Asian culture a diabetes challenge
When Dr Shirine Boardman was asked to educate the local south Asian community about diabetes, she was well aware of the challenges she faced.
She is of Asian origin herself and her mother sees obesity as
a sign of rude health – viewing moves to promote weight loss with intense suspicion.
'As a community we need to change the way we cook, eat and live in order to change the pattern of illness,' says Dr Boardman, who is a consultant physician at Warwick Hospital.
South Asian culture is just one of the factors fuelling the alarmingly high rates of diabetes among members of the community. South Asian patients living in the UK are six times more likely to develop diabetes than white people. Prevalence in the 1970s was 1 per cent, but it's now 10-fold higher.
It is increasingly becoming clear that the old one-size-fits-all approach to managing cardiovascular risk is not doing the job, as experts made clear at a South Asian Health Foundation conference last week.
Professor Muir Gray, director of the National Screening Committee, told the conference: 'Our position at the moment is that everybody is at risk. But the response should be in proportion to that risk.'
In practice, just working out a patient's risk is tricky enough, particularly given that most cardiovascular risk tools take little account of ethnic differences.
Dr Jonathan Mant, senior lecturer in public health at the University of Birmingham, says: 'The problem is the algorithm is for the Framingham study of white Americans so it doesn't reflect the risk of minority groups. It does need readjusting, but we're not sure how. JBS2 guidelines suggest a fudge factor.'
This fudge factor involves multiplying the risk score by 1.5 for ethnic groups. Alternatively, it is possible to use the UKPDS risk calculator – which is specific to type 2 diabetes and includes ethnicity.
But Dr Vinod Patel, associate professor in clinical skills at the University of Warwick, insists this too fails to factor the effect of ethnicity properly. Until more data is available, Dr Patel recommends Framingham, with a fudge factor of his own. 'If you look at Framingham, it does predict as long as you add 10 years on. We either use that or we'd have to treat everyone.'
But he believes the most useful risk assessment is even more simple. 'The best risk factor is just your eyes. If you are Asian and have a big waist, you need very, very aggressive treatment,' he says. 'We must concentrate on exercise, smoking, weight
reduction and targeting cholesterol to at least less than five. If they have an increased waist-to-hip ratio you should throw the whole package at them.'
But Dr Peter Brindle, NICE's leading expert on cardiovascular risk, is suspicious of attempts to treat all south Asians as though they belong to the same ethnic group.
'Ethnicity is fraught with classification problems,' he says. 'I was unhappy with the fact that all south Asians were lumped together, there was no guidance, and men and women were lumped together.'
Dr Brindle, who is a GP in Bristol, developed the Ethrisk web tool as an attempt to overcome these difficulties. 'Ethrisk gives a more refined measure. It served to open the debate and provide a better tool,' he says.
But it is not only the risk prediction tools which perform poorly in south Asian patients, it is tests for diabetes too.
New University of Leicester research suggests although
fasting blood glucose tests are cheap, they miss about a third of south Asian patients and
a lesser proportion of white
Inpatient oral glucose tolerance tests do rather better.
Dr Sagar Doshi, consultant cardiologist at Nuffield Hospital in Birmingham, argues better methods to identify south Asian patients with diabetes are required, possibly through screening. 'There probably needs to be better screening, but once you've identified it the treatment needs to be more
intense. Their control tends to be sub-optimal for cultural reasons, as well as medical reasons. Asian education needs to be better,' he says.
Which brings us back to one of the buzz phrases of last week's conference – 'culturally sensitive healthcare'.
Dr Boardman started a campaign called Apnee Sehat – 'our health' in Punjabi – using Bollywood-style storytelling to persuade the community to 'get ghee out of the Gurdwara'.
She insists: 'There's an element of group we can tap into. The whole issue of belonging to a community – the community can make a change.'
Managing south Asian patients
• Use oral glucose tolerance tests to pick up type 2 diabetes
• Adapt Framingham risk scores by multiplying by 1.5 or adding 10 years
• Or Use Ethrisk tool to predict risk in different ethnic sub-groups
• Treat to aggressive JBS2 targets for blood pressure and cholesterol
• Tailor education to take account of cultural differences