Research Commentary  March 2017
Mar 1, 2017
This month the research commentary focuses on the launch of the newly published International Benchmarking of Asian Health Outcomes for Waitemata and Auckland DHBs report. Disparities highlighted in the report include a greater risk of CVD in South Asian populations. The review also features four articles which explore the internationally well-known PODOSA (Prevention of Diabetes & Obesity in South Asians) study. PODOSA is a model of best practice for community-based strategies to prevent CVD/diabetes/obesity in South Asian populations. Additionally the commentary also promotes the New Zealand nutrition resources Healthy Eating for South Asian People in English, Gujarati, Hindi and Punjabi.
Commentary provided by Dr Annette Mortensen, eCALD® Project Manager: Research and Development
The following are articles reviewed:
International Benchmarking of Asian Health Outcomes for Waitemata and Auckland DHBs (2017)
This report finds that the overall health outcomes for Asian populations in Waitemata and Auckland DHBs are very good. Both DHBs are national and international leaders in Asian health with Asian peoples experiencing excellent health outcomes and health status compared to the rest of the population and when benchmarked internationally. Asian populations in Auckland enjoy high life expectancy at birth, lower rates of infant mortality and lower mortality from cardiovascular disease, diabetes and cancer. The results are consistent with the healthy migrant effect. However, as the authors report, international evidence suggests that the ‘healthy migrant effect’ wanes among migrants with additional years in the new ‘host’ country and we need to be active in protecting and sustaining the excellent health outcomes that Asian populations experience. Of particular concern are the disparities highlighted in the report including greater risks of CVD in South Asian populations, and the higher risk of diabetes, and child hood obesity.
In this review the prevention of CVD/diabetes/obesity is the primary focus. The healthy migrant effect abates over time as acculturation occurs. Crucially, comparison of data from Mehta’s (2012) Health Needs Assessment of Asian People living in the Auckland Region with the HNAs of Asian health in Counties Manukau DHB (Gala, 2008) and WDHB (Zhou, 2009) and more recently the Counties Manukau Asian Health Plan 2016/17 indicate that this is already occurring. CVD mortality rates are rising among Indians, the burden of diabetes is increasing in Other Asian communities and to a lesser extent, among Chinese people in Auckland; and the proportion of live deliveries complicated by diabetes in pregnancy is higher among women from the three Asian groups (Chinese, Indian and Other Asian) as compared to European/Other women, with the highest proportion among Indian women (Mehta, 2012).
Evidence of the impact of acculturation is shown in comparisons of mortality data and hospitalisation rates for cardiovascular disease among men and women aged 35 to 74 years across the Auckland region (Mehta, 2012). The trends for Asian populations indicate that the burden of CVD morbidity is relatively high among Indians in particular, while CVD mortality although higher than among European/Others, is not as prominent. This is likely to be accounted for by the relatively recent arrival of a large proportion of Asian communities in Auckland, such that the cardiovascular morbidity among Indian and, to a lesser extent, Other Asian populations has not yet had time to be fully reflected in the mortality data of those communities (Mehta, 2012, p. 29). Further evidence is indicated in Scragg’s (2016) study of Asian Health in Aotearoa in 2011-2013-Trends since 2002-2003 and 2006-2007 which shows that the prevalence of being on treatment for diabetes increased 5 to 6 fold in South Asian and Pacific, three-fold in Maori and two-fold in Other Asian populations over the four year period.
International studies of diabetes prevention in comparable South Asian communities provide some answers to the question of how to maintain good health in migrants from South Asian backgrounds. While research has shown that maintaining a healthy weight and being physically active can prevent or delay the onset of type 2 diabetes in people at high risk of developing the disease, there are no New Zealand studies and few international studies that demonstrate the effect of lifestyle interventions in South Asian populations in Western societies.
New Zealand researchers, clinicians and health promoters have much to learn from the experience of the British PODOSA (Prevention of Diabetes and Obesity in South Asians) study. PODOSA is one of the first community-based, randomised lifestyle intervention trials to focus on South Asian populations in Western nations. The results provide valuable evidence for tackling the high levels of diabetes in New Zealand South Asian populations. The articles reviewed here address: culturally adapting lifestyle interventions for South Asian groups; interventions for Indian and Pakistani adults; effective health education messages to promote self-management behaviour change; and the associations between weight change and biomarkers of cardiometabolic risk in South Asians.
