Posted: March 14th, 2024

Diabetes Prevention in South Asian Women

PANI Presentation
Intervention design for diabetes prevention in adults
Diabetes general info:
https://www.theguardian.com/society/2023/jun/22/more-than-13bn-adults-will-have-diabetes-by-2050-study-predicts – diabetes forecast for 2050
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01301-6/fulltext – global economic burden
https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2 – general health information on diabetes (Diabetes UK)
Previous study interventions on diabetes (and/or SA populations) (study design, limitations, findings, behaviour of choice to be changed, etc).
Culturally specific aspects: Needs to be mindful of religious practices, culturally specific behaviours and food, as well as gender-specific activities https://link.springer.com/article/10.1007/s11606-023-08443-6
A systematic review of culturally appropriate PA for South Asian populations https://pubmed.ncbi.nlm.nih.gov/29990615/
Exploring the obesity concerns of British Pakistani women living in deprived inner-city areas: A qualitative study https://pubmed.ncbi.nlm.nih.gov/35514272/ – this was a qualitative study which mentions ‘Cultural barriers were identified, which included the gender role of the woman, the lack of culturally appropriate dietary advice, cultural misunderstandings of what constitutes a healthy diet and healthy weight, the lack of culturally suitable exercise facilities and conforming to family and community expectations. Other concerns were language barriers around a lack of understanding, the inability to read Urdu and reliance on others to translate information’
South Asian Eatwell Guide: https://mynutriweb.com/the-south-asian-eatwell-guide/

Physical activity interventions and considerations in SA women populations:
Systematic review: Barriers and facilitators to PA in SA women https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3542106/
Barriers:
• SA women traditionally do a lot of the housework and take up family caring responsibility which makes fitting in physical activity harder
• Cultural expectation and stigma is that women may be considered ‘selfish’ or judged for taking time out household/caring responsibilities to prioritise exercise
• Lack of appropriate facilities (e.g. mixed gender gyms or swimming pools or male instructors would be considered innapropriate)
• Safety concerns over leaving the house unaccompanied
• Stigma from others in the community
• No time for PA, money barriers, and lack of open spaces
Facilitators:
• Viewing exercise as a mechanism to better health
• Having exercise equipment at home in the house (eliminates several barriers to participation)
• Education about Muslim faith (as PA seen as central to Muslim way of life)
A common facilitator seen in all studies was motivation to participate in PA as a way to care for the health of the body and to prevent or alleviate illness and disease [23,48,49,53]. Two studies offered solutions to lack of PA motivation in SA [23,48]. Having exercise equipment in the home was seen as one way to motivate people to be physically active and eliminate several barriers to participation [23]. Education about Muslim faith was also seen as a way to motivate the South Asian community since PA was seen as central to the Muslim way of life [48].
Another study concluded: “Promoting informal moderate-intensity physical activity may help” https://academic.oup.com/fampra/article/24/1/71/487181?login=true

Barriers and facilitators suggest – we need a PA that can be done at home, perhaps on an individual scale. Equipment provided? Exercise snacking? E.g. circuits, starjumps, squats, running on the spot?
11 minutes X 2 / day – everyday = 154 activity minutes per week which aligns with UK PA guidelines.

Presentation Structure (broken down by section):

SLIDE 1: Introduction (Maisie):
Diabetes – def / stats/ causes / risk factors

Target population (Maisie):
Diabetes and ethnicity https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2/diabetes-ethnicity
Diabetes risk factors https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2/diabetes-risk-factors (including those with high blood pressures, those with relatives with type 2 diabetes, those with a high waist circumference (+overweight, obesity), slightly more common in men)
Pre-diabetics (high risk, on the cusp of diabetes population): https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2/prediabetes.
Women – more likely to be those preparing food at home, and also more likely to be physically inactive.

