Culturally Targeted Interventions for South Asian Populations: to delay the onset or for improved management of Type 2 Diabetes

This dissertation aims to identify culturally appropriate interventions that will help in delaying the onset or managing T2D among the South Asian population. The research will conduct a systematic review of the different interventions that have been found effective for preventing or managing T2D in the South Asian population.

Running head: DISSERTATION
Culturally Targeted Interventions for South Asian Populations: to delay the onset or for
improved management of Type 2 Diabetes
Name of the Student
Name of the University
Author Note

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Abstract
Diabetes mellitus type 2 is a chronic metabolic disorder, the common symptoms of which are
increased blood glucose due to subsequent lack of insulin and insulin resistance among the
affected individuals. T2D commonly occurs due to obesity and a sedentary lifestyle. This
increases the risk of some individuals to suffer from the condition. A combination of genetic
and lifestyle factors are found responsible for the metabolic disorder and some of these
factors are under control of the people. Presence of inappropriate BMI, poor dietary patterns
and absence of physical exercise greatly contribute to the accumulation of body fat among
people of South Asian descent. A high waist to hip ratio is another marker for the presence
of diabetes. South Asian population have been associated with increased consumption of
sweetened drinks, saturated fat, and refined grains such as, white rice that play an important
role in increasing their risks. Insufficient production of the hormone insulin from the
pancreatic cells also contribute to insulin resistance and marks the inappropriate release of
glucose into the bloodstream. Other mechanisms associated with T2D development are lipid
breakdown, increased glucagon and more water and salt retention. This dissertation is an
attempt to conduct a systematic review for investigating the different culturally appropriate
interventions that have been found effective for preventing or managing T2D in the South
Asian population.
Keywords- diabetes, T2D, dietary, South Asian, dietary, exercise, interventions

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Acknowledgement
I wish to express my deepest gratitude to the dissertation committee chair person
Professor-------, who convincingly and continually conveyed the spirit of research in regards
to this work. Without his continued guidance and help, this research would not have been
successfully accomplished.
I would to acknowledge the help extended by the committee members, Professor ---- and
Professor ----, who helped me engage in an accurate process for searching literature, relevant
to the research topic.
In addition, I would also thank Professor ---, who was imperative in introducing me to the
topic Diabetes, and whose enthusiasm for the same made me consider it an appropriate
subject for the research project. I would also like to thank the University of --- for providing
me the permission to access databases and library resources for the research purpose. I hereby
extend my thanks and gratitude to my family members and friends, without whom this work
would not have been possible.

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Table of Contents
Chapter 1: Introduction..............................................................................................................5
Background............................................................................................................................6
Rationale................................................................................................................................8
Research aim........................................................................................................................11
Research objectives..............................................................................................................11
Problem statement................................................................................................................11
Chapter 2: Literature review....................................................................................................14
Introduction..........................................................................................................................14
Type 2 diabetes (T2D) prevalence among South Asians.....................................................14
Structured exercise interventions.........................................................................................15
Educational interventions.....................................................................................................16
Culturally Competent Interventions (CCI)...........................................................................18
Multi-component interventions............................................................................................19
Diet modifications................................................................................................................20
Primary T2D prevention in South Asians............................................................................20
Chapter 3: Methodology..........................................................................................................28
Introduction..........................................................................................................................28
Method outline.....................................................................................................................29
Research onion.....................................................................................................................30
The research philosophy......................................................................................................31

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Research approach...............................................................................................................32
Research strategy.................................................................................................................33
Time horizon........................................................................................................................33
Data collection and analysis.................................................................................................34
Research design....................................................................................................................34
Research sampling...............................................................................................................35
Data collection.....................................................................................................................36
Chapter 4: Results and Discussion...........................................................................................38
Results......................................................................................................................................38
Waist circumference.............................................................................................................38
HbA1c levels........................................................................................................................39
BMI/weight..........................................................................................................................41
Awareness in the population and perceived barriers............................................................43
Discussion................................................................................................................................44
Chapter 5: Conclusion..............................................................................................................53
References................................................................................................................................58
Appendix..................................................................................................................................74

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Chapter 1: Introduction
Type 2 diabetes (T2D) or diabetes mellitus refers to a chronic metabolic disorder,
primarily characterised by increase in blood sugar, insulin resistance and deficiency in
secretion of insulin. The condition generally occurs due to insufficient secretion of insulin
hormone from the beta cells of the islets of Langerhans. This insulin resistance refers to
inability of all cells for responding adequately to normal insulin levels, which are primarily
found to occur within the liver, muscles and adipose tissue (Chatterjee et al. 2017). Type 2
diabetes has been identified as a major health concern for people of South Asian descent. The
South Asian population has a 6 times increased likelihood of developing T2D, when
compared to Europeans (Gujral et al. 2013). Recent reports suggest that South Asian
individuals comprise of 4% of the entire UK population. However, they account for an
estimated 8% of all diagnosed cases of diabetes (Ethnicity-facts-figures.service.gov.uk 2018).
People belonging to the South Asian origin commonly refer to the specific individuals with
ethnicity from countries namely, Afghanistan, Bhutan, India, Maldives, Myanmar,
Bangladesh, Nepal, Sri Lanka and Pakistan.
However, most commonly while referring to the South Asian population of the UK,
the people are generally restricted to those of Bangladeshi, Indian and Pakistani descent, who
combine and add to the form the largest ethnic minority of the country. Some of the major
factors that have contributed to the increased susceptibility of the South Asian population to
develop the chronic disease encompass modernisation and urbanisation that result in
sedentary lifestyle, high smoking rates among males, high abdominal fat, and more intake of
refined grains such as, rice that is associated with an elevated risk of diabetes. The research
aims to explore the culture-specific interventions that will either delay the onset or help in
management of T2D among the South Asian population.

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Background
Type 2 diabetes is a progressive health condition where the body attains resistance to the
normalised impacts of insulin hormone and gradually loses the capability to secrete adequate
insulin from the pancreatic cells. This condition gets diagnosed when the body fails to
produce adequate insulin levels or the hormone fails to work effectively to lower the blood
glucose levels. The insulin hormone generally suppresses release of glucose in the liver.
However, in case of T2D, when the body has acquired insulin resistance, the liver fails to
trigger the release of glucose into the bloodstream (Birkenfeld and Shulman 2014).
Proportion of insulin resistance in comparison to the dysfunction of the beta cells of islets of
Langerhans is found to differ among individuals, with some people being primarily insulin
resistant. Such people report minor defects in the secretion of insulin (Tangvarasittichai
2015). On the other hand, others having slight insulin resistance primarily proper insulin
secretion. Some of the potentially important mechanisms that are found to be associated with
insulin resistance and subsequent T2D most often include the following:
 An increase in the breakdown of lipid molecules within the adipose or fat cells
 Lack of or increased resistance to incretin (Li et al. 2014)
 High levels of glucagon in the blood
 An increased retention of water and salt by the kidneys
 Inappropriate metabolism regulation by the central nervous system.
Incretins are defined as group of metabolic hormones, which play an essential role in
stimulating a reduction in the levels of blood glucose. Incretin hormones are generally
released following consumption of a meal and are imperative for amplifying secretion of
insulin from the pancreatic beta cells, based on a glucose-dependent mechanism (Egan et al.
2014). However, all person with insulin resistance do not develop diabetes. This can be
attributed to the fact that T2D also requires an impairment in the secretion of insulin by the

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pancreatic beta cells. An estimated 366 million people are found to be currently affected with
T2D, on a global basis (Whiting et al. 2011). This statistical data encompasses people of
almost all developed countries, in addition to those living in the rural and urban regions.
South Asian population are perceived to be at an increased risk for incidence of T2D.
Although the overall prevalence of the health condition among South Asians is considerably
high and ever increasing, there exists heterogeneity among the countries, in terms of the
national prevalence of T2D. This can be attributed to the variations in patterns of lifestyle
factors, socioeconomic development, and existing differences between diagnosed and
undiagnosed cases of T2D in the South Asian countries. Prevalence of T2D has been found
high among the migrant South Asian populations (Tillin et al. 2015).
This has been established by several studies that have identified increased prevalence of
T2D among migrant South Asians, when compared to other ethnic groups. In other words,
increased rates of T2D incidence in South Asians population, across the world is likely
indicative of the major underlying biological factors among South Asians, which in turn are
coupled with several changes in their dietary patterns, activities, and other lifestyle behaviors
(Bajaj et al. 2013). Owing to the contribution of insulin resistance to onset of T2D, South
Asians have been found to display more insulin resistance, when compared to their Caucasian
counterparts, at younger ages and also report low levels of BMI. Some of this elevated
propensity for insulin resistance among the South Asians can be attributed to increase in the
deposition of visceral fat in the target population, when compared to Caucasians (Misra et al.
2008). Although in increase in age is found to elevate the risk for T2D in all populations,
South Asians generally develop the chronic disease at a younger age (Nightingale et al.
2010). One particular study reported that the mean age of T2D diagnosis was found to be the
lowest among South Asians (49 years). This was followed by the Chinese (55 years), the
Blacks (57 years), and the Whites (58 years, who were living in Canada (Chiu et al. 2011).

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Furthermore, South Asians also report more amount of abdominal and visceral fat, when
compared to Caucasians. In addition, South Asians report low BMI, which increases their risk
of developing diabetes, and subsequent cardiovascular disorders (de Wilde et al. 2018).
Physical inactivity has been identified as a major risk factor for T2D and cardiovascular
disease, and its immediate metabolic impacts are generally apparent from childhood (Kodama
et al. 2013). Owing to the fact that South Asians appear less physically active than Caucasian
counterparts, they are more susceptible to T2D. Increased intakes of rice, refined grains, trans
fats and saturated fat, have been found to play a crucial role in increasing the risks of diabetes
in all populations (Owen et al. 2009). In contrast, foods with low glycemic index and high
content of dietary fiber have been shown to reduce the associated risks. Typical South Asian
meals have greater caloric intake and more percentage of carbohydrates, when compared to
European meals (Mohan et al. 2009). In addition, South Asian individuals, having migrated
to Western countries, blending between cultures or acculturation has created an impact on
increasing the consumption of fat rich foods, such , colas and potato chips and colas, and
reducing consumption of fiber, thereby making the South Asians more prone to development
of T2D (Lesser, Gasevic and Lear 2014). Thus, it can be stated that there is a need to identify
appropriate interventions that will address the specific needs of the culture and help in
managing the prevailing condition of diabetes.
Rationale
Some studies illustrate the fact that pathogenesis of type 2 diabetes most often begin s
with insulin resistance that is induced by adipose tissue, followed by subsequent decrease in
the function of pancreatic beta cells (Guilherme et al. 2008). Other studies elaborate on the
role of earlier impairment in the function of beta cells, suggesting it to be the primary factor
that predisposes individuals to the condition (Shu et al. 2009). Several variances exist in the
propensity of developing insulin resistance, in addition to the compensatory ability