Authors: Dr Lifeng Zhou, Samantha Bennett
Reference: Zhou, L. & Bennett, S. (2017). International benchmarking of Asian Health Outcomes for Waitemata and Auckland DHBs. Auckland: Waitemata District Health Board.
Counties Manukau Health (2016). Asian Health Plan 2016-17. Auckland: Counties Manukau Health. Retrieved from: http://www.countiesmanukau.health.nz/assets/About-CMH/Reports-and-planning/Annual-reports-and-plans/2016-17-CM-Health-Asian-Health-Plan.pdf.
Gala, G. (2008). Health Needs Assessment for Asian People in Counties Manukau. Auckland: Counties Manukau District Health Board. Retrieved from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.583.8170&rep=rep1&type=pdf.
Mehta, S. (2012) Health Needs Assessment of Asian People living in the Auckland Region. Auckland: Northern DHB Support Agency. Retrieved from: http://www.countiesmanukau.health.nz/assets/About-CMH/Performance-and-planning/health-status/2012-health-needs-of-asian-people.pdf.
Scragg, R. (2016) study of Asian Health in Aotearoa in 2011-2013-Trends since 2002-2003 and 2006-2007. Retrieved from: http://www.ecald.com/Portals/49/Docs/Publications/Asian%20Health%20Aotearoa%202011.pdf.
Zhou, L. (2009). Health Needs Assessment for Asian People in Waitemata. Auckland: Waitemata District Health Board. Retrieved from: http://www.academia.edu/23356088/Health_Needs_Assessment_for_Asian_People_in_Waitemata.
Design and baseline characteristics of the PODOSA (Prevention of Diabetes & Obesity in South Asians) trial: a cluster, randomised lifestyle intervention in Indian and Pakistani adults with impaired glycaemia at high risk of developing type 2 diabetes
The PODOSA trial involves 156 families in Scotland, comprising 171 South Asian people (mean age 52 years; 64% women) with impaired glycaemia and waist sizes ≥80 cm (women) and ≥90 cm (men), plus 124 family volunteers. Families were randomised to receive either an intensive intervention of 15 dietitian visits providing lifestyle advice, or a light (control) intervention of four visits, during a period of 3 years. The dietitian intervention was family-focused, was based in the home and was culturally adapted from the Finnish Diabetes Prevention Study for people of Indian and Pakistani origin. The primary outcome was weight change over 3 years, the main driver of prevention or delay of the onset of type 2 diabetes. The research dietitians were trained in venepuncture, measurement, delivery of information, behaviour change and in the promotion of physical activity. The contacts with the family were, in effect, the intervention, and in general, each family was seen by the same dietitian for the duration of the trial. The dietitian’s toolkit contained culturally adapted and translated existing resources on diet and physical activity. Pedometers were used for motivation, self-monitoring and for dietitians to assess client’s progress; along with food diaries and weight and waist measures.
The PODOSA trial’s key achievements include: establishing the infrastructure for the trial; recruiting, training and forging a multi-ethnic team to implement the trial; and the involvement and support from within the wider South Asian community, particularly in the recruitment phase. It was encouraging that 95% of eligible recruits consented to participate in the 3-year trial (171/196). In New Zealand, GPs and diabetes specialists with South Asian patients with type 2 diabetes may find referral to dietitians who are culturally and linguistically matched to the patient and their family may result in good outcomes for the patient and their family.
Authors: Douglas A, Bhopal RS, Bhopal R, Forbes JF, Gill JM, McKnight J, Murray G, Sattar N, Sharma A, Wallia S, Wild S, Sheikh A.
Reference: Douglas et al. (2013). BMJ Open, 3 (2), pii:e002226
Culturally adapting the prevention of diabetes and obesity in South Asians (PODOSA) trial
While New Zealand health promoters have a good understanding of the general principles of providing culturally appropriate lifestyle interventions, we have little evidence about which approaches work best. The PODOSA study details how to achieve effective cultural adaptations to lifestyle modifications to prevent diabetes for South Asian populations. This detail is important more generally for healthy lifestyle interventions in ethnically diverse populations in New Zealand. The article highlights the important adaptations that led to high participation rates in South Asian communities in this trial and to their ongoing engagement over 3 years. These were: employing registered dietitians who were bilingual and were aware of the relevant food and physical activity practices of South Asians; staff training on principles for achieving the cross-cultural validity of self-report data; and developing an adapted dietitians’ toolkit with translated health promotion resources in English, Urdu, Hindi and Gurmukhi (written Punjabi). The authors draw attention to the need to pay attention to conceptual and cultural factors in epidemiological and clinical studies where self-report is used to gather data. This is of relevance to the inclusion of Asian and other ethnically diverse groups in the New Zealand Health Survey amongst other national self-report studies, in particular for non-English speakers. When data collection instruments designed for English speakers are literally translated without testing the translations on community members, measurement errors can result due to: poor translation; inappropriate and insensitive content; and the failure of researchers to make themselves familiar with cultural norms and beliefs of those they are interviewing. As Hunt and Bhopal (2003) say, modifying data collection materials and methods requires participatory research with members of the linguistic communities concerned.