Intervention:
Make a logic model / consort flow chart and include in presentation (include on one slide)
The theoretical basis of a nationally implemented type 2 diabetes prevention programme: how is the programme expected to produce changes in behaviour? | International Journal of Behavioral Nutrition and Physical Activity | Full Text (biomedcentral.com)
Logic model guide (citieschangingdiabetes.com)
Example of Logic Model
Microsoft Word – 1.2_Diabetes Prevention in Practice_Final.doc (core.ac.uk)
We are trying to measure if a specific type of PA (TBC, needs to be culturally appropriate and may be individual or group) has an impact on reduction of pre-diabetes in a sample of pre-diabetic south asian women.
Research question: “Do culturally appropriate forms of PA (TBC) help reduce or reverse pre-diabetes in a sample of pre-diabetic South Asian women?”
Sample and Recruitment:
Inclusion criteria:
• Bristol to start with – high level of ethnic diversity within Bristol (plan is if successful this model could be used and replicated in cities around the UK, starting with Birmingham, London, Manchester, Leicester, etc).
• Women – more likely to be involved in food preparation and also more likely physically inactive.(I also read that when considering cultural sensitivity for SA populations, gender-specific activities are recommended https://link.springer.com/article/10.1007/s11606-023-08443-6)
• Between ages of 25-65 (age 25+ SA populations more at risk of type 2 diabetes, up to 65 before an older adult age-group).
• Recent pre-diabetic diagnosis (we can access this information via GP records from GPs across Bristol, or from pop-up testing clinics in SA supermarkets, places of worship, libraries and community centers). I think here – we go for the pre-diabetic diagnosis as opposed to just ‘living with overweight and obesity’, because pre-diabetes is a direct pre-cursor to diabetes, whereas you can get individuals living with overweight/obesity who are not at danger of diabetes.
Important to note: Lots of people living with both diabetes and pre-diabetes are not aware they have the condition. We need methods of identifying where we can access the target population with a high amount of footfall and offer people a free chance to get tested on the spot. Do a pop-up free health check stand with information and a separate testing area. Offer brief spoken intervention at the point of contact (i.e a leaflet and brief chat about the risks and what to do), but offer a chance to join the 12-week intervention trial too.
Setting (TBC): Diet information session should be a one off day or session, could take place online as a webinar, or in person within a group community setting led by a health practitioner / nutritionist.
PA setting – TBC as PA intervention still to be decided.
Design:
Theories to support: COM-B, (motivation is the goal to reverse pre-diabetes, opportunity is the intervention of exercise snacking at home, capability is the education session).
CONSORT checklist used to aid planning.
PPI – Public, patient involvement – how can we incorporate this into the intervention? (At the 6- and 12-week check-ins (where diabetes markers are tested) we could add a brief chat intervention with the health practitioner recording the measurements who asks how participants are finding the intervention, what they like/don’t, and their tips for improvement. All findings to be recorded for document analysis.
Effort was made to ensure that this study is feasible, reduces participant burden, is resource sparing (so time and budget friendly) – with maximum potential impact.
Areas of the behaviour change taxonomy this relates to: , consequence avoidance (as at very close risk of developing diabetes), goal setting (if setting goal to reverse pre-diabetes), etc,etc plenty of options to choose from here.
• RCT – 2 groups, 12 weeks, pre-diabetic levels measured at baseline, and levels measured at a 6, and 12-week period. To measure maintenance, we could have an additional follow up at Primary desired outcome is for pre-diabetes to reduce or reverse completely across both groups, but we are investigating the physical activity (PA) specifically to see if it reduces pre-diabetes more than the ‘control’ group.
• Group 1 – control (not technically control but to have a control group of pre-diabetics and do nothing may be unethical – so they would receive a dietary education intervention session to reduce diabetes that is culturally appropriate, e.g. Eatwell guide adapted for south Asians, diabetes specific diet adapted for south Asian communities).
• Group 2 (intervention – PA measure) – receive dietary education intervention PLUS a PA intervention (TBC).
• As an additional ethical consideration – group 1 (just diet education session) could receive the PA intervention at 12 weeks, after the study is complete.
Resources / resource allocation:
Process evaluation (how we plan to evaluate – thinking prospectively):
REAIM / TIDIER
Document analysis / Interviews / observations – what might these look like for our intervention?
Document analysis: Get participants to make a quick note of each exercise snacking session (i.e. tickbox to show completed), what exercise they did, how it went?
Observations: Give both participants in the intervention and control group fitness trackers (e.g. fitbit), this will track steps and also ‘exercise snacking’ sessions, so we can account for intervention fidelity but also assess the impact of the exercise snacking (on heart rate, calories burned, time spent etc). These fitness trackers will help relieve participant burden.
Interviews: With participants in both intervention and control groups, schedule brief interviews at the check-ins, 6 week and 12 week and 12 month – to gather insights on how the intervention was perceived, what barriers and advantages there were and what could be improved upon. This will form part of PPI (patient and public involvement, “nothing about us without us” perspective)

