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Nutrition, Immigration and Health Determinants are Linked to Verbal Fluency among Anglophone Adults in the Canadian Longitudinal Study on Aging (CLSA)



Later-life cognitive impairment is an important health issue; however, little is known about the condition among diverse groups such as immigrants. This study aims to examine whether the healthy immigrant effect exists for verbal fluency, an indicator of cognitive functioning, among anglophone middle-aged and older adults in Canada.


Using from the baseline data of the Canadian Longitudinal Study on Aging (CLSA), multiple linear regression was employed to compare associations among immigrants (recent and long-term) and Canadian-born residents without dementia for two verbal fluency tests, the Controlled Oral Word Association Test (COWAT) and the Animal Fluency (AF) task. Covariates included socioeconomic, physical health, and dietary intake.


Of 8,574 anglophone participants (85.7% Canada-born, 74.8% aged 45–65 years, 81.8% married, 81.9% with a post-secondary degree), long-term immigrants (settled in Canada >20 years) performed significantly better than Canadian-born residents for the COWAT (42.8 vs 40.9) but not the AF task (22.4 vs 22.4). Results of the multivariable adjusted regression analyses showed that long-term immigrants performed better than Canadian-born peers in both the COWAT (B=1.57, 95% CI: 0.80–2.34) and the AF test (B=0.57, 95% CI: 0.19–0.95), but this advantage was not observed among recent immigrants. Other factors associated with low verbal fluency performance included being single, socioeconomically disadvantaged, having hypertension, excess body fat, and consuming low amounts of pulses/nuts or fruit/vegetables.


Long-term immigrants had higher verbal fluency test scores than their Canadian-born counterparts. Immigration status, social, health and nutritional factors are important considerations for possible intervention and prevention strategies for cognitive impairment.

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Figure 1

Availability of data and material: Data are available from the Canadian Longitudinal Study on Aging ( for researchers who meet the criteria for access to de-identified CLSA data.


  1. 1.

    Statistics Canada. 2017a. Immigrant population in Canada, 2016 Census of Population. [Data file]. Retrieved from

  2. 2.

    Statistics Canada. 2016. 150 years of immigration in Canada. [Data file]. Retrieved from Government of Canada

  3. 3.

    Statistics Canada. 2017b. Census Profile, 2016 Census -Canada. [Data file]. Retrieved from

  4. 4.

    Ng, E. The healthy immigrant effect and mortality rates. Health Reports / Statistics Canada, Canadian Centre for Health Information/ Rapports Sur La Sante / Statistique Canada, Centre Canadien D’information Sur La Sante, 2011;22(4), 25–29.

    Google Scholar 

  5. 5.

    Gee, E. M., Kobayashi, K. M., & Prus, S. G. Examining the healthy immigrant effect in mid- to later life: findings from the Canadian Community Health Survey. Canadian Journal on Aging / La Revue Canadienne Du Vieillissement, 2004;23(5), S61–S69.

    Article  Google Scholar 

  6. 6.

    Vang, Z. M., Sigouin, J., Flenon, A., & Gagnon, A. Are immigrants healthier than native-born Canadians? A systematic review of the healthy immigrant effect in Canada. Ethnicity & Health, 2017;22(3), 209–241.

    Article  Google Scholar 

  7. 7.

    Prince, M., Ali, G.-C., Guerchet, M., Prina, A. M., Albanese, E., & Wu, Y.-T. Recent global trends in the prevalence and incidence of dementia, and survival with dementia. Alzheimer’s Research & Therapy, 2016;8(1), 23.

    Article  Google Scholar 

  8. 8.

    Ienca, M., Shaw, D. M., & Elger, B. Cognitive enhancement for the ageing world: opportunities and challenges. Ageing & Society, 2019;39(10), 2308–2321.

    Article  Google Scholar 

  9. 9.

    Prince, M., Guerchet, M., & Prina, M. The epidemiology and impact of dementia: current state and future trends. Geneva: World Health Organization, 2015

    Google Scholar 

  10. 10.

    Baumgart, M., Snyder, H. M., Carrillo, M. C., Fazio, S., Kim, H., & Johns, H. (2015). Summary of the evidence on modifiable risk factors for cognitive decline and dementia: A population-based perspective. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 2015;11(6),718–726.

    Article  Google Scholar 

  11. 11.

