A culturally adapted lifestyle intervention addressing a Middle Eastern immigrant population at risk of diabetes, the MEDIM (impact of Migration and Ethnicity on Diabetes In Malmö): study protocol for a randomized controlled trial

Interventions for improving health literacy in migrants

BACKGROUND

Health literacy (HL) is a determinant of health and important for autonomous decision-making. Migrants are at high risk for limited HL. Improving HL is important for equitable promotion of migrants' health.

OBJECTIVES

To assess the effectiveness of interventions for improving HL in migrants. To assess whether female or male migrants respond differently to the identified interventions.

SEARCH METHODS

We ran electronic searches to 2 February 2022 in CENTRAL, MEDLINE, Embase, PsycInfo and CINAHL. We also searched trial registries. We used a study filter for randomised controlled trials (RCTs) (RCT classifier).

SELECTION CRITERIA

We included RCTs and cluster-RCTs addressing HL either as a concept or its components (access, understand, appraise, apply health information).

DATA COLLECTION AND ANALYSIS

We used the methodological procedures recommended by Cochrane and followed the PRISMA-E guidelines. Outcome categories were: a) HL, b) quality of life (QoL), c) knowledge, d) health outcomes, e) health behaviour, f) self-efficacy, g) health service use and h) adverse events. We conducted meta-analysis where possible, and reported the remaining results as a narrative synthesis.

MAIN RESULTS

We included 28 RCTs and six cluster-RCTs (8249 participants), all conducted in high-income countries. Participants were migrants with a wide range of conditions. All interventions were adapted to culture, language and literacy. We did not find evidence that HL interventions cause harm, but only two studies assessed adverse events (e.g. anxiety). Many studies reported results for short-term assessments (less than six weeks after total programme completion), reported here. For several comparisons, there were also findings at later time points, which are presented in the review text. Compared with no HL intervention (standard care/no intervention) or an unrelated HL intervention (similar intervention but different information topic) Self-management programmes (SMP) probably improve self-efficacy slightly (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.50; 2 studies, 333 participants; moderate certainty). SMP may improve HIV-related HL (understanding (mean difference (MD) 4.25, 95% CI 1.32 to 7.18); recognition of HIV terms (MD 3.32, 95% CI 1.28 to 5.36)) (1 study, 69 participants). SMP may slightly improve health behaviours (3 studies, 514 participants), but may have little or no effect on knowledge (2 studies, 321 participants) or subjective health status (MD 0.38, 95% CI -0.13 to 0.89; 1 study, 69 participants) (low certainty). We are uncertain of the effects of SMP on QoL, health service use or adverse events due to a lack of evidence. HL skills building courses (HLSBC) may improve knowledge (MD 10.87, 95% CI 5.69 to 16.06; 2 studies, 111 participants) and any generic HL (SMD 0.48, 95% CI 0.20 to 0.75; 2 studies, 229 participants), but may have little or no effect on depression literacy (MD 0.17, 95% CI -1.28 to 1.62) or any health behaviour (2 studies, 229 participants) (low certainty). We are uncertain if HLSBC improve QoL, health outcomes, health service use, self-efficacy or adverse events, due to very low-certainty or a lack of evidence. Audio-/visual education without personal feedback (AVE) probably improves depression literacy (MD 8.62, 95% CI 7.51 to 9.73; 1 study, 202 participants) and health service use (MD -0.59, 95% CI -1.11 to -0.07; 1 study, 157 participants), but probably has little or no effect on health behaviour (risk ratio (RR) 1.07, 95% CI 0.91 to 1.25; 1 study, 135 participants) (moderate certainty). AVE may improve self-efficacy (MD 3.51, 95% CI 2.53 to 4.49; 1 study, 133 participants) and may slightly improve knowledge (MD 8.44, 95% CI -2.56 to 19.44; 2 studies, 293 participants) and intention to seek depression treatment (MD 1.8, 95% CI 0.43 to 3.17), with little or no effect on depression (SMD -0.15, 95% CI -0.40 to 0.10) (low certainty). No evidence was found for QoL and adverse events. Adapted medical instruction may improve understanding of health information (3 studies, 478 participants), with little or no effect on medication adherence (MD 0.5, 95% CI -0.1 to 1.1; 1 study, 200 participants) (low certainty). No evidence was found for QoL, health outcomes, knowledge, health service use, self-efficacy or adverse events. Compared with written information on the same topic SMP probably improves health numeracy slightly (MD 0.7, 95% CI 0.15 to 1.25) and probably improves print literacy (MD 9, 95% CI 2.9 to 15.1; 1 study, 209 participants) and self-efficacy (SMD 0.47, 95% CI 0.3 to 0.64; 4 studies, 552 participants) (moderate certainty). SMP may improve any disease-specific HL (SMD 0.67, 95% CI 0.27 to 1.07; 4 studies, 955 participants), knowledge (MD 11.45, 95% CI 4.75 to 18.15; 6 studies, 1101 participants) and some health behaviours (4 studies, 797 participants), with little or no effect on health information appraisal (MD 1.15, 95% CI -0.23 to 2.53; 1 study, 329 participants) (low certainty). We are uncertain whether SMP improves QoL, health outcomes, health service use or adverse events, due to a lack of evidence or low/very low-certainty evidence. AVE probably has little or no effect on diabetes HL (MD 2, 95% CI -0.15 to 4.15; 1 study, 240 participants), but probably improves information appraisal (MD -9.88, 95% CI -12.87 to -6.89) and application (RR 1.51, 95% CI 1.29 to 1.77) (1 study, 608 participants; moderate certainty). AVE may slightly improve knowledge (MD 8.35, 95% CI -0.32 to 17.02; low certainty). No short-term evidence was found for QoL, depression, health behaviour, self-efficacy, health service use or adverse events. AVE compared with another AVE We are uncertain whether narrative videos are superior to factual knowledge videos as the evidence is of very low certainty. Gender differences Female migrants' diabetes HL may improve slightly more than that of males, when receiving AVE (MD 5.00, 95% CI 0.62 to 9.38; 1 study, 118 participants), but we do not know whether female or male migrants benefit differently from other interventions due to very low-certainty or a lack of evidence.

