Diabetes in Minority Ethnic Groups Smita Grant & Rubina Iqbal NHS Lothian Minority Ethnic Health Inclusion Service (MEHIS)

MEHIS Works with all minority ethnic communities, including refugees and asylum seekers across Lothian. Provides a link-worker / advocacy service. Addresses health inequalities. Encourages best practice and race equality in health service planning and provision.

Higher risk Type 2 diabetes is up to six times more common in people of South Asian descent. The South Asian community is also at risk of Type 2 diabetes from the age of 25, opposed to 40 in the White population. People of Black African origin are up to three times more likely to develop Type 2 diabetes than people of White European origin (Diabetes UK 2014) South Asians appear to progress more rapidly from ‘pre-diabetes’ to diabetes than white Europeans Once diabetes is diagnosed, migrant South Asians have more rapid deterioration in glycaemic control. Type 2 diabetes in migrant South Asians: mechanisms, 1 mitigation and management (Sattar and Gill, 2015)

Census 2011 Total Lothian Population 834,350 White Ethnic Groups % White Scottish 648,746 77.75 White Other British 80,366 9.63 White: Other White 29,276 3.51 White Polish 17,357 2.08 White Irish 11,156 1.34 White Gypsy Traveller 551 0.07

Census 2011 Black Ethnic Groups Number of people % Chinese 8913 1.07 Pakistani 7936 0.95 Indian 7566 0.91 Other Asian 5282 0.63 Mixed or Multiple Ethnic groups 5194 0.62 African 5138 Arab 2719 0.33 Bangladeshi 1372 0.16 Other Ethnic Group 1298 Caribbean 879 0.08 Black 167 0.02 Other African 126

Drive UK Study (2012) (Type 2 Diabetes) Prevalence of any Retinopathy 52% in African / African Caribbean 43% in South Asians 38% prevalence in White Europeans Sight Threatening Diabetes Retinopathy 11.5% in African / African Caribbean 10.3% in South Asians 5.5 % in White Europeans 2 cohorts , Yorkshire and SE London 50,285 people

Lessons from Conversation Map Pilot NHS Lothian and NHS GGC Communication –issues with and without interpreter Training needs for Interpreters, Link workers and Educators Timing of Diabetes education classes Perception of the value of Diabetes Education Possibility of Under-diagnosis in some ethnic groups

Case Study Mr. P is a Pakistani man with Type 1 Diabetes. He is 47 years old and lives with his wife, four children (10 -16 ) and his mother Mrs. P used to work in their family business until she was diagnosed with a terminal illness. The relationships in the family are not good and Social Work have become involved with the 10 year old. Mr. P is concerned about his diabetes management and very worried about becoming blind as he has a secondary care appointment from the Eye Pavilion in a few weeks. Is there anything that can be done to support Mr. P?

MEHIS experience In almost every family and at younger age Delayed diagnosis Low Literacy and health literacy Self Management –totally new concept Lifestyle change advice –what does it actually mean in their context? Multiple barriers to access physical activity or change diet Structural and societal barriers (or facilitators ) for change Stigma rather than nurture (beliefs about health, attitudes and actions influenced or mediated by others Knowledge, values beliefs, cultural / religious norms

Fasting and social events Fasting is practiced in many religions Religious permission to skip fast Experiencing Ramadan in 2017- Dates around 26 May – 24 June……….. Eid –Feasting around 24 June Pilgrimage to Mecca Hajj 2017, 30 August to 4 September Urmrah – all year Weddings and other festivals Social gatherings /social contracts Dawn to dusk without food or water for 19+hours for one month 2017 Meal times –approx -5 hours between 21.45 and 01.45

Oral Health Multiple barriers in access to dentists Understanding of oral health and diabetes Higher rates of smoking in Bangladeshi and Pakistani men Smoking bidi, or use of smokeless tobacco products in shisha, chewing paan or gutkha etc Do you smoke versus do you use tobacco?

Medication Adherence South Asian patients Beliefs about the need for medicines and their effectiveness Fears around the toxicity of medicines Traditional remedies versus 'Western medicines’ Stigma and social support Communication by health professionals Recommendation Tailored medical advice that highlights the long-term consequences of diabetes and CVD.” Understanding adherence-related beliefs about medicine amongst patients of South Asian origin with diabetes and cardiovascular disease patients: a qualitative synthesis (Kumar et al,2016) Too many medicines lead to death Resistance to insulin –culturally unacceptable f Family influence Weddings /parties /festivals top taking medicines so can enjoy Lifestyle OK therefore don’t need , stop taking Understanding adherence-related beliefs about medicine amongst patients of South Asian origin with diabetes and cardiovascular disease patients: a qualitative synthesis Kanta Kumar, Sheila Greenfield, Karim Raza, Paramjit Gill author and Rebecca Stack

Thank you