Minority ethnic groups - understanding diet, weight and type 2 diabetes: scoping review

Executive Summary

The aim of this report was to bring together as much information and research as possible to summarise what we can reasonably say about:

• diet quality, weight status and type 2 diabetes (T2D) prevalence (and susceptibility) in minority ethnic (ME) groups;
• their experiences of accessing type 2 diabetes prevention and treatment services, weight management services (WMS) and programmes (WMP);
• evidence-based solutions to address any inequalities and recommendations arising from research and engagement work.

This is to help inform policy discussion, particularly in relation to "reinvigorating efforts on culturally competent health promotion and disease prevention of diabetes for people from minority ethnic communities", a key commitment in the 2021 Race Equality Immediate Priorities Improvement Plan (Scottish Government, 2021).

A scoping review was conducted rather than a typical more systematic literature review due to the broad scope of the project and limited timescale (3 months). The aim of this scoping review was to give a comprehensive overview of the key themes and the gaps in our knowledge of ME communities and diet quality, weight status and the prevalence of type 2 diabetes.

The work involved three main approaches:

• Mapping of key sources of information and databases; main organisations operating in the field; key Scottish University research centres dealing with health inequalities and academics carrying out research in this area
• Reading of relevant grey and academic literature identified combined with hand searching academic paper reference lists and forward citations to look for other and more recent publications
• Informal conversations with a range of experts and key informants, who helped in developing a better understanding of the key themes and identifying further relevant sources of information.

The following are the key messages that emerged from this work.

In the last years, there have been significant improvements in the collection of data on ethnicity and health. Information on ethnic group at the time of death has been collected since April 2012. The Scottish Health and Ethnicity Linkage Study (SHELS) examined the links between a person's ethnic group and health outcomes in Scotland (Bhopal et al., 2011). The Scottish Diabetes Survey records information on ethnic group and the completeness of this data has risen from 69.6% in 2010 to 81.7% of the registered population with type 1 and type 2 diabetes in the last survey (Scottish Diabetes Survey, 2020).

Despite these improvements, this is an area where important data and information is still lacking. For example, there is no comprehensive data set on diet quality of ME groups, and not much is known about the numbers of people from ME communities accessing and attending weight management programmes. However, important work is under way in this regard and in the future more accurate information will be available.

There is a wide variety of factors affecting ME diet and weight, and as a consequence the higher non-biological risk of developing T2D (Agyemang et al., 2021; Leung & Stanner, 2011). These include: changes in dietary and lifestyle habits after migration; dietary acculturation; accessibility of food; cultural attitudes towards weight and obesity; and stress and discrimination which might lead to risky healthy behaviours.

It has been known for a long time that South Asian communities have a significant higher risk of developing T2D and the onset of the disease occurs much earlier than in white populations (Bhopal et al., 2014). More recent research has shown that also Black African and Caribbean communities in the UK suffer disproportionately from T2D (Goff, 2019). Assessing if people from these ME groups are aware of their higher risk of developing T2D would be helpful to inform awareness campaigns and/or prevention programmes.

Recently, there has been an increased focus on providing culturally appropriate and competent diabetes health education, for example by considering the types of food of traditional diets, giving information in different languages and considering different religious beliefs (NICE, 2011). However, there are also deeper factors and structures of a culture that might act as strong barriers to effective self-management. These for example include cultural preferences for being overweight or different illness beliefs. Qualitative work is helpful to uncover these deep barriers (Moore et al., 2022) and community engagement activities have the potential to improve health outcomes through nudging adherence to dietary and lifestyle advice (Nam et al., 2012).

Although several academic studies have been carried out in the last years to evaluate the effectiveness of culturally appropriate health interventions, this is an area that requires further research, especially in the UK (Goff, 2019). The delivery of the programme should be taken into account, in addition to the design, and issues around cost-effectiveness, sustainability and clinical outcomes should be evaluated (Creamer et al., 2016). Furthermore, it is still not clear 'what' works, for 'whom', and in 'what context' (Davidson et al., 2021). More evaluation studies are needed to assess the effectiveness of different interventions, and further qualitative work and realist evaluations are required to explore the casual mechanisms that lead to the intended positive health outcomes.