    Deal, J. A., Betz, J., Yaffe, K., Harris, T., Purchase-Helzner, E., Satterfield, S., … Health ABC Study Group. Hearing Impairment and Incident Dementia and Cognitive Decline in Older Adults: The Health ABC Study. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 2017;72(5), 703–709.

    Google Scholar 

  12. 12.

    Tuokko, H., & Smart, C. Neuropsychology of Cognitive Decline: A Developmental Approach to Assessment and Intervention. New York, NY: Guilford Publications, 2018

    Google Scholar 

  13. 13.

    Livingston, G., Sommerlad, A., Orgeta, V., Costafreda, S. G., Huntley, J., Ames, D., & Cooper, C. Dementia prevention, intervention, and care. The Lancet, 2017;390(10113), 2673–2734.

    Article  Google Scholar 

  14. 14.

    Tolea, M. I., Chrisphonte, S., & Galvin, J. E. Sarcopenic obesity and cognitive performance. Clinical interventions in aging, 2018;13, 1111.

    PubMed  PubMed Central  Article  Google Scholar 

  15. 15.

    Chang K, Hsu T, Wu W, Huang K, Han D. Association between sarcopenia and cognitive impairment: A systematic review and meta-analysis. Journal of the American Medical Directors Association, 2016;17(12), 1164.e7–1164.e15.

    Article  Google Scholar 

  16. 16.

    Solfrizzi, V., Custodero, C., Lozupone, M., Imbimbo, B. P., Valiani, V., Agosti, P., … & Guerra, V. Relationships of dietary patterns, foods, and micro-and macronutrients with Alzheimer’s disease and late-life cognitive disorders: a systematic review. Journal of Alzheimer’s Disease, 2017;59(3), 815–849.

    CAS  PubMed  Article  Google Scholar 

  17. 17.

    McDonald, J. T., & Kennedy, S. Is migration to Canada associated with unhealthy weight gain? Overweight and obesity among Canada’s immigrants. Social Science & Medicine, 2005;61(12), 2469–2481.

    Article  Google Scholar 

  18. 18.

    Goel, M. S., McCarthy, E. P., Phillips, R. S., & Wee, C. C. Obesity among US immigrant subgroups by duration of residence. JAMA, 2004;292(23), 2860–2867.

    CAS  PubMed  Article  Google Scholar 

  19. 19.

    Abraido-Lanza, A. F., Chao, M. T., & Florez, K. R. Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox. Social Science and Medicine, 2005;61(6), 1243–1255.

    PubMed  Article  Google Scholar 

  20. 20.

    Lear, S. A., Humphries, K. H., Hage-Moussa, S., Chockalingam, A., & Mancini, G. J. Immigration presents a potential increased risk for atherosclerosis. Atherosclerosis, 2009;205(2), 584–589.

    CAS  PubMed  Article  Google Scholar 

  21. 21.

    Davison, K.M. & Gondara, L. A comparison of mental health, food insecurity, and diet quality indicators between foreign-born immigrants of Canada and native-born Canadians. Journal of Hunger & Environmental Nutrition, DOI:

  22. 22.

    Johnson, C. S., & Garcia, A. C. Dietary and activity profiles of selected immigrant older adults in Canada. Journal of Nutrition for the Elderly, 2003;23(1), 23–39.

    PubMed  Article  Google Scholar 

  23. 23.

    Sanou, D., O’Reilly, E., Ngnie-Teta, I., Batal, M., Mondain, N., Andrew, C., … & Bourgeault, I. L. Acculturation and nutritional health of immigrants in Canada: a scoping review. Journal of Immigrant and Minority Health, 2014;16(1), 24–34.

    PubMed  Article  Google Scholar 

  24. 24.

    Raina, P. S., Wolfson, C., Kirkland, S. A., Griffith, L. E., Oremus, M., Patterson, C,… & Wister, A. The Canadian longitudinal study on aging (CLSA). Canadian Journal on Aging/La Revue canadienne du vieillissement, 2009;28(3), 221–229.

    Article  Google Scholar 

  25. 25.

    Malek-Ahmadi, M., Small, B. J., & Raj, A. The diagnostic value of controlled oral word association test-FAS and category fluency in single-domain amnestic mild cognitive impairment. Dementia and Geriatric Cognitive Disorders, 2011;32(4), 235–240.

    PubMed  PubMed Central  Article  Google Scholar 

  26. 26.

    Arab, L., & Ang, A. A cross sectional study of the association between walnut consumption and cognitive function among adult US populations represented in NHANES. The Journal of Nutrition, Health & Aging, 2015;19(3), 284–290.

