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

ME Diet, Weight and T2D: Culturally Competent Health Promotion

Context: The importance of Health Education for T2D

Research has shown that the key to stemming the flow of global diabetes is early prevention, education and awareness.

It is estimated that the cost of diabetes to the NHS is close to £10 billion each year (Public Health England, 2015), meaning that prevention is a priority. Individuals at high risk of T2D, including from ME groups and those who are obese, are encouraged to have a risk assessment at their GP surgery or pharmacy, or using a validated web-based tool such as the one on the Diabetes UK website (NICE, 2012). As weight is the biggest modifiable factor for T2D, preventative programmes usually consist of lifestyle intervention involving weight loss and increasing physical activity.

As argued by Goff (2019), there is a need to promote patient involvement and self-management for the management of long-term conditions, and patient education is a keystone of effective T2D treatment. Yet, as reported by Dallosso et al. (2022), it is estimated that people with T2D spend on average 3 hours per year with a health care professional and manage their own care for the remaining 8,757 hours. Self-management programmes are therefore the cornerstone of diabetes care, and structured diabetes health education is advocated for patient empowerment and self-management, which will result in clinical and patient-centred improvements (Goff, 2019). Health education programmes for T2D usually focus on diet and lifestyle advice, weight management and glycaemic control.

Need for Culturally Competent Health Promotion

While the effectiveness of structured diabetes health education is acknowledged, there is evidence that many education programmes are considerably less successful in people from minority ethnic groups. For example, as previously highlighted, Goff (2019) reports that African American participating in a diabetes prevention programme achieved approximately half of the weight loss than what achieved by white Americans. In Scotland, a higher rate of suboptimal glycaemic control has been found in migrants compared to white Scottish (Negandhi et al., 2013).

This is usually attributed to the lack of cultural competency among healthcare practitioners and the failure of generic diabetes education to account for cultural beliefs and language requirements (Goff, 2019). Access to health-care is similarly hindered by a lack of cultural sensitivity in service provision and under use of clinic-based interpreters and community-based services (Wilson et al., 2012). As reported in Creamer et al. (2016), ME groups often face significant barriers to effective healthcare because of migrant status, low socio-economic status, language and cultural differences and poor health literacy. This results in minority ethnic patients generally having inadequate knowledge of diabetes, poorer glycaemic control and higher diabetes complications.

In their in-depth study on diabetes self-management among UK Black African and Caribbean communities, Moore et al. (2022) observe significant challenges faced by the participants in following advice and guidance to manage their diabetes. Firstly, in relation to language and health literacy. For example, the understanding of a concept like 'BMI' is taken for granted, but some of the participants did not understand and felt uncomfortable in asking for clarification. Then, participants perceived a lack of cultural relevance in dietary advice, as the foods that were familiar to them were not generally discussed in conventionally structured education sessions.

While language discordance is of course one of the first barriers to access material and resources, it is important to take into account the deeper cultural structures which may even act as stronger barriers to healthy self-management practices (Goff, 2019). Moore et al. (2022) observe that in some cultures excess weight is seen as a sign of good health and wealth, and this discouraged participants to follow health advice to lose weight. Furthermore, there is a sense of social responsibility in relation to keeping a traditional diet and eating large portions of cultural food is important in social gatherings. Other themes that emerge in the literature in relation to different cultural beliefs that act as barriers to healthy self-management are different illness beliefs of South Asian communities, with a more fatalistic view of diabetes (Dallosso et al., 2022), and a desire for natural, non-pharmacological therapies in Black and African communities (Goff, 2019). Moreover, there is a need to consider physical activities that resonate with participants, such as walking and dancing, and using gender-specific exercise facilities (Goff, 2019).

