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

Ethnic Minorities and Diet

Diet Quality in ME communities: Existing Evidence

This is an area where in general we do not have a large amount of evidence. Despite the increasing number of ME communities in high-income countries, national food consumption surveys do not generally include information about the specific dietary intakes of ethnic minorities and limited research has been carried out to compare the dietary habits of different ME groups (Bennett et al., 2022).

In the UK, no comprehensive data exists on eating habits and nutritional status of ME groups. Although the UK-wide National Diet and Nutrition Survey (NDNS) is designed to be representative of the population, sample sizes of minority ethnic groups are not large enough to allow separate analysis (Leung & Stanner, 2011).

Food Standards Scotland (FSS) is the public sector food body for Scotland. FSS has a statutory objective to improve the extent to which members of the public have diets which are conducive to good health. Part of the FSS remit is dietary surveillance, including monitoring population progress towards the Scottish Dietary Goals. Currently FSS use an online dietary recall tool called Intake24 to gather information on dietary intake, as well as market research data on the retail and out of home food environment from Kantar^[2]. Due to small numbers within national surveys, it has not so far been possible assess dietary intakes in ethnic minority populations.

Intake24 has been included in the Scottish Health Survey in 2018 and 2021, to collect nationally representative dietary intake data from people living in Scotland. FSS have recently commissioned a programme of three further surveys using Intake24 to assess dietary intake in populations of specific policy interest. The first survey is in children aged 2-15 years living in Scotland. Subject to outcomes from Scotland's census 2021 and policy discussions, FSS may direct one of these surveys towards one or more ethnic minority population groups living in Scotland.

Some evidence about the dietary habits of different ME groups comes from the Scottish Health Survey (SHeS) Topic Report (Scottish Government, 2012). The small size of ME groups makes it difficult to obtain representative information from a single year of the national health survey, therefore this report combines data from four consecutive Scottish Health Surveys (2008-2011). This enables in-depth analysis of different health conditions and behaviours, such as those related to diet, by socio-demographic characteristics, including ethnic group and religion. From the analysis carried out in the SHeS Topic Report, we know that:

• White British respondents were least likely to eat 5 portions of fruit and vegetables a day;
• Respondents from White Other, Pakistani, Chinese, Asian Other and Other ethnic groups all had significantly higher consumption of fruit and vegetables than the national average;
• Buddhists, Muslims and Hindus were most likely to meet the 5-a-day recommendation and consumed the highest mean daily portions of fruit and vegetables.

Figures 1 and 2 below show the daily portions of fruit and vegetables by ethnic group and religion in 2008-2011 (Figure 1 and Figure 2). This is quite dated now and more up to date analysis would be welcomed.

In relation to academic research carried out in this field, Bennett et al. (2022) conducted a systematic review on dietary intakes in ME groups globally. They included 49 studies in their review, the majority of which were carried out in North America (31). They concluded that Black groups had the lowest fruit and vegetable intakes and did not meet daily recommendations. Hispanic and Latino groups had higher fruit and vegetable consumption than other ME groups, but a significant proportion did not meet the daily recommendations either. Results for Asian groups were inconsistent, as they varied across different communities and countries.

Bennett et al. (2022) also discuss other food group intakes, finding that red meat intake was low among Asian and Black groups compared to White and Hispanic communities. Fish was the food type with the lowest number of daily servings across all ethnic groups. Asian groups were found to have the highest fish intake, which contributed to the high quality of their diet in general, but their consumption of calcium-rich foods was consistently low.

While fruit and vegetable intake is a key diet quality indicator, it is also important to consider total calorie and nutrients intake and meal patterns when assessing the quality of a diet. Bennett et al. (2022) observe that this is a major limitation of the studies included in their review, as they only focused on food group intake. Drawing on a review of surveys and studies carried out in the UK, Leung & Stanner (2011) reported that Asian groups consistently consume minimal calcium-rich foods, and South Asian children have a low intake of vitamin C. Vitamin D deficiency is observed across all ME groups, especially in winter months. Fat intake is lower for men and significantly lower for women from minority ethnic groups compared with the general population, with lowest intakes among Indian, Chinese and Black African men and Black Caribbean, Bangladeshi and Pakistani. A higher use of salt when cooking and eating is reported in ME groups compared to the general population.

Leung & Stanner (2011) also provided a description of the typical diet of South Asian, African-Caribbean and Chinese groups in the UK, as they are the 3 largest non-White populations:

• The traditional diet of South Asians consists of staples, such as rice and bread, eaten with vegetables, beans and pulses (dhals), meat or seafood in a curry. A wide range of herbs and spices are used for flavouring.
• Regarding African-Caribbean communities, the authors note that there are a number of specific terms that are used to refer to traditional dishes and that may vary between subgroups. The traditional diet includes a range of starchy foods such as rice, plantains, cassava, fufu, yams and potatoes. Various vegetables are also consumed with meat or fish dishes as well as different tropical fruits. Commonly eaten snacks include beef patties, salt fish fritters and fried dumplings.
• As regards to the Chinese diet, noodles or buns are commonly consumed as staples in northern China, while rice is typical for southern China. These dishes are often packed with lots of green, leafy vegetables and mushrooms. Soy milk and other soy products, such as bean curd (tofu) and its derivatives, are commonly used in the Chinese diet.