    CAS  Article  Google Scholar 

  27. 27.

    Andresen, E. M., Malmgren, J. A., Carter, W. B., & Patrick, D. L. Screening for depression in well older adults: Evaluation of a short form of the CES-D. American Journal of Preventive Medicine, 1994;10(2), 77–84.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Spreen, O., & Benton, A. L. Neurosensory Center Comprehensive Examination for Aphasia. Neuropsychological Laboratory. Retrieved from

  29. 29.

    Crossley, M., D’Arcy, C., & Rawson, N. S. Letter and category fluency in community-dwelling Canadian seniors: a comparison of normal participants to those with dementia of the Alzheimer or vascular type. Journal of Clinical and Experimental Neuropsychology, 1997;19(1), 52–62.

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Tierney, M. C., Yao, C., Kiss, A., & McDowell, I. Neuropsychological tests accurately predict incident Alzheimer disease after 5 and 10 years. Neurology, 2005;64(11), 1853–1859.

    PubMed  Article  Google Scholar 

  31. 31.

    Gourovitch, M. L., Kirkby, B. S., Goldberg, T. E., Weinberger, D. R., Gold, J. M., Esposito, G., … & Berman, K. F. (A comparison of rCBF patterns during letter and semantic fluency. Neuropsychology, 2000;14(3), 353.

    CAS  PubMed  Article  Google Scholar 

  32. 32.

    Schmidt, C. S., Schumacher, L. V., Römer, P., Leonhart, R., Beume, L., Martin, M.,… & Kaller, C. P. Are semantic and phonological fluency based on the same or distinct sets of cognitive processes? Insights from factor analyses in healthy adults and stroke patients. Neuropsychologia, 2017;99, 148–155.

    PubMed  Article  Google Scholar 

  33. 33.

    Tuokko, H., Griffith, L. E., Simard, M., & Taler, V. Cognitive measures in the Canadian longitudinal study on aging. The Clinical Neuropsychologist, 2017;31(1), 233–250.

    PubMed  Article  Google Scholar 

  34. 34.

    Strauss, E., Sherman, E. M., & Spreen, O. A compendium of neuropsychological tests: Administration, norms, and commentary (3rd ed.). Toronto, ON: Oxford University Press, 2006.

    Google Scholar 

  35. 35.

    Guerra, R. S., Fonseca, I., Pichel, F., Restivo, M. T., & Amaral, T. F. Handgrip strength cutoff values for undernutrition screening at hospital admission. European Journal of Clinical Nutrition, 2014;68(12), 1315.

    CAS  PubMed  Article  Google Scholar 

  36. 36.

    Keller, H. H., Goy, R., & Kane, S. L. Validity and reliability of SCREEN II (Seniors in the community: risk evaluation for eating and nutrition, Version II). European Journal of Clinical Nutrition, 2005;59(10), 1149.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Shatenstein, B., & Payette, H. Evaluation of the relative validity of the Short Diet Questionnaire for assessing usual consumption frequencies of selected nutrients and foods. Nutrients, 2015;7(8), 6362–6374.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  38. 38.

    Davison, K. M., Lung, Y., Lin, S. L., Tong, H., Kobayashi, K. M., & Fuller-Thomson, E. Depression in middle and older adulthood: the role of immigration, nutrition, and other determinants of health in the Canadian longitudinal study on aging. BMC psychiatry, 2019;19(1), 329.

    PubMed  PubMed Central  Article  Google Scholar 

  39. 39.

    Davison, K. M., Lung, Y., Lin, S. L., Tong, H., Kobayashi, K. M., & Fuller-Thomson, E. Psychological distress in older adults linked to immigrant status, dietary intake, and physical health conditions in the Canadian Longitudinal Study on Aging (CLSA). Journal of Affective Disorders, 2020;265, 526–537.

    PubMed  Article  Google Scholar 

  40. 40.

    Hahs-Vaughn, D. L. (A primer for using and understanding weights with national dataseis. The Journal of Experimental Education, 2005;73(3), 221–248.

    Article  Google Scholar 

  41. 41.

    Hill, T. D., Angel, J. L., Balistreri, K. S., & Herrera, A. P. Immigrant status and cognitive functioning in late-life: an examination of gender variations in the healthy immigrant effect. Social Science & Medicine, 2012;75(12), 2076–2084.

    Article  Google Scholar 

  42. 42.

