The increase in prevalence of type 2 diabetes mellitus is attributed to increased levels of central obesity and the consequent detrimental effect on insulin resistance in individuals; this is despite evidence that both type 2 diabetes and obesity can be prevented^2,3. However, the distribution of prevalence is not uniform to all populations and societies, and there are much higher proportions in certain distinct groups.

Diabetes in South Asians

It has long been known if not entirely understood why, that people from certain ethnic minority communities can have a much greater propensity to develop diabetes than those of other origins¹. Estimates of prevalence show that India has the highest rate of diabetes in the world, Pakistan the seventh highest¹. Generations of people from the South Asian (SA) population in the United Kingdom are up to six times more likely to develop diabetes than those people of Caucasian origin⁴ and are more at risk of developing the long-term complications of diabetes⁴.

Although the reasons why the higher prevalence occurs are not entirely clear, certain factors have been shown to contribute⁵. Much research endeavour has focused on socio-economic factors and health related behaviour⁶, such as increased sedentary lifestyles, increased fat intake, reduced physical activity, low income and poor education⁶.

There is also some data supporting the notion that people from SA populations have more propensity to develop central adiposity and increased fat cell deposition generally⁶. Attention has also been given to genetic reasons for the increased prevalence, with the ‘thrifty’ phenotype theory as the probable cause of genetic predisposition to diabetes; poor foetal growth and poor nutrition in early life can lead to permanent changes in glucose-insulin metabolism⁷.

Religious and cultural influences relating to ‘fatalism’ may be an attributable to the higher prevalence and increased tendency to develop complications of diabetes, although this is cause for debate⁸. Some studies suggest that people from the SA community may choose to ignore health warnings regarding dietary intake due to religious prohibitions and beliefs^9,10. Therefore, they may attribute the reason why diabetes has occurred to a deity and thus outside of their control. Some believe that incidence of the complications of diabetes has occurred due to the cultural restrictions and beliefs surrounding diet and certain physical activities, for example; Bangladeshi originated people were reported to believe that in their cultural perception ‘strong’ foods such as fat, were more nourishing than ‘weaker’ foods such as boiled rice¹¹. It is argued that currently there is a need for further research into the reasons why there is a higher prevalence of diabetes in the SA Community to build on the knowledge base available¹².

Educational strategies

Type 2 diabetes related mortality risk in the SA population is predominantly cardiovascular disease and typified as a ‘cluster’ of major metabolic abnormalities¹³. Known as the ‘metabolic syndrome’^13,14, features include insulin resistance, dyslipidaemia and central obesity.

Therefore, education programmes to prevent and manage type 2 diabetes in the SA population should address these key risk factors, particularly those relating to lifestyle, and deliver these in a way which is culturally sensitive and acceptable whilst avoiding stereotyping¹⁵. Furthermore, any interventions should be framed within cultural beliefs and values and their influences on gen�der roles, family life, and the significance of food and its preparation^16,17. There will be individual interpretations of these, for example managing diabetes during Ramadan¹⁸ or perception of risk related to the development of long-term complications¹⁶. Whilst the Koran may exempt those who are sick from fasting during the holy month of Ramadan, in a review of studies from 13 Muslim countries, Hui et al¹⁸ reported that many patients with both type 1 and type 2 diabetes will choose to fast. Fasting may have physiological outcomes including an increased risk of hypoglycaemia, hyperglycaemia and diabetic-ketoacidosis^18,19. However, for many Muslims there may be a psychological benefit from this period of

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spiritual peace, reflection and self-sacrifice; consequently not being able to fast may have a significant impact on well-being^19,20. Ideally, preparation for Ramadan should begin well in advance and will include identifying those most at risk of developing problems during the fast such as patients experiencing recurrent hypoglycaemia, lack of hypo awareness, recurrent diabetic ketoacidosis, or working in heavy manual jobs¹⁸. Advice and support for self-management should include meal planning, exercise, adjustment of medications, blood glucose monitoring and recognising and managing acute complications^18-20. Some local healthcare organisations may provide an organised programme for supporting patients during Ramadan which includes a toolkit and patient literature²¹.