In conclusion, cultural barriers to accessing healthcare and inappropriate health education make a significant contribution to ethnic inequalities in diabetes (Goff, 2019). There is a need to develop culturally tailored advice and education programmes that are respectful of, and responsive to, the health beliefs, practices, cultural and linguistic needs of diverse people (Goff, 2019). 'Cultural Appropriateness' is one of the guiding principles of NICE (2011)'s recommendations and refers to interventions that take into account people's first language, literacy skills, cultural and religious beliefs. It is fundamental to understand the target community, use messages that resonate with them and take into account different cultural and religious beliefs, for example by separating physical activity sessions for women and men; considering culturally appropriate activities, such as dancing and walking; considering cultural practices about food, hospitality and religious events; teaching/counselling about dietary change by modifying ethnic foods and recipes (Nam et al., 2012; NICE, 2011).

Culturally Competent Health Promotion

This section provides some recommendations and solutions that have been put forward and implemented to provide culturally competent and appropriate health promotion and education, in order to overcome the barriers outlined above.

Language and Health Literacy

It is recommended that health education is delivered in the language preferred by the participants, including all informative material (NICE, 2011). For example, My Diabetes, My Way is NHS Scotland's interactive diabetes website to help support people who have diabetes and their family and friends. In the section 'My Languages', there are diabetes resources in several languages, including Arabic, Bengali, French, Punjabi and Gujarati. Something that could be improved here is to use multicultural images (e.g. photos of people from different origins), so that people can identify with what they see, rather than perceiving that 'it's not for them', as emerges in some conversations with experts.

The delivery of health education in different languages is done by using interpreters, involving staff that can speak the languages used by the community, including link workers, and/or training lay educators to provide the education. Something that is observed in this regard is that when interpreters are involved, more time is needed for the delivery of the education programme (Dallosso et al., 2022).

Experts argue that involving link workers is the most powerful and effective way for engaging with a community because they are 'more than interpreters'. They understand the culture and act as a bridge towards that community, building strong relationships.

Furthermore, the information has to be provided for varying levels of literacy. This can be done by using images to replace or supplement writing to tailor to low-literacy needs; using less and simple text in leaflets; and using basic street language, even when the programme is delivered in English, to make sure that people understand.

Culturally Appropriate Food

Food is an important part of people's identity and cultural food is cherished among ME communities (CWIN, 2019). As observed by Moore et al. (2022), translating dietary advice to traditional cultural food was a key challenge for their participants from Black African and Caribbean communities. The foods that were familiar to them were not generally discussed in conventionally structured education sessions. They had to go through a process of 'reconciliation' between the healthcare advice and their own perspective, through absorbing guidance, facilitating knowledge with informal conversations with their peers, and filtering what they felt they could and could not do.

This emerges also from community engagement work in Scotland. Third sector organisations have carried out significant work in the field of food among ME groups, generally with the threefold aim of health promotion, fighting food insecurity and promoting community integration. Although not specifically focused on T2D, this work offers important insights, both in terms of challenges faced by ME groups in relation to food, and in terms of successful programmes. For example, BEMIS and Community Food Health (Scotland) (2013) carried out a study to map the voluntary and community organisations on maternal and infant nutrition across ME groups. They conducted interviews and focus groups with women from different ME communities (African, Czech, Polish and Roma) to explore their experiences of seeking and receiving support in relation to maternal and infant nutrition. In line with what was reported above, what emerged is the confusion faced by these women between the advice received by the NHS versus that received from their peers because of differences in diet and eating habits.

This highlights the need to consider a broader range of types of food in health promotion and education, including the types of food that are relevant to traditional diets. There is a need to include ethnic-style cuisine in nutrient datasets to gain a better understanding of the nutritional composition of these foods (Leung & Stanner, 2011).

Edinburgh Community Food have designed a specific 'Eat Well Guide' for African & Caribbean and South Asian communities, taking into account their traditional foods. During the pandemic, they ran a successful programme called 'Be a Healthier Me (BaHMe)', which consisted of sending a 'cultural food box' to ME households and then holding video calls to cook together. The aim of the programme was to offer access to a targeted healthier lifestyles programme to ME groups, through incorporating cultural understanding of food, with the final aim of tackling persistent health inequalities. Food has been used here as 'the hook' to then achieve good health results, such as lose weight and prevent diabetes.

