How physically active are South Asians in the United Kingdom? A literature review

Factors facilitating and hindering South Asian immigrant adults from engaging in exercise and physical activity - a qualitative systematic review

BACKGROUND

Exercise and physical activity are key components of management in patients with rheumatic musculoskeletal diseases (RMD), but people of the South Asian communities have a lower level of engagement with these activities compared to their Caucasian counterparts. The aim of this qualitative systematic review was to determine the barriers and facilitators of exercise and physical activity in South Asian communities who have migrated and live in western countries, particularly in those who have RMD.

METHODS

Qualitative studies, published in English between 1999 and 2021 and including evaluation of barriers and/or facilitators to exercise or physical activity behaviour in people of South Asian adult communities who have migrated and/or lived in western countries were identified from Embase, MEDLINE, CINAHL, PsycINFO, Google Scholar and manual searches. The studies were appraised using the CASP checklist. Inductive thematic synthesis was used to identify common and global themes.

RESULTS

A total of 32 studies that discussed barriers and facilitators of physical activity in South Asian communities who have migrated and lived in western countries were used for this review but there were no studies identified that focussed specifically on those with RMD. Following appraisal of the reporting of the studies, 30 studies were included in the pooling of the results. The facilitators and barriers to physical activities were broadly categorized into 'extrinsic' and 'intrinsic' factors. Extrinsic factors such as 'opportunity' included environmental factors such as weather and safety; socioeconomic factors such as education, language and literacy, and support in the form of social, psychological and resources. Intrinsic factors included cultural factors, such as life stages and family influence, beliefs and knowledge, which impacted attitudes and skills.

CONCLUSIONS

This review has synthesised evidence of barriers or facilitators and identified potentially modifiable factors influencing physical activity and exercise engagement, which could form the basis of evidence-based interventions to promote participation in healthy behaviour change. Provision of a safe, comfortable and culturally acceptable environment together with culturally-aligned cognitive strategies to facilitate acquisition of exercise-efficacy skills could help engagement.

REGISTRATION

The systematic review was registered on PROSPERO, registration no. 289,235.

Barriers and enablers to engagement in exercise and physical activity in non-English speaking South Asian people with chronic musculoskeletal disease

BACKGROUND

Exercise and physical activity (EPA) are recommended for people with chronic musculoskeletal disease; however, lower levels of engagement with EPA has been consistently reported in people from the South Asian community across a range of diseases. As language can pose a significant barrier in healthcare, this study aimed to understand the enablers and barriers to the acceptance of EPA among non-English speaking South Asian people who attended rheumatology clinics.

METHODS

12 non-English speaking individuals from the South Asian community who had chronic musculoskeletal disease with significant pain scores were interviewed via telephone or face-to-face in their spoken languages. The audio recordings of the interviews were translated into English and transcribed verbatim. Data was analysed using thematic analysis implemented in the NVivo 12 Pro software program.

RESULTS

The mean age was 52 years (9 women and 2 men). One main theme was identified: 'Enablers and barriers to exercise and physical activity'. Enablers to EPA were having knowledge about the benefits of EPA, being given resources in a language that they understood, and supportive environments such as having access to community facilities for those who could not undertake EPA in their houses. Barriers included physical health such as pain and fatigue, lack of time, difficulties with transportation to exercise venues, dislike of group exercises and lack of understanding of what and how to do exercise and be physically active. Participants' beliefs about EPA and whether they impacted their physical health seemed to influence whether they were undertaken or not. There was a perception that their culture shaped their compatriots' beliefs about EPA, and it was not normal practice for people from their country of birth to engage in it.

CONCLUSIONS

This is the first qualitative study to explore the barriers and enablers to engagement in EPA in non-English speaking South Asian people with chronic musculoskeletal disease. Modifiable factors such as addressing the level of knowledge on the benefits of EPA in the management of chronic joint and muscle pain; aiding the development of the skills required to exercise safely and confidently despite chronic pain and providing information and services in the native language could promote the EPA engagement of non-English speaking South Asian individuals with chronic musculoskeletal disease. The findings may inform improvements within clinical services to promote the benefits, impact and self-efficacy of engagement with EPA as part of chronic musculoskeletal disease management.

ETHICS APPROVAL

The West Midlands-Edgbaston Research Ethics Committee (reference:20/WM/0305).

Diabetes mellitus and obesity among South Asians with ischemic stroke across three countries

BACKGROUND

Diabetes mellitus and central obesity are more common among South Asian populations than among White British people. This study explores the differences in diabetes and obesity in South Asians with stroke living in the United Kingdom, India, and Qatar compared with White British stroke patients.

METHODS

The study included the UK, Indian, and Qatari arms of the ongoing large Bio-Repository of DNA in Stroke (BRAINS) international prospective hospital-based study for South Asian stroke. BRAINS includes 4580 South Asian and White British recruits from UK, Indian, and Qatar sites with first-ever ischemic stroke.

RESULTS

The study population comprises 1751 White British (WB) UK residents, 1165 British South Asians (BSA), 1096 South Asians in India (ISA), and 568 South Asians in Qatar (QSA). ISA, BSA, and QSA South Asians suffered from higher prevalence of diabetes compared with WB by 14.5% (ISA: 95% confidence interval (CI) = 18.6-33.0, p < 0.001), 31.7% (BSA: 95% CI = 35.1-50.2, p < 0.001), and 32.7% (QSA: 95% CI = 28.1-37.3, p < 0.001), respectively. Although WB had the highest prevalence of body mass index (BMI) above 27 kg/m2 compared with South Asian patients (37% vs 21%, p < 0.001), South Asian patients had a higher waist circumference than WB (94.8 cm vs 90.8 cm, p < 0.001). Adjusting for traditional stroke risk factors, ISA, BSA, and QSA continued to display an increased risk of diabetes compared with WB by 3.28 (95% CI: 2.53-4.25, p < 0.001), 3.61 (95% CI: 2.90-4.51, p < 0.001), and 5.24 (95% CI: 3.93-7.00, p < 0.001), respectively.

CONCLUSION

South Asian ischemic stroke patients living in Britain and Qatar have a near 3.5-fold risk of diabetes compared with White British stroke patients. Their body composition may partly help explain that increased risk. These findings have important implications for public health policymakers in nations with large South Asian populations.

Physical activity and sedentary behaviour among south Asian immigrants in Australia

ISSUE ADDRESSED

South Asians make up the second-largest group of immigrants in Australia and experience a higher burden of chronic diseases compared with non-immigrants. Most chronic diseases are associated with insufficient physical activity (PA) and sedentary behaviour (SB); however, studies involving PA and SB in immigrants are limited. This study aimed to explore PA and SB and associated factors among South Asian immigrants in Australia.

METHODS

South Asian adult immigrants in Australia were surveyed online (from November 2020 to March 2021) about PA, SB, knowledge and barriers to PA. Logistic regressions were used to examine factors associated with insufficient PA (<150 minutes/week) and a high sitting time (>8 hours/day).

RESULTS

A total of 321 participants provided complete data. Approximately 76% of participants reported insufficient PA and 27% reported high sitting time. Only 6% of participants walked or bicycled. The main reported barriers to PA were lack of time, costs, transport facilities, skills, and culturally appropriate resources. Around 52% of participants were not aware of the importance of PA. Participants with self-reported poor health and who used motorized travel were more likely to have inadequate PA. High sitting time was more common among middle-aged, overweight/obese, and middle-income participants.

CONCLUSIONS

Most South Asian immigrants are insufficiently active with a lack of socio-economically appropriate PA facilities identified as a major challenge. A stronger collaboration between policymakers and community is required for sustainable solutions. SO WHAT?: Affordable and appropriate PA facilities in neighbourhoods could overcome major barriers. Also, information about PA should incorporate cultural expectations in the general recommendations to encourage participation.

The Epidemiology of Domain-Specific Physical Activity in New Zealand Adults: A Nationally Representative Cross-Sectional Survey

BACKGROUND

Surveillance of domain-specific physical activity (PA) helps to target interventions to promote PA. We examined the sociodemographic correlates of domain-specific PA in New Zealand adults.

METHODS

A nationally representative sample of 13,887 adults completed the International PA Questionnaire-long form in 2019/20. Three measures of total and domain-specific (leisure, travel, home, and work) PA were calculated: (1) weekly participation, (2) mean weekly metabolic energy equivalent minutes (MET-min), and (3) median weekly MET-min among those who undertook PA. Results were weighted to the New Zealand adult population.