AUTHORS' CONCLUSIONS

Adequately powered studies measuring long-term effects (more than six months) of HL interventions in female and male migrants are needed, using well-validated tools and representing various healthcare systems.

The effect of a randomised controlled lifestyle intervention on weight loss and plasma proneurotensin

AIMS

Proneurotensin (Pro-NT) is a strong predictor of cardiometabolic disease including type 2 diabetes and obesity, however, the effect of lifestyle change on Pro-NT has not been investigated in this context. Middle Eastern (ME) immigrants represent the largest and fastest growing minority population in Europe and are a high-risk population for obesity and type 2 diabetes. In this randomised controlled lifestyle intervention (RCT) addressing ME immigrants to Sweden where weight-loss was previously studied as the main outcome, as a secondary analysis we aimed to study change in Pro-NT during follow-up and if baseline Pro-NT predicted weight loss.

METHODS

Immigrants from the Middle East at high risk for type 2 diabetes were invited to participate in this RCT adapted lifestyle intervention of four months' duration. The intervention group (N = 48) received a culturally adapted lifestyle intervention comprising seven group sessions and a cooking class addressing healthier diet and increased physical activity. The control group (N = 44) received treatment as usual with information to improve lifestyle habits on their own. Data assessed using mixed effects regression.

OUTCOMES

Primary outcome; change in Pro-NT. Secondary outcome; change in BMI in relation to baseline plasma concentration of Pro-NT.

RESULTS

During the four months follow up, weight was significantly reduced in the intervention (-2.5 kg) compared to the control group (0.8 kg) (β -0.12, 95% CI -0.24 to -0.01, P = 0.028). Pro-NT increased to a significantly greater extent in the intervention compared to the control group during follow up (28.2 vs. 3.5 pmol/L) (β 11.4; 4.8 to 18.02, P < 0.001). Change over time in BMI was associated with baseline Pro-NT (β 0.02; 0.01 to 0.04, P = 0.041).

CONCLUSION

In consistence with data from surgical weight loss, this RCT paradoxically shows increased levels of Pro-NT during a multifactorial lifestyle intervention resulting in weight loss. Long term studies of Pro-NT following weight loss are needed.

TRIAL REGISTRATION

This study is a secondary analysis of the RCT trial registered at www.

