South Asians are at higher risk than White Caucasians for the development of obesity and obesity-related non-communicable diseases (OR-NCDs), including insulin resistance, the metabolic syndrome, type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD). Rapid nutrition and lifestyle transitions have contributed to acceleration of OR-NCDs in South Asians. Differences in determinants and associated factors for OR-NCDs between South Asians and White Caucasians include body phenotype (high body fat, high truncal, subcutaneous and intra-abdominal fat, and low muscle mass), biochemical parameters (hyperinsulinemia, hyperglycemia, dyslipidemia, hyperleptinemia, low levels of adiponectin and high levels of C-reactive protein), procoagulant state and endothelial dysfunction. Higher prevalence, earlier onset and increased complications of T2DM and CHD are often seen at lower levels of body mass index (BMI) and waist circumference (WC) in South Asians than White Caucasians. In view of these data, lower cut-offs for obesity and abdominal obesity have been advocated for Asian Indians (BMI; overweight >23 to 24.9 kg m(-2) and obesity ≥ 25 kg m(-2); and WC; men ≥ 90 cm and women ≥ 80 cm, respectively). Imbalanced nutrition, physical inactivity, perinatal adverse events and genetic differences are also important contributory factors. Other differences between South Asians and White Caucasians include lower disease awareness and health-seeking behavior, delayed diagnosis due to atypical presentation and language barriers, and religious and sociocultural factors. All these factors result in poorer prevention, less aggressive therapy, poorer response to medical and surgical interventions, and higher morbidity and mortality in the former. Finally, differences in response to pharmacological agents may exist between South Asians and White Caucasians, although these have been inadequately studied. In view of these data, prevention and management strategies should be more aggressive for South Asians for more positive health outcomes. Finally, lower cut-offs of obesity and abdominal obesity for South Asians are expected to help physicians in better and more effective prevention of OR-NCDs.

Obesity-related non-communicable diseases: South Asians vs White Caucasians

AIMS: To study factors such as sex, educational status and place of care, which might influence knowledge and self-management of diabetes, and glycaemic control in a Pakistani moslem diabetic population attending primary care general practices (GP) and secondary care clinics at the Manchester Diabetes Centre (MDC). METHODS: Patients with Type 2 diabetes mellitus took part in a one-to-one semi-structured interview and gave blood for haemoglobin A1c levels. RESULTS: Two hundred and one patients entered the study. Knowledge about diabetic diets was good (average scores 72%), and patients claimed to perform regular glucose measurements (66%), but they were not good at applying their knowledge to problems in daily life. Only 24% knew how to manage persistent hyperglycaemia. Women were worse than men at this (19 vs. 31% (chi2 = 3.8, P = 0.05)), were less likely to understand why glucose levels should be monitored, and had poorer glycaemic control overall (HbA1c 8.8 vs. 8.1%, P = 0.04). Fifty-four patients were completely illiterate. They had similar knowledge scores to readers but were less able to handle problem scenarios. Forty-five of these patients were women, and multiple regression analysis showed they were more likely to have the poorest glycaemic control. No major differences were found between general practitioner and hospital attenders, or between patients with and without known complications, except that hospital attenders were more likely to have complications and poorer control. CONCLUSIONS: Women who cannot read in this population are likely to have poorer glycaemic control and may be finding it more difficult to learn how to apply their knowledge to daily life. This subgroup may need more intensive, culturally appropriate, health education and support.

Pakistani moslems with Type 2 diabetes mellitus: effect of sex, literacy skills, known diabetic complications and place of care on diabetic knowledge, reported self-monitoring management and glycaemic control.

Religious and cultural distance in beliefs about health and illness in women with diabetes mellitus of different origin living in Sweden.

Aim. This paper reports the findings of a study exploring the health and illness beliefs of men with diabetes, who were from different cultural backgrounds and living in Sweden.