    Graves, A. B., Rajaram, L., Bowen, J. D., McCormick, W. C., McCurry, S. M., & Larson, E. B. (Cognitive decline and Japanese culture in a cohort of older Japanese Americans in King County, WA: the Kame Project. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 1999;54(3), S154–S161.

    CAS  Article  Google Scholar 

  43. 43.

    Fuller-Thomson, E., & Kuh, D. The healthy migrant effect may confound the link between bilingualism and delayed onset of Alzheimer’s disease. Cortex; a Journal Devoted to the Study of the Nervous System and Behavior, 2014;52, 128–130.

    PubMed  Article  Google Scholar 

  44. 44.

    Fuller-Thomson, E., Brennenstuhl, S., Cooper, R., & Kuh, D. An investigation of the healthy migrant hypothesis: Pre-emigration characteristics of those in the British 1946 birth cohort study. Canadian Journal of Public Health/ Revue Canadienne de Sante Publique, 2016;106(8), e502–e508.

    PubMed  Google Scholar 

  45. 45.

    Luo, L., Luk, G., & Bialystok, E. Effect of language proficiency and executive control on verbal fluency performance in bilinguals. Cognition, 2010;114(1), 29–41.

    PubMed  Article  PubMed Central  Google Scholar 

  46. 46.

    Bialystok, E. Bilingualism: The good, the bad, and the indifferent. Bilingualism: Language and Cognition, 2009;12(1), 3–11.

    Article  Google Scholar 

  47. 47.

    Birn, R. M., Kenworthy, L., Case, L., Caravella, R., Jones, T. B., Bandettini, P. A., & Martin, A. Neural systems supporting lexical search guided by letter and semantic category cues: a self-paced overt response fMRI study of verbal fluency. Neurolmage, 2010;49(1), 1099–1107.

    Article  Google Scholar 

  48. 48.

    Kousaie, S., & Phillips, N. Ageing and bilingualism: Absence of a “bilingual advantage” in Stroop interference in a nonimmigrant sample. Quarterly Journal Of Experimental Psychology, 2012;65(2), 356–369. doi:

    Article  Google Scholar 

  49. 49.

    Alladi, S., Bak, T. H., Duggirala, V., Surampudi, B., Shailaja, M., Shukla, A. K.,… & Kaul, S. Bilingualism delays age at onset of dementia, independent of education and immigration status. Neurology, 2013;81(22), 1938–1944.

    PubMed  Article  Google Scholar 

  50. 50.

    Gu, Y., Luchsinger, J. A., Stern, Y., & Scarmeas, N. Mediterranean diet, inflammatory and metabolic biomarkers, and risk of Alzheimer’s disease. Journal of Alzheimer’s Disease, 2010;22(2), 483–492.

    CAS  PubMed  Article  Google Scholar 

  51. 51.

    Corrêa Leite ML, Nicolosi A, Cristina S, Hauser WA, Nappi G. Nutrition and cognitive deficit in the elderly: a population study. European Journal of Clinical Nutrition, 2001;55(12), 1053–8.

    PubMed  Article  Google Scholar 

  52. 52.

    Miller, J. W., Harvey, D. J., Beckett, L. A., Green, R., Farias, S. T., Reed, B. R.,… & DeCarli, C. Vitamin D status and rates of cognitive decline in a multiethnic cohort of older adults. JAMA neurology, 2015;72(11), 1295–1303.

    PubMed  PubMed Central  Article  Google Scholar 

  53. 53.

    Czyż, K., Bodkowski, R., Herbinger, G., & Librowski, T. Omega-3 fatty acids and their role in central nervous system-a review. Current medicinal chemistry, 23(8), 816–831.

  54. 54.

    Stephan, B. C. M., Hunter, S., Harris, D., Llewellyn, D. J., Siervo, M., Matthews, F. E., & Brayne, C. The neuropathological profile of mild cognitive impairment (MCI): a systematic review. Molecular Psychiatry, 2012;17(11), 1056.

    CAS  PubMed  Article  Google Scholar 

  55. 55.

    Valenzuela, M. J., & Sachdev, P. Brain reserve and dementia: a systematic review. Psychological Medicine, 2006;36(4), 441–454.

    PubMed  Article  Google Scholar 

  56. 56.

    Scarmeas, N., & Stern, Y. Cognitive reserve and lifestyle. Journal of Clinical and Experimental Neuropsychology, 2003;25(5), 625–633.

    PubMed  PubMed Central  Article  Google Scholar 

  57. 57.