CLINICALTRIALS

gov .

REGISTRATION NUMBER

NCT01420198. Date of registration 19/08/2011. The performance and results of this trial conform to the CONSORT 2010 guidelines.

Effects of a randomized, culturally adapted, lifestyle intervention on mental health among Middle-Eastern immigrants

BACKGROUND

Middle-Eastern immigrants in Sweden are at increased risk for type 2 diabetes (T2D) and poor mental health. Physical activity not only prevents/delays onset of T2D but also shows favorable effects on mental health. However, the effects of a culturally adapted lifestyle intervention on mental health among Middle-Eastern immigrants have not been explored before. We aimed to study the effects of a randomized controlled, culturally adapted lifestyle intervention on anxiety and depression levels in diabetes-prone Iraqi immigrants.

METHODS

Participants (n = 96) were randomized to intervention group, IG (n = 50) or control group, CG (n = 46). The IG received seven group sessions addressing lifestyle change and the CG received treatment as usual. Montgomery-Åsberg Depression Rating Scale (MADRS-S) and Hospital Anxiety and Depression Scale (HADS) assessed mental health at start, mid (2 months) and end of the study (4 months). Proportional odds ratio (OR) model was used to study the effect of the intervention.

RESULTS

The odds of scoring lower on MADRS-S and HADS depression scale at visit 3 vs. baseline were higher in the IG compared to the CG (MADRS-S OR 5.9, 95% CI: 1.6-22.5; HADS OR 4.4, 95% CI: 0.9-20.3). The findings persisted after adjustment for age, sex, body mass index, time since migration, sedentary lifestyle and language spoken at home. Group differences were non-significant at visit 2 vs. baseline.

CONCLUSION

A culturally adapted lifestyle intervention addressing T2D prevention in Middle-Eastern immigrants has favorable effects on mental health. The effect was more pronounced at the 4 months than at 2 months follow-up, indicating beneficial effect of longer study duration.

TRIAL REGISTRATION

www.clinicaltrials.gov NCT01420198.

Cost-effectiveness analysis of comprehensive intervention programs to control blood glucose in overweight and obese type 2 diabetes mellitus patients based on a real-world setting: Markov modeling

Background

Blood glucose control management in overweight and obese diabetic patients poses heavy public health and economic burdens on the health system. This study aimed to evaluate the short-term cost-effectiveness of a comprehensive intervention program for blood glucose management in different groups using a Markov model.

Methods

Based on real-world data, a Markov model was developed to calculate the cost per quality-adjusted life-year (QALY) gained. The division of Markov states was in accordance with clinical practice. A three-month cycle length and a 5-year time horizon were applied. A 3% discounting rate was applied for both the costs and utilities.

Results

The incremental cost-effectiveness ratios (ICER) was more favorable for the male group than the female group, with an associated ICER of 104 K RMB per QALY gained. Compared with the younger group, the incremental gain of the middle-aged group was -0.062 QALY, and the incremental cost was -3,198.64 RMB; meanwhile, the incremental gain of the elderly group was -0.176 QALY, and the incremental cost was 4,485.746 RMB. The sensitivity analysis showed that the ICER is sensitive to the costs of this program and less sensitive to the discounting rate and the time horizon.

Conclusions

The comprehensive intervention program for blood glucose management of overweight and obese patients with diabetes is cost-effective for the middle-aged male group and elderly female group, respectively. Moreover, the male group was more favorable than the female group if three times the gross domestic product (GDP) per capita was adopted as the maximum willingness to pay (WTP) for a QALY in China.

Community and stakeholders' engagement in the prevention and management of Type 2 diabetes: a qualitative study in socioeconomically disadvantaged suburbs in region Stockholm