RESULTS

The average contribution of domain-specific activity to total PA was 37.5% for work activities (participation = 43.6%; median participating MET-min = 2790), 31.9% for home activities (participation = 82.2%; median participating MET-min = 1185), 19.4% for leisure activities (participation = 64.7%; median participating MET-min = 933), and 11.2% for travel activities (participation = 64.0%; median MET-min among participants = 495). Women accumulated more home PA and less work PA than men. Total PA was higher in middle-aged adults, with diverse patterns by age within domains. Māori accumulated less leisure PA than New Zealand Europeans but higher total PA. Asian groups reported lower PA across all domains. Higher area deprivation was negatively associated with leisure PA. Sociodemographic patterns varied by measure. For example, gender was not associated with total PA participation, but men accumulated higher MET-min when taking part in PA than women.

CONCLUSIONS

Inequalities in PA varied by domain and sociodemographic group. These results should be used to inform interventions to improve PA.

Metabolic Syndrome and Chronic Disease Risk in South Asian Immigrants: A Review of Prevalence, Factors, and Interventions

South Asians (SAs) are among the fastest-growing ethnic groups in the U.S. Metabolic syndrome (MetS) is a condition that is characterized by multiple health factors that increase the risk for chronic diseases, such as cardiovascular disease (CVD) and diabetes. MetS prevalence among SA immigrants ranges from 27-47% in multiple cross-sectional studies using different diagnostic criteria, which is generally higher compared to other populations in the receiving country. Both genetic and environmental factors are attributed to this increased prevalence. Limited intervention studies have shown effective management of MetS conditions within the SA population. This review reports MetS prevalence in SAs residing in non-native countries, identifies contributing factors, and discusses ways to develop effective community-based strategies for health promotion targeting MetS among SA immigrants. There is a need for more consistently evaluated longitudinal studies to facilitate the development of directed public health policy and education to address chronic diseases in the SA immigrant community.

A Scoping Review on Community-Based Programs to Promote Physical Activity in Older Immigrants

Older immigrants are at higher risks for inactivity due to cultural, environmental, and social barriers in the postmigration context. Community-based physical activity (PA) programs increase PA in older adults, yet little is known about approaches that specifically target older immigrants. This scoping review explores the literature on community-based programs that increase PA and physical fitness in immigrant older adults and identifies barriers and facilitators to PA program participation in this population. A systematic search of electronic databases and gray literature was conducted, and a total of 11 articles met the inclusion criteria after full-text screening. A range of populations and PA program characteristics are described, yet there is a lack of studies on older immigrant men, Black older immigrants, and immigrants from Arab and African countries. There is a need for further research to develop evidence-informed PA programs for this diverse population.

Ischaemic stroke in South Asians: The BRAINS study

BACKGROUND AND PURPOSE

Studies on stroke in South Asian populations are sparse. The aim of this study was to compare differences in age of onset of ischaemic stroke in South Asian patients living in the United Kingdom and South Asian patients living in India versus White British stroke patients.

METHODS

We studied the UK and Indian arms of the ongoing BRAINS study, an international prospective hospital-based study of South Asian stroke patients. The BRAINS study includes 4038 South Asian and White British patients with first-ever ischaemic stroke, recruited from sites in the United Kingdom and India.

RESULTS

Of the included patients, 1126 were South Asians living in India (ISA), while 1176 were British South Asian (BSA) and 1736 were White British (WB) UK residents. Patients in the ISA and BSA groups experienced stroke 19.5 years and 7.2 years earlier than their WB counterparts, respectively (mean [interquartile range] age: BSA 64.3 [22] years vs. ISA 52.0 [18] years vs. WB 71.5 [19] years; p < 0.001). Patients in the BSA group had higher rates of hypertension, diabetes mellitus and hypercholesterolaemia than those in the ISA and WB groups. After adjustment for traditional stroke risk factors, an earlier age of stroke onset of 18.9 years (p < 0.001) and 8.9 years (p < 0.001) was still observed in the ISA and BSA groups, respectively. In multivariable stepwise linear regression analysis, ethnicity accounted for 24.7% of the variance in early age onset.

CONCLUSION

Patients in the BSA and ISA groups experienced ischaemic stroke approximately 9 and 19 years earlier, respectively, than their WB counterparts. Ethnicity is an independent predictor of early age of stroke onset. Our study has considerable implications for public health policymakers in countries with sizable South Asian populations.

‘We just don’t have this in us…’: Understanding factors behind low levels of physical activity in South Asian immigrants in Metro-Vancouver, Canada

Background

South Asian immigrants in western countries are at a high risk for metabolic syndrome and associated chronic disease. While a physically active lifestyle is crucial in decreasing this risk, physical activity (PA) levels among this group remain low. The objectives of this study were to explore social and cultural factors that influence PA behavior, investigate how immigration process intersects with PA behaviors to influence PA levels and to engage community in a discussion about what can be done to increase PA in the South Asian community.

Methods

For this qualitative study, we conducted four Focus Group Discussions (FGDs) among a subset of participants who were part of a larger study. FGD data was coded and analysed using directed content analysis to identify key categories.

Results

Participants expressed a range of opinions, attitudes and beliefs about PA. Most believed they were sufficiently active. Women talked about restrictive social and cultural norms that discouraged uptake of exercise. Post-immigration levels of PA were low due to change in type of work and added responsibilities.

Conclusion

Health promoters need to consider social, cultural, and structural contexts when exploring possible behavior change interventions for South Asian immigrants.

Implementation of a Physical Activity Vital Sign in Primary Care: Associations Between Physical Activity, Demographic Characteristics, and Chronic Disease Burden

INTRODUCTION

Physical activity is important to prevent and manage multiple chronic medical conditions. The objective of this study was to describe the implementation of a physical activity vital sign (PAVS) in a primary care setting and examine the association between physical activity with demographic characteristics and chronic disease burden.

METHODS

We extracted data from the electronic medical records of patients who had visits from July 2018 through January 2020 in a primary care clinic in which PAVS was implemented as part of the intake process. Data collected included self-reported physical activity, age, sex, body mass index, race, ethnicity, and a modified Charlson Comorbidity Index score indicating chronic disease burden. We classified PAVS into 3 categories of time spent in moderate to strenuous intensity physical activity: consistently inactive (0 min/wk), inconsistently active (<150 min/wk), and consistently active (≥150 min/wk). We used χ² tests of independence to test for association between PAVS categories and all other variables.

RESULTS

During the study period, 13,704 visits, corresponding to 8,741 unique adult patients, had PAVS recorded. Overall, 18.1% of patients reported being consistently inactive, 48.3% inconsistently active, and 33.7% consistently active. All assessed demographic and clinical covariates were associated with PAVS classification (all P < .001). Larger percentages of consistent inactivity were reported for female, older, and underweight or obese patients. Larger percentages of consistent activity were reported for male, younger, and normal weight or overweight patients.

CONCLUSION

Using PAVS as a screening tool in primary care enables physicians to understand the physical activity status of their patients and can be useful in identifying inactive patients who may benefit from physical activity counseling.

Acceptability, Usability and Weight Loss Outcomes in a Randomized Cross-Over Study of Commercially Available Portion Size Tools in an Overweight South Asian Community

South Asian women living in the UK are particularly at high risk of obesity-related complications, such as type 2 diabetes and cardiovascular disease. Exposure to large portion sizes is a risk factor for obesity. Specifically designed tableware helps individuals to manage weight by controlling food portion sizes. Thirty-one (n = 31) overweight or obese South Asian adult women participated in a randomised cross-over trial aimed to assess the efficacy, acceptance, and weight change of two guided/calibrated commercially available portion control tools (Utensil set and Crockery Set) used in free-living conditions. Data on acceptance, perceived changes in portion size, frequency, and meal type was collected using paper questionnaires and 3-day diet diaries. Scores describing acceptance, ease of use, and perceived effectiveness were derived from five-point Likert scales from which binary indicators (high/low) were analysed for significance using multivariate variance analysis for repeated measurements. A reduction in BMI was observed at each point of measurement (p = 0.007). For overall tool use, the crockery set scored higher in all areas of acceptance, ease of use, and perceived efficacy for all comparisons. Self-selected portion sizes increased for salads and decreased for cooking oil and breakfast cereals with both tools. Further research to scale up and evaluate similar weight management interventions for this group is warranted.

Does the longitudinal association between neighbourhood cohesion and mental health differ by ethnicity? Results from the UK Household Longitudinal Survey

PURPOSE

While the association between neighbourhood cohesion and mental health has been widely studied in the general population, the effects of neighbourhood cohesion across ethnic groups are not well understood. Ethnicity is often left out of study design, many studies do not consider effect modification by ethnicity, or they rely on overly simplistic ethnic categories.

