwise analysis also showed that US-born individuals of Mexican heritage experienced higher odds of elevated waist-to-hip ratio than return migrants in Mexico (OR 2.72). Return migrants experienced lower odds of elevated waist-hip ratio than foreign-born Mexicans in the USA (OR 0.45). US-born individuals of Mexican heritage and foreign-born Mexican immigrants, however, did not experience significantly different odds of elevated waist–hip ratios (OR 1.22) Clinical hypertension The odds of clinical hypertension did not differ between non-migrants and return migrants in Mexico (OR 1.05, 95% CI 0.83 to 1.84). However, foreign-born Mexicans in the USA (OR 0.49, 95% CI 0.34 to 0.68) and US-born individuals of Mexican heritage (OR 0.35, 95% CI 0.28 to 0.46) had lower odds of clinically diagnosed hypertension compared with non-migrants in Mexico. Return migrants showed higher odds of clinically diagnosed hypertension than foreign-born Mexicans (OR 0.47) and US-born individuals of Mexican heritage (OR 2.92), but their hypertension rates were comparable to non-migrants in Mexico. Among foreign-born Mexicans in the USA, each year lived in the country was associated with a 0.1 percentage-point reduction in the probability of hypertension (95% CI 0.1% to 0.1%). Self-reported hypertension After adjustment for covariates, return migrants in Mexico had similar odds of self-reported hypertension compared with non-migrants (OR 1.09, 95% CI 0.55 to 1.84) and to foreign-born Mexicans in the USA (OR 0.57). Foreign-born Mexicans (OR 3.20, 95% CI 1.92 to 4.92) and US-born individuals of Mexican heritage (OR 1.85, 95% CI 1.24 to 2.57) had higher odds of self-reported hypertension than non-migrants. In addition, US-born individuals of Mexican heritage reported higher hypertension odds compared with foreign-born Mexican immigrants (OR 1.72) and return migrants (OR 3.00). Each year lived in the USA was associated with a 0.2 percentage-point increase in the probability of self-reported hypertension among foreign-born Mexican immigrants (95% CI 0.1 to 0.2%). Self-reported health Non-migrants and return migrants in Mexico did not differ significantly (OR 1.16, 95% CI 0.93 to 1.99). However, foreign-born Mexican immigrants (OR 2.46, 95% CI 1.81 to 3.69) and US-born individuals of Mexican heritage (OR 3.79, 95% CI 3.07 to 5.33) reported better health than non-migrants in Mexico. These two US-based groups also had better self-rated health than return migrants, although US-born individuals of Mexican heritage were somewhat less likely than foreign-born Mexican immigrants to report better health (OR 0.65,). For every additional year living in the USA, foreign-born Mexican immigrants experienced a roughly 1 percentage-point increase in the probability of reporting excellent, very good or good health (95% CI 1% to 2%). DISCUSSION We compared cardiovascular disease risk factors and SRH indicators across four Mexican heritage groups—non-migrants in Mexico, return migrants in Mexico, foreign-born Mexican immigrants in the USA and US-born individuals of Mexican heritage—by combining data from the HCHS/SOL and the MxFLS. Overall, these findings (summarised in table 3 ) document systematic associations between migration status, US residency and cardiovascular risk profiles, suggesting that US residence, whether through birth or immigration—is generally associated with health disadvantages for overweight, obesity and self-reported hypertension compared with Mexicans who have never migrated. Return migrants, however, exhibit health outcomes that often align more closely with non-migrants in Mexico. Table 3. Summary of association of USA–Mexico migration and nativity with cardiovascular disease risk factors and outcomes, HCHS/SOL and MXFLS (n=13 611) Health outcomes Contrast Overweight Elevated waist-hip ratio Diagnosed hypertension Self-reported hypertension Self-reported health (excellent/good/very good) Compared with non-migrants in Mexico Return migrants in Mexico Same Same Same Same Same Foreign-born in the USA. Higher Higher Lower Higher Higher US-born in the USA Higher Higher Lower Higher Higher Compared with return Foreign-born in the USA Same Higher Lower Same Higher migrants US-born in the USA Same Higher Lower Higher Higher Compared with foreign-born in the USA US-born in the USA Same Same Same Higher Lower Additional years in the USA Higher Higher Lower Higher Higher Overall health advantage Mexico Mexico USA Mexico USA Open in a new tab This table presents the summary of the pairwise comparison of migration-nativity status and health outcomes. Samples from the HCHC/SOL and MxFLS studies were pooled, and all variables were cleaned and harmonised. Multiple imputation using chained equations was employed to impute missing values. Multivariable logistic regression models were used to examine the association between migration-nativity status and health outcomes. All models accounted for age, gender and behavioural factors, including current smoking status and physical activity level, as well as socioeconomic factors such as insurance status, high school degree attainment, employment status, marital status and homeownership. Self-reported diseases including cancer, heart disease, diabetes and hypertension were also controlled for when examining the association between migration-nativity status and self-reported health. To account for the survey design, survey weights were incorporated in all tests. Final estimates were pooled using Rubin’s rules 31 to ensure accurate inferences from the imputed datasets. P values obtained from the pairwise comparisons were adjusted using the Holm-Bonferroni method to account for multiple comparisons. 