Background: Community-based approaches have been identified as an effective strategy to address the growing burden of noncommunicable diseases (NCDs) worldwide. However, little is known about community as a concept among people living in socioeconomically disadvantaged settings and stakeholders' interactions and engagement in NCDs prevention and management. Objective: The aim of this study was to understand; (1) the meaning of community among people living in socioeconomically disadvantaged suburbs in Region Stockholm and (2) how communities interact and engage with stakeholders at local and regional levels for the prevention and management of type 2 diabetes (T2D). Methods: This qualitative study was conducted in three municipalities in Region Stockholm with a high proportion of migrants. Multiple data collection methods were used, including observations of community activities; interviews with community members, representatives of public authorities and NGOs; and group interviews with healthcare providers. Data were analyzed using content analysis. Results: Community was perceived as living in close proximity with shared beliefs, values and resources. Although they recognized its social and cultural diversity, community members focused more on the commonalities of living in their neighborhood and less on their differences in country of birth and languages spoken. Several mismatches between awareness of community needs and the available skills and resources among stakeholders for T2D prevention were identified. Stakeholders expressed awareness of T2D risk and interest in addressing it in a culturally appropriate manner. Conclusion: Interaction between the communities and stakeholders was limited, as was engagement in T2D prevention and management. This highlights barriers in the collaboration between community, healthcare institutions and other stakeholders which consequently affect the implementation of preventive interventions. Innovative ways to link the community to the healthcare sector and other local government institutions are needed to build the capacity of health systems for T2D prevention in socioeconomically disadvantaged communities.

Physical Activity in a Randomized Culturally Adapted Lifestyle Intervention

INTRODUCTION

Middle Eastern immigrants exhibit high levels of physical inactivity and are at an increased risk for Type 2 diabetes. The primary aim of this study was to examine the changes in objectively assessed physical activity levels following a culturally adapted lifestyle intervention program. The secondary aim was to examine the association between objectively assessed physical activity and insulin sensitivity.

STUDY DESIGN

RCT conducted over 4 months in 2015.

PARTICIPANTS

Iraqi immigrants residing in Malmö, Sweden, exhibiting one or more risk factors for Type 2 diabetes.

INTERVENTION

The intervention group (n=50) was offered a culturally adapted lifestyle intervention comprising seven group sessions including a cooking class. The control group (n=46) received usual care.

MAIN OUTCOME MEASURES

Raw accelerometry data were processed by validated procedures and daily mean physical activity intensity, vector magnitude high-pass filtered (VM-HPF), was inferred. Further inferences into the number of hours/day spent in sedentary (VM-HPF <48 milli-Gs [mGs] where G=9.8 m/sec²) and light- (48- <163 mGs); moderate- (163- <420 mGs); and vigorous-intensity (≥420 mGs) activities were also calculated (year of analysis was 2016-2017).

RESULTS

No difference was observed between the two groups in terms of change over time in VM-HPF. There was a significant increase in the number of hours/day spent in light intensity physical activity in the intervention group compared with the control group (β=0.023, 95% CI=0.001, 0.045, p=0.037). The intervention group also increased the time spent in sedentary activities, with the highest VM-HPF (36- <48 mGs) within the sedentary behavior (B=0.022, 95% CI=0.002, 0.042, p=0.03). Higher VM-HPF was significantly associated with a higher insulin sensitivity index (β=0.014, 95% CI=0.0004, 0.025, p=0.007).

CONCLUSIONS

The findings favor the culturally adapted intervention approach for addressing low physical activity levels among Middle Eastern immigrants. Replacing sedentary time with light-intensity activities could be an achievable goal and will have potential beneficial effects for diabetes prevention among this sedentary group of immigrants.

TRIAL REGISTRATION

This study was registered at www.clinicaltrials.gov NCT01420198.

Valuing a Lifestyle Intervention for Middle Eastern Immigrants at Risk of Diabetes

Willingness-to-pay (WTP) techniques are increasingly being used in the healthcare sector for assessing the value of interventions. The objective of this study was to estimate WTP and its predictors in a randomized controlled trial of a lifestyle intervention exclusively targeting Middle Eastern immigrants living in Malmö, Sweden, who are at high risk of type 2 diabetes. We used the contingent valuation method to evaluate WTP. The questionnaire was designed following the payment-scale approach, and administered at the end of the trial, giving an ex-post perspective. We performed logistic regression and linear regression techniques to identify the factors associated with zero WTP value and positive WTP values. The intervention group had significantly higher average WTP than the control group (216 SEK vs. 127 SEK; p = 0.035; 1 U.S.$ = 8.52 SEK, 2015 price year) per month. The regression models demonstrated that being in the intervention group, acculturation, and self-employment were significant factors associated with positive WTP values. Male participants and lower-educated participants had a significantly higher likelihood of zero WTP. In this era of increased migration, our findings can help policy makers to take informed decisions to implement lifestyle interventions for immigrant populations.