METHODS

Data from the UK household longitudinal study were used to investigate whether changes in neighbourhood cohesion are independently associated with changes in mental health (measured using the GHQ) over 9 years (2009-2018), and whether the association differed across 17 ethnic groups. The study used a fixed-effect modeling approach that includes within-person estimators that allow each participant to act as their own control.

RESULTS

Compared to British White, the following ethnic groups all saw a similar improvement in GHQ (- 0.76, 95% CI - 0.83 to - 0.70) for each point increase in neighbourhood cohesion: Irish, any other White, White and Asian mixed, Chinese, Caribbean, African, any other Black, Arab, and others. Some ethnic groups saw stronger improvements in mental for each point increase in neighbourhood cohesion, including White and Black Caribbean mixed, any other mixed, Indian, Pakistani, any other Asian, with the strongest effect seen in Bangladeshi participants (- 2.52. 95% CI - 3.48 to - 1.56).

CONCLUSION

Our study highlights the importance of ethnocultural data in research examining neighbourhood effects on mental health. Future research should evaluate policies to improve neighbourhood cohesion for ethnic minorities to address ethnic mental health disparities.

Behavioural interventions to promote physical activity in a multiethnic population at high risk of diabetes: PROPELS three-arm RCT

BACKGROUND

Type 2 diabetes is a leading cause of mortality globally and accounts for significant health resource expenditure. Increased physical activity can reduce the risk of diabetes. However, the longer-term clinical effectiveness and cost-effectiveness of physical activity interventions in those at high risk of type 2 diabetes is unknown.

OBJECTIVES

To investigate whether or not Walking Away from Diabetes (Walking Away) - a low-resource, 3-hour group-based behavioural intervention designed to promote physical activity through pedometer use in those with prediabetes - leads to sustained increases in physical activity when delivered with and without an integrated mobile health intervention compared with control.

DESIGN

Three-arm, parallel-group, pragmatic, superiority randomised controlled trial with follow-up conducted at 12 and 48 months.

SETTING

Primary care and the community.

PARTICIPANTS

Adults whose primary care record included a prediabetic blood glucose measurement recorded within the past 5 years [HbA_1c ≥ 42 mmol/mol (6.0%), < 48 mmol/mol (6.5%) mmol/mol; fasting glucose ≥ 5.5 mmol/l, < 7.0 mmol/l; or 2-hour post-challenge glucose ≥ 7.8 mmol/l, < 11.1 mmol/l] were recruited between December 2013 and February 2015. Data collection was completed in July 2019.

INTERVENTIONS

Participants were randomised (1 : 1 : 1) using a web-based tool to (1) control (information leaflet), (2) Walking Away with annual group-based support or (3) Walking Away Plus (comprising Walking Away, annual group-based support and a mobile health intervention that provided automated, individually tailored text messages to prompt pedometer use and goal-setting and provide feedback, in addition to biannual telephone calls). Participants and data collectors were not blinded; however, the staff who processed the accelerometer data were blinded to allocation.

MAIN OUTCOME MEASURES

The primary outcome was accelerometer-measured ambulatory activity (steps per day) at 48 months. Other objective and self-reported measures of physical activity were also assessed.

RESULTS

A total of 1366 individuals were randomised (median age 61 years, median body mass index 28.4 kg/m², median ambulatory activity 6638 steps per day, women 49%, black and minority ethnicity 28%). Accelerometer data were available for 1017 (74%) and 993 (73%) individuals at 12 and 48 months, respectively. The primary outcome assessment at 48 months found no differences in ambulatory activity compared with control in either group (Walking Away Plus: 121 steps per day, 97.5% confidence interval -290 to 532 steps per day; Walking Away: 91 steps per day, 97.5% confidence interval -282 to 463). This was consistent across ethnic groups. At the intermediate 12-month assessment, the Walking Away Plus group had increased their ambulatory activity by 547 (97.5% confidence interval 211 to 882) steps per day compared with control and were 1.61 (97.5% confidence interval 1.05 to 2.45) times more likely to achieve 150 minutes per week of objectively assessed unbouted moderate to vigorous physical activity. In the Walking Away group, there were no differences compared with control at 12 months. Secondary anthropometric, biomechanical and mental health outcomes were unaltered in either intervention study arm compared with control at 12 or 48 months, with the exception of small, but sustained, reductions in body weight in the Walking Away study arm (≈ 1 kg) at the 12- and 48-month follow-ups. Lifetime cost-effectiveness modelling suggested that usual care had the highest probability of being cost-effective at a threshold of £20,000 per quality-adjusted life-year. Of 50 serious adverse events, only one (myocardial infarction) was deemed possibly related to the intervention and led to the withdrawal of the participant from the study.

LIMITATIONS

Loss to follow-up, although the results were unaltered when missing data were replaced using multiple imputation.

CONCLUSIONS

Combining a physical activity intervention with text messaging and telephone support resulted in modest, but clinically meaningful, changes in physical activity at 12 months, but the changes were not sustained at 48 months.

FUTURE WORK

Future research is needed to investigate which intervention types, components and features can help to maintain physical activity behaviour change over the longer term.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN83465245.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 77. See the NIHR Journals Library website for further project information.

Differences in ill health and in socioeconomic inequalities in health by ethnic groups: a cross-sectional study using 2011 Scottish census

Objectives: We compare rates of ill health and socioeconomic inequalities in health by ethnic groups in Scotland by age. We focus on ethnic differences in socioeconomic inequalities in health. There is little evidence of how socioeconomic inequalities in health vary by ethnicity, especially in Scotland, where health inequalities are high compared to other European countries.Design: A cross-sectional study using the 2011 Scottish Census (population 5.3 million) was conducted. Directly standardized rates were calculated for two self-rated health outcomes (poor general health and limiting long-term illness) separately by ethnicity, age and small-area deprivation. Slope and relative indices of inequality were calculated to measure socioeconomic inequalities in health.Results: The results show that the White Scottish population tend to have worse health and higher socioeconomic inequalities in health than many other ethnic groups, while White Polish and Chinese people tend to have better health and low socioeconomic inequalities in health. These results are more salient for ages 30-44. The Pakistani population has high rates of poor health similar to the White Scottish for ages 15-44, but at ages 45 and above Pakistani people have the highest rates of poor self-rated health. Compared to other ethnicities, Pakistani people are also more likely to experience poor health in the least deprived areas, particularly at ages 45 and above.Conclusions: There are statistically significant and substantial differences in poor self-rated health and in socioeconomic inequalities in health between ethnicities. Rates of ill health vary between ethnic groups at any age. The better health of the younger minority population should not be taken as evidence of better health outcomes in later life. Since socioeconomic gradients in health vary by ethnicity, policy interventions for health improvement in Scotland that focus only on deprived areas may inadvertently exclude minority populations.

Exploring the physical activity of Iranian migrant women in the United Kingdom: a qualitative study

PURPOSE

This article explores the role migration has on the physical activity of Iranian migrant women living in the United Kingdom.

METHOD

This qualitative study includes 22 first-generation Iranian migrant women, aged 24-64, residing in London. Data was collected through in-depth, semi-structured, individual interviews and was analyzed thematically.

RESULTS

The findings show that for those women from traditional backgrounds, migration corresponds with liberation from social and cultural pressures experienced in Iran and greater motivation to adopt a physically active lifestyle. However, for Iranian women who had arrived in the UK more recently and had a higher social standing in Iran, migration was associated with the loss of their careers, sources of income, and social networks. These issues were compounded by a lack of cohesion in Iranian migrant communities and poor access to local physical activity resources. This resulted in diminishing motivation and the subsequent de-prioritisation of the women's physical activity, even though they had regularly engaged in physical activity in Iran.

CONCLUSION

Despite migration leading to improving physical activity for some Iranian women, for others, migration leads to marginality in Britain. Local authorities and Iranian community organizations need to adopt innovative strategies to reach out to recent Iranian migrant women.