These are of course generalisations, as the dietary habits of ME groups vary widely and there is also significant heterogeneity within each group, depending on the specific country/region of origin. However, it is helpful to have information about different traditional diets, as will be explained further in Section 6.

To conclude, while comprehensive and accurate data on the eating habits of different ME communities is still lacking, it is important to note that the situation has improved and is set to improve further.

Factors Influencing Diet in ME Communities

It is beyond the scope of this work to review the general factors that influence people's choices in relation to diet. However, a number of interesting issues emerged during this project specifically in relation to the dietary habits of ME communities living in the UK and other high-income countries.

Central and West Integration Network (CWIN)^[3]carried out a community-led research project in 2019 to explore food security among Black and Minority ethnic people in Glasgow (CWIN, 2019). Participants were 56 people from 23 different countries, including people from Iraq, Iran, Pakistan, Sudan, Sri Lanka, Libya, Eritrea, Afghanistan, and other countries. What emerges is the emphasis placed on 'cultural food'. While this concept is not concretely defined, it refers to food typical of people's cultures. It is generally seen as healthy, except when eaten in great quantities if guests are visiting. Participants say that cultural food is sometimes expensive, but it is still considered important to buy it. This suggests that cultural food is cherished and has greater significance than just its nutritional value. This was also a recurring theme in the informal conversations with experts working in the field. Cultural food becomes an important indicator of identity, resulting in some ME groups living in the UK eating more traditional dishes than their family and friends living in the country of origin.

Leung & Stanner (2011) note that there are usually differences in generationsamong the dietary habits of ME groups. Older generations are more likely to follow traditional diets and less likely to change their dietary habits compared with younger generations. They report the results of a qualitative study conducted in Bradford, which found that first-generation British Pakistanis were more reluctant to try any English foods compared with the second generation. The latter perceived English foods as convenient, a way to conform to the mainstream culture and a reflection of independence from their parents. Also women of the first generation were more adventurous in this regard compared with their husbands, mostly because they wanted to share the same experience of consuming English foods with their children (Jamal 1998; cited in Leung & Stanner, 2011).

It has been noted that sometimes older generations try and make traditional food richer and more calorific in order to please children and teenagers by competing with McDonald's and other takeaway food (Davidson et al., 2021). A qualitative study carried out in Glasgow found something similar in relation to the younger generations of ME groups, who felt culturally torn between ideas and attitudes of their parents and those of their Scottish peers. In addition, it was also noted that the longer working hours and frenetic lifestyle of the younger generation also led to irregular dietary habits, which may encourage them to eat more convenience foods (Mullen et al. 2006; cited in Leung & Stanner, 2011).

Considering these differences among generations, it will be important to monitor if the higher consumption of fruit and vegetables in some ME groups compared to the general population in the UK will be retained over time, or if this difference will diminish as the population gets more and more diverse.

While older generations are more likely to keep a traditional diet, it has been observed that there might be a phenomenon of 'dietary acculturation' of ethnic minorities after migration (Leung & Stanner 2011; Satia-Abouta et al., 2002). This is the process by which migrants assimilate the dietary habits of the host country, and it usually entails eating more junk food, therefore adopting a less healthy diet that is higher in energy, fat and salt and lower in fruit and vegetables. Integration can be challenging for immigrants in terms of adapting to new lifestyles, cultures and dietary norms. In their review on T2D among migrants in Europe, Agyemang et al. (2021) consider the changes in dietary behaviours as a post-migration risk factor for developing diabetes among South Asians, as they are not used to this type of food and they are likely to develop the metabolic syndrome.

Beyond these issues of migration, integration and generational differences, there are other broader factors that affect food choices among ME groups in high-income countries. Drawing on Bennett et al. (2022) and Osei-Kwasi et al. (2016)'s systematic reviews, these are:

• Socio-economic status – income is significantly associated with healthier and more diverse food intake, including higher fruit, vegetable and fish consumption, and it is known that some ME groups tend to be poorer than the general population;
• Accessibility of food, including traditional foods availability, shops proximity (more an issue in the US) and food price, which might be a barrier to a healthier diet;
• Cultural identity and religious beliefs, which might forbid to eat some types of foods;
• Food beliefs, including the social role of food and perceptions of healthy food;
• Perceptions of body images, such as preferences for a larger body size, covered in more detail in section 4;
• Gender differences, such as husband's food preferences, that are likely to influence the food consumption of the whole household;
• Lack of time for cooking, which might be a problem for younger people, especially women, who work and have less time to cook.

Some of these factors are personal and depends on individual choices, but others are profoundly shaped by the food environment we live in, such as the types of food that are more expensive/cheaper, and the foods that are more readily available. Furthermore, the majority of these factors do not exclusively influence the dietary behaviours of ME community, but concern the overall population.

To conclude, dietary behaviours are complex, multidimensional and dynamic. They are affected by a broad range of underlying mechanisms and might change over time. Quantitative work is helpful to get a comprehensive picture of diet quality and behaviour patterns in the population to identify problems and design interventions. But qualitative work is also necessary to uncover these deep issues and structures that affect our food choices.