Self-rated health and social capital in Iraqi immigrants to Sweden: The MEDIM population-based study

OBJECTIVES

Poor self-rated health is an estimator of quality of life and a predictor of mortality seldom studied in immigrant populations. This work aimed to study self-rated health in relation to social capital, socioeconomic status, lifestyle and comorbidity in immigrants from Iraq - one of the largest non-European immigrant group in Sweden today - and to compare it with the self-rated health of native Swedes.

DESIGN

The study was a cross-sectional population-based study conducted from 2010 to 2012 among citizens of Malmö, Sweden, aged 30-65 years and born in Iraq or Sweden. All participants underwent a health examination and answered questionnaires on self-rated health, social capital, comorbidity, lifestyle and socioeconomic status.

RESULTS

In total, 1348 Iraqis and 677 Swedes participated. Poor self-rated health was identified in 43.9% of Iraqis and 21.9% of native Swedes ( p<0.001), with the highest prevalence (55.5%) among Iraqi women. Low social capital was highly prevalent in the immigrants. Female gender showed higher odds of poor self-rated health in Iraqis than in Swedes (OR 1.8, 95% CI 1.4-2.5, p_interaction=0.024), independent of other risk factors connected to social capital, socioeconomic status, lifestyle or comorbidity.

CONCLUSIONS

Although public health initiatives promoting social capital, socioeconomic status and comorbidity in immigrants are crucial, the excess risk of poor self-rated health in Iraqi women is not fully attributed to known risk factors for self-rated health, but remains to be further explored.

Changes in dietary intake following a culturally adapted lifestyle intervention among Iraqi immigrants to Sweden at high risk of type 2 diabetes: a randomised trial

Objective

To investigate the effectiveness of a culturally adapted lifestyle intervention for changing dietary intake, particularly energy, fat and fibre intakes, in the intervention group (IG) compared with the control group (CG).

Design

Randomised controlled trial.

Setting

IG (n 50) and CG (n 46). The IG was offered seven group sessions, including one cooking class, over a period of 4 months. The participants filled out 4 d food diaries at the start, mid and end of the study.

Subjects

Iraqi-born residents of Malmö, Sweden, at increased risk for developing diabetes.

Results

At baseline, participants’ fat intake was high (40 % of total energy intake (E%)). The predefined study goals of obtaining <30 E% from fat and ≥15 g fibre/4184 kJ (1000 kcal) were met by very few individuals. In the IG v. the CG, the proportion of individuals obtaining <40 E% from fat (48·4 v. 34·6 %, P=0·65), <10 E% from saturated fat (32·3 v. 11·5 %, P=0·14) and ≥10 g fibre/4184 kJ (45·2 v. 26·9 %, P=0·46) appeared to be higher at the last visit, although the differences were statistically non-significant. A trend towards decreased mean daily intakes of total energy (P=0·03), carbohydrate (P=0·06), sucrose (P=0·02) and fat (P=0·02) was observed within the IG. Differences in changes over time between the groups did not reach statistical significance.

Conclusions

Although no significant differences were observed in the two groups, our data indicate that this culturally adapted programme has the potential to modify dietary intake in Middle Eastern immigrants. The high fat intake in this group should be addressed.

Internet as a Source of Long-Term and Real-Time Professional, Psychological, and Nutritional Treatment: A Qualitative Case Study Among Former Israeli Soviet Union Immigrants

Background

The Internet is considered to be an effective source of health information and consultation for immigrants. Nutritional interventions for immigrants have become increasingly common over the past few decades. However, each population of immigrants has specific needs. Understanding the factors influencing the success of nutrition programs among immigrants requires an examination of their attitudes and perceptions, as well as their cultural values.

Objective

The purpose of this study was to examine perceptions of the Internet as a tool for long-term and “real-time” professional, psychological, and nutritional treatment for immigrants from the former Soviet Union who immigrated to Israel (IIFSU) from 1990 to 2012.

Methods

A sample of nutrition forum users (n=18) was interviewed and comments of 80 users were analyzed qualitatively in accordance with the grounded theory principles.