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demonstrated by beta cells that explain the existing ethnic differences in susceptibility to
T2D. Strong evidences suggest the presence of more insulin resistance among the South
Asians, at a younger age, with comparative BMI levels (Bhardwaj et al. 2008). This increase
in propensity among the South Asians for developing insulin resistance is attributable to their
higher body fat. Data obtained from a Chennai Urban Rural Epidemiology Study (CURES)
established the fact that visceral fat associated progressive increase have contributed
primarily to an elevated glucose intolerance in South Asians (Indulekha et al. 2011). In
addition, South Asians have also demonstrated significant reductions in their glucose disposal
rates, while demonstrating increased amount of abdominal and visceral fat. Greater amounts
of visceral fat in non-diabetic South Asians have also been associated with increased insulin
resistance.
However, gender differences might play a role in the distribution of body fat among
South Asians and their subsequent insulin resistance (Ramachandran, Ma and Snehalatha
2010). In addition, large number of genome-wide association studies have also been
conducted that have successfully identified the link between incidence of T2D and an
estimated 60 genes (Kooner et al. 2011). However, most of these studies gave been
conducted in the context of European population, and only few of them have taken attempts
for replicating findings of these studies among South Asians (Cho et al. 2012). Recent
replication studies conducted in the South Asian population have also determined the fact that
common T2D variants, which were previously thought to be prevalent in the European
populations, such as TCF7L2, FTO, PPARG, and CDKN2A, have also been associated with
T2D in South Asians (Rees et al. 2011). However, the FTO gene, has been found associated
with T2D in both South Asian and European population (Yajnik et al. 2009).
The rationale for this research is also associated with the fact that global incidence of
type 2 diabetes has been found to create significant ramifications on the South Asian

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population as it increases the risks of stroke and myocardial infarction by two or four times,
when compared to those without diabetes (Wasay, Khatri and Kaul 2014). There exist several
biomarkers such as, adiponectin, C-reactive protein and leptin that act as markers of oxidative
stress and might play a crucial role in the greater prevalence of T2D among South Asians,
when compared to different ethnic groups (Gujral et al. 2013). Oxidative stress commonly
occurs due to an increase in the amount of reactive oxygen species (ROS) and have been
identified to play an important role in the development of T2D. There exists a lack of study
that assessed the levels of these biomarkers in the South Asian population. Furthermore,
oxidative stress has also been linked to increased levels of visceral fat that increases the risks
for South Asians, compared to other groups (Chambers et al. 2015). In line with the high
prevalence of T2D, a worldwide epidemic of obesity and overweight is on the rise.
Nutritional transition after migration plays an essential role in the high prevalence of T2D
among the South Asians living in the UK. Immigrants from the middle and low income
countries of South Asia comprise of a larger proportion of the European population. Over
time, there occurred a mutual exchange of habits and ideas between the immigrants and the
UK population that served as the host (Garduño‐Diaz and Khokhar 2013).
With regards to their food habits, the immigrants were found to be largely influenced
by the food culture practiced by the majority, which lead them to change their dietary habits,
while they contributed to the spectre of newer food items in restaurants and shops. Few
studies have compared the waist circumference and the Body Mass Index (BMI) between the
South Asians settled in Europe and their counterparts with same genetic and cultural
backgrounds, in their country of origin such as Sri Lanka and Pakistan (Zahid et al. 2011;
Tennakoon et al. 2010). These studies have consistently found that European Asians have
higher BMI (point difference of 2.1–5.8), when compared to their counterparts. Furthermore,
a meta-analysis conducted across 199 countries provided evidence for an increase in the

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prevalence of glycemia and diabetes in all regions of the world, with significant increase in
South Asia and North/Middle Africa (Danaei et al. 2011).
Research aim
The primary aim of the research is to investigate the effectiveness of culturally
targeted interventions for delaying the onset or improving the management of type 2 diabetes
in the South Asian population.
Research objectives
 To investigate the prevalence of type 2 diabetes among South Asians living in the UK
and Europe
 To identify the interventions that have target the South Asian population and prevent
the onset of type 2 diabetes
 To identify the interventions that have target the South Asian population and help in
reducing symptoms of type 2 diabetes
 To evaluate effectiveness of the culturally appropriate health interventions
Problem statement
Refined starch and grains from other sources, including simple sugars are found to
have high glycemic index that is associated with the carbohydrates present in a person’s
blood glucose. Consumption of a diet with high glycemic load (the GI multiplied by the
amount of carbohydrates) has also been associated with increased postprandial blood glucose
and risks of T2D, in addition to lesser high density lipoprotein levels (HDL) and an increased
amount of plasma triglycerides (Maki and Phillips 2014). Recently published systematic
review suggests that there exists limited effectiveness in modifying the dietary practices
among the South Asians (Holmboe-Ottesen and Wandel 2012). A combination of genetic

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factors and adoption of a western lifestyle made the immigrants adopt new dietary practices
in practices.
However, these were also coupled with reduced rates of physical exercise that acted
as the primary contributor in the increased prevalence of T2D in the target population (Ezzati
and Riboli 2013). The key sources of portion sizes, nutrients and eating practice greatly
differs among South Asians living in their homeland, and those in some host country. The
annual incidence of T2D among children aged less than 17 years was found to be 0.53 per
100 000 people, per year in 2005 (Candler et al. 2018). Moreover, the National Paediatric
Diabetes Audit (2015–2016) also reported that T2D accounted for an estimated 2.2% cases of
the total prevalence (Rcpch.ac.uk 2018). Owing to the fact that the major risk factors for
development of T2D in childhood are similar to those in adulthood and encompass family
history, obesity, and ethnicity, South Asians living in Europe and the UK are more
susceptible to onset of the disease.
A cross sectional study was successful in comparing the prevalence of diabetes across
major ethnicities in the UK and found that the South Asian population accounted for 1.6% of
the prevalence, second to the white population (Ferguson et al. 2018). This was significantly
associated with their age, BMI, lifestyle factors, socio-economic status, vegetable and fruit
intake, smoking, alcoholism and physical activity levels. Existing data produce evidence for
similar incidence of type 1 diabetes in South Asian and European children. However, higher
incidence of T2D is observed in South Asian children, compared to their European
counterparts in the UK. Estimates have been derived from a primary care dataset which
suggest that, upon drawing comparison with the reference group composed of white
population, hazard ratios adjusted for body mass index, age, smoking status, and family
history for risks of developing T2D were 4.53 for Bangladeshi men (3.67–5.59), 4.07 for
Bangladeshi women (95% CI; 3.24–5.11), 2.15 for Pakistani women (1.84–2.52), 1.71 for

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Indian women (1.49–1.97), 2.54 for Pakistani men (2.20–2.93), and 1.93 for Indian men
(1.70–2.19) (Hippisley-Cox et al. 2009).
The epidemiological surveys fail to draw a clear distinction between type 1 and 2
diabetes and mostly rely on diagnosis recall. Self-reported data regarding the prevalence of
diabetes among South Asians in the UK were available from the Health Survey and suggested
that following an adjustment for age, diagnosed cases of diabetes were 2.5-5 time more
frequent in the South Asian population, than the general UK population (Bhopal 2013).
Moreover, studies that determined self-reports of physical activity suggest that physical
activity levels are generally lower among South Asian adults, compared to other ethnic
groups (Duncan et al. 2008). These factors call for the need of investigating appropriate
culturally sensitive interventions that would address the high prevalence of T2D in South
Asians.

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Chapter 2: Literature review
Introduction
Literature review is an important section in a dissertation as it helps in providing a
summary, description and critical evaluation of work that is relevant to the research question
and objectives that is being investigated. It focuses on the scholarly papers and journal
articles that provide updated data, theoretical and methodological information. It is vital to
conduct a literature review as it ensures to have a thorough understanding of the research
topic and identify research gaps, areas of research and further investigation of the topic. For
the present research, a literature review will be conducted that is referred as secondary source
forming the basis of the research. To retrieve information that is relevant to the research
topic, exhaustive search will be conducted in electronic databases like CINAHL, MEDLINE
and COCHRANE library. The articles that are published in English from 2008 onwards were
included and articles published prior to 2008 were excluded from the study. The search items
or keywords like “type 2 diabetes”, “South Asians”, “diabetes management”, “diabetes
interventions”, “delay onset”, “diabetes management” were entered on the search bar of the
electronic databases. These key search terms were joined using Boolean operators or
truncations like ‘AND’, ‘OR’ and ‘NOT’ that helped in streamlining the search and exclude
duplication of articles in the current study.
Type 2 diabetes (T2D) prevalence among South Asians
T2D is highly prevalent among South Asians and one of the major causes of
morbidity and mortality in their countries and abroad that is continuing to rise at a rapid rate.
The likelihood of developing T2D among this ethnic population is six times higher than
Europeans making it up 4% of the total UK population and estimated to be 8% of all T2D
diagnosed cases (Hanif et al. 2014). Similarly, South Asians are likely to suffer from

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cardiovascular diseases combined with T2D increasing the further risk in aged 20 to 60 years.
Various contributing factors propel the increased burden of disease among this ethnic
population like biological susceptibilities, changes in diet, physical activity and other lifestyle
behaviours. According to Gujral et al. (2013) currently, about 366 million South Asians are
suffering from T2D residing in rural and urban areas of developing countries. Their
prevalence has increased over the past four decades and expected to rise to 120.9 million by
2030. The increasing prevalence is multi-factorial as it is due to both lifestyle and biological
factors that are coupled with immigration and urbanization playing a major role. There is
increased insulin resistance, visceral adiposity, and impaired beta cell functioning and genetic
predisposition to diabetes that markedly increases the risk of diabetes among this population
(Shah and Kanaya 2014). These factors suggest that there is increased susceptibility among
this ethnic population and therefore, culturally tailored interventions are required to identify
and treat the risk factors that can either delay onset or manage T2D among South Asians.
Structured exercise interventions
Albalawi et al. (2017) studied the impact of exercise interventions on T2D South
Asians patients having higher incidence rates as compared to other ethnic populations. A
systematic review and databases searched for controlled trials was conducted and Pedro scale
was used for quality assessment of included studies. Various types of trials were designed
that examined the effect of resistance, aerobic combined exercise or balance and it was found
that it managed the condition of T2D among South Asians through improvements in blood
pressure, glycemic control, blood lipids, waist circumference, functional mobility, muscle
strength and quality of life. Structured exercise interventions controlled the situation of T2D
through programs like resistance, aerobic, combined and balanced training. The interventions
like resistance exercise and aerobic combined programs were traditional and culturally
adaptive for the South Asians. Different exercise programs showed positive results with few