33 HCHS/SOL, Hispanic Community Health Study/Study of Latinos; MxFLS, Mexican Family Life Survey. This study contributes to a growing literature pointing to potential shifts in health patterns across Mexico–US migrant groups. In longstanding research, foreign-born Mexican immigrants have had optimal health profiles when compared with US-born Mexican Americans, and in some cases, non-migrating compatriots. Instead, we observe that foreign-born Mexican immigrants and US-born individuals of Mexican heritage exhibit similar levels of overweight, adiposity and hypertension. Importantly, these findings underscore the need to consider migration dynamics and policy, environmental and social conditions in sending and receiving countries that may be associated with these observed health patterns. 34 Foreign-born Mexican immigrants and US-born individuals of Mexican heritage in our US sample experienced the Great Recession in 2008, widening chronic disease and risk factors, and an increasingly exclusionary climate for Mexican immigrants and coethnics. 35 36 While this study cannot establish that these contextual factors caused the observed health patterns, our finding that, on net, foreign-born Mexicans in the USA had worse health than those in Mexico is consistent with the possibility that changing social and economic conditions may be associated with differences in the expression or persistence of immigrant health selection advantages. Although our analysis does not establish causal or mechanistic pathways, we present both the age-adjusted and sex-adjusted models to distinguish overall associations from estimates that account for social and behavioural factors that may function as confounders, mediators or both. Notably, when socioeconomic, demographic and behavioural factors are included, the estimated association between exposure to the US context and adverse health increases for both US-born Mexicans and Mexican immigrants. This pattern is consistent with negative confounding, whereby characteristics patterned by migration status, such as higher education, employment or health-related behaviours, are associated with better health and may partially mask underlying structural health disadvantages in minimally adjusted models. However, several of these covariates may also lie along the causal pathway through which migration experiences shape health and may constitute overcontrol. The fully adjusted models can be interpreted as descriptive contrasts that help clarify how observed health differences are patterned by downstream social and behavioural factors. Notably, Mexican immigrants in the USA had lower levels of hypertension as determined by blood pressure measurements, but higher odds of self-reported hypertension. Diaz and colleagues similarly document that migrants had lower rates of hypertension in their comparison of Mexican non-migrants and migrants in Tijuana. 37 Although we control for health insurance, the USA uses a lower standard for determining high blood pressure than Mexico. 38 39 Mexicans in the USA may have better medically controlled hypertension, which would explain why they have better blood pressure than Mexicans in Mexico. 40 Consistent with this explanation, supplemental analyses within the HCHS/SOL show that among individuals who self-reported hypertension, only 37% met measured blood-pressure criteria at the exam, while the remainder did not; however, once antihypertensive medication use was incorporated into the clinical definition, all self-reported hypertensive individuals were classified as hypertensive, suggesting a substantial role of treatment and blood-pressure control. While medication utilisation is available in the HCHS/SOL, we were unable to ascertain comparable medication use in the MxFLS data to test this directly. In addition, our study contributes to a growing literature on return migration and health. 11 13 41 42 Despite their exposure to the USA, return migrants were comparable to non-migrants in Mexico in all anthropometric and SRH outcomes. Compared with the Mexicans in the USA and US-born individuals of Mexican heritage, return migrants’ health was a more mixed picture. Overweight status was the same, elevated waist-hip ratio was lower and diagnosed hypertension was higher among return migrants than Mexicans in the USA. In contrast, Ulmann and colleagues found a more mixed health profile of return migrants to non-migrants in Mexico in their analysis of return migrants in the Mexican Migration Project. 14 These differences may reflect heterogeneity in migration experiences, including experiences during their US residence, reasons for return and postreturn socioeconomic reintegration. In one study, Mexican return migrants who voluntarily returned had better health than Mexicans who were deportees. 43 While our small sample of return migrants and limited information on return migrants’ migration history precluded us from conducting additional analysis, future studies should explore heterogeneity in health within return migrants. Uniquely, our study allowed us to compare measures of self-reported and anthropometric health where we found opposing trends—Mexicans in the USA had higher levels of self-rated health but worse objective health measures than Mexicans in Mexico. Similarly, foreign-born Mexicans in the USA had lower odds of reporting excellent health than the US-born, despite similar objective health metrics. Many studies have noted potential issues of whether SRH measures are equivalent in English versus Spanish language and USA versus foreign-born participants. 