Frailty in ethnic minority women

In majority populations in high- and middle-income countries, women live longer yet experience higher levels of frailty than men of the same age. It is unclear whether this 'sex-frailty paradox' is present in ethnic minority populations. In this narrative review, we explore biological, behavioural and social factors associated with mortality, morbidity and frailty in women, particularly ethnic minority women. We ascertain that natural menopause occurs earlier in women of particular ethnicities. Ethnic minority women (living in high-income countries) have more children and higher rates of chronic disease and disability, all of which are associated with frailty. In some ethnic minorities, women are less likely to engage in deleterious health behaviours such as smoking and alcohol consumption. However, in others the reverse is true. Women from migrant ethnic minorities tend to have lower levels of physical activity. With time, they can also adopt adverse behavioural patterns of the majority population. Although the evidence is sparse, sex differences in health reporting and social assets, as well as gender roles, are likely to contribute to sex differences in frailty in ethnic minorities. Overall, ethnic minority women are a particularly vulnerable group, but the majority of risk factors for frailty appear to be mutable rather than fixed. Future research may examine interventions that target frailty in different races and ethnicities at individual, population and global levels.

The Prevalence of Daily Sedentary Time in South Asian Adults: A Systematic Review

This study aimed to systematically review total daily sedentary time in South Asian adults. Seven electronic databases were searched, identifying relevant articles published in peer-reviewed journals between March 1990 and March 2021. The study was designed in accordance with PRISMA guidelines. Prospective or cross-sectional design studies reporting total daily sedentary time in South Asian adults (aged ≥18 years), reported in English, were included. Study quality and risk of bias were assessed, and the weighted mean total daily sedentary time was calculated. Fourteen full texts were included in this systematic review from studies that were conducted in Bangladesh, India, Norway, Singapore, and the United Kingdom. Pooled sedentary time across all studies was 424 ± 8 min/day. Sedentary time was measured using self-report questionnaires in seven studies, with a weighted mean daily sedentary time of 416 ± 19 min/day. Eight studies used accelerometers and inclinometers with a weighted mean sedentary time of 527 ± 11 min/day. South Asian adults spend a large proportion of their time being sedentary, especially when recorded using objective measures (~9 h/day). These findings suggest that South Asians are an important target population for public health efforts to reduced sedentary time, and researchers and practitioners should seek to standardise and carefully consider the tools used when measuring sedentary time in this population.

Cardio-metabolic outcomes in South Asians compared to White Europeans in the United Kingdom: a matched controlled population-based cohort study

BACKGROUND

There appears to be an inequality in the risk of cardio-metabolic disease between those from a South Asian (SA) background when compared to those of White Europeans (WE) descendance, however, this association has not been explored in a large European cohort. This population-based open retrospective cohort explores the incidence of cardio-metabolic disease in those without pre-existing cardiometabolic disease taken from a large UK primary care database from 1st January 2007 to 31st December 2017.

METHODS

A retrospective open cohort matched population-based study using The Health Improvement Network (THIN) database. The outcomes of this study were the incidences of cardio-metabolic events (type 2 diabetes mellitus, hypertension, ischemic heart disease, stroke, heart failure, and atrial fibrillation).

RESULTS

A total of 94,870 SA patients were matched with 189,740 WE patients. SA were at an increased risk of developing: T2DM (adjusted hazard ratio (aHR) 3.1; 95% CI 2.97-3.23); HTN (1.34; 95% CI: 1.29-1.39); ischaemic heart disease (IHD) (1.81; 95% CI: 1.68-1.93) and heart failure (HF) (1.11; 95% CI: 1.003-1.24). However, they were at a lower risk of atrial fibrillation (AF) (0.53; 95% CI: 0.48-0.59) when compared to WE. Of those of SA origin, the Bangladeshi community were at the greatest risk of T2DM, HTN, IHD and HF, but were at the lowest risk of AF in when compared to Indians and Pakistanis.

CONCLUSION

Considering the high risk of cardio-metabolic diseases in the SA cohort, differential public health measures should be considered in these patients to reduce their risk of disease, which may be furthered tailored depending on their country of origin.

The Underrepresentation of Females in Studies Assessing the Impact of High-Dose Exercise on Cardiovascular Outcomes: a Scoping Review

High-dose exercise-induced cardiac outcomes may vary between sexes. However, many studies investigating the cardiovascular effects of high-dose exercise have excluded or under-recruited females. This scoping review aimed to describe the recruitment of females in studies assessing the impact of high-dose exercise on cardiovascular outcomes and describe how this has changed over time. This scoping review followed the protocol outlined by Arksey and O’Malley and is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. The OVID and EMBASE databases were searched for studies that assessed the effects of high-dose exercise on cardiovascular outcomes. Both professional and nonprofessional groups were included. The review found 2973 studies, and 250 met the inclusion criteria including cumulatively 17,548,843 subjects. Over half the studies (n = 127) excluded females entirely, and only 8 (3.2%) studies recruited all-female participants. The overall mean percentage of females recruited was 18.2%. The mean percentage was 14.5% in studies conducted before 2011 and 21.8% in studies conducted after 2011. Females are an underrepresented group in studies assessing the cardiovascular outcomes related to high-dose exercise. As cardiovascular outcomes vary between sexes, translating findings from a largely male-based evidence may not be appropriate. Future investigators should aim to establish and overcome barriers to female recruitment.

Risk factors for non-communicable diseases related to obesity among first- and second-generation Bangladeshi migrants living in north-east or south-east England

BACKGROUND

Obesity is a global burden, which significantly increases the risk of non-communicable diseases (NCDs). More than a quarter of adults in the United Kingdom are obese, but prevalence varies by ethnicity, and South Asians have the largest burden of NCDs. This paper assesses how sex, generation, and region interplay to vary the predisposition to obesity-related (OR) NCDs among UK Bangladeshis.

METHODS

We used National Institute for Health and Care Excellence suggested grading for combining body mass index and waist circumference to define populations at risk of OR-NCDs. Data from 517 adults of Bangladeshi origin from a cross-sectional study (March 2013 to April 2015) were analysed. Male and female participants from London and north-east England were equally sampled including: (1) adult migrants, who came to the UK aged >16 years; (2) child migrants, who came to the UK aged ≤16 years; and (3) second-generation Bangladeshis (who were born and brought up in the UK). A generalised estimating equation using a binomial distribution and a logit link was used to explore the relationship between the binary outcome of being 'at risk of OR-NCDs' and associated factors.

RESULTS

Females, married individuals, those living in London, the second-generation, and those of lower self-assessed financial status, with low acculturation status, or who did not walk daily for at least 20 min were more likely to develop OR-NCDs. A striking sex difference was found with more females prone to OR-NCD risk in the north-east than in London.

CONCLUSIONS

Our study observed important inter- and intra-regional inequality in OR-NCD risk which worsens the health of ethnic minorities and widens inequality.

Global Prevalence of Physical Activity, Sedentary Behaviour, and Sleep of Immigrant Children: a Systematic Review

BACKGROUND

Although insufficient physical activity (PA), high sedentary behaviour (SB), and inadequate sleep are fairly common among children, little is known about these behaviours in immigrant children. This systematic review examined the prevalence of PA, SB, and sleep among immigrant children aged 5-17 years around the globe.

METHODS

Four electronic databases were searched to retrieve the English language peer-reviewed original articles published between 2000 and 2019. Cross-sectional, cohort, or longitudinal studies that reported on the prevalence of PA, SB, or sleep-related outcomes among immigrant children were included.

RESULTS

Of 2724 retrieved articles, 55 were selected for full-text screening and 12 met the eligibility criteria. Five studies were based on nationally representative samples. Over half (n = 7; 58%) of the studies assessed only PA, one reported only sleep, three reported both PA and SB, and one reported all three behaviours. Only one study used device-based measure. Assessment of PA and SB varied greatly across the studies with their differing definitions. The prevalence of doing PA ranged from 48 to 72%. Three studies reported an average sedentary time ranging from 1 to 3 h/day. One study reported that 10-13% of immigrant children in the USA had inadequate sleep. All of the studies reviewed were from Western countries with no study from non-Western countries.

CONCLUSIONS

Future studies should include all three movement behaviours and use standard assessment tools and definitions. Future research should extend beyond Western countries to non-Western countries with immigrant children.

A Qualitative Exploration of Immigrant Muslim Older Adults' Experiences and Perceptions of Physical Activity

Physical activity is essential for healthy aging; however, there has been little exploration of physical activity in Muslim older immigrants in Canada. Over one million Canadians identify as Muslim, the majority is first-generation immigrants, with increasing cohorts entering older age. A community-based participatory research project on healthy aging was conducted with 68 older adults and community members from South Asian, Arab, and African Muslim ethnocultural communities in a Canadian urban center. A combination of individual interviews and focus groups discussions were completed, followed by thematic analysis of data. Participating community groups emphasized the importance of physical activity in older age and prioritized the need for physical activity programs. The four themes highlight Muslim older immigrants' perspectives on physical activity in Canada: (a) values and approaches to staying active; (b) health factors: pain and health limitations; (c) social factors: culture, religion, and belonging; and (d) environmental factors: safety and accessibility.