    Luchsinger, J. A., & Gustafson, D. R. Adiposity and Alzheimer’s disease. Current Opinion in Clinical Nutrition and Metabolic Care, 2009;12(1), 15.

    PubMed  PubMed Central  Article  Google Scholar 

  58. 58.

    Hersi M, Irvine B, Gupta P, Gomes J, Birkett N, Krewski D. Risk factors associated with the onset and progression of Alzheimer’s disease: A systematic review of the evidence. Neurotoxicology 2017;61, 143–187.

    PubMed  Article  Google Scholar 

  59. 59.

    Emmerzaal, T. L., Kiliaan, A. J., & Gustafson, D. R. 2003-2013: a decade of body mass index, Alzheimer’s disease, and dementia. Journal of Alzheimer’s Disease, 2015;43(3), 739–755.

    PubMed  Article  Google Scholar 

  60. 60.

    Solfrizzi, V., Frisardi, V., Capurso, C., D’Tntrono, A., Colacicco, A. M., Vendemiale, G., … & Panza, F. Dietary fatty acids in dementia and predementia syndromes: epidemiological evidence and possible underlying mechanisms. Ageing Research Reviews, 2010; 9(2), 184–199.

    CAS  PubMed  Article  Google Scholar 

  61. 61.

    Stephen, R., Liu, Y., Ngandu, T., Rinne, J. O., Kemppainen, N., Parkkola, R., … & Antikainen, R. Associations of CAIDE Dementia Risk Score with MRI, PIB-PET measures, and cognition. Journal of Alzheimer’s Disease, 2017;59(2), 695–705.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  62. 62.

    Robitaille, A., Piccinin, A. M., Hofer, S. M., Johansson, B., & Muniz Terrera, G. An examination of the heterogeneity in the pattern and association between rates of change in grip strength and global cognition in late life. A multivariate growth mixture modelling approach. Age and Ageing, 2018;47(5), 692–697.

    PubMed  Google Scholar 

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This research was made possible using the data collected by the Canadian Longitudinal Study on Aging (CLSA). Funding for the Canadian Longitudinal Study on Aging (CLSA) is provided by the Government of Canada through the Canadian Institutes of Health Research (CIHR) under grant reference: LSA 9447 and the Canada Foundation for Innovation. This research has been conducted using the CLSA Baseline Comprehensive Dataset version 4.0, under Application ID 170605. The CLSA is led by Drs. Parminder Raina, Christina Wolfson and Susan Kirkland. The development, testing and validation of the Short Diet Questionnaire (SDQ) were carried out among NuAge study participants as part of the CLSA Phase II validation studies, CIHR 2006–2008. The NuAge study was supported by the CIHR, Grant number M0P-62842, and the Quebec Network for Research on Aging, a network funded by the Fonds de Recherche du Québec-Santé. The opinions expressed in this manuscript are the authors’ own and do not reflect the views of the Canadian Longitudinal Study on Aging.The authors declare that they have no competing interests.


Funding: Part of this study was funded through E.F.T.’s Sandra Rotman endowed chair funds and K.M.D.’s Fulbright Canada Research Chair.

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Author Contribution: EFT, SLL, KMD, KK, HT, and VT conceptualized the paper and developed the analysis plan. SLL conducted the analysis and populated the tables/ figures with the direction of EFT. EFT, ZS, SLL, KMD, and VT wrote the first manuscript draft. EFT, SLL, KMD made the final revisions. All team members provided feedback. EFT supervised all components of the project. All authors read and approved the final manuscript.

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Correspondence to Esme Fuller-Thomson.

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Conflict of interest: We have no conflict of interest to declare.

Ethical Standards: The secondary analysis of CLSA data conducted in this paper was approved by the University of Toronto’s Health Sciences Research Ethics Board (protocol number: 34065).

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Disclaimer: The opinions expressed in this manuscript are the author’s own and do not reflect the views of the Canadian Longitudinal Study on Aging.

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Fuller-Thomson, E., Saab, Z., Davison, K.M. et al. Nutrition, Immigration and Health Determinants are Linked to Verbal Fluency among Anglophone Adults in the Canadian Longitudinal Study on Aging (CLSA). J Nutr Health Aging 24, 672–680 (2020).

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Key words

  • Executive function
  • letter fluency
  • semantic fluency
  • Canadian Longitudinal Study on Aging (CLSA)
  • immigrants
  • dietary intake