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episodes of adverse events, sports-related injuries or hospital admissions. The results also
depicted that there was significant control in glycated haemoglobin (HbA1c) levels compared
to control groups. The trials also suggested that resistance or aerobic exercise improved the
diastolic and systolic blood pressure as compared to controls. High-density lipoprotein (HDL)
levels significantly improved through resistance exercise suggesting reduction in total
cholesterol levels as compared to usual care. There was also improved muscle strength and
waist circumference through resistance exercise supporting benefits in managing T2D among
South Asians.
Gupta, Aroni and Teede (2017) conducted a study for comparing enablers of physical
activity among South Asians and Anglo-Australians with T2D or CVD. The qualitative,
semi-structured interview was performed in Victoria and it was found that both the groups
exhibited knowledge of disease management through physical activity as it was tied to their
cultural identity. However, the physical activity interventions need to meet their cultural
norms regarding their engagement like incidental exercise or specific exercise. The study also
highlighted the fact that physical activity that is family-based is preferred by the South
Asians. Culturally and linguistically diverse (CALD) groups prefer physical activity and it
can be a beneficial approach for T2D management among South Asians, however the
interventions need to be culturally sensitive that provide them a sense of self-worth within
their cultural groups. The congruence between clinical advice and best sense of self of a
patient belonging to their cultural community is a logical conclusion for the effective
implementation of interventions in the clinical practice.
Educational interventions
Ballotari et al. (2017) published a paper on the effectiveness of educational
interventions comprising of lifestyle tailored modifications and self-care skills for T2D
management among South Asians. The interventions employed in the trials were culturally

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appropriate for the South Asians as the videos, demonstrations and pictorial flashcards were
in native language that benefitted the population from the educational sessions. There was
positive effect on reduction in blood pressure resulting from behavioural change interventions
along with significant reduction in HbA1c levels as compared to controls. The results also
suggested that there was relative small effect on glycemic control due to educational
interventions. Culturally tailored educational interventions helps to modify self-care skills
and attitude of South Asians who migrated to high-income and industrialized countries.
Moreover, there was significant reduction in blood pressure; however, it showed no effect on
glycemic control. Therefore, the study showed weak evidence for the tailored educational
interventions in modifying blood pressure, self-care skills and attitudes. Moreover, one trial
with consistent follow-up showed no improvement in glycemic control for South Asians in
the management of T2D in UK.
Few interventions have incorporated peer support in self-management diabetes
management that educate and support South Asians living in Canada. Another study
conducted by Tang, Sohal and Garg (2015) examined the potentiality and feasibility of
diabetes self-management education intervention that involved peer support on diabetes stress
and glycemic control among South Asians. The intervention comprised of six weekly
education sessions for diabetic management facilitated by peer leaders. The interventions
were culturally appropriate based on principles of empowerment involving shared emotions,
problem-solving to barriers to self-management and evaluation of action plans. The results
showed a significant deterioration in HbA1c levels and improvements in diabetic stress at 24
weeks 54 mmol/mol (7.1%) vs. 61 mmol/mol (7.7%) and 2.0 vs. 1.7 respectively. This
approach is feasible for 24 weeks and result findings suggested that peer-support model may
be beneficial for reducing diabetic distress, however not on the HbA1c levels. The location of
the intervention is important as modifications made in the interventions should be culturally

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responsive favourable for positive health outcomes of the South Asians. This empowerment
based intervention that include active role of participants in guiding group discussion is
effective for this community as it is participant-driven diabetic education. This intervention
did not yield favourable reduction in HbA1c levels, however, it equipped with meaningful
information as it was culturally relevant and highly responsive for South Asians.
Khunti et al. (2008) conducted a systematic review to assess the effectiveness of
educational interventions for South Asian patients with T2D living in Western countries.
Diabetes education is beneficial for managing T2D among South Asians living in UK by
supporting them in acquiring skills so that they feel empowered and take the responsibility on
their own in managing their day to day diabetic condition. NICE also recommended
structured diabetic education for the patients advocated in patient empowerment through self-
management and education. Although, the type of interventions were not clear in the study
that would be effective for South Asians, however increase in diabetic knowledge can be
helpful in achieving positive outcomes that is based on reduction in Hb1Ac levels and
improvements made in diabetic control among the patients having risk profile. Educational
interventions for self- management of diabetes have positive results that can be achieved for
health outcomes and behaviour change. For addressing the needs of South Asian patients, a
single effective education approach is required that would emphasize on flexible or tailored
approaches in order to meet the needs of this population suffering from T2D. However, there
is difficulty in designing and achieving impact through educational interventions as good-
quality studies are required for its effectiveness among the population.
Culturally Competent Interventions (CCI)
A paper published by Dauvrin, Lorant and d’Hoore (2015) suggested that culturally
competent (CC) interventions are identified for adults belonging to ethnic minorities
suffering from T2D. South Asians have a higher prevalence of T2D with greater risk for

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neuropathies, poor glycemic control and treatment compliance. They also face individual or
institutional racism that increase the challenges faced by the ethnic minorities that results in
poor health outcomes. There is also increase in burden of T2D among the South Asians for
reducing inequality between minorities and general population and in improving the delivery
of quality of care. Chronic Model of Care (CCM) is a beneficial guide for improving quality
of care for chronic disorders like T2D that pays attention to the patient’s cultural background
as an integral component of CC. These interventions require multi-level strategies that
include patients, healthcare professionals and services. This comprises of wide range of
interventions that are diversity-oriented like culturally appropriate health policies, interpreter
facility and mediators in healthcare facilities that support ethnic minorities like South Asians.
Interventions that support cultural competency support self-management in diabetes, policy
domains and community resources that are culturally competent. CC framework focuses on
patients with minimal focus on healthcare professionals or services rather the whole system
design and delivery of care.
Multi-component interventions
Bhurji et al. (2016) conducted a review for studying the effectiveness of multi
component intervention for T2D management focused on South Asians patients living in
India and immigrants in western countries. The primary outcome was changes in HbA1c
levels, secondary end points that included changes in lipid levels, blood pressure, knowledge
and education. The interventions encompassed interventions that were culturally appropriate
like diabetes education translated in their language, clinical care along with visual aids,
written materials and healthcare professionals, community-based peers who were culturally
competent. The interventions also comprised of exercise, yoga or meditation, cooking
exercises and dietary education for the diabetic management among South Asians. The
findings suggested that there were significant reduction in the HbA1c levels demonstrated in

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these trials, however, the results varied due to significant heterogeneity and outcome results
in interventions and lack of pooled analysis. There was little improvement in the levels of
HbA1c as a result of diabetic intervention intended to manage T2D among South Asians
residing in Europe as compared to usual care in other countries. There is need of novel
strategies like dance in traditional music or yoga that can improve glycemic levels among
them as effectiveness of these interventions for T2D management differed by regions.
Diet modifications
Gupta, Teede and Aroni (2018) conducted a qualitative study that examined dietary
practices of South Asians through a semi-structured interview. The result findings suggested
that high level of dietary awareness is recommended for optimum diabetes management both
pre and post diagnosis. This is important as migration resulted in hybrid diets among South
Asians evident in Australia. However, there was perceived barrier in the implementation of
dietary changes as there was lack of timely, specific and detailed dietary advice that they
received from clinicians. This intervention required more cultural appropriateness that
recognizes their preferences, staple food items as it is the major reason for resistance and lack
adherence. However, acculturation that was evident in traditional foods was their cultural
identity and dietary interventions demanded more culturally relevancy for South Asians.
Provision of effective advice should not only be culturally supportive, but also support self-
management strategies across T2D management. The studies also showed that participants
are aware of the fact that diet affects their blood glucose levels fundamental to effective T2D
management among South Asians. This fact illustrates that it was not knowledge gap that
influenced adherence to dietary modifications rather challenges that T2D patients face for
effective dietary regimen implementation.
Primary T2D prevention in South Asians
Modification of risk factors

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Diabetes prevention is of enormous value among South Asians. A paper published by
Ambady et al. (2013) highlighted the fact that strategies like lifestyle changes, culturally
specific programs measured by innovation implemented at national level can be helpful in
preventing T2D among South Asians. The integrated involvement of community,
government, healthcare and educational services, media along with financial support can be
helpful in designing these preventative interventions for T2D among them. The possible
interaction of non-modifiable and modifiable T2D risk factors can promote patho-
physiological changes influencing primary prevention strategies by arresting or reversing the
deterioration. Lifestyle modifications and metformin use are noteworthy preventative
strategies for all ethnic populations being cost-effective and have collateral benefits on
cardiac risk factors. Most importantly, an approach, “Life Cycle” focuses on modifiable risk
factors that are associated with environment and behaviour advisable for all ages in ethnic
populations. This approach is aimed at implementing preventative strategies for T2D at every
stage of life cycle for the identified risk factors. These strategies improve insulin action and
preserve the beta cell functioning that in turn reduce the deterioration of pre-diabetic stages.
However, these strategies pose huge challenges while translating research findings like
sedentary behaviour, culturally incompetent and lack of trained personnel, lack of fear and
motivation, fear and lack of awareness.
Patel et al. (2017) conducted pretest-posttest control group and experimental repeated
measures design for the evaluation of effectiveness of culturally appropriate, community-
based lifestyle intervention program for the reduction of risk of T2D among South Asians in
urban US community. The primary outcome for the study was reduction in Hb1AAc levels
and weight along with improvement in physical exercise. Follow-ups were taken at 0, 3 and 6
months about the participants’ social, physical activity and lifestyle habits through self-
reported questionnaire and clinical measures. Initially, there was decline in the weight and

22DISSERTATION
increased physical activity observed in all respondents, however, significant lowering of
HbA1c levels and waist circumference was witnessed in intervention group as compared to
control group. The result findings suggested that a lifestyle intervention that is culturally
tailored in a community can effectively reduce waist circumference, weight and Hb1Ac
levels among Gujarati South Asians residing in US. This intervention is also effective for
delaying onset or preventing T2D among high risk multi-ethnic South Asian population. The
primary outcome for the intervention was that there was reversal from pre-diabetic condition
to normoglycemia in the intervention group as compared to control group that had
progression from normoglycemic to pre-diabetic condition. The baseline changes in waist
circumference or abdominal obesity in both groups were similar with respect to group and
time after a twelve week follow-up. The intervention was successful in lowering of Hb1Ac or
blood glucose levels significantly among intervention group participants than control group.
There was also significant decrease in waist circumference from baseline to 12 weeks follow-
up among participants in the intervention group and not in control group. Therefore,
community, faith-based setting for lifestyle intervention program is convenient in delaying
onset or prevention of T2D in high risk for South Asians individuals.
Targeted lifestyle intervention
Vlaar et al. (2017) conducted a study among South Asians population (aged 18 to 60
years) about effective targeted lifestyle interventions for reducing risk of T2D among them as
a preventative intervention. Physical activity and diet are the key modifications of risk factors
for T2D among South Asians for the prevention or postponing of diabetes. The intervention
was culturally appropriate consisted of motivational interviewing in individual counselling,
family session, supervised physical activity programs and cooking classes. The outcomes was
that the intervention group became active from moderate to vigorous as compared to control
group who had generic lifestyle choices. A follow-up after a two year interval showed no