Results

The results show that IIFSU perceive the Internet as a platform for long-term and “real-time” dietary treatment and not just as an informative tool. IIFSU report benefits of online psychological support with professional dietary treatment. They attribute importance to cultural customization, which helps reduce barriers to intervention.

Conclusions

In light of the results, when formulating nutritional programs, it is essential to have a specific understanding of immigrants’ cultural characteristics and their patterns of Internet use concerning dietary care.

Culturally Targeted Strategies for Diabetes Prevention in Minority Population

Purpose The purpose of this study is to (a) assess the effectiveness of culturally tailored diabetes prevention interventions in minority populations and (b) develop a novel framework to characterize 4 key domains of culturally tailored interventions. Prevention strategies specifically tailored to the culture of ethnic minority patients may help reduce the incidence of diabetes. Methods We searched PubMed, EMBASE, and CINAHL for English-language, randomized controlled trials (RCTs) or quasi-experimental (QE) trials testing culturally tailored interventions to prevent diabetes in minority populations. Two reviewers independently extracted data and assessed risk of bias. Inductive thematic analysis was used to develop a framework with 4 domains (FiLLM: Facilitating [ie, delivering] Interventions Through Language, Location, and Message). The framework was used to assess the overall effectiveness of culturally tailored interventions. Results Thirty-four trials met eligibility criteria. Twelve studies were RCTs, and 22 were QE trials. Twenty-five out of 34 studies (74%) that used cultural tailoring demonstrated significantly improved A1C, fasting glucose, and/or weight loss. Of the 25 successful interventions, 21 (84%) incorporated at least 3 culturally targeted domains. Seven studies used all 4 domains and were all successful. The least utilized domain was delivery (4/34) of the intervention's key educational message. Conclusions Culturally tailoring interventions across the 4 domains of facilitators, language, location, and messaging can be effective in improving risk factors for progression to diabetes among ethnic minority groups. Future studies should evaluate how specific tailoring approaches work compared to usual care as well as comparative effectiveness of each tailoring domain.

Attitudes Regarding Participation in a Diabetes Screening Test among an Assyrian Immigrant Population in Sweden

Immigrants from the Middle East have higher prevalence and incidence of type 2 diabetes (T2D) compared with native Swedes. The aim of the study was to describe and understand health beliefs in relation to T2D as well as attitudes regarding participation in a screening process in a local group of Assyrian immigrants living in Sweden. A qualitative and quantitative method was chosen in which 43 individuals participated in a health check-up and 13 agreed to be interviewed. Interviews were conducted, anthropometric measurements and blood tests were collected, and an oral glucose tolerance test was performed. In total, 13 of the 43 participants were diagnosed with impaired glucose metabolism, 4 of these 13 had TD2. The interviewed participants perceived that screening was an opportunity to discover more about their health and to care for themselves and their families. Nevertheless, they were not necessarily committed to taking action as a consequence of the screening. Instead, they professed that their health was not solely in their own hands and that they felt safe that God would provide for them. Assyrians' background and religion affect their health beliefs and willingness to participate in screening for TD2.

Effects of a culturally adapted lifestyle intervention on cardio-metabolic outcomes: a randomized controlled trial in Iraqi immigrants to Sweden at high risk for Type 2 diabetes

BACKGROUND AND AIMS

Middle-Eastern immigrants constitute a growing proportion of the Swedish population and are at high risk for Type 2 diabetes. This calls for a more proactive preventive approach for dealing with diabetes risk in this target group. The aim was to test the effect of a culturally adapted lifestyle intervention programme on changes in lifestyle habits and cardio-metabolic outcomes comparing an intervention group with a control group receiving usual care.

METHODS

Citizens of Malmö, Sweden born in Iraq and at high risk for Type 2 diabetes (n=636) were invited. Participation rate was 15.1%. In all, 96 participants were randomized to the intervention group (n=50) or to the control group (n=46). The intervention group was offered seven group sessions addressing healthy diet and physical activity including one cooking class. Changes in body weight, physical activity levels and cardio-metabolic outcomes were evaluated using linear mixed-effects models.