Nationally there have been a number of diabetes education initiatives specifically targeted at black and minority ethnic (BME) groups such as DESMOND BME (Developing Quality Structured Education in Diabetes)²², and Expert Patient Programmes specific to South Asian Patients with diabetes^15,23. DESMOND BME is delivered at a number of sites across the UK, usually by local diabetes specialist teams with support from an interpreter. Resources are culturally specific, including images which avoid over-reliance on the written word; the content includes exploration of thoughts and feeling around diabetes, encourages self management and self efficacy, with sessions on understanding diabetes, risk factors and complications, monitoring and medication, food choices and physical activity²². Expert Patient Programmes²⁴ provide support for people living with long-term conditions and have been developed in some areas with BME populations to meet specific needs of this group. Often the sessions are led by non-specialist staff from the SA community with support from specialist nurses or dieticians. Key to the success of these programmes is making the local BME community and local healthcare professionals, aware of their existence and ensuring that people with diabetes are referred to the programme and then encouraged and supported to attend.

What is unclear is whether improvements reported to metabolic parameters such as HbA1c, weight and cholesterol and patient reported outcomes, such as diabetes knowledge, are sustained over time as many studies report relatively short term data. We could assume that if it is a still a problem over 10 years later, such interventions are not really working, although some are still reporting and more longitudinal data is emerging such as that from the DESMOND collaborative²². However, it is suggested that a period of improved control, even if not sustained over years, appears to delay complications. Consequently, it is problematic to correlate reported data to improved clinical outcomes or quality of life measurements, although the consensus seems to favour targeted educational interventions over usual care¹⁵. Evidence for the Expert Patient Programme appears to indicate there are a number of personal and economic benefits for improving self-care²⁵; however, it does not identify specific interventions for BME patients. Anecdotally, the author’s experience of a local expert patient programme for South Asian women is positive, with good sustained attendance for the six weeks of the course. Attendees feel they have had the opportunity to meet and share their experiences with others who have similar issues with their diabetes and that they can start to take charge of their diabetes by being able to set achievable goals. Indeed the majority have been able to lose some weight but longitudinal follow up data is not yet available to confirm if this has been sustained.

Providing services

The potential impact on future care in the primary sector has implications on both resource management and the way that care is delivered^26,27. By appropriate and timely interventions for this group, reliance may be reduced on expensive screening programmes²⁸, and by adopting a long term view which incorporates appropriate management strategies, involving structured educational programmes, appropriate support can be delivered²⁹.

Community practitioner’s recognise and respect a person’s autonomy and acknowledge a person’s right to make decisions based on personal values and beliefs. Although there is still debate in the literature as to whether true partnership working exists, and if it does not, it could impede access to appropriate care³⁰.

Johnson et al³¹ suggest that practitioner’s may lack the cultural competence to provide appropriate care; this links to a paternalistic attitude of practitioners who identify stereotypical perceptions of why there is a lack of successful intervention in the SA community, as lack of motivation, and reluctance to attend clinic. However, it has been identified that SA people with diabetes who have a high incidence of social deprivation and poor literacy levels, do have a good knowledge and understanding of healthy lifestyle in relation to their condition³⁰. This suggests that strategies to risk factor management of diabetes by communicating directly with South Asian people with diabetes in their own locality, instead of trying to achieve this in an unfamiliar environment, may be more effective. Zeh²⁹ suggests early identification of themes is required, to help improve systems of education delivery by taking into account; staffing levels, skills required and who can best give advice; and languages used by the client group and what community nurses needs are, such as developing knowledge and awareness of specific cultural issues.

To resolve these issues, Cone et al³² suggest using less written materials and opting for more visual alternatives address misunderstanding and also by using bilingual professionals. This can legitimise the process of autonomy and reducing cost and is perceived to be non-discriminatory³³. The way information is presented can influence how it is received by people from SA origins, and for some people it may need to be delivered in the appropriate language, style and context. It should also be reliable and valid, in that it is from a structured process that can be revisited to clarify issues as required.

This may resolve issues of consent and the reliance on interpreters and standardises what information supplied, thereby reducing issues of bias by others. The Nursing and Midwifery Council (NMC) Code³³, requires nurses to respect the right of the patient when making a choice, if appropriate advice is given in the non-dominant cultural perspective and in a non threatening environment, there may be a greater chance of prompting the individual to make more informed lifestyle decisions²⁶. This could resolve issues of traditional mistrust of professionals from outside the SA culture, and encourage the partnership approach envisioned by current policy guidelines³⁴. It is argued that community nursing services address all the above issues, and maybe what is required is standardisation of these approaches across all services involved in providing care for people with diabetes from the SA community.