44 – 46 In our analysis, we are unable to adjudicate whether Mexicans in the USA reported better SRH due to true differences in perception or measurement errors. Given that anthropometric health outcomes among Mexicans in the USA are worse (as evidenced by our findings), studies that compare migrant health using SRH require caution and further inspection. Despite the strengths of the study, several limitations must be acknowledged. The MxFLS and HCHS/SOL variables are not perfectly aligned. Though sample weights from each study are incorporated in the analysis, the MxFLS does not provide the complete sampling structure, which may have affected SE estimates. Some potentially informative health measures (eg, total cholesterol) were excluded due to high missingness in the MxFLS, limiting the scope of our comparison. We also lacked migration history variables including age at arrival, years in the USA and documentation status, which would add nuance to our analysis. Similarly, important contextual variables on migrant’s experiences in the USA and the reasons and reintegration of return migrants precluded us from exploring mediating and causal mechanisms and heterogeneity across groups. Previous work has also suggested that early-life socioeconomic conditions, childhood health and psychosocial dimensions of migrant selectivity may differ systematically across migrant groups and influence observed adult health outcomes, which we are unable to account for in the current analysis. Future work should leverage richer data with migration information (eg, the Mexican Migration Project) to address these gaps. Finally, while the age of these data means they do not reflect more recent changes in Mexican migration flows or sociopolitical conditions, they are nonetheless the strongest available binational datasets that collect comparable, validated health metrics across migrant groups in the USA and Mexico. In summary, our findings highlight the complex interplay between migration, nativity and cardiovascular health among Mexican-heritage individuals, underscoring both risks and protective factors associated with US residency and return migration. Future research should further explore how evolving migration patterns, social determinants and health policies on both sides of the border shape long-term health outcomes in this population. Supplementary Material Supplemental Figures NIHMS2161942-supplement-Supplemental_Figures.pdf (25.8KB, pdf) Supplemental Tables NIHMS2161942-supplement-Supplemental_Tables.pdf (111KB, pdf) Additional supplemental material is published online only. To view, please visit the journal online ( https://doi.org/10.1136/jech-2025-225433 ). Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. WHAT IS ALREADY KNOWN ON THIS TOPIC Previous research has shown that migration between the Mexico and the USA influences health outcomes, with Mexican immigrants in the USA historically exhibiting better health than US-born counterparts. However, contemporary shifts in migration and return migration trends may complicate these prevailing relationships. WHAT THIS STUDY ADDS This study provides binational evidence that US residency for both US-born Mexican Americans and foreign-born Mexicans is associated with both health benefits, such as lower hypertension prevalence, and risks, such as higher obesity rates. Return migrants, however, exhibit mixed health outcomes that align more closely with non-migrants in Mexico. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY These findings highlight the need for binational public health strategies that address the long-term cardiovascular risks associated with migration and consider the unique health challenges of return migrants in Mexico. Association between USA–Mexico migration and cardiovascular health in Mexicans: a binational analysis using the Hispanic Community Health Study and Mexican Family Life Survey. Acknowledgements The authors thank Alexa Uribe and Sophie Hare for assistance with data cleaning, Donald Hedeker for valuable advice on the statistical approach, and the staff and participants of HCHS/SOL for their important contributions. Investigators’ website: http://www.cscc.unc.edu/hchs/ Funding The authors have no direct funding to disclose. The Hispanic Community Health Study/Study of Latinos is a collaborative study supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) to the University of North Carolina (HHSN268201300001I/N01-HC-65233), University of Miami (HHSN268201300004I/N01-HC-65234), Albert Einstein College of Medicine (HHSN268201300002I/N01-HC65235), University of Illinois at Chicago (HHSN268201300003I/N01-HC-65236 Northwestern University) and San Diego State University (HHSN268201300005I/N01-HC-65237). The following institutes/centres/offices have contributed to the HCHS/SOL through a transfer of funds to the NHLBI: National Institute on Minority Health and Health Disparities, National Institute on Deafness and Other Communication Disorders, National Institute of Dental and Craniofacial Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Neurological Disorders and Stroke, NIH Institution-Office of Dietary Supplements. 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[ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplemental Figures NIHMS2161942-supplement-Supplemental_Figures.pdf (25.8KB, pdf) Supplemental Tables NIHMS2161942-supplement-Supplemental_Tables.pdf (111KB, pdf) Data Availability Statement Data are available in a public, open access repository. Data may be obtained from a third party and are not publicly available. MxFLS data are publicly available at https://www.ennvih-mxfls.org/english/ . HCHS/SOL data are available from the HCS/SOL Coordinating Center https://sites9.cscc.unc.edu/hchs/ ACTIONS View on publisher site PDF (444.5 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top