While the examples above are more about healthy eating in general, there are specific resources that have been developed in relation to T2D management and diet advice. For example, Diabetes UK has some resources aimed at the South Asian community - 'Healthy eating for the South Asian community'(2011) and Healthy Eating and Diet Tips for South Asians (2019). These consider culturally appropriate foods and provide guidance for making traditional recipes healthier and reducing portion sizes.

Religious Beliefs and Celebrations

To address the needs of different ethnic groups, another important aspect to consider includes specific religious beliefs and celebrations, as these might affect the dietary habits in general and/or in specific periods of time. For example, during Ramadan Muslim people are obligated to fast every day from sunrise to sunset. This is challenging for people with T2D as it might lead to hypoglycaemic events. Self-management education programmes have therefore been adapted to meet the needs of Muslim people during Ramadan to allow for safer fasting. Daly et al. (2014) provides a rich description of DESMOND culturally adapted programme, 'A Safer Ramadan'.

Community Engagement

Another important aspect of culturally competent and appropriate health promotion and education is to work with and alongside communities, in order to understand their specific needs and improve health promotion. As mentioned before, there might be deep cultural barriers to effective self-management, such as different cultural attitudes to weight or different illness beliefs, that hinder people's engagement with educational programmes and their adherence to medical advice. Community engagement activities can help in overcoming these barriers and improve health outcomes for ME groups (Creamer et al., 2016).

For example, health promotion programmes may be promoted and implemented in faith settings. In Gutierrez et al. (2014), a diabetes prevention program was offered free of charge in Latino communities' churches in New York. Through spiritual messaging and the support of the church community, the program consisted of promoting healthier food and physical activity using goal-setting techniques. Each session included a 1-hour nutrition discussion followed by a 1-hour exercise session. After the 12 weeks of the program, participants reported significant improvements in weight, BMI, fasting glucose, healthy nutrition and physical activity behaviours.

It is recommended to involve community organisations and identify and encourage community champions, such as religious and community leaders, to improve awareness of T2D, promote healthy lifestyle and encourage other members of the communities to be involved (Nam et al., 2012; NICE, 2011). Creamer et al. (2016) suggest to train lay and peer workers from the community, who can be involved in a supportive role in the delivery of health promotion activities in order to provide support to participants, encourage attendance to sessions and ensure adherence to dietary and lifestyle advice.

The Minority Ethnic Health Inclusion Project (MEHIS) in Lothian works with link-workers from different communities. Those involved in the project report that they are 'more than interpreters', as it is not only a matter of speaking different languages, but they are part of the community and know the culture very well. Their programmes are very well attended as on one side, they understand very well the needs of their community, and on the other they work for the NHS, so they are seen as a trustworthy source of information.

Academic research in this field is increasingly adopting participatory methods to co-produce culturally competent and appropriate health interventions. For example, Goff et al. (2021) worked with Black-British adults living with T2D, healthcare professionals and community leaders to co-design a culturally tailored diabetes self-management education and support programme. Firstly, they conducted focus groups and interviews with participants to identity the main barriers to effective health education, from both the professional and patient's point of view. Then, they organised and facilitated an interactive workshop which resulted in some key requirements of health education, such as avoidance of medical settings, appropriately trained and culturally knowledgeable educators, flexible appointments, preference for verbal and visual information and avoidance of technical/medical terms. Lastly, the material for the education was developed by the participants and this included culturally-sensitive videos, information booklets and food photography to provide dietary advice. The authors argue that participatory methods provided an important means to understand the needs of the community, enabling the development of an intervention that was sensitive to the needs of both the service users and the providers.

O'Mara-Eves et al. (2013) define 'community engagement' as involving communities in decision-making and in the planning, design, governance and delivery of services. In their systematic review of community engagement activities, they find that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes across a range of conditions. Co-production is therefore an important means to reduce health inequalities and it is recommended that should be incorporated in public health interventions.