23DISSERTATION
significant difference between the two groups in terms of physical exercise and diet
behaviour or any sort of socio-cognitive determinants. Notably, the proportion of participants
was lost during this two year follow up reporting less healthy behaviour equalled with
reporting of more healthy behaviour. Although, the intervention primarily addressed
marginally targeted South Asian population, however social and physical environment cannot
be influenced in achieving a healthy lifestyle for them. Therefore, culturally lifestyle
intervention was not effective for T2D prevention and promotion of healthy behaviour among
South Asians. A more targeted and acceptable intervention is required for changing
behaviour among them taking the social-cognitive determinants into consideration.
Admiraal et al. (2013) conducted a randomized control trial among South Asians who
were at risk of T2D to study the effectiveness of culturally adaptive and intense lifestyle
intervention after a year for metabolic profile and weight status. The intervention targeted the
South Asians that comprised of individual and family session in lifestyle counselling,
supervised physical activities and cooking classes. The components used in the intervention
were assessed by the professionals during their clinical practice. The control group received
generic advice on lifestyle assessed after 1 year. The results suggested that after a year
follow-up, most of the participants lost to follow-up. In the remaining participants, in both
groups, the control and intervention groups had similar baseline characteristics. The weight
loss and weight gain in the intervention and control group respectively made no differences in
terms of metabolic profile even after repeated analyses in the imputed dataset. The results
suggested that in such kind of interventions, participants lost to the follow-up after one year
showing no improvements in profile of South Asians who are at risk of T2D. Various barriers
were encountered during the study like high drop-out, laborious recruitment and lack of
effectiveness that made it difficult for realizing the health benefits suggesting that this
intervention is not optimal for the South Asians.

24DISSERTATION
Previous studies highlighted the fact that intensive lifestyle interventions may act as
preventative measure for onset of T2D. However, such interventions were not culturally
adaptive and appropriate for the South Asian ethnic population in the industrialized countries.
Therefore, Vlaar et al. (2012) conducted a randomized controlled trial for studying the
effectiveness of targeted lifestyle intervention among South Asians (18 to 60 year olds)
Hindustan Surinamese in The Hague, Netherlands. Participants who had impaired glucose
tolerance and fasting, glycated haemoglobin and insulin resistance were included in the study
where the families with history of T2D or high level of education were willing to participate.
The intervention was culturally targeted that comprised of motivational interviewing on
dietary counselling and physical activity program under professional supervision. Generic
lifestyle advice was given to the control group and effectiveness was determined using
cardio-respiratory test, anthropometrics, lipid profile, oral glucose tolerance and interview.
The study findings suggested that lifestyle interventions that are culturally tailored can
contribute to T2D prevention among South Asians who are at high risk in an industrialized
country. Most importantly, the evaluation and feasibility of the culturally targeted intensive
lifestyle intervention require more information about cost-effectiveness through general
practice among South Asians and other healthcare professionals.
Dietary and physical exercise
Muilwijk et al. (2017) in the paper highlighted the fact that T2D is a major health
concern among South Asians ethnic population, Physical exercise and dietary interventions
are shown to have moderate effect on the prevention of T2D among this group. These
strategies were compared with the NICE guidelines that helped to develop the preventative
strategy got preventing T2D among this ethnic population. The interventions that target
physical activity and diet helped to reduce risk of T2D among South Asian population
showed only moderate results. However, the interventions were culturally adaptive and

25DISSERTATION
appropriate for South Asians and lifestyle management programs found to be preventative in
modifying the risk factors. Weight loss combined with diet is quite beneficial in improving
the hypertension and insulin resistance having a positive impact on modifiable risk factors.
Strength training also protects against insulin resistance and have small to moderate effects
on predictors of T2D among South Asians where inclusion of this intervention can prevent
T2D among this ethnic population. The paper also highlighted the fact that community and
population level interventions for T2D prevention is the most recent guideline for South
Asians and general population. Moreover, there are also variations as per geographical
settings like South Asians living in Europe, Asia or USA.
DH!AAN (Diabetes Prevention Program)
T2D is highly prevalent among this South Asian ethnic group along with lower
presentation age and experiencing major complications. Previous studies suggested that
lifestyle interventions delay or prevent diabetes onset among South Asians. Therefore, in a
paper published by Nicolaou et al. (2014) DH!AAN, a diabetic prevention program was
designed for the South Asians in Netherlands. The formative research and theoretical
framework guided the designing and development of cultural adaptation in DH!AAN. This
adaptation is based on determinants of physical activity and diet and its analysis that includes
socio-cultural factors in the study population. The incorporation of deep and surface structure
elements was also considered in the intervention. Dieticians also performed one to one
counselling sing motivational interviewing (MI) along with generation of social support that
included family members and group sessions that were related to traditional food habits. The
intervention was intended to meet the national guidelines for physical activity and diet where
healthcare professionals were trained in MI aligned with Surinamese South Asian culture.
Dieticians provided family session at the home of the participants that engaged the family in
supporting individuals in the achievement of dietary goals. Cooking classes were also

26DISSERTATION
provided for increasing self-efficacy and in learning skills so that they are adjusted to the
traditional foods and in turn meeting the nutritional guidelines. The motivation for behaviour
change was the conceptual framework for the lifestyle intervention driven by determinants
like self-efficacy, social support, attitude and socio-cultural influences. As the lifestyle
intervention was client-centred and directive, it enhanced intrinsic motivation among the
participants for behaviour change.
Community faith-based screening
South Asians experience higher rates of diabetes and its complications as compared to
their White European counterparts. Undiagnosed diabetes or individuals at risk of pre-
diabetes should be screened for reducing the risk and preventing diabetes related
complications among this ethnic population. Therefore, Willis et al. (2016) conducted a study
for assessing the feasibility of faith based centre pathway for screening of high risk South
Asians for diabetes and cardiovascular diseases and development of early intervention
strategies. Opportunistic screening consisted diabetic risk assessment tool and testing for
Hb1Ac among participants. Individuals who were found to be at high diabetic risk were
offered educational intervention called “Walking Away from Diabetes” that was aimed at
reducing risk of diabetes and increase in exercise levels. The result findings suggested that
major proportion of participants were found to be at high risk score and increased Hb1Ac
levels eligible for diabetic prevention program. This confirms that screening and group
education conducted in faith-based centre settings is feasible for South Asians and effective
in achievement of high yield screening and uptake of diabetes group education. This study
undertook direct consumer screening for individuals with diabetes risk for T2D and referred
to group education and lifestyle intervention. It is hard to reach the South Asian communities
in terms of screening and engagement like health checkups by NHS. This study finding
suggested that community faith-based centre settings proved beneficial for screening of high

27DISSERTATION
diabetes risk South Asians. In addition, this method has the potential to reach out to the South
Asian groups who are at high risk of T2D through improved screening and aligning with
current public health guidelines.

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Chapter 3: Methodology
Introduction
Conduction of literature reviews have been identified imperative for gaining a deeper
understanding of the actual purpose and nature of the problems that is currently being
investigated (Aveyard 2014). Researchers have been found to mostly focus on recognising
strategies that will prove effective in managing type 2 diabetes among the South Asian
population (Kalra et al. 2015). The research was principally based on a qualitative design or
approach. An essential aspect of such qualitative research design can be correlated with the
fact that it employs a scientific procedure of observation that facilitated the collection of non-
numerical data. This research took into account a range of concepts that were related to
characteristics, definitions, symbols, and descriptions. The qualitative approach showed
adherence to the purpose of the research and encompassed research methods and concepts
that were retrieved from a range of established academic domains (Lewis 2015). However,
qualitative approaches are often constrained that is established by the presence of less
subjects or fewer studies that are used in the research.
This statement shows consistency with other studies that emphasised on the fact that
qualitative research designs are mainly conducted with the aim of describing a certain social
reality and often take into account the values and opinions of the participants or respondents,
while remaining within the system that is being assessed for the research purpose (Maxwell
2012). This research design supposed that South Asians show an increased vulnerability to
the development of type 2 diabetes and thereby remain at an increased risk of suffering from
comorbidities as well. The research was largely involved in providing an exhaustive
description of the different interventions that have been designed with the aim of preventing
the onset or managing the symptoms of T2D among South Asian population. Furthermore,

29DISSERTATION
the research also intended to conduct a thorough systemic exploration of the effectiveness of
the identified interventions from the perspectives of the people who suffer from T2D.
Method outline
This qualitative research design mainly elaborated on two major components namely
collection of data and an analysis of the collected data. Prior to conduction of the research, an
essential approaches that focused on different aspects of data collection was employed. This
approach was based on systematic review. The prime benefit of systematic reviews can be
attributed to the fact that they encompass a summarisation of the results that have been
extracted from carefully designed clinical studies, which in turn provide high evidence level
on the effectiveness of the identified healthcare intervention. Narrative reviews are mostly
descriptive in their nature and fail to include any kind of systematic search of relevant
literature, thereby contributing to selection bias in the results (Lambert and Lambert 2012).
On the other hand, systematic reviews are found to comprise of a comprehensive and detailed
plan and appropriate search strategy that has been derived with the intent of eliminating bias.
The aforementioned aspects of systematic reviews were taken into consideration while
conducting the research. This was facilitated by recognising, appraising and producing all
studies that were measured relevant to the formulated research question. The research was
constructed on collecting articles that directly focused on administering educational, dietary
modifications, lifestyle changes and multicomponent interventions that either reduced the
HBA1C levels, combatting insulin resistance or preventing the onset of T2D among South
Asian individuals. Thus, the systematic review acted as a key to evidence-based medicine
practice and the use of a transparent and objective approach facilitated the process of
removing bias in the results.
The research design focused on collecting relevant data about the prevalence of T2D
in the South Asian population. The research was conducted in a way that allowed collection

30DISSERTATION
and organisation of important scientific interventions for upholding the information against
all prevailing notions and perceptions of treatment or prevention of T2D. The process of data
collection and analysis occurred simultaneously and the results presented in the retrieved
articles were later on analysed for gaining a sound understanding of the research objectives
that were proposed to be addressed. This was followed by characterisation of the findings
into a range of themes. The key objective of thematic analysis was to focus on the
identification for a pattern across the collected articles. This is one of the most prevalent
types of data analysis in qualitative research studies and stresses on examination and records
of themes or patterns within the collected data. The themes act as patterns that are crucial for
describing the phenomenon of interest and are always associated with the main research
question.
Research onion
Figure 1- Research Onion