Social networks, health and identity: exploring culturally embedded masculinity with the Pakistani community, West Midlands, UK

Background

Migrants from South Asia living in developed countries have an increased risk for developing cardiovascular disease (CVD), with limited research into underlying social causes.

Methods

We used social capital as an interpretive lens to undertake analysis of exploratory qualitative interviews with three generations of at-risk migrant Pakistani men from the West Midlands, UK. Perceptions of social networks, trust, and cultural norms associated with access to healthcare (support and information) were the primary area of exploration.

Results

Findings highlighted the role of social networks within religious or community spaces embedded as part of ethnic enclaves. Local Mosques and gyms remained key social spaces, where culturally specific gender differences played out within the context of a diaspora community, defined ways in which individuals navigated their social spheres and influenced members of their family and community on health and social behaviours.

Conclusions

There are generational and age-based differences in how members use locations to access and develop social support for particular lifestyle choices. The pursuit of a healthier lifestyle varies across the diverse migrant community, determined by social hierarchies and socio-cultural factors. Living close to similar others can limit exposure to novel lifestyle choices and efforts need to be made to promote wider integration between communities and variety of locations catering to health and lifestyle.

Objective measurement of physical activity and sedentary behavior among South Asian adults: A systematic review

Background

South Asians are one of the fastest growing ethnic groups in western countries with a high incidence of chronic diseases like metabolic syndrome and cardiovascular disease occurring at younger ages and lower body weight compared with white Europeans. Physically active lifestyle and reduced sedentary time are modifiable risk factors that can decrease burden of chronic diseases. Population-level surveys based on self-report show South Asians engage in low levels of physical activity. Because of known limitations with self-report data, we aimed to synthesize available evidence to generate a physical activity /sedentary time profile of South Asians from studies using accelerometry.

Methods

We systematically searched Medline, EMBASE, CINAHL, PsycINFO, and SportDiscus. We included studies applying accelerometry to measure physical activity /sedentary time under free-living. Studies with an exclusive focus on drugs or including participants with health conditions/physical disability, and special populations (athletes/pregnant women) were excluded. Two authors independently adjudicated inclusion of citations at title/abstract and full text. We applied a standardized data abstraction form to extract relevant data. We evaluated methodological quality using Newcastle Ottawa Quality Assessment Scale. Due to variability and inconsistencies in measurement and reporting of physical activity /sedentary time, we only provide a narrative synthesis.

Findings

We identified only 14 studies(n = 1,338). Despite using similar accelerometry assumptions, we noted variability in reported outcomes for physical activity and sedentary time. Sedentary time ranged from 482(98) to 587 min/day. Mean light physical activity ranged from 211.69(67. 38) to 574(227) min/day. Moderate to vigorous physical activity among South Asian women ranged from 17–41 min/day and among men, 32–43 min/day.

Conclusion

South Asians exhibited higher levels of physical activity when compared to the Canadian population level survey but not when compared to the American population level survey. Overall, fewer studies, and small sample sizes led to considerable variability limiting any effective comparisons. Results highlight the importance of conducting methodologically robust studies based on random sampling to advance the field, and to capture true levels of sedentary time and physical activity in the South Asian population.

Exploring Knowledge and Perspectives of South Asian Children and Their Parents Regarding Healthy Cardiovascular Behaviors: A Qualitative Analysis

South Asian children and parents have been shown to have a higher risk for cardiovascular disease (CVD) relative to white individuals. To design interventions aimed at addressing the comparatively higher burden in South Asians, a better understanding of attitudes and perspectives regarding CVD-associated behaviors is needed. As a result, we sought to understand knowledge about CVD risk in both children and parents, and attitudes toward physical activity and diet in both the children and parents, including potential cultural influences. In-depth interviews were conducted with 13 South Asian child-and-parent dyads representing a range of child body mass index (BMI) levels, ages, and with both sexes. South Asian children and parents demonstrated good knowledge about CVD prevention; however, knowledge did not always translate into behavior. The influence of social and cultural dynamics on behavior was also highlighted. To ensure that interventions aimed at this population are effective, an understanding of the unique social dynamics that influence diet and physical activity-related behaviors is needed.

Neighborhood walkability and pre-diabetes incidence in a multiethnic population

INTRODUCTION

We examined whether adults living in highly walkable areas are less likely to develop pre-diabetes and if so, whether this association is consistent according to immigration status and ethnicity.

RESEARCH DESIGN AND METHODS

Population-level health, immigration, and administrative databases were used to identify adults aged 20-64 (n=1 128 181) who had normoglycemia between January 2011 and December 2011 and lived in one of 15 cities in Southern Ontario, Canada. Individuals were assigned to one of ten deciles (D) of neighborhood walkability (from lowest (D1) to highest (D10)) and followed until December 2013 for the development of pre-diabetes.

RESULTS

Overall, 220 225 individuals in our sample developed pre-diabetes during a median follow-up of 8.4 years. Pre-diabetes incidence was 20% higher among immigrants living in the least (D1) (adjusted HR 1.20, 95% CI 1.15 to 1.25, p<0.0001) versus most (D10, referent) walkable neighborhoods after accounting for age, sex, and area income. Findings were similar among long-term residents and across sexes. However, susceptibility to walkability varied by ethnicity where D1 versus D10 adjusted HRs ranged from 1.17 (95% CI 1.02 to 1.35, p=0.03) among West Asian and Arab immigrants to 1.32 (95% CI 1.19 to 1.47, p<0.0001) in Southeast Asians. Ethnic variation in pre-diabetes incidence was more marked in low walkability settings. Relative to Western Europeans, the adjusted HR for pre-diabetes incidence was 2.11 (95% CI 1.81 to 2.46, p<0.0001) and 1.50 (95% CI 1.27 to 1.77, p<0.0001) among Sub-Saharan African and the Carribean and Latin American immigrants, respectively, living in the least walkable (D1) neighborhoods, but only 1.24 (95% CI 1.08 to 1.42, p=0.002) and 1.00 (95% CI 0.87 to 1.15, p=0.99) for these same groups living in the most walkable (D10) neighborhoods.

CONCLUSIONS

Pre-diabetes incidence was reduced in highly walkable areas for most groups living in Southern Ontario cities. These findings suggest a potential role for walkable urban design in diabetes prevention.

Measuring upper limb function and patient reported outcomes after major breast cancer surgery: a pilot study in an Asian cohort

Background

Breast cancer is the most common cancer in women worldwide. Major breast cancer surgery especially with axillary lymph node dissection (ALND), is associated with upper limb functional decline. Majority of studies are conducted in Western population and may not be applicable to Asians. This pilot study aims to evaluate whether major breast surgery results in upper limb functional impairment in a cohort of Asian women with breast cancer.

Methods

This is a prospective cohort study of 41 patients who underwent 44 major breast surgeries from April 2018 to August 2019. Main inclusion criteria were patients over 21 years of age undergoing major breast surgery for breast cancer. Major breast surgery was defined as wide local excision (WLE) or mastectomy. Main exclusion criteria were patients with pre-existing neurological or rheumatological co-morbidities affecting upper limb function or previous trauma with resulting deformities to the upper limbs. Patients underwent early rehabilitation from post-operative day 1. Shoulder flexion and abduction active range of motion (AROM) and QuickDASH disability score were assessed 1 week before surgery, post-operative week 2 and week 6. Baseline demographics and peri-operative data were also collected.

Results

Median age was 62.5 years. There were 16 (36.4%) wide local excisions and 28 (63.6%) simple mastectomies. Two (4.5%) cases had neoadjuvant chemotherapy. Fifteen (34.1%) cases had ALND. At post-operative week 6, shoulder flexion was comparable to baseline (p = 0.775), while abduction improved from baseline (p = 0.016). However, QuickDASH disability score was significantly worse at post-operative week 6 compared to baseline (median score 2.5 vs 0, p = 0.027). Subgroup analysis of patients with ALND demonstrated significantly worse QuickDASH disability score at post-operative week 6 (p = 0.010) but not for patients with only sentinel lymph node biopsy (p = 0.396).

Conclusion

This pilot study in an Asian cohort found that patients were able to regain AROM of shoulder after major breast surgery at post-operative week 6 but had a worse QuickDASH disability score, especially in the subgroup with ALND. Aggressive and early rehabilitation should be encouraged. However, a longer follow-up is required to evaluate long term functional outcomes.