Background.  No studies have been reported that have focused on the beliefs about health and illness in men with diabetes mellitus of different ethnic origin. Beliefs may affect self-care and care-seeking behaviour.



Method.  An explorative study design and purposive sampling procedure was used. Focus-group interviews were held with 35 men with diabetes and aged between 39 and 78 years. Fourteen participants were born in Arabic countries, 10 in former Yugoslavia and 11 in Sweden.



Findings.  Important factors for health were the ability to be occupied/employed and economically independent and, especially among Arabs and former Yugoslavians, sexual functioning. Swedes focused on heredity, lifestyle and management of diabetes, while non-Swedes claimed the influence of supernatural factors and emotional stress related to the role of being an immigrant and migratory experiences as factors related to development of diabetes and having a negative influence on health. Swedes and Arabs described health as ‘freedom from disease’ in contrast to many former Yugoslavians who described health as ‘wealth and the most important thing in life’. Knowledge about diabetes was limited among the men studied, but Arabs showed an active information-seeking behaviour compared with Swedes and former Yugoslavians. Non-Swedish respondents, particularly Arabs, had sought help from health care professionals to a greater extent than Swedes, who were more likely to use self-care measures.



Conclusion.  Being occupied/employed and having knowledge about the body and management of diabetes are important for positive health development. There are dissimilarities in beliefs about health and diabetes that influence self-care behaviour and health care seeking. Men's cultural backgrounds and spiritual beliefs need to be considered in diabetes care.

Beliefs about health and diabetes in men of different ethnic origin.

In a multicultural society the frequency of contact with migrant diabetic individuals will increase, as well as the need for knowledge about their beliefs about health and illness, which have rarely been studied. The aim of the present study was to explore beliefs about health and illness among migrant Yugoslavian and Swedish diabetic subjects that might affect their self-reported self-care practices and care-seeking behaviours. The study design was explorative, and a purposive sampling procedure was used. Fifteen females born in Sweden and 13 in former Yugoslavia, aged 33-73 years, with previously known diabetes mellitus were recruited from primary health care centres in southern Sweden. Median time of residence in Sweden was 5 years (range 2-30 years). Eight of the Yugoslavians had their diabetes diagnosed in Sweden. Focus-group interviews including scenarios of common problems related to diabetes mellitus were held. Yugoslavian females in general gave less tangible examples concerning beliefs about health and illness. Yugoslavians were orientated towards feelings related to their migratory experiences, enjoyed life by making deviations from dietary advice and retaining former traditions, and were less inclined towards self-monitoring and preventive foot care. They also expressed a passive role, depending on health care personnel, and discussed the influence of supernatural forces. Swedes expressed themselves in terms of medicine and a healthy lifestyle, took active part in their self-care and let self-monitoring guide their actions. Self-care was mainly practised to restore health when ill in both groups, and when help was needed it was sought in the professional sector (nurse or physician). Yugoslavians expressed higher confidence in physicians and used more natural cure medicine, side by side with biomedicine, while Swedes more frequently used alternative medicine. Demonstrated dissimilarities illustrate that beliefs about health and illness differ between migrant Yugoslavian and Swedish diabetic individuals, and are essential for self-care practice and care-seeking behaviour and must be considered when planning diabetes care.

Beliefs about health and illness essential for self-care practice: a comparison of migrant Yugoslavian and Swedish diabetic females.

Type 2 diabetes is four times more common in people originating from the Indian subcontinent (Asians) than in white English Caucasians. British Asians with diabetes have been shown to have poorer blood glucose control, awareness of diabetes management, and knowledge of complications. This review examines some of the dietary customs that can affect glucose control, problems with communication and diabetic education, and a brief description of health beliefs commonly held by Asian patients that may help the physician understand why some patients appear to show poor compliance with accepted Western medicine. Patients must always be approached as individuals with their own unique needs within the context of their cultural backgrounds.

K. Hawthorne

Papers

Cultural and Religious Influences in Diabetes Care in Great Britain