Surrey-North Delta Division of Family Practice

Diabetes

Diabetes and Your South Asian Patients

Prepared by Saira Abrar
March 2019

Surrey and North Delta boasts a thriving ethnic population whose roots are in South Asia. Surrey-North Delta also has the highest prevalence of South Asian patients with type-2 diabetes in Metro Vancouver, alongside Abbotsford. It is widely accepted that South Asians have a higher prevalence of diabetes when compared to other ethnicities. It is estimated that approximately 11% of Surrey’s population is diabetic, with 3,455 new cases diagnosed each year. It stands to reason that the high incidence and prevalence of diabetes observed in Surrey and North Delta is influenced by the high proportion of South Asian immigrants residing in our community.

As a physician in Surrey-North Delta, the chances are high that you serve South Asian patients with diabetes. Read on to learn about diabetes management techniques and how you can use them to best serve your South Asian patients.

South Asian Patients at Increased Risk

The term “South Asian” includes people from seven countries: India, Pakistan, Bangladesh, Sri Lanka, Bhutan, Nepal, and Mauritius. 15-20% of them will develop diabetes as compared to 2-5% in Caucasians. 

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Increased Risk Factors for Type 2 Diabetes

South Asians are more susceptible than Caucasians, Chinese or Black people to type 2 diabetes. They get diagnosed at an early age and have more complications at the time of diagnosis. While environmental factors play a role, it is agreed upon by researchers that whether South Asians are in their home countries or migrate to other parts of the world, they are more susceptible due to genetic factors, as well as increased rates of central obesity and insulin resistance. In fact, South Asians are at higher risk of developing type 2 diabetes at lower thresholds of waist circumference as compared to other ethnicities.

A Greater Prevalence of Metabolic Syndrome

South Asians are at higher risk of developing metabolic syndrome, a condition characterized by high blood pressure, high cholesterol and increased waist circumference. It is considered a precursor of type-2 diabetes and cardiovascular disease. Various surveys have shown that one-third of the populations of big cities in South Asia have metabolic syndrome. South Asian immigrants have the highest prevalence of metabolic syndrome as compared to other ethnicities. Obesity and overweight are highly prevalent, leading to metabolic syndrome in these populations.

Increased Complications from Diabetes

South Asians are also at higher risk of developing complications related to diabetes including chronic kidney disease, heart disease, eye complications, lower limb amputations and damage to peripheral nerves. Diabetes also has a bidirectional relationship with anxiety and depression. According to Diabetes Canada, 30% of people with diabetes experience some form of depression, meaning that South Asian patients with diabetes are also at increased risk for mental health complications.

Diabetes Management & South Asian Cultural Beliefs 

Diabetes is clinically managed by medications and monitored through regular blood tests, but its management would be incomplete without behavioral and lifestyle interventions. People diagnosed with diabetes must change their diets, be more active physically and aim to reduce excess weight. They are expected to learn how to count calories, to eat more fruits and vegetables and to check their blood glucose every day. It is a daunting list, but in the absence of these lifestyle changes, medications alone are rarely successful in managing diabetes.

South Asian people face a particularly challenging set of obstacles in enacting these changes: South Asians are culturally diverse, and their behaviors are strongly influenced by their cultures. Food is an important aspect of their social lives and they consume a diet rich in fat, sugars, and deep-fried foods. If diagnosed with diabetes, it is very challenging for many South Asian people to change their traditional diet – this is often the most difficult aspect of their care routine. South Asian immigrants are also less physically active compared to other ethnicities, contributing to high rates of obesity in those residing in Western countries.

Diabetes is also widely misunderstood in South Asian communities. It is mostly regarded as something inevitable and brings guilt and discomfort to the one diagnosed. It is believed that there isn’t much that can be done to manage diabetes as the illness is God’s will.

Sometimes obesity is considered a sign of prosperity and better health. Some groups observe fasting or pilgrimages and then end the day with a rapid consumption of a high-calorie diet. This leads to abrupt blood glucose levels changes and makes diabetes management more complicated.

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On top of these cultural factors, South Asian diabetics also face the same management challenges as the general diabetic population. Diabetics often feel overwhelmed and anxious due to the high demands of managing their disease. It is not an easy task to keep track of one’s calorie, monitor blood glucose and inject insulin daily. This feeling of helplessness is termed as “diabetes burnout”. Diabetes UK defines it as, “worrying about not taking enough care of your diabetes but unmotivated or unwilling to change” or “feeling overwhelmed and defeated by diabetes”.

3 Ways to Help Your South Asian Patients Manage Their Diabetes 

1. Motivational Interviewing (MI) Training for Health Care Providers 
Researchers have found that patients suffering from chronic diseases like diabetes follow a complex daily regimen to manage their disease and are not really motivated by others’ advice. Hence new techniques are being used by health care professionals to address diabetes burn out. MI is a behavioral intervention technique that has recently garnered a lot of interest in diabetes management. The technique takes health professionals away from “teach and tell” towards a more “collaboration and empowerment” approach. MI techniques are very effective in brief interactions in busy clinical settings.

Health care providers can enroll in MI training available through some organizations to develop an environment of shared understanding and decision making particularly in the context of SA culture.

Please contact Saira Abrar (sairaabrar.sndfp@gmail.com) to learn more about available MI training opportunities. 

2.    A Culturally Relevant Model of Care

A major barrier to diabetes care and education is a poor understanding of the disease by the patients as diabetes is not considered a serious disease in South Asian culture. Educators and policymakers should have a clear understanding of the South Asian culture while developing new policies and strategies to impact our community’s health. Health information should incorporate familiar music, clothing, and language to make it more relevant for this group. Guided shopping visits, cooking classes and informal education classes in a community setting have shown to be effective in some communities. Patients are more motivated to listen and respond if the information is shared in a culturally relevant environment. Diabetes management related interventions should educate communities to promote a healthy lifestyle focusing on improved diet and enhanced physical activity leading to reduced diabetes incidence and its related complications. 

3.    Team-Based Care

Culturally relevant team-based care wrapped around family physicians’ offices is the key to address education and access disparities among various ethnic groups. Research has proved that Interprofessional Diabetes Health Care (DHC) teams including primary care physicians, nurses and dietitians supported by specialists and social workers can reduce lower limb amputations and chronic kidney disease in diabetics.  Interprofessional teams also lead to higher self-reported patient satisfaction and decrease health care costs.

If you are interested in learning more about culturally relevant team-based care in diabetes and would like to share your experience and ideas, please join us on April 14 for a community discussion about integrating primary and community care for diabetes.

A Way Forward for Diabetes in South Asian Communities in Surrey-North Delta

In Surrey and North Delta, diabetes in South Asians is a growing and serious concern that can lead to unimaginable direct and indirect health care costs.  Policy makers and health care professionals must collaborate to develop a plan for the management and early prevention of diabetes in South Asian communities that includes engaging community leaders at cultural centers and places of religious worship. South Asian children need to learn in school about the greater risk they are exposed to and learn how they can incorporate healthier lifestyle choices throughout their whole life. Culturally relevant, collaborative and empowering approaches and prevention strategies that meet South Asian patients where they are at to eliciting behavior change might be our answer to the diabetes epidemic among South Asians.