Patient-Practitioner Relationship

It has been observed that a good patient-practitioner relationship has the potential to positively affect health outcomes, as it nudges adherence to recommendations. Factors increasing trust in the healthcare team include to give people time, appreciating that it is difficult to receive a diabetes diagnosis; to relate to them as individual, showing empathy and offering encouragement; and respecting cultural practices and beliefs, tailoring explanations and providing salient relevant advice. (Moore et al., 2022)

It is important to ensure cultural competency of healthcare professionals, meaning that they understand and can address the needs of people from different backgrounds who have different beliefs, values and habits (Goff, 2019). Cultural concordance is not necessary, but healthcare professionals should appreciate cultural diversity and be inclusive in their guidance (Moore et al., 2022).

Patients' knowledge and understanding of their illness is fundamental for the effective self-management of diabetes (Wilson et al., 2012). Health practitioners need to help people understand the short, medium and longer-term consequences of their health-related behaviours, helping them plan changes in terms of easy sustainable steps over time (NICE, 2011). This includes recognising how people's social context affects their behaviours. For example, on the website of Diabetes UK there is a section on 'Eating out with diabetes', which provides guidance for small lifestyle changes when eating out that don't compromise people's social life. This could be expanded to consider a wider range of social gatherings.

Other factors

There are other factors that are important for an effective structured education programme. These do not apply only to ME groups but are important for person-centred care. A combination of both group and individual education sessions is recommended (Creamer et al., 2016), so that people can have peer support but also feel comfortable in asking any questions they need to. It is important to give the opportunity for family members to attend the education programme, so they can provide home-based support (Nam et al., 2012). The programme has to be affordable and accessible, and it has to be delivered in different ways in order to take into account different working patterns and needs, such as childcare. Digital and/or face-to face options can be offered, so people can choose what works best for them.

Evaluation Studies and Open Issues

The evaluation of culturally appropriate health interventions for T2D is an area that has received increasing attention in academic research. In Creamer et al. (2016), the authors carried out the same systematic review as Hawthorne et al. (2010), searching for randomised controlled trials (RCTs) on culturally appropriate health education for any ME group in high-income countries. They found 22 new studies to be added to the original 11 included in first review. They conclude that culturally appropriate health education, defined as health education that has been tailored to the cultural and religious beliefs, linguistic and literacy skills of the community receiving the programme, led to better health outcomes than conventional health education. These include improvements in glycaemic control, diabetes knowledge and self-efficacy. Drawing on the reviewed studies, they provide evidence-based guidance for designing and delivering health education interventions in ME groups (see box below).

1. Use previous research, experience of working with the community and the community themselves to inform the design of the intervention.

2. A combination of both groups and individual education sessions.

3. When designing the intervention, consider participants' socio-economic status, health literacy and any other potential barriers to effective diabetes self-management .

4. Use of lay-workers in a supportive role.

5. Educational group sessions held at weekly intervals, followed by regular telephone calls for reinforcement .

6. Use more personal methods, such as referral through clinics or telephone calls, when recruiting participants.

7. When recruiting, focus on individuals who are currently demonstrating poor diabetes self-management and glycaemic control.

Pilot the interventions to assess their effectiveness and allow participant feedback to be incorporated into the intervention

Adapted from Creamer et al. (2016, p. 180)

As mentioned in section 6.3.4, Gutierrez et al. (2014) report improvements in BMI and weight resulting from the church-based diabetes prevention programme, showing that culturally competent health promotion and community engagement can achieve positive health outcomes also in relation to weight management. Bhopal et al. (2014) conducted a trial in Scotland to asses a weight control and physical activity intervention (PODOSA) in South Asian communities. The description of the cultural adaptation is in Wallia et al. (2013), and mainly consisted of delivering the intervention at home instead of in a clinic, and using dieticians rather than clinic staff. The authors conclude that the results in the intervention group were better than in the control one, with a significant but relatively modest mean weight loss of 1.13 Kg.