RESULTS

The mean follow-up time was 3.9 and 3.5months in the intervention and control groups, respectively. The drop-out rate from baseline to the last visit was 30.0% in the intervention group (n=15) and 30.4% in the control group (n=14). The mean insulin sensitivity index increased significantly at follow-up in the intervention group compared to the control group (10.9% per month, p=0.005). The intervention group also reached a significant reduction in body weight (0.4% per month, p=0.004), body mass index (0.4% per month, p=0.004) and LDL-cholesterol (2.1% per month, p=0.036) compared to the control group. In total, 14.3% in the intervention group reached the goal to lose ≥5% of body weight versus none in the control group.

CONCLUSIONS

This culturally adapted lifestyle intervention programme shows a beneficial effect on insulin action, body weight reduction, as well as LDL-cholesterol reduction, in Middle-Eastern immigrants. The programme adapted to resources in primary health care provides tools for improved primary prevention and reduced cardio-metabolic risk in this high-risk group for Type 2 diabetes.

Migrant adults with diabetes in France: Influence of family migration

•

There is a high prevalence of poorly controlled diabetes in migrants.

•

Family gathering is associated with a better control of diabetes.

•

Exploration of migration’ story is important in the health care process.

Aim

To explore the influence of migration and this parameters on the control of diabetes.

Methods

A cohort of migrant patients with type 2 diabetes was recruited in a center affiliated to the French national insurance system situated in a department with important migratory phenomenon. Patients fulfilled a questionnaire about diabetes, their migration history, and the EPICES score (deprivation score). We have explored by univariate and multivariate analysis if any of the characteristics of migration could be related to the control of diabetes. This cohort was compared to a non-migrant control group of age and sex-matched patients.

Results

We included 72 patients, 36 women and 36 men from 20 different countries. The mean age was 57.7 ± 9.6 years. A migration for family reunification was associated with better diabetes equilibrium (Risk of having an HbA1c ⩾8% (63.9 mmol/mol): OR 0.07 (95% IC [0.005–0.86], p = 0.04). The migrant patients who wished to share their time between France and country of origin during their retirement had a better glycaemic control than the migrant patients who would like to go alone into their country (OR 0.08 [0.01–0.78], p = 0.03). Compared to the non migrant group, the EPICES score was higher in the migrant group (52.8 vs. 28.3, p < 0.05), HbA1c was also higher in the migrant group (8.4 vs. 6.7% (68 vs. 50 mmol/mol)).

Conclusions

We may fear that migrants share an increased risk of uncontrolled diabetes. Individual migration could be a risk factor of uncontrolled diabetes. Knowing the migration history of migrant patients is fundamental to understand some barriers of care.

Middle Eastern Conflicts: Implications for Refugee Health in the European Union and Middle Eastern Host Countries

Until very recently, health care in conflict settings was based on a model developed in the second half of the twentieth century. Things have changed, and present civil wars, such as those that are currently taking place in the Middle East, do not address the complexity of the ongoing armed conflicts in countries such as Syria, Iraq, and Afghanistan. These conflicts have caused a significant increase in the number of refugees in the region, as well as in Europe. Hundreds of thousands of refugees succeed in settling in mid- and north-European countries, and their health issues are becoming of great importance. Refugees in Europe in the twenty-first century do not suffer so much from infectious diseases but more from noninfectious chronic diseases such as diabetes, cardiac disease, and cancer. These facts profoundly alter the demographics and disease burden of hostility-derived migrants. Thus, host European countries face situations they have never faced before. Hence, new approaches and strategies are urgently needed to cope with this new situation. The efforts to absorb refugees of different traditions and cultural backgrounds often cause increasing ethnic and religious tensions, which frequently escort the emergence of social violence. To date, little attention has been paid to the overall load of distress being experienced, especially among the first-generation refugees. The current ongoing hostilities in the Middle East induce a long-term health impact on people expelled from their homes, communities, traditions, and cultural environment. The realization of collective suffering forces communities and governmental health agencies to develop new programs that include social determinants to overcome the severe cultural gaps of the newcomers in their new European host countries.

A family history of diabetes determines poorer glycaemic control and younger age of diabetes onset in immigrants from the Middle East compared with native Swedes

AIMS

Immigrant populations from the Middle East develop diabetes earlier than indigenous European populations; however, the underlying etiology is poorly understood. This study looked at the risk factors associated with early diabetes onset and, in non-diabetics, glycaemic control in immigrants from Iraq compared with native Swedes.