The Effects of Combined Movement and Storytelling Intervention on Motor Skills in South Asian and White Children Aged 5-6 Years Living in the United Kingdom

Early motor development has an important role in promoting physical activity (PA) during childhood and across the lifespan. Children from South Asian backgrounds are less active and have poorer motor skills, thus identifying the need for early motor skill instruction. This study examines the effect of a movement and storytelling intervention on South Asian children’s motor skills. Following ethics approval and consent, 39 children (46% South Asian) participated in a 12-week movement and storytelling intervention. Pre and post, seven motor skills (run, jump, throw, catch, stationary dribble, roll, and kick) were assessed using Children’s Activity and Movement in Preschool Study protocol. At baseline, South Asian children had poorer performance of motor skills. Following the intervention, all children improved their motor skills, with a bigger improvement observed for South Asian children. Early intervention provided remedial benefits to delays in motor skills and narrowed the motor skills gap in ethnic groups.

Should Bangladeshi Race Be Considered as an Independent Risk Factor for Multi Vessel Coronary Artery Disease?

Introduction

Coronary Artery Disease (CAD) continues to be on the rise not only in the Western developed world but also affecting the South Asian race, particularly Bangladeshis. The objectives of this study were as follows: To determine whether or not risk factors of Bangladeshis differ from non-Bangladeshis, whether there is any difference in the extent of CAD for both groups, and if there are risk factors that can significantly affect the extent of CAD.

Methods

All patients with a diagnosis of CAD admitted to our 800-bed tertiary care hospital between January 2001 and December 2015 were retrospectively analyzed. We reviewed the age, sex, body-mass index (BMI), cardiac risk factors such as family history of CAD, dyslipidemia, hypertension, diabetes and smoking. We also reviewed coronary angiographic findings of these consecutive 150 Bangladeshis and a randomly selected group of 193 non-Bangladeshis.

Results

A total of 343 medical records were evaluated, this included two groups: 193 non-Bangladeshis and 150 Bangladeshi subjects. The Bangladeshi group was older than the non-Bangladeshi group (63.49 vs 59.22, p-value=0.001), and included a larger proportion of males than the non-Bangladeshi group (28.7% vs 15.68%, p-value=0.0116). Bangladeshi subjects are more likely to be smokers than non-Bangladeshi (11.75% vs 6.67%, χ2=12.7, p-value=0.0004). Non-obstructive, 1-vessel, 2-vessel and 3-vessel accounts for 13.33%, 36.67%, 22%, and 28% for Bangladeshis, and 16.39%, 20.77% 34.43% and 28.42% for non-Bangladeshis, respectively. The difference of extent of CAD is significant between two groups (χ2 =12.397, p-value=0.0061). The findings suggest that Bangladeshi ethnicity has almost 2 times the likelihood of having 1-vessel CAD at coronary angiography (OR=2.361, 95% CI 1.452-3.839, p=0.0005).

Conclusion

This study is a pivotal starting point for further evaluating the link between Bangladeshis and CAD. In our study we found that being Bangladeshi increases the risk of having CAD and may be an independent risk factor for multi-vessel CAD.

Educational differentials in key domains of physical activity by ethnicity, age and sex: a cross-sectional study of over 40 000 participants in the UK household longitudinal study (2013-2015)

OBJECTIVES

To assess whether educational differentials in three key physical activity (PA) domains vary by age, sex and ethnicity.

DESIGN

National cross-sectional survey.

SETTING

UK.

PARTICIPANTS

Altogether 40 270 participants, aged 20 years and over, from the UK Household Longitudinal Study with information on education, PA and demographics collected in 2013-2015.

OUTCOME MEASURES

Participation in active travel (AT), occupational activity (OA) and leisure time physical activity (LTPA) at the time of assessment.

RESULTS

Lower educational attainment was associated with higher AT and OA, but lower weekly LTPA activity; these associations were modified by sex, ethnicity and age. Education-related differences in AT were larger for women-the difference in predicted probability of activity between the highest and the lowest education groups was -10% in women (95% CI: -11.9% to 7.9%) and -3% in men (-4.8% to -0.4%). Education-related differences in OA were larger among men -35% (-36.9% to -32.4%) than women -17% (-19.4% to -15.0%). Finally, education-related differences in moderate-to-vigorous LTPA varied by ethnicity; for example, differences were 17% (16.2% to 18.7%) for white individuals compared with 6% (0.6% to 11.6%) for black individuals.

CONCLUSIONS

Educational differences in PA vary by domain and are modified by age, sex and ethnicity. A better understanding of physically inactive subgroups may aid development of interventions to both increase activity levels and reduce health inequalities.

Racial/ethnic differences in the burden of type 2 diabetes over the life course: a focus on the USA and India

Type 2 diabetes is a common disease worldwide, but its prevalence varies widely by geographical region and by race/ethnicity. This review summarises differences in the frequencies of type 2 diabetes according to race, ethnicity, socioeconomic position, area of residence and environmental toxins. Type 2 diabetes susceptibility often begins early in life, starting with genetic susceptibility at conception and continuing in later life, via in utero, childhood and adult exposures. Early-life factors may lead to overt type 2 diabetes in childhood or in later life, supporting the concept of developmental origins of health and disease. The causes of the racial/ethnic differences in incidence of type 2 diabetes are not well understood. Specifically, the relative contributions of genetic and environmental factors to such differences are largely unknown. With a few exceptions in isolated populations, there is little evidence that differences in frequencies of known type 2 diabetes susceptibility genetic alleles account for racial/ethnic differences, although the search for genetic susceptibility has not been uniform among the world's racial/ethnic groups. In the USA, race/ethnicity is associated with many other risk factors for type 2 diabetes, including being overweight/obese, diet and socioeconomic status. Some studies suggest that some of these factors may account for the race/ethnic differences in prevalence of type 2 diabetes, although there is inadequate research in this area. A better understanding of the impact of these factors on type 2 diabetes risk should lead to more effective prevention and treatment of this disease. This has not yet been achieved but should be a goal for future research.

Factors associated with accelerometer measured movement behaviours among White British and South Asian children aged 6-8 years during school terms and school holidays

OBJECTIVES

To investigate factors associated with movement behaviours among White British (WB) and South Asian (SA) children aged 6-8 years during school terms and holidays.

DESIGN

Cross-sectional.

SETTING

Three primary schools from the Bradford area, UK.

PARTICIPANTS

One hundred and sixty WB and SA children aged 6-8 years.

PRIMARY AND SECONDARY OUTCOMES

Sedentary behaviour (SB), light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) measured by accelerometry during summer, winter and spring and during school terms and school holidays. Data were analysed using multivariate mixed-effects multilevel modelling with robust SEs. Factors of interest were ethnicity, holiday/term, sex, socioeconomic status (SES), weight status, weekend/weekday and season.

RESULTS

One hundred and eight children (67.5%) provided 1157 valid days of data. Fifty-nine per cent of children were WB (n=64) and 41% (n=44) were SA. Boys spent more time in MVPA (11 min/day, p=0.013) compared with girls and SA children spent more time in SB (39 min, p=0.017) compared with WB children in adjusted models. Children living in higher SES areas were more sedentary (43 min, p=0.006) than children living in low SES areas. Children were more active during summer (15 min MVPA, p<0.001; 27 LPA, p<0.001) and spring (15 min MVPA, p=0.005; 38 min LPA, p<0.001) and less sedentary (-42 min and -53 min, p<0.001) compared with winter. Less time (8 min, p=0.012) was spent in LPA during school terms compared with school holidays. Children spent more time in MVPA (5 min, p=0.036) during weekend compared with weekdays. Overweight and obese children spent more time in LPA (21 min, p=0.021) than normal-weight children.

CONCLUSION

The results of our study suggest that significant child level factors associated with movement behaviours are ethnicity, sex, weight-status and area SES. Significant temporal factors are weekends, school holidays and seasonality. Interventions to support health enhancing movement behaviours may need to be tailored around these factors.

Contribution of lower physical activity levels to higher risk of insulin resistance and associated metabolic disturbances in South Asians compared to Europeans

BACKGROUND

Insulin resistance and related metabolic disturbances are major risk factors for the higher T2D risk and associated morbidity and mortality amongst South Asians. The contribution of physical activity to the increased prevalence of insulin resistance and related disturbances amongst South Asians is unknown.

METHODS

We recruited 902 South Asian and European men and women, aged 35-85 years from the ongoing LOLIPOP study. Clinical characterisation comprised standardised questionnaire and measurement of height, weight, waist and hip circumference and blood pressure. Fasting bloods were taken for assessment of glucose, insulin, lipids and HbA1c. Physical activity was quantified using a validated accelerometer, Actigraph GT3X+, worn for 7 days. Univariate and multivariate approaches were used to investigate the relationship between ethnicity, physical activity, insulin resistance and related metabolic disturbances.