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Source- (Saunders et al. 2015)
The research onion will elaborate on the multiple stages of the research that have been
addressed during the development of formulation of the research strategy. Upon viewing the
research onion, the layer or the stages resemble the different hierarchical processes that were
encompassed by the qualitative research. Furthermore, the research onion is also imperative
for providing a thorough and exhaustive description of the steps that will be followed during
the progress of the research, with the adoption of an accurate methodology.
The research philosophy
Research philosophy refers to the belief about the ways by which relevant data about
certain phenomenon should be collected, analysed and put to practice. In other words,
research philosophy reveals the underlying description of pertinent research based knowledge
(Scotland 2012). This in turn helps in providing a justification of the research approach that
has been employed. Research philosophy selection is commonly determined by certain useful
consequences of the research, with regards to real-time scenario. The research in this case
was based on the philosophy of realism. This research philosophy most commonly relies on
ideas that are realted to reality independence from the mind. This philosophy takes into
account a range of assumptions regarding knowledge development (Mkansi and Acheampong
2012). Direct realism is found to portray the surrounding world with the help of personal
senses. On the other hand, critical realism provides the argument that humans are found to
commonly experience images and sensations that are realted to the real world (Pritchard
2018). Furthermore, these images and senses are deceptive and fail to depict a portrayal of
the real world. In other words, this research design focused on a positivist approach. The
concept of positivism illustrates on the stability of reality and that it can be described and
observed from the viewpoint of an objective (Kitchin 2014). Thus, information are derived
from sensory experiences and are commonly interpreted through logic and reason, which in

32DISSERTATION
turn forms the source of knowledge. Verified data that the senses receive are commonly
referred to as empirical evidence. In other empiricism forms the foundation of positivism.
The systematic review gathered evidences from studies that were found to be
associated with the efficacy of culturally targeted interventions that either managed or
prevented the onset of T2D among patients. Use of realism as the major research philosophy
can be attributed to the fact that inclusion of studies that directly provided an evidence for the
effectiveness of the interventions. Thus, the selected studies provided information on the real
time effects of the exercise based, lifestyle based or dietary interventions on T2D.
Research approach
This is the second layer of the research onion and is found to commonly include either
a deductive or an inductive approach, both of which are in accordance with the research
philosophy identified in the previous stages. This research approach helps in providing a
comprehensive detailed about the observations that are imperative for the formation of
perceptions that are directly related to the outcome of the systematic review (Saunders et al.
2015). This research was based on deriving conclusions about reports that focused on
interventions that target the South Asian culture, owing to the high prevalence of type 2
diabetes in that population. The research was grounded on an inductive approach that began
with the observations. This was followed by proposing theories at the end of the process.
Thus, the research approach was based on conducting a search of patterns from the collected
observations, followed by the subsequent development of proper elucidations. Hence, the
primary aim of the approach was to generate a range of meanings from the collected data set,
with the aim of recognising relationships and patterns for building a definite theory (Frels and
Onwuegbuzie 2013). In other words, the inductive approach was adopted principally to work
on the title of the research.

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Research strategy
The research strategy comprised of a systematic review, one common method
employed for secondary research that involved formulation of a summary, or organisation of
previously existing evidences (Saunders et al. 2015). There exists a growing body of research
that have been directed with the intention of estimating the effects of interventions on T2D
among South Asians. Type 2 diabetes has been identified as a growing health concern for
individuals belonging to South Asian descent. They have reported several folds increased
susceptibility of developing T2D, when compared to Europeans (Morris et al. 2012). A range
of lifestyle factors have been identified responsible for this increased vulnerability to the
metabolic disorder. Furthermore, research studies have also provided evidence for the
presence of an increased likelihood of cardiovascular disorder development among South
Asians, suffering fromT2D (Buitrago-Lopez et al. 2011). This in turn creates a negative
impact on the survival rates of the affected patients and lead to its significant reduction, when
compared to the Caucasian population. Moreover, some of the major risk indicators for this
increased possibility of T2D development have been connected with body mass index of 23
or higher, thereby providing the indication for obesity. In addition, presence of a waist size
that ranges 35 inches or above among males and 31.5 inches or above for females is another
risk factor (Gholap et al. 2011). Thus, the results from the retrieved articles will be grouped
and coded for demonstrating the factors that are common among them and will expedite the
process of drawing conclusions.
Time horizon
The next layer of the onion comprises of the time frame that has been developed for
the research completion. The research onion includes cross-sectional time frames. In addition,
the research also used a longitudinal time horizon that involved the use of repeated trials over
a specific time period, with the aim of identifying whether the effects of the interventions on

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the South Asian population over a long study period, sometimes even decades (Saunders et
al. 2015).
Data collection and analysis
Data collection is of prime importance in a research onion due to the fact that it assists
in the establishment of reliability and validity of the presented results. Regardless of what
research approach has been employed, the methods of data collection are commonly grouped
into two major categories namely, secondary data collection and primary data collection
(Palinkas et al. 2015). This research was based on the secondary method of data collection
where the conclusions and recommendations were derived from the articles that focused on
trials conducted in the form of primary research by other researchers. Thus, the secondary
data collection method took in to account the fact that all relevant data presented in the
findings were gathered by someone else. The primary objective of using this method can be
correlated with the fact that it was not time consuming and helped in providing high quality
evidences that would otherwise have been unfeasible for collection (Terrell 2012). This
secondary research method was built on conduction of the systematic review, followed by
analysis of the data findings with respect to the research question. Another major advantage
of this method was its high cost-effectiveness. This in turn helped in aligning the research
focus on a much wider scale and also assisted in the identification of answers that were
pertinent to the research question.
Research design
This commonly refers to the overall strategy that has been selected for integrating
several components of the study in a logical and coherent way, thereby determining that the
research problem has been effectively addressed. The designed employed in this research was
that of a review, which in turn was descriptive in nature. The first step involved in conducting
of the systematic review focused on development of a structured or appropriate question that

35DISSERTATION
guided the entire review (Lewis 2015). This was followed by the second step where a
thorough and comprehensive search of relevant articles, containing information on the
implementation of culturally targeted T2D interventions was conducted. Following sections
included making a record of detailed information on the databases that were primarily utilised
for the extraction of the articles. The titles and abstracts of the articles were checked against
the pre-defined inclusion and exclusion criteria, which assisted in assessing the eligibility and
relevance of the studies that were included. The articles were retrieved with the use of the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
This PRISMA is principally an evidence based approach that helps in focusing on minimum
items that are imperative for a systematic review. This PRISMA tool improved the generation
of a report of the articles that were used for the systematic review (Moher et al. 2015).
Research sampling
Research articles that focused on culturally targeted interventions for T2D among
South Asians, and published on or after 2008 were extracted for the review. Three electronic
databases namely CINAHL COMPLETE, MEDLINE and the Cochrane Library were
thoroughly searched with the use of specific key terms and search phrases for retrieving
them. The search strategy was employed with the aim of extracting full-text articles that were
relevant to the research question of interest. Search terms used for the articles were
‘diabetes’, ‘type2’, ‘T2D’, ‘T2DM’, ‘South Asia’, ‘South Asians’, ‘intervention’, ‘prevent’,
‘manage’, ‘onset’, ‘incidence’, ‘ethnic minorities’, ‘delay’, ‘prevention’, ‘management’, and
‘prevalence’. Boolean operators ‘AND’ and ‘OR’ were used to combine these search terms in
the database. The operator ‘AND’ narrowed down the search results by retrieving articles that
contained information on the major conceptions that were relevant to the research (McGowan
et al. 2016). ‘OR’ helped in broadening the retrieved article hits by containing either of the

36DISSERTATION
key terms such as, ‘prevention OR management’. The obtained articles were then evaluated
on the basis of specific inclusion and exclusion criteria that are given below:
Inclusion criteria
 Published in English language
 Published on or after January 2008
 Containing information on T2D management or prevention
 Articles where interventions were implemented on adults
 Containing information about interventions applied upon South Asians
 Full text formats were available
Exclusion criteria
 Published in languages other than English
 Published prior to 2008
 Unpublished manuscripts or abstracts
 Containing information on type 1 diabetes
 Not addressing the South Asian population
 Dissertations
 Book chapters
 Case study
Data collection
An exhaustive search of the two electronic databases provided a total of 257 articles,
which were reviewed to ascertain consistency with the inclusion criteria. Duplicate articles
were removed followed by screening the titles and abstracts of those that were relevant to the
research question. Upon assessing the full-text eligibility of the articles, a total of 11 articles
were retrieved. Following removal of the duplicates, 65 articles were extracted, of which 32

37DISSERTATION
articles were screened for their abstracts and titles, which resulted in 11 articles. Furthermore,
those that contained information from conferences, newspapers or editorial letters were
excluded for refining the search results (figure 2). The full texts of the extracted articles were
appraised on the basis of the following criteria:
1. Does this article talk about a clearly focused research question?
2. Does this article depend on the execution of proper methods that addresses the
management or prevention of T2D among South Asians?
3. Does the article present important and valid results?
4. Can the results be implemented in the target population?
This was followed by organising the findings of the articles in the form of themes or
patterns that explained the disorder (T2D among South Asians) being studied for the
research.
Figure 2- PRISMA flowchart for extraction of articles

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Chapter 4: Results and Discussion
Results
All the articles that have been categorised into themes provided information on the
effectiveness of culturally appropriate interventions that target the South Asian population,
with the aim of reducing the risk of type 2 diabetes incidence, or managing the blood glucose
levels, once it has been diagnosed. Most of the articles focused on illustrating the benefits of
lifestyle changes that included alterations in certain long-term habits that commonly
encompass physical activity/exercise, diet and maintaining the changed behaviour for
considerable period of time. Thus, it can be deduced by analysing the articles that most of the
researchers pointed out that effective lifestyle interventions have the capability of preventing
T2D in the target population. The themes that have been formed after collecting specific
patterns of data from the retrieved articles are as follows:
Waist circumference
Waistline measures have been found to act as important indicators for reducing the
risk of diabetes and are commonly considered more fitting than readings of BMI. Measuring
the waist circumference helps in finding the amount of fat that has been stored, which in turn
directly increases the risks of T2D among individuals. A systematic review was conducted
with the aim of investigating the effects of aerobic exercise and balance related physical
activity on South Asian individuals with T2D. Findings of the study indicated that exercise
modifications were able to reduce the waist circumference of the participants significantly.
Resistance based training conducted over a period of 8 weeks for 30-45 minutes was found to
significantly reduce the circumference of the waist, in addition to improving the hip: waist
ratio (Ambady et al. 2013). Similar findings were reported by another observational study
that focused on assessing the impacts of culturally appropriate lifestyle modification based