Conclusion

South Asian people represent a high risk

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group for developing type 2 diabetes and cardiovascular disease. Strategies for prevention of diabetes and to support people with pre-existing diabetes do need to take account of cultural beliefs but should not assume that South Asian people represent a homogenous group. There are many ethnic groups within the region and within these groups there may be individual interpretations of cultural and religious practices. Successful strategies tend to be those that work with, rather than against, cultural norms³⁵. Furthermore, some groups within the SA population, such as first generation women migrants, may be more isolated from healthcare provision if English is not their first language or they experience cultural barriers towards adopting healthier lifestyles, for example, walking out alone³⁵. However, community healthcare professionals may be well placed to raise awareness of local services for South Asian patients and to support individuals to attend group sessions where they can share experiences and seek mutual support to gain some mastery over their diabetes.

References

1. World Health Organization (WHO). (2010) Country and regional data on diabetes. www.who.int/diabetes/facts/world_figures/en/ (accessed May 2012)
2. The Yorkshire and Humberside Public Health Observatory (YHPHO). (2010) Diabetes Health Intelligence. www.yhpho.org.uk/default.aspx?RID=8467 (accessed May 2012)
3. Tuomilehto J, Lindstorm J, Eriksson JG, et al. (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 3; 344 (18): 1343-50
4. Department of Health (2006) Turning the corner: improving diabetes care. DH, London
5. Rafnsson S, Bhopal R. (2009) Large-scale epidemiological data on cardiovascular diseases and diabetes in migrant and ethnic minority groups in Europe. European Journal of Public Health. 19; 5: 484-491
6. Misra A, Khurana L. (2009) The metabolic syndrome in South Asians: epidemiology, determinants, and prevention. Metabolic Syndrome and Related Disorders. 7; 6: 497-514
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12. Diabetes UK (2009) Diabetes UK pinpoints key research in South Asian people. www.diabetes.org.uk/About_us/News_Landing_Page/Diabetes-UK-pinpoints-key-diabetes-research-in-South-Asianpeople/(accessed May 2012)
13. International Diabetes Federation IDF (2006) The IDF consensus worldwide definition of the metabolic syndrome. www.idf.org/webdata/docs/IDF_Meta_def_final.pdf (accessed May 2012)
14. Barnet AH, Dixon AN, Bellary S, et al. (2006) Type 2 diabetes and cardiovascular risk in the UK south Asian community. Diabetologia, 49: 2234–2246
15. Hawthorne K, Robles Y, Cannings-John R, et al. (2008) Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database of Systematic Reviews. Issue 3
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19. NHS Greater Glasgow and Clyde. (2011) Ramadan and your Diabetic patient: A resource pack for Healthcare Professionals. http://library.nhsggc.org.uk/mediaAssets/My%20HSD/2011-05-31-AMADAN_RESOURCE_PACK.pdf (accessed May 2012)
20. Hassanein MH. (2010) Diabetes and Ramadan: how to achieve a safer fast for Muslims with diabetes British Journal of Diabetes & Vascular Disease. 10: 246
21. The DESMOND (Developing Quality Structured Education in Diabetes) collaborative (2008) A Safer Ramadan: An exciting new initiative to support safer fasting. www.desmond-project.org.uk/342.html (accessed May 2012)
22. Diabetes Education for Self Management Ongoing and Newly Diagnosed (DESMOND). DESMOND BME (South Asian) Newly Diagnosed & Foundation Modules. www.desmond-project.org.uk/bmefoundationnewlydiagnosed-279.html (accessed May 2012)
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Editors Note

Ramandan this year will run from around the 20^th July to around the 19^th August, depending on the expected visibility of the hilal (waxing crescent moon following a new moon). This comprehensive and informative article gives an insight into some of the religious and cultural influences on the SA community and thus, why managing their diabetes at this time can be problematic. It also provides some approaches that community nurses may find helpful to meet these challenges, and the references provide direction to appropriate guidance.

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Diabetes in the South Asian community