RESULTS

Total physical activity was ~31% (P = 0.01) lower amongst South Asians compared to Europeans (Mean MET.minutes [SD]: 1505.2 [52] vs. 2050.9 [86.6], P<0.001). After adjusting for age and sex, total physical activity had a negative association with HOMA-IR (B [SE]: -0.18 [0.08], P = 0.04) and fasting glucose levels (B[SE]: -0.11 [0.04], P = 0.02). There was no association between physical activity and other glycemic and lipid parameters. Total physical activity per week contributed towards the differences in insulin resistance and associated metabolic disturbances between South Asians and Europeans.

CONCLUSION

Lower levels of physical activity may contribute to the increased insulin resistance in South Asians compared to Europeans. Our results suggest that lifestyle modification through increased physical activity may help to improve glucose metabolism and reduce the burden of excess T2D and related complications amongst South Asians.

Differences in objectively measured physical activity and sedentary behaviour between white Europeans and south Asians recruited from primary care: cross-sectional analysis of the PROPELS trial

BACKGROUND

Self-reported data have consistently shown South Asians (SAs) to be less physically active than White Europeans (WEs) in developed countries, however objective data is lacking. Differences in sedentary time have not been elucidated in this population. This study aimed to quantify differences in objectively measured physical activity and sedentary behaviour between WEs and SAs recruited from primary care and to investigate differences in demographic and lifestyle correlates of these behaviours.

METHODOLOGY

Baseline data were utilised from a randomised control trial recruiting individuals identified at high risk of type 2 diabetes from primary care. Light intensity physical activity, moderate-to-vigorous intensity physical activity (MVPA) and steps were measured using the Actigraph GT3X+, while sitting, standing and stepping time were measured using the activPAL3™. Devices were worn concurrently for seven days. Demographic (employment, sex, age, education, postcode) and behavioural (fruit and vegetable consumption, alcohol consumption, smoking status) characteristics were measured via self and interview administered questionnaires.

RESULTS

A total of 963 WE (age = 62 ± 8, female 51%) and 289 SA (age = 55 ± 11, female 43%) were included. Compared to WEs, SAs did less MVPA (24 vs 33 min/day, p = 0.001) and fewer steps (6404 vs 7405 per day, p ≤ 0.001), but sat less (516 vs 552 min/day, p ≤ 0.001) and stood more (328 vs 283 min/day, p ≤ 0.001). Ethnicity also modified the extent to which demographic and behavioural factors act as correlates of physical activity and sedentary behaviour. Differences between sex in levels of MVPA and sitting time were greater in SAs compared to WEs, with SA women undertaking the least amount of MVPA (19 min/day), the least sitting time (475 min/day) and most standing time (377 min/day) than any other group. Smoking and alcohol status also acted as stronger correlates of sitting time in SAs compared to WEs. In contrast, education level acted as a stronger correlate of physical activity in WEs compared to SAs.

CONCLUSION

SAs were less active yet less sedentary than WEs, which demonstrates the need to tailor the behavioural targets of interventions in multi-ethnic communities. Common correlates of physical activity and sedentary behaviour also differed between ethnicities.

TRIAL REGISTRATION

ISRCTN83465245 Trial registration date: 14/06/2012.

The Role of Physical Activity Prescription in Cardiovascular Disease Prevention Amongst South Asian Canadians

Unequivocal evidence suggests an increased prevalence of cardiovascular disease (CVD) amongst South Asian Canadians (SACs) compared to other ethnic cohorts, due to a combination of their unique cardiometabolic profile and environmental factors. This unfavorable CVD profile is characterized by an elevated risk of dyslipidemia, high apolipoprotein B/apolipoprotein A1 ratio, hypertension, glucose intolerance, type 2 diabetes mellitus, as well as increased BMI, body fat percentage, abdominal and visceral adiposity. Despite the overwhelming evidence for the effectiveness of physical activity (PA) in circumventing the onset of CVD and in the reduction of CVD risk factors, SACs are among the most physically inactive cohorts in Canada. This relates to a set of common and unique socio-cultural barriers, such as gender, beliefs and perceptions about illness, immigration, unfavorable PA environments, and their high prevalence of debilitating chronic diseases. Several strategies to improve PA participation rates in this high-risk population have been suggested, and include the implementation of culturally sensitive PA interventions, as well as clinician training in PA prescription through workshops that emphasize knowledge translation into clinical practice. Therefore, the purpose of this mini-review is to highlight and discuss: (1) the burden of heart disease in SACs (2) the cardiovascular benefits of PA for SACs; (3) factors affecting PA participation among SACs and how they can be addressed; (4) the impact of culturally sensitive PA prescription on CVD prevention; (5) barriers to culture-specific PA prescription by clinicians, and strategies to improve its use and impact.

Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association

South Asians (from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) make up one quarter of the world's population and are one of the fastest-growing ethnic groups in the United States. Although native South Asians share genetic and cultural risk factors with South Asians abroad, South Asians in the United States can differ in socioeconomic status, education, healthcare behaviors, attitudes, and health insurance, which can affect their risk and the treatment and outcomes of atherosclerotic cardiovascular disease (ASCVD). South Asians have higher proportional mortality rates from ASCVD compared with other Asian groups and non-Hispanic whites, in contrast to the finding that Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) aggregated as a group are at lower risk of ASCVD, largely because of the lower risk observed in East Asian populations. Literature relevant to South Asian populations regarding demographics and risk factors, health behaviors, and interventions, including physical activity, diet, medications, and community strategies, is summarized. The evidence to date is that the biology of ASCVD is complex but is no different in South Asians than in any other racial/ethnic group. A majority of the risk in South Asians can be explained by the increased prevalence of known risk factors, especially those related to insulin resistance, and no unique risk factors in this population have been found. This scientific statement focuses on how ASCVD risk factors affect the South Asian population in order to make recommendations for clinical strategies to reduce disease and for directions for future research to reduce ASCVD in this population.

Slowing the diabetes epidemic in the World Health Organization South-East Asia Region: the role of diet and physical activity

The nutrition transition occurring in the World Health Organization South-East Asia Region, as a result of rapid urbanization and economic development, has perhaps made this region one of the epicentres of the diabetes epidemic. This review attempts to evaluate the role of diet and physical inactivity in the South-East Asia Region in promoting this epidemic and points to strategies to slow it down by lifestyle modification. The emerging new food-production technologies and supermarkets have made energy-dense foods more easily available. This includes refined carbohydrate foods like those with added sugars, and refined grains and unhealthy fats. In addition, increased availability of modern technology and motorized transport has led to decreased physical activity. South Asian diets tend to be based on high-carbohydrate foods, with a predominance of refined grains. All of these accentuate the risk of diabetes in people of this region, who already have a unique "south Asian phenotype". However, there is increasing evidence that altering diet by replacing refined cereals like white rice with whole grains (e.g. brown rice) and increasing physical activity can help to prevent diabetes in high-risk individuals. An urgent, concerted effort is now needed to improve diet quality and encourage physical activity, by introducing changes in policies related to food and built environments, and improving health systems to tackle noncommunicable diseases like diabetes.

Ethnicity influences cardiovascular outcomes and complications in patients with type 2 diabetes

AIM

To determine whether cardiovascular outcomes in type 2 diabetes (T2D) differ according to ethnicity, and whether ethnicity influences the effect of gender on these outcomes in Caucasians, East-Southeast-Asians, Middle-Easterners, South-Asians and Pacific-Islanders.

METHODS

We compared demographics, HbA1c, lipid profile, renal function markers, and prevalence of macrovascular and microvascular complications between ethnic groups. Cross-sectional data was prospectively collected from 204 consecutive patients at Westmead Hospital's T2D clinic from April-October 2015. Univariate analysis was performed using chi-squared test for categorical data, and Mann-Whitney-U or Kruskal-Wallis test for continuous data.

RESULTS

Compared to Caucasians, South-Asians were diagnosed younger, were currently younger, had lower body-mass-index (BMI) and better renal function but higher rates of non-ST-elevation myocardial infarction (STEMI, 21.7% versus 3.5%, p<0.05). East-Southeast-Asians had lower BMI but more nephropathy than Caucasians (59% versus 39%, p<0.05). East-Southeast-Asian males had fewer CVD than Caucasians, but this protection was absent in East-Southeast-Asian females. Middle-Easterners had more non-STEMI than Caucasians (5.3% vs 3.5%, p<0.05). Middle-Eastern females were not at lower CVD risk than males. Caucasians had most PVD (20% versus 6%, p<0.05).