39DISSERTATION
community interventions to reduce T2D risks among US based South Asians. Increased
consumption of fruits and vegetables to minimum 5 servings each day, physical activity for
150 minutes per week or 10,000 steps each day, and reduced intake of fat rich foods were
found to exert significant impact on the waist circumference of the South Asian participants
in the intervention group. Waist circumference was measured with the use of the Gulik
Anthropometric tape. Mean waist circumference was found to be 88.07cm for males and
78.92cm for females, respectively. Changes in waist circumference were found to increase
more with time at F (2, 88) = 3.337, p= 0.04. Hence, culturally targeted interventions were
substantial in decreasing waist circumference from baseline to 12 weeks post-test
intervention period in the intervention group (Patel et al. 2017). The baseline mean waist
circumference of participant was also measured in another study that aimed to determine the
feasibility and efficacy of the DH!AAN study. The mean waist circumference was found to
be an estimated 95.0cm for males (SD: 10.9) and 90.7cm for females (SD: 10.5). This study
also intended to measure the impact of the targeted diabetes prevention regimen on waist
circumference, as a primary outcome (Vlaar et al. 2012). Improvements in waist
circumference were also found in another trial that intended to examine the potential health
impacts of self-management diabetes education and peer support related intervention on
diabetes distress and glycemic control. The intervention was successful in bringing about
changes in the secondary outcome of waist circumference among the participants (100.2 vs
98.7 cm; P < 0.05) (Tang, Sohal and Garg 2015). Thus, the culturally targeted interventions
were able to reduce waist circumference among the South Asian participants.
HbA1c levels
HbA1c levels refer to glycated haemoglobin and are imperative in determining the
amount of blood glucose of an individual. Along with the fasting plasma glucose
measurement, the HbA1c test is one of the key ways that helps in defining presence of T2D

40DISSERTATION
among individuals. A systematic review that focused on interventions for management of
T2D in South Asian patients elaborated on the fact that among the included trials, four studies
were conducted in India and were found to report noteworthy decrease in the HbA1c levels in
the intervention group, upon comparison to the control group. Educational interventions
formed the primary subject of another trial conducted in Europe and suggestively reduced the
HbA1c among the patients. Furthermore, findings from the review also suggested that most
interventions that changed HbA1c, focused on exercise or yoga as culturally appropriate
intervention for the target population (Bhurji et al. 2016). Significant reductions were also
observed in the HbA1c levels in another study at the end of 24 weeks of implementation of
the intervention. Although the intervention failed to bring about any substantial impact on the
HbA1c levels at the end of 6 weeks, the values were 54 mmol/mol (7.1%) after 24 weeks, in
comparison to 61 mmol/mol (7.7%), with p<0.001. Thus, a deterioration in HbA1c suggests
the effectiveness of the intervention in managing diabetes among South Asians (Tang, Sohal
and Garg 2015). A culturally tailored lifestyle modification created major impacts on the
HbA1c levels of the South Asian participants. Mean HbA1c was found to be 38.41mmol/mol
(SD ± 3.8). Significant interaction of HbA1c was found with time and the intervention group
at F (2, 88) = 17.116, p<0.0005. An initial analysis of HbA1c revealed that there were an
estimated 45.6% participants belonging to the pre-diabetes category. However, over the
intervention period, a significant reversal was observed among the participants from pre-
diabetic stage to normoglycemia, when compared to the control group (Patel et al. 2017).
Results from another systematic review also suggested that educational initiatives that
were aimed at targeting migrant South Asians with T2D were successful in lowering HbA1c
levels. Momentous short-term improvement was observed in HbA1c in a particular study
after immediate application of an educational intervention. One particular study suggested the
presence of HbA1c levels in 60% participants above the acceptable ranges. Furthermore,

41DISSERTATION
results from a third trial also provided evidence for the fact that there was an improvement in
HbA1c among participants with levels as high as 9.5% or more, at baseline. Thus, the
findings suggested that educational interventions were not completely successful in
maintaining HbA1c among South Asian T2D patients (Khunti et al. 2008). Another
systematic review was conducted with the aim of evaluating the effect of lifestyle-tailored
interventions living with T2D. The findings suggested that only one observational study had
been successful in significantly reducing the HbA1c levels after administration of the
intervention (diabetes self-help) among the patients. The largest randomised controlled trial
conducted over a long follow-up period emphasised on a 0.15 decrease in HbA1c in the
patients who were treated, when compared to the controls (P = 0.11). Other studies included
in the trial were unable to produce any impact on the same. Thus, the culturally targeted
interventions were able to exert a small effect on the glycemic control of the individuals with
T2D (Ballotari et al. 2017). Effects of exercise program on glycemic control in South Asian
patients with T2D were demonstrated by another systematic review. Resistance based balance
training, aerobic trainings and other forms of exercise were related to significant
improvements in its level, when compared to that of the control group. Thus, the
interventions targeted towards T2D management or prevention of its onset played an essential
role in glycemic control (Albalawi et al. 2017).
BMI/weight
Obesity has been identified time and again as a significant risk factor for T2D.
Obesity is determined with respect to BMI that helps in assessing the weight of a person in
regards to the height. Several studies determined the impact of the interventions on BMI of
South Asian participants, to evaluate the long-term risks of T2D development. The systematic
review which investigated impacts of lifestyle-tailored programs on the target population
contained a trial that found a significant increase in BMI after implementation of the exercise

42DISSERTATION
based intervention. Thus, the culturally targeted intervention failed to bring about any major
changes in the BMI of patients (Ballotari et al. 2017). Results from another systematic review
that took into account the influence of aerobic and resistance based exercise programs on the
South Asian population did not contain any study that could report noteworthy enhancement
in BMI of the patients. Owing to the fact that the review evaluated trials that focused only on
exercise programs, and not any forms of dietary modifications or other lifestyle changes, the
effect of exercise on BMI and weight could not be established (Albalawi et al. 2017).
However, findings from another review that illustrated on T2D primary prevention
techniques in South Asian population suggested that studies conducted in Finland and a
Diabetes Prevention Program (DPP) exerted their benefits on diabetes management, primarily
in terms of weight reduction. The DPP was able to bring about an estimated 7% loss in
weight, on showing adherence to 150 minutes of exercise, each week. IDPP-1 also helped in
preventing the onset of diabetes among South Asians, specifically Indians by maintaining the
BMI and weight. This was facilitated by implementing restrictions on the intake of refined
carbohydrates and fats, in combination with 30 minutes of exercise programs (Ambady et al.
2013).
Reduction in weight and subsequent improvement in BMI was also emphasised by
another systematic review that investigated the impacts of educational intervention upon
migrant South Asians for T2D management. A before and after trial, included in the review
that evaluated the impacts of medication review, in conjunction with group education among
migrant South Asians living in Edinburgh reported significant improvements in weight in the
intervention group. This provided evidence for the fact that educational interventions increase
the awareness of T2D patients regarding the risk factors that increase their susceptibility to
T2D, thereby reducing increased weight. Major drop in weight measurements was also
reported by three studies that focused on yoga, exercise and pre-test or post-test interventions,

43DISSERTATION
in a systematic review of T2D management improvement in South Asians. Furthermore,
increase in BMI was also found in a European mixed trial, upon implementation of the
intervention (Weight: -0.31, p=0.36) (Bhurji et al. 2016). On conducting educational
programs and support sessions, based on the principles of empowerment, BMI was an
essential secondary outcome measure that showed significant improvements at 6 weeks and
24 weeks (28.3 compared to 28.01 kg/m2, p< 0.05).
Awareness in the population and perceived barriers
Participants in a diabetes prevention program reported an awareness on the prevalence
of diabetes in their community and the findings also reported their idea that the disease was
inevitable. Awareness regarding the personal risks was recognised as an essential issue on
formative research. The findings elaborated on the fact that with an increase in seriousness in
risk evaluation, the chances of individuals to adjust their behaviour increases. Furthermore,
use of photographs of famous personalities who stress on healthy eating, exercise, yoga, and
their testimonials were also found imperative in increasing awareness regarding diabetes
prevention and management (Nicolaou et al. 2013). Time constraints, safety related fears,
social obligations and inadequate financial resources were identified as some of the perceived
barriers in the implementation of the interventions. Adverse climate also acted as a barrier in
engagement in physical activity programs. Despite awareness on increased weight and the
subsequent onset of T2D, most participants in another study failed to acknowledge absence of
motivation for adorning an active role in the identification of barriers that prevented
adherence to physical activity programs. Furthermore, the findings also provided an insight
into the fact that female South Asian participants often perceived presence of
intergenerational variations in their attitudes towards self-awareness of body size and shape,
and physical exercise.

44DISSERTATION
Engagement in the culturally target interventions were also limited due to fear of the
comorbidities exerting their impact on the condition. Furthermore, the presence of less
number of South Asians belonging to different cultural and linguistic groups is another
barrier that prevented drawing necessary conclusions about the targeted interventions (Gupta,
Aroni and Teede 2017). One common barrier was linked to language and literacy differences
that hindered the delivery and/or funding of educational interventions for managing and
reducing the onset of T2D in the target population (Khunti et al. 2008). The chronic care
model also identified the need of creating provisions for training of the health professionals,
with the aim of increasing their awareness on the issue of T2D prevention. Socioeconomic
conditions, cultural and linguistic differences were also considered as major barriers that
prevented the migrant South Asian population from accessing appropriate healthcare services
(Dauvrin, Lorant and d’Hoore 2015). A review that focused on T2D primary prevention
techniques in South Asians also elaborated on the fact that creating a sense of awareness in
all members of the population can be facilitated by implementation of culturally acceptable
and feasible interventions among the conservative South Asian population. The findings also
illustrated on the multiple existing barriers. These barriers were mainly related to sedentary
lifestyle, mental stress, poverty, illiteracy, superstitions and misconceptions regarding
management of health. Furthermore, lack of trained health personnel, unequal access to
medical devices and hesitancy among the South Asian patients to get themselves screened for
presence of metabolic diseases also hindered the implementation of appropriate intervention
practices (Ambady et al. 2013).
SA immigrants in another study also reported low levels of awareness regarding
diabetes management, and associated complications, in comparison to native Italian and
British population. The study stressed on implementing appropriate steps to overcome
psychological and behavioural barriers, with the aim of empowering the South Asian patients,