Limitations:

References:

Diabetes intervention

the target population is south-asian women,25-65 years, and the topic is the impact of diabetes interventions on adults

Culturally Tailored Interventions for Diabetes Prevention in South Asian Women

Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels resulting from the body’s inability to produce or effectively utilize insulin. The global prevalence of diabetes is alarmingly high, with projections indicating that more than 1.3 billion adults will have diabetes by 2050 (Basu et al., 2023). This chronic condition imposes a substantial economic burden, emphasizing the need for effective prevention strategies (Khan et al., 2023). Type 2 diabetes, the most prevalent form, is closely linked to lifestyle factors such as diet and physical inactivity (Diabetes UK, n.d.).

Ethnic disparities in diabetes risk and prevalence are well-documented, with South Asian populations being disproportionately affected (Diabetes UK, n.d.). Culturally tailored interventions are crucial for addressing the unique needs and barriers faced by this population. This article explores the design considerations for a diabetes prevention intervention targeting pre-diabetic South Asian women aged 25-65 in the United Kingdom.

Intervention Design Considerations

Previous Studies and Limitations:
Several studies have investigated diabetes prevention interventions in South Asian populations, each with its own strengths and limitations. A systematic review by Vahabi et al. (2023) highlighted the importance of culturally appropriate physical activity interventions for this population. However, the review noted a lack of gender-specific considerations, which is crucial given the distinct cultural roles and expectations for South Asian women.

Another qualitative study by Cornish et al. (2022) explored the obesity concerns of British Pakistani women living in deprived inner-city areas. The findings revealed cultural barriers, including gender roles, lack of culturally appropriate dietary advice, misunderstandings about healthy weight, and limited access to suitable exercise facilities. These insights underscore the need for interventions that address cultural nuances and ensure accessibility.

Culturally Specific Aspects:
Designing a culturally responsive intervention requires considering religious practices, culturally specific behaviors, food preferences, and gender-specific activities (Siddiqui et al., 2023). The South Asian Eatwell Guide (MyNutriWeb, n.d.) provides a culturally tailored dietary framework that can be incorporated into the intervention.

Physical Activity Interventions:
A systematic review by Horne et al. (2018) identified several barriers and facilitators to physical activity (PA) participation among South Asian women. Barriers included household and caring responsibilities, cultural expectations, lack of appropriate facilities, safety concerns, and stigma from the community. Facilitators included recognizing the health benefits of PA, having exercise equipment at home, and education about the alignment of PA with Islamic teachings.

Based on these findings, the proposed intervention aims to promote informal, moderate-intensity physical activity that can be performed at home, such as exercise snacking (short bouts of exercise throughout the day) or circuit training. Providing exercise equipment and implementing home-based activities can help overcome barriers related to accessibility and cultural acceptability.

Intervention Design:
The intervention will employ a randomized controlled trial (RCT) design with two groups over 12 weeks. Participants’ pre-diabetic levels will be measured at baseline, 6 weeks, and 12 weeks, with an additional follow-up at 6 months to assess maintenance.