CONCLUSIONS

Ethnicity influences rates of diabetes-related complications. Female CVD protection is altered in some groups. Ethnicity should be considered in assessing CVD and complications risk.

Improving prevention, monitoring and management of diabetes among ethnic minorities: contextualizing the six G's approach

Objective

People from Black, Asian and Minority Ethnic (BAME) groups are known to have an increased risk of developing diabetes and face greater barriers to accessing healthcare resources compared to their ‘white British’ counterparts. The extent of these barriers varies by demographics and different socioeconomic circumstances that people find themselves in. The purpose of this paper is to present and discuss a new framework to understand, disentangle and tackle these barriers so that improvements in the effectiveness of diabetes interventions for BAME communities can be achieved.

Results

The main mediators of lifestyle behavioural change are gender, generation, geography, genes, God/religion, and gaps in knowledge and economic resources. Dietary and cultural practices of these individuals significantly vary according to gender, generation, geographical origin and religion. Recognition of these factors is essential in increasing knowledge of healthy eating, engagement in physical activity and utilisation of healthcare services. Use of the six G’s framework alongside a community centred approach is crucial in developing and implementing culturally sensitive interventions for diabetes prevention and management in BAME communities. This could improve their health outcomes and overall wellbeing.

Fundamental Movement Skills of Children Living in England: The Role of Ethnicity and Native English Language

The development of fundamental movement skills (FMS) has been associated with children's general health, and, while there is evidence to suggest that age, gender, physical activity, and socioeconomic status relate to FMS, the relationship of ethnicity and language barriers to FMS competence has been underexplored. These factors may be of particular interest for South Asian (SA) children who have lower physical activity and increased risk of metabolic disease. This cross-sectional study examined ethnic and language differences in FMS among 218 ethnically diverse five-year-old children (61 White ethnic background, 91 SA, 29 Black ethnic background, and 37 other), some with English as a native language ( n = 90) and some with English as an additional language ( n = 75), all recruited from within central England. Each child was assessed performing five locomotor skills (run, gallop, hop, leap, and jump) and six object skills (catch, kick, bounce, strike, underarm roll, and overarm throw) on the Test of Gross Motor Development-2 . A 2 (gender) × 4 (ethnicity) factor analysis of covariance assessed differences in the locomotor and object composite scores and total FMS score, while controlling for body mass index. A two-factor analysis of covariance assessed native language differences in their impact on FMS. We found ethnic and gender differences in FMS ( p < .05) in that SA children had poorer total FMS and locomotor scores than children of either White or Black ethnic backgrounds ( p = .004, p = .001, and p = .008, p = .002, respectively). Girls had poorer total ( p = .001) and locomotor FMS skills ( p < .001). Children with English as an additional language had similar FMS scores compared to children whose native language was English ( p > .05). The findings of low FMS competency in SA children and girls, irrespective of body mass index, suggest that developmentally appropriate interventions targeting SA children and girls are needed in early years. We discuss some unclear factors related to these differences.

A formative review of physical activity interventions for minority ethnic populations in England

Background

Physical activity (PA) levels are lower among some UK Black and minority ethnic (BME) groups than the majority White British population and a variety of tailored interventions have emerged. This study documents the characteristics and logic of local adaptations, a vital first step in evaluating such innovations.

Methods

An English PA data set was examined to identify and characterize PA programmes focussed on BME populations. Three case studies were conducted, employing documentary analysis and qualitative interviews. Netto et al.'s principles of adapting health promotion interventions for BME populations guided the analysis.

Results

Out of 861 PA interventions, 57 focussed on BME populations. These were typically aimed to engage the most inactive groups, improve both health and social outcomes and were largely publically/charitably funded. Tailored approaches matched Netto et al.'s five principles: using community resources for publicity, identifying and addressing barriers, developing sensitive communication strategies, working with values and accommodating cultural identification. Another common principle was identified: building community capacity for sustainability.

Conclusions

PA interventions tailored to the needs of BME groups reflect their largely disadvantaged position in society and focus on inactivity. The six principles could be used as a framework for developing, designing and evaluating tailored interventions for BME populations.

Effectiveness of Exercise on Visceral Adipose Tissue in Older South Asian Women

INTRODUCTION

Individuals of South Asian (SA) origin have a greater risk for type 2 diabetes and cardiovascular disease than other ethnic populations. This increased risk is in part explained by the unique obesity phenotype of elevated visceral adipose tissue (VAT) among this population. Aerobic exercise in Europeans is effective at reducing VAT, but this has not been studied in SA, who have some of the lowest levels of physical activity in the world. Therefore, the purpose of this study was to determine whether exercise can reduce VAT given the unique obesity phenotype and associated disease risk in the SA population.

METHODS

A total of 75 physically inactive, postmenopausal SA women were randomized to either culturally based (Bhangra dance), standard (gym-based), or control (nonexercise) program for 12-wk. The primary outcome was change in VAT.

RESULTS

The average attendance in the culturally based and standard program was 78% ± 33% and 67% ± 25%, respectively. After an intention-to-treat analysis, VAT was not significantly reduced in culturally based (-60 cm, 95% confidence interval [CI] = -172 to 54, P = 0.300) or standard (-98 cm, 95% CI = -216 to 21, P = 0.106) exercise compared with control after adjustment for baseline physical activity and age. In those participants who attended more than two-thirds of the exercise classes, VAT was significantly reduced compared with control (-109 cm, 95% CI = -204 to -13, P = 0.026).

CONCLUSION

In intention-to-treat analysis VAT was not significantly reduced after 12 wk of either standard or culturally based exercise. However, attendance in both standard and culturally based exercise was high, and VAT was significantly reduced among SA women who adhered to these programs.

A Mixed-Methods Examination of Physical Activity and Sedentary Time in Overweight and Obese South Asian Men Living in the United Kingdom

South Asian men living in the UK have higher rates of central obesity and Type 2 Diabetes Mellitus (T2DM) compared with their white British counterparts. Physical activity (PA) and sedentary time (ST) are important risk factors for the development of T2DM. The purpose of this study was to objectively measure PA, ST, and to explore the factors influencing these behaviours in this high-risk population. A mixed-methods cross-sectional research design was employed, including the quantification of PA and ST using the self-report International Physical Activity Questionnaire (IPAQ)-long form and accelerometry in overweight and obese UK South Asian men (n = 54), followed by semi-structured interviews in a purposive sub-sample to explore the factors influencing PA and ST (n = 31). Accelerometer-derived moderate-to-vigorous PA (MVPA) and ST were 298.9 ± 186.6 min/week and 551.4 ± 95.0 min/day, respectively. IPAQ-derived MVPA was significantly lower than accelerometer-derived MVPA (p < 0.001). IPAQ-derived ST was significantly higher than accelerometer-derived ST (p < 0.001). Lack of time and family commitments were identified as the main barriers to being more physically active, with group exercise identified as an important facilitator to being more active. A cultural norm of focusing on promoting education over sport participation during childhood was identified as an important factor influencing long-term PA behaviours. Work commitments and predominantly sedentary jobs were identified as the main barriers to reducing ST. Healthcare professionals and researchers need to consider the socio-cultural factors which affect PA engagement in overweight and obese South Asian men living in the UK, to ensure that advice and future interventions are tailored to address the needs of this population.

Examining sedentary time as a risk factor for cardiometabolic diseases and their markers in South Asian adults: a systematic review

OBJECTIVES

The objective was to systematically review the literature to determine whether sedentary time was associated with cardiometabolic diseases and their risk factors among South Asian adults.

METHODS

Six electronic databases were searched to identify all studies that examined the association between sedentary time and cardiometabolic diseases (e.g., diabetes, cardiovascular disease) and their risk factors [e.g., body mass index (BMI), waist circumference (WC), lipids, blood pressure (BP), glucose] among South Asian adults. Two independent reviewers performed abstract/full-text screening, data abstraction, and quality assessments.

RESULTS

Searching identified 1757 potential articles; 22 were used in the analysis. Greater sedentary time was associated with an increased likelihood of diabetes (n = 5), higher BMI (n = 13), WC (n = 3), BP (n = 2), and glucose (n = 4). Thirteen out of 22 studies were of higher quality.

CONCLUSION

Results identified a trend whereby greater sedentary time was associated with an increased risk for diabetes, and several other cardiometabolic risk factors among South Asian adults. High quality studies are needed to identify whether risk factors are independent of physical activity levels to inform culturally-specific interventions for South Asians.