METHODS

This cross-sectional population-based study comprised 1398 Iraqi immigrants and 757 Swedes (ages 30-75years) residing in the same area of Malmö, Sweden. Outcomes were age at diabetes onset and glycaemic control (HbA1c) as assessed by Cox proportional hazards and linear regression, respectively.

RESULTS

In Iraqis vs Swedes, clustering in the family history (in two or more relatives) was more prevalent (23.2% vs 3.6%, P<0.001) and diabetes onset occurred earlier (47.6years vs 53.4years, P=0.001). Having an Iraqi background independently raised the hazard ratio (HR) for diabetes onset. Diabetes risk due to family history was augmented by obesity, with the highest HRs observed in obese participants with clustering in the family history (HR: 5.1, 95% CI: 3.2-8.2) after adjusting for country of birth and gender. In participants without previously diagnosed diabetes (Iraqis: n=1270; Swedes: n=728), HbA1c levels were slightly higher in Iraqis than in Swedes (4.5% vs 4.4%, P=0.038). This difference was explained primarily by clustering in the family history rather than age, obesity, lifestyle or socioeconomic status.

CONCLUSION

The study shows that the greater predisposition to diabetes in Middle Eastern immigrants may be explained by a more extensive family history of the disorder; clinical interventions tailored to Middle Eastern immigrants with such a family history are thus warranted.

Ethnicity is an independent risk indicator when estimating diabetes risk with FINDRISC scores: a cross sectional study comparing immigrants from the Middle East and native Swedes

AIMS

This study sought to compare type 2 diabetes (T2D) risk indicators in Iraqi immigrants with those in ethnic Swedes living in southern Sweden.

METHODS

Population-based, cross-sectional cohort study of men and women, aged 30-75 years, born in Iraq or Sweden conducted in 2010-2012 in Malmö, Sweden. A 75g oral glucose tolerance test was performed and sociodemographic and lifestyle data were collected. T2D risk was assessed by the Finnish Diabetes Risk Score (FINDRISC).

RESULTS

In Iraqi versus Swedish participants, T2D was twice as prevalent (11.6 vs. 5.8%, p<0.001). A large proportion of the excess T2D risk was attributable to larger waist circumference and first-degree family history of diabetes. However, Iraqi ethnicity was a risk factor for T2D independently of other FINDRISC factors (odds ratio (OR) 2.5, 95% CI 1.6-3.9). The FINDRISC algorithm predicted that more Iraqis than Swedes (16.2 vs. 12.3%, p<0.001) will develop T2D within the next decade. The total annual costs for excess T2D risk in Iraqis are estimated to exceed 2.3 million euros in 2005, not accounting for worse quality of life.

CONCLUSIONS

Our study suggests that Middle Eastern ethnicity should be considered an independent risk indicator for diabetes. Accordingly, the implementation of culturally tailored prevention programs may be warranted.

Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus

BACKGROUND

Ethnic minority groups in upper-middle-income and high-income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus.

SEARCH METHODS

A systematic literature search was performed of the following databases: The Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper-middle-income or high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta-analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education.Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) -0.4% (95% confidence interval (CI) -0.5 to -0.2); 14 trials; 1442 participants; high-quality evidence) and at six months (MD -0.5% (95% CI -0.7 to -0.4); 14 trials; 1972 participants; high-quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD -0.2% (95% CI -0.3 to -0.04); 9 trials; 1936 participants) and at 24 months (MD -0.3% (95% CI -0.6 to -0.1); 4 trials; 2268 participants; moderate-quality evidence) post intervention. Neutral effects on health-related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies - the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI -40 to -8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low-density lipoprotein (LDL) cholesterol or high-density lipoprotein (HDL) cholesterol were reported at any follow-up point. Other outcome measures (blood pressure, body mass index, self-efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient.Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self-reported via questionnaires, leading to high bias in subjective outcome assessment.

AUTHORS' CONCLUSIONS

Culturally appropriate health education has short- to medium-term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long-term trials, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long-term, standardised, multi-centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium-term effects could lead to clinically important health outcomes, if sustained.