Authors: Wallia S, Bhopal RS, Douglas A, Bhopal R, Sharma A, Hutchison A, Murray G, Gill J, Sattar N, Lawton J, Tuomilehto J, McKnight J, Forbes J, Lean M and Sheikh A.
Reference: Wallia et al. (2014). Culturally adapting the prevention of diabetes and obesity in South Asians (PODOSA) trial. Health Promot Int, 29(4), 768-79.
Associations between weight change and biomarkers of cardiometabolic risk in South Asians: second analyses of the PODOSA trial
Given the elevated cardiometabolic risks among South Asians, it is important to investigate the effect of lifestyle intervention and associated modest weight loss specifically in this ethnic group. The aim of the study was to utilise data from the PODOSA Trial in a planned exploratory analyses to explore the effect of weight loss on the cardiometabolic risk profile over four domains (i.e. lipids, liver function, inflammatory, and metabolic) to address two pre-specified research questions. The first was to determine the effects of the culturally-adapted PODOSA lifestyle intervention on cardiometabolic risk factors using an intention-to-treat analysis. The second explored pre-specified analysis, the association of changes in weight and waist circumference with these risk factors using data for all individuals in this trial (i.e. combining intervention and control groups) as a single cohort study.
The study demonstrated that modest weight decrease in South Asians is associated with improvements in markers of total and ectopic fat as well as insulin resistance and glycaemia in those at risk of diabetes. Future trials with more intensive weight change are needed to extend these findings.
Authors: Paul Welsh, Genevieve Cezard, Jason M.R. Gill, Sunita Wallia, Anne Douglas, Aziz Sheikh, Sarah H. Wil2, Jaakko Tuomilehto, John McKnight, Gordon Murray, Raj Bhopal, Mike Lean and Naveed Sattar.
Reference: Welsh et al., (2016). Associations between weight change and biomarkers of cardiometabolic risk in South Asians: second analyses of the PODOSA trial. Int J Obes (Lond), 40 (6), 1005-1011.
Diet and physical activity interventions to prevent or treat obesity in South Asian children and adults: a systematic review and meta-analysis
The metabolic risks associated with obesity are greater for South Asian populations compared with European and other ethnic groups, and levels of obesity in childhood are known to track into adulthood. Tackling obesity in South Asians is therefore a high priority. The rationale for this systematic review is the suggestion that there may be differential effectiveness in diet and physical activity interventions in South Asian populations compared with other ethnicities. The research territory of the present review is an emergent, rather than mature, field of enquiry, but is urgently needed. Thus the aim of this systematic review and meta-analysis was to assess the effectiveness of diet and physical activity interventions to prevent or treat obesity in South Asians living in or outside of South Asia and to describe the characteristics of effective interventions.
Conclusions: Meta-analysis of a limited number of controlled trials found an unclear picture of the effects of interventions on body mass index for South Asian children. Meta-analyses of a limited number of controlled trials showed significant improvement in weight for adults but no significant differences in body mass index and waist circumference. One high quality study in South Asian children found that a school-based physical activity intervention that was delivered within the normal school day which was culturally sensitive, was effective. There is also evidence of culturally appropriate approaches to, and characteristics of, effective interventions in adults which the authors believe could be transferred and used to develop effective interventions in children. There was no evidence that interventions were more or less effective according to whether the intervention was set in South Asia or not, or by socio-economic status.
Authors: Tamara Brown, Sarah Smith, Raj Bhopal, Adetayo Kasim, and Carolyn Summerbell.
Reference: Brown et al. (2015). Diet and physical activity interventions to prevent or treat obesity in South Asian children and adults: a systematic review and meta-analysis. Int J Environ Res Public Health, 12 (1), 566-94.
Related Resource: Healthy Eating for South Asian People Guide available in English, Gujarati, Hindi and Punjabi