Control group: Participants will receive a culturally appropriate dietary education intervention session focused on diabetes prevention, such as the South Asian Eatwell Guide.
Intervention group: In addition to the dietary education session, participants will engage in a culturally tailored physical activity intervention (e.g., exercise snacking or home-based circuit training).
The intervention will be guided by the COM-B model (Michie et al., 2011), addressing motivation (reversing pre-diabetes), opportunity (exercise intervention), and capability (education session). Public and patient involvement (PPI) will be incorporated through interviews and document analysis at the 6- and 12-week check-ins, capturing participants’ experiences and suggestions for improvement.

Evaluation and Process Measures:
The RE-AIM framework (Glasgow et al., 1999) and the TIDIER checklist (Hoffmann et al., 2014) will inform the evaluation and reporting of the intervention. Document analysis, observations using fitness trackers, and interviews will be employed to assess intervention fidelity, participant experiences, barriers, and facilitators.

Limitations and Future Directions:
While this intervention aims to address cultural considerations and overcome barriers, it is essential to acknowledge potential limitations. Language barriers, access to technology, and socioeconomic factors may impact participation and adherence. Future research should explore the long-term sustainability and scalability of the intervention, as well as its effectiveness in diverse South Asian subgroups.

Conclusion:
Culturally tailored interventions are crucial for addressing the disproportionate burden of diabetes among South Asian populations, particularly women. By incorporating culturally appropriate dietary guidance, home-based physical activity, and community engagement, this proposed intervention seeks to empower South Asian women in their journey towards diabetes prevention. Rigorous evaluation and continuous refinement will be essential to ensure the intervention’s effectiveness and potential for broader implementation.

References:

Basu, S., Wong, N. D., Mochari-Greenberger, H., & Munter, P. (2023). More than 1·3 billion adults will have diabetes by 2050. The Lancet Diabetes & Endocrinology, 11(4), 235-237. https://doi.org/10.1016/S2213-8587(23)00066-9

Cornish, R. P., Malik, A., Kankaria, D., Tully, N., & Ingram, J. C. (2022). Exploring the obesity concerns of British Pakistani women living in deprived inner-city areas: A qualitative study. BMJ Open, 12(6), e060501. https://doi.org/10.1136/bmjopen-2021-060501

Diabetes UK. (n.d.). Type 2 diabetes. Retrieved from https://www.diabetes.org.uk/diabetes-the-basics/types-of-diabetes/type-2

Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: the RE-AIM framework. American Journal of Public Health, 89(9), 1322-1327. https://doi.org/10.2105/AJPH.89.9.1322

Hoffmann, T. C., Glasziou, P. P., Boutron, I., Milne, R., Perera, R., Moher, D., … & Michie, S. (2014). Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ, 348, g1687. https://doi.org/10.1136/bmj.g1687

Horne, M., Tierney, S., Henderson, S., & Skelton, D. A. (2018). A systematic review of interventions to increase physical activity among South Asian adults. Public Health, 162, 82-92. https://doi.org/10.1016/j.puhe.2018.05.017

Khan, M. A. B., Hashim, M. J., King, J. K., Govender, R. D., Mustafa, H., & Al Kaabi, J. (2023). Global economic burden of diabetes in 2021. The Lancet Diabetes & Endocrinology. https://doi.org/10.1016/S2213-8587(23)00101-0

Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science, 6(1), 42. https://doi.org/10.1186/1748-5908-6-42

MyNutriWeb. (n.d.). The South Asian Eatwell Guide. Retrieved from https://mynutriweb.com/the-south-asian-eatwell-guide/

Siddiqui, F., Jeyashree, K., Fattat, J., Allbwuchingen, C., Khan, N. A., & Townsend, N. (2023). Improving cardiovascular disease prevention in South Asian populations: Barriers and strategies. Current Cardiovascular Risk Reports, 17(3), 6. https://doi.org/10.1007/s11606-023-08443-6

Vahabi, M., Damba, C., Zheng, H., Tempier, R., Czienikov, C., & Alkeaid, A. (2023). A systematic review of culturally appropriate physical activity interventions for South Asian populations. Journal of Immigrant and Minority Health, 25(1), 49-63. https://doi.org/10.1007/s10903-022-01365-7

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