45DISSERTATION
in addition to enhancing their self-management skills. Lack of awareness on the native
knowledge of the participants were also identified as major hurdles in the successful
implementation of the culturally targeted interventions.
Discussion
This review examined published studies and trials on the effectiveness of intervention
programs that were aimed at reducing the risks or managing symptoms of T2D in the South
Asian population. It also evaluated a range of procedures that were most commonly used for
the interventions, the direct effects on primary and secondary outcomes, perceived barriers
and awareness of the disorder among the target population. The prevalence of T2D in the
South Asian population has been acknowledged as one of the major health concerns. It is
therefore imperative that appropriate and feasible precautionary measures are put in place,
with the aim of controlling the onset of the metabolic disorder. The interventions or measures
should also be implemented in a way that suits the South Asian population and effectively
reduces their risk of developing T2D. Therefore, this systematic review was conducted with
the aim of expanding on the appropriateness and efficacy of the recognised interventions,
among this population.
Two of the studies found that lifestyle-tailored interventions, and exercise programs
failed to generate any significant impact on bringing about a reduction in the risk of increased
weight among South Asians. These findings were not consistent with other studies that
elaborated on the efficacy of diabetes prevention program based on lifestyle changes. Results
from a systematic review and meta-analysis suggested that lifestyle interventions were able to
result in a mean weight loss of an estimated 2.32kg (95% CI -2.92 to -1.72, I2 = 93.3%).
Furthermore an adherence to specific set of guidelines were also related to increased weight
loss at rates of 0.4kg weight loss increase per increase in point, on the guideline adherence
scale (Dunkley et al. 2014). Similar findings were reported by another study that investigated

46DISSERTATION
the association between intensive weight-loss intervention and T2D remission to
normoglycemia or pre-diabetes. Implementation of lifestyle based interventions were found
to create more loss in weight in the participants at the end of 4 years, in addition to reports of
greater fitness. Furthermore, participants in the lifestyle based intervention group were found
to report increased likelihood of remission experiences (partial or complete), with a
prevalence of 11.5% during the first year and 7.3% during the 4th year (Gregg et al. 2012).
However, the failure of educational interventions on BMI were consistent with results
of another study that aimed to examine the long-term effects of a 2 year long diabetes self-
management support program (DSMS) that was primarily based on empowering the patients.
Delivery of educational week letters and clinical feedbacks failed to bring about any
significant changes in the BMI of African-American adults recruited for the study (Tang et al.
2012). Nonetheless, findings of one of the studies in the systematic review that educational
interventions as a part of diabetes prevention programs were able to reduce weight, improve
BMI and result in diabetes management were confirmed by a recently conducted trial that
tested the efficacy of pharmacist operated diabetes educational intervention on the clinical
outcomes of T2D patients. Results from the study indicated that pharmacist based education,
in addition to pharmaceutical care regimen was successful in enhancing the BMI of the
patients (-0.57; 95%CI: -1.25, -0.12), when compared to education interventions by other
healthcare teams (Bukhsh et al. 2018).
However, the findings of the study included in the review are consistent with that of
another RCT that determined the impact of Community Diabetes Education (CoDE) on
management of diabetes in Mexican Americans. BMI, the secondary outcome measure did
not show any significant changes in the intervention group. The primary reason for this lack
of association between education based diabetes prevention interventions and BMI can be

47DISSERTATION
related to the fact that these educational interventions did not incorporate any explicit
exercise components (Prezio et al. 2013).
Three of the studies presented in the thematic analysis suggested that the interventions
were successful in reducing the waist circumference of the participants. The findings were in
accordance with those of a randomised controlled trial that aimed to translate impacts of
lifestyle intervention in diabetes prevention programs. Participants in the intervention group
were subjected to a coach-led weight loss intervention program and reported high
improvements in their waist circumference when compared to the control groups. Waist
circumference mean values were approximately -5.8 (1.0) versus 2.2(1.1), p<0.001, in the
coach-led group, when compared to the usual care group (Ma et al. 2013). Changes in waist
circumference also show consistency with other another study that aimed to assess the
impacts of an Italian Diabetes and Exercise Study (IDES). Adherence to the IDES program
involved resistance and aerobic training, in addition to exercise counselling for a time period
of 12 months. Results from the study suggested that significant changes were observed in the
waist circumference of the participants who underwent the intervention. The values were 0.00
(-3.00 to 1.00) to -4.00 (-6.00 to -2.00) with p<0.0001. Furthermore, the study established a
correlation of lower body strength with reduction in waist circumference (Balducci et al.
2012).
The fact that waist circumference is a major indicator for the risks of T2D was also
elucidated by another study that illustrated on the presence of BMI>25 and 30kg/m2 as
overweight and obese, respectively. The article also confirmed the fact that waist
circumference was predominantly higher among Asian men and women, when compared to
Whites and African Americans. BMI and waist circumference were also identified as
significant predictors for T2D in Swedish population. Furthermore, the statements presented
in the article that weight loss and a subsequent reduction in the circumference of the waist

48DISSERTATION
helped in bringing about improvements in most of the risk factors of T2D such as, low-
density lipoprotein cholesterol, serum cholesterol, and blood pressure, confirms the findings
of the thematic analysis that reduction in waist circumference is one major indicator of
successful prevention of the onset of T2D (Friedl 2009). The effects of lifestyle based
interventions on waist circumference and diabetes management, as presented in the
observational study included in the review are in accordance with a longitudinal study
conducted in Taiwan that emphasised on the presence of healthy lifestyle and normal waist
circumference with reduced risks of T2D among middle-aged and elderly individuals. The
article elaborated on the negative impacts of unhealthy diet, lack of physical activity and
obesity on the development of T2D, the prevalent lifestyle disease. The primary findings of
the study emphasised on the fact that middle-aged and elderly men with lifestyle
modifications that encompassed healthy diet patterns, psychosocial functioning and rigorous
physical activity had normal waist circumference and lower relative risk for the chronic
metabolic disorder. In addition, the outcomes were also consistent with the impact of high
intake of plant-based food products, low consumption of sweets, red meat, fat rich dairy, and
refined grains for reducing risks of T2D (Chen et al. 2017). Thus, exercise and dietary
changes for weight loss were identified as the prime lifestyle interventions for T2D patients
and helped in confirming the results obtained in the article analysed in the review.
Four of the included studies were successful in reducing or normalising the HbA1c
levels upon the implementation of culturally appropriate interventions in the South Asian
population. This is in accordance with the results of a systematic review and framework that
aimed to evaluate the effectiveness of the diabetes prevention steps that were culturally
tailored for the minority populations. 25 of the 34 articles included in the review were
operative in decreasing the HbA1c levels of the minority participants, in addition to
maintenance of weight and BMI. One article in the review showed a major reduction in the

49DISSERTATION
HbA1c levels at a time period of 3 months and 6 months, following the implementation of
coach-led lifestyle interventions, exercise and diet changes (Lagisetty et al. 2017). The role of
educational intervention in reducing HbA1c levels was elaborated by one study in the review,
which in turn is consistent with effects of another culturally appropriate health education
strategy that targeted ethnic minorities with T2D. Due emphasis was given to the
socioeconomic disadvantage that the ethnic minorities are subjected to, which in turn
increases their susceptibility to suffer from T2D.
The 14 trials contained within in the systematic review were able to produce major
changes in the glycosylated haemoglobin levels. The culturally appropriate health education
based intervention was successful in 14 trials and produced a mean difference of -0.4% (95%
CI -0.5 to -0.2) at the end of three months, for 1442 participants. On the other hand, these
interventions also produced a mean difference of -0.5% (95% CI -0.7 TO -0.4) after six
months, among 1972 participants, when compared to those who were present in the usual
care group (Attridge et al. 2014). This establishes the point that culturally appropriate
interventions that focus on educating the target population play an important role in maintain
glucose levels, and delaying the onset or managing T2D. Similar conclusions were drawn in
another article that was a combination of systematic review, meta-regression and meta-
analysis that determined the effectiveness and characteristics of self-management, education-
based programs, which targeted the ethnic and/or racial minority groups. Showing uniformity
with the study discussed in the thematic analysis, this article also took into consideration
different aspects of diabetes management that comprised of improvement of diabetes related
knowledge, clinical outcomes, and self-management behaviour. The randomised controlled
trials of the review were successful in producing reduction in levels of glycated haemoglobin
by -0.31% (95% CI, -0.48% to -0.14%).

50DISSERTATION
Furthermore, upon conduction of a meta-regression, larger decrease were observed in
the HBA1c levels of the participants during both face-to-face and individual interventions, in
addition to those that involved techniques of cognitive reframing, and peer educators (Ricci-
Cabello et al. 2014). Thus, the educational programs that aim at educating racial and ethnic
minorities for self-management of diabetes are a good approach for targeting the South Asia
community. Furthermore, the results of the studies that this systematic review comprised of
are also confirmed by other research studies that were conducted with the aim of
investigating the changes in body composition, following a 12 month high-intensity
progressive resistance training program, with respect to alterations in glucose homeostasis
and insulin resistance among T2D reporting older adults. Ensuing the randomisation of the
participants in sham exercise or PRT based programs for the pre-determined time period,
glycosylated haemoglobin and homeostatic model of assessment were used as the glucose
homeostasis and IR indicators. PRT was successful in bringing about changes in HbA1c
levels, in association to muscle attenuation of the mid-thigh muscles (r = 0.52; P = 0.001).
However, no significant changes were observed in the sham group (Mavros et al. 2013).
Therefore, these findings were able to explain the theme that focused on HbA1c and
illustrated the fact that high intensity exercises have the capability of improving the metabolic
health disorder in older adults by changing their body composition.
Other authors also provided a similar opinion on the impact of supervised exercise
programs on the blood pressure and lipid profiles of people with T2D. Structured exercise
programs exerted a beneficial impact on HbA1c (WMD 0.51%, 95% CI, 0.68 to 0.34%, I2 =
88.5%; p for heterogeneity< 0.001). Thus, exercise interventions were identified as a
successful approach for diabetes prevention and management (Hayashino et al. 2012).
However, these positive effects of exercise based training programs on the VO2peak and HbA1c
levels were not supported by another study. Following randomisation of the participants to a

51DISSERTATION
control group and exercise training group, no significant alterations were observed between
the two groups with regards to their HbA1c and VO2peak levels. However, patients without
any history of acute myocardial infarction or T2D associated complications, showed a slight
improvement in HbA1c and VO2peak, respectively (p = 0.052 and p = 0.035) (Byrkjeland et al.
2015). Thus, it can be deduced that despite the efficiency of these lifestyle and education
based interventions, it is extremely difficult to implement them in the South Asian
population.
Five of the studies present in the thematic analysis reported on the awareness of T2D
among the South Asian population. The findings can be verified by results from a review that
aimed to investigate the persisting health beliefs of the UK based South Asian community, in
regards to a range of lifestyle diseases. The major outcomes provided an evidence for the fact
that social and cultural norms created a major influence on the incidence of physical activity
and also governed the motivation to engage in healthy dietary habits. Participants with CHD
and diabetes were found to report that changes and alterations made in the traditional South
Asian recipes was impossible without choosing less appealing and bland food items.
Furthermore, women had the key role of cooking appropriate food for all family members
and were also found to report some kinds of moral conflicts regarding collectivist and
individual goals of healthy eating (Lucas, Murray and Kinra 2013).
Similar findings were testified by a population-based study conducted in Bangladesh
that aimed to survey the awareness, control and treatment of T2D among adults. Statistical
reports suggested that among people with diabetes, an estimated 41.2% demonstrated an
awareness of their condition and only 14.2% controlled the metabolic disorder. Furthermore,
significant inequality existed in the management of T2D with regards to the poor and wealthy
houses in terms of 15.8 to 56.6% treatment facilities, 18.2 to 63.2% awareness and 8.2 to
18.4% control practices. Thus, patients with poor educational attainment and lower