Considering the cultural attitudes towards overweight and the significant differences in obesity rates among ME groups highlighted in section 4, this is an area where further academic research is needed. Moore et al. (2022) focus on Black African and Caribbean communities, who in general have positive attitudes towards overweight and obesity. In their qualitative study, they explored the barriers that participants faced in following health practitioners' advice to lose weight and provided some recommendations to improve this, including establishing strong community partnerships between ME groups and healthcare. Evaluation of these approaches would be beneficial.

Ross et al. (2022) evaluated the impact of a pilot digital stream of the diabetes prevention programme 'Healthier You' in England. They concluded that participation in the digital diabetes prevention programme was associated with clinically significant reductions in weight and glycated haemoglobin (HbA1c) at 12 months. They observe that there was no effect of ethnicity on outcomes or age, unlike comparable face-to-face programs that had previously reported worst outcomes for those from ethnic minorities (Valabhji et al., 2020). The digital provision of diabetes education programmes is an important development and it will be something to monitor in future. The authors conclude that digital diabetes education can be effective and wide-reaching and could provide an important component of a population-based approach to addressing type 2 diabetes prevention and self-management.

While the results outlined above are positive and promising, there are some issues that are still not clear and require further investigation. The majority of the studies included in Creamer et al. (2016) were conducted in the US, with only 4 studies carried out in the UK and all focusing on South Asian communities. As highlighted by Goff (2019), very few culturally tailored programmes have been evaluated in the UK and further research is therefore needed in this field.

Furthermore, it is not clear whether improvements in glycaemic control and diabetes knowledge translate into better clinical outcomes. Additional trials of longer duration are needed to investigate clinical outcomes such as the development of diabetes complications, mortality and patient quality of life (Creamer et al., 2016). Moreover, little is known about the cost effectiveness of these programmes (Goff, 2019).

An intervention that is successful in a specific location may not be as successful if replicated somewhere else because of the unique circumstances of every ME community. Guidance for culturally competent and appropriate health promotion are generic and need to be tailored to the specific needs of the target population (Creamer et al., 2016).

Health interventions designed and implemented in a research setting do not usually become embedded within existing health service or community structures and are not sustainable once the research project has come to an end. This means that the achieved positive health outcomes are short lived and the community might feel let down by the lack of on-going commitment (Davidson et al., 2021). Sustainability should therefore be given more attention when designing an intervention, including consideration of how the new intervention might become embedded in established health and/or community services if shown to be successful.

As highlighted by Goff et al. (2019, p. 934), "'culture' is an ever-changing concept [and] this is particularly true among different generations of migrant groups". As discussed previously in this report, there are significant generational differences in lifestyles, dietary habits and religious beliefs among ME communities. This means that something that is effective for a first generation of people who have moved to the UK, might be completely inappropriate for a second or third generation of individuals who were born here. Future work on culturally competent health promotion should take this into account.

It is still not possible to identify which aspects of the culturally appropriate health education programme makes the strongest difference in the health outcomes and for whom (Hawthorne et al., 2010). As argued by Davidson et al. (2021), there is still a limited theoretical understanding of 'how' cultural adaptation works, for 'whom' and in 'what contexts'. It is for this reason that they carried out a realist review to synthesise the literature on culturally adapted T2D prevention interventions for South Asian populations living in Europe or elsewhere as a minority group. Davidson et al. (2021) concluded that the intervention context and broader context strongly affect the effectiveness of the health education programme, meaning that participants' response to the same intervention might vary. The main contextual influences that they identify are:

• situation in which the intervention takes place – for example, as previously mentioned, if the intervention takes place in a research setting, the intervention is not likely to be sustainable when the research project comes to an end;
• heterogeneous populations, consisting of individuals with diverse and intersecting identities;
• broader social context, shaped by traditional cultural beliefs and Western lifestyles;
• socio-cultural stress, such as lack of resources and/or time to access the intervention.

There are therefore different causal mechanisms that lead to the intended health outcomes for some individuals. A more nuanced understanding of what works, for whom, and why is fundamental to advance cultural adaptation and tackle inequalities in health, considering this large and growing population that is extremely heterogeneous.