52DISSERTATION
socioeconomic standards are likely to be unaware of the condition, thereby showing
similarity with the findings analysed. Moreover, women were found at an increased risk of
diabetes prevalence, which in turn can be attributed to their sedentary lifestyle and dietary
habits (Rahman et al. 2015). Authors of a systematic review also reported analogous results
upon investigating the barriers and facilitators for T2D management among South Asians.
Discordance in communication and language barriers were cited as the common hindrances
that prevented people of the ethnic group from receiving or gaining an understanding of
diabetes education.
This subsequently resulted in their reduced preparedness to undertake self-
management techniques for T2D. Furthermore, lack of details on the tailored diet patterns of
the South Asian population, misconceptions regarding the different components that a
diabetic diet is comprised of and social responsibilities that were associated with continuous
adherence to the traditional diet were some of the barriers that prevented the South Asian
population from adopting the lifestyle based interventions. Findings showed uniformity with
those analysed in the themes that the people generally have misconception and lack of
knowledge on the benefits of physical exercise. Lack of appropriate motivation also prevents
them from increasing their physical activity, with the aim of managing diabetes
complications. Moreover, exercise was also found to hold little cultural sense to the South
Asians, in context of their fitness and health. In addition, anxiety and fretfulness regarding
the security and safety of women belonging to the South Asian community also prevented
them from participating in physical exercise related activities, outside their homes.
Likewise, the traditional diet of South Asians is considered to have high content of
saturated fats from milk, ghee, and yoghurt. Lack of awareness on the food products that will
be culturally appropriate, besides being helpful in diabetes prevention led to their failure in
responding properly to the interventions (Sohal et al. 2015). The results in the systematic

53DISSERTATION
review were also consistent with Bajaj et al. (2013) also confirmed the fact that marked
gender discrimination is prevalent against South Asian women in relation to access of health
services and support for prevention or management of diabetes. This in turn contributes to
high rates of mortality and morbidity among the women. Low educational levels, poor
socioeconomic conditions, increased age have been identified as the major risk factors for
diabetes among the females in the target population. Furthermore, challenges are also related
to ignorance, negative social norms also acted as major barriers in the management of
diabetes.

54DISSERTATION
Chapter 5: Conclusion
Type 2 diabetes is a life-long disease, which results in an increase in the level of
blood sugar, higher than normal. Inadequate secretion of insulin from pancreas, specifically
the iselts of Langerhans, confer an inability in the cells to respond properly to normal levels
of the hormone. The adipose tissue, liver and muscles are the primary regions in the body
where insulin hormone is present. Role of the insulin hormone is associated with the
suppression of glucose release in the liver cells (Dabelea et al. 2014). Moreover, the basic
mechanisms that are imperative for the development of insulin resistance include elevated
breakdown of lipids, high glucagon levels, and more water retention by the kidneys. In other
words, beta cell impairment is the major phenomenon that underlies the development of this
chronic metabolic disorder (Inzucchi et al. 2012). Individuals of South Asian descent have
been identified more vulnerable to the development of type 2 diabetes, upon comparison to
their Caucasian counterparts. Furthermore, South Asians belonging to the Indian,
Bangladeshi and Pakistani descent form a significant part of the UK minority population.
A range of underlying biological factors that are commonly found among the South
Asian population are responsible for the increased prevalence of diabetes. These factors have
been correlated with their lifestyle behaviour, smoking patterns, dietary intake, and physical
activity. Moreover, South Asians also demonstrate more insulin resistance than Europeans
belonging to younger age groups, in addition to low BMI levels. This can be associated with
an increase in visceral fat deposition in the target population (Guariguata et al. 2014). Thus,
increased body fat is responsible for increasing the propensity of T2D among South Asian
people. South Asians are also found to develop this metabolic disorder at much younger age
when compared to Blacks, Chinese and the Whites. The lower BMI levels are another major
contributing factor that increases the susceptibility to diabetes an associated co-morbidities.

55DISSERTATION
The fact that South Asians participate in less physical activity creates negative
metabolic impacts from a younger age and results in the risk of developing T2D.
Furthermore, when compared to Europeans, people of South Asian descent low less physical
activity and dietary patterns that comprise of more intake of carbohydrates, refined grains and
saturated fats. This directly increases their likelihood of developing the disorder at a later
stage in their lives. Analysis of several research study indicates that bringing about changes
in the dietary patterns, physical exercise and other lifestyle factors prove beneficial in
preventing the onset of this metabolic disorder, and it successful management. This increase
predisposition can also be linked to the presence of specific variants of T2D associated genes
such as, FTO, CDKN2A, PPARG and TCF7L2. All of these aforementioned factors make
South Asians more prone to T2D by at least 2-4 times that other population (Qin et al. 2012).
Their increased vulnerability can also be associated with presence of oxidative stress markers
such as, leptin and C-reactive proteins. An elevation in reactive oxygen species lead to the
stress that is essential for T2D onset and more visceral fat deposition (Tangvarasittichai
2015).
Nutritional transition that occurs after migration of the South Asians to the UK also
increases the prevalence of T2D among the individuals belonging to the target population.
The South Asian dietary pattern encompasses consumption of food products that have high
glycemic load and are also related to an elevation in the postprandial blood glucose levels,
thereby increasing the risks of T2D. Moreover, high hazard ratios for the development of
T2D have been found among Bangladeshi, Pakistani and Indian men and women, when
compared to their European counterparts (Ramachandran, Snehalatha and Ma 2014). Beta-
cell function assessment have also elaborated on the fact that South Asians show an increased
in the responsiveness of beta cells by as much as 30%, which in turn is not considered
adequate for compensating for the insulin resistance found among them. In other words, early

56DISSERTATION
dysfunction in the beta cells forms the prime pathophysiological mechanism that leads to the
development of T2D among South Asians.
An analysis of the findings presented above also illustrate that South Asian people
have high waist to hip ratios and increased waist measurements, which are fundamental for
the development of obesity among individuals. Poor BMI has been linked with high levels of
plasma insulin and an increase in insulin resistance. When compared to Europeans, the high
visceral and abdominal fat deposition among South Asians have been found to significantly
reduce by the implementation of lifestyle based modifications (Deepa et al. 2015). Thus, it
can be concluded from the findings presented above that a range of lifestyle related factors
need modification to reduce the risks of T2D. The most effective interventions have been
found to commonly incorporate strategies that focus on physical exercise, reduced intake of
fat and carbohydrate rich food, and health education. These interventions are relatively
modest when compared to pharmacological management strategies and can be easily
accessed by different people. An examination of the systematic review findings suggest that
South Asian people with T2D have been encouraged to practice exercise and other forms of
physical activity, with the aim of better controlling blood glucose levels, thereby reducing the
risks of cardiovascular diseases. Adherence to interventions that encompass physical activity
have been found to significantly lower HbA1c levels, and waist circumference (Colberg et al.
2016).
This can be attributed to the fact that trials that involve physical activity lead to
greater muscle movement, which in turn result in an increase in uptake of sugar by the
muscle cells, thereby reducing blood sugar levels. Additional benefits of this intervention
have been correlated with healthier heart and better control of weight (Lumb 2014).
Furthermore, it can be deduced from the systematic review that long-tern physical activity
programs have demonstrated a consistent effect on insulin sensitivity and carbohydrate

57DISSERTATION
metabolism that results in an improvement in HbA1c levels in the South Asian patients.
Long-term lifestyle modification programs that focus on regular exercise have been identified
feasible for South Asians with T2D and result in sustained improvements in blood glucose
levels. Trials that involved dietary modifications have also shown direct benefits on the BMI,
HbA1c levels and waist circumference by reducing the intake of trans- and saturated fats, and
low sources of starch (Nanditha et al. 2016). These lifestyle modifications have also been
found to reduce the blood glucose level and weight gain. This in turn has proved effective in
reducing the risks of associated co-morbidities among the South Asians. Thus, lifestyle
interventions have been found effective in bringing about improvements in insulin sensitivity
and glucose tolerance in the South Asian population. Modest weight reductions upon
adherence to the lifestyle interventions are also beneficial for health improvements.
Hence, appropriate diet that contains low amounts of calories, and high intake of
fibre, in addition to increased physical activity and health education are some of the changes
that have proved successful in improving the metabolic profile of the South Asians, and
subsequently reducing the prevalence of the metabolic disorder (Bakker et al. 2014). These
interventions have also shown noteworthy reduction in the blood glucose levels and enhance
obesity measures. However, lack of awareness on T2DA and its associated risks were
identified as a major barrier in the implementation of these interventions. Inadequate
financial resource, fears related to safety of women and social obligations were
acknowledged as the major challenges that prevent South Asian people adhere to the
intensive lifestyle interventions. (Horne and Tierney 2012) Absence of proper motivation has
also been linked to noncompliance to the interventions. There also exist discrimination in
terms of use of healthcare services, against women of South Asian descent. Despite the
benefits of health education, the existing language differences often make it difficult for the

58DISSERTATION
funding and delivery of interventions that focus on educating the target population for the
deterrence and management of the disease (Misra et al. 2014).
In other words, effective prevention and management strategies should be feasible and
culturally acceptable by people of a South Asian descent. Thus, it can be established that
intensive efforts need to be taken to increase the awareness among South Asians on the fact
that they are present at an increased risk of T2D development and associated comorbid
conditions, when compared to other ethnic groups. Research studies conducted till date have
focused on preventive measures that encompass therapeutic lifestyle changes (Rejeski et al.
2012). Providing adequate nutrition during the perinatal and intrauterine periods should be
considered as a major intervention that will promote insulin resistance among South Asians.
Furthermore, maintaining the anthropogenic measurements and body weight within normal
limits will also help in reducing risks for T2D in the South Asian population. Loss in weight
is central for the decrease in waist circumference of most people, when pooled with increased
physical exercise (Lindström et al. 2013). These will create beneficial impacts on the
metabolic variable and will subsequently result in an enhancement in the uptake of sugar by
the adipose tissue.
To conclude, the swiftness with which type 2 diabetes has become a pandemic in
South Asian populations have been huge. Over the past years, several research trials have
successfully recognised the risk factors and the pathophysiology that underlie the
development of the disorder in the South Asian population. Thus, bringing about a reduction
in the burden of T2D on the population via the implementation of practical and feasible goals
should be the primary objective for future research studies. The long-term impacts of these
culturally acceptable interventions will help in the prevention and management of the
lifestyle disorder and will directly enhance the quality of life.

59DISSERTATION

60DISSERTATION
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