diets of minority ethnic groups in the uk

8/13/2019 Diets of Minority Ethnic Groups in the UK

1/38

B R I E F I N G PA P E R

Diets of minority ethnic groups in the UK:influence on chronic disease risk andimplications for prevention nbu_1889 161..198

G. Leung and S. StannerBritish Nutrition Foundation, London, UK

Summary

Introduction

1 Definitions of ethnic groups and demographics of minority ethnic groups in the

UK

1.1 Definitions of ethnic groups and ethnicity

1.2 Demographics and characteristics of minority ethnic groups in the UK

Countries of origin Age/sex distribution and life expectancy

Geographical distribution and size of household

Religious beliefs

Education and employment patterns

Key points

2 Overview of the health profile and dietary habits of minority ethnic groups in the

UK

2.1 Available surveys

2.2 Overview of the health profiles among adults from minority ethnic groups

Overall health

Cardiovascular disease (CVD)

Coronary heart disease (CHD)

Stroke

Type 2 diabetes

Obesity

2.3 Possible causes of increased disease risk among minority ethnic groups

2.4 Smoking, drinking and physical activity habits

2.5 Dietary habits and nutritional status

2.6 Overview of the health profiles and dietary and health behaviour patterns

of children from minority ethnic groups

Overall health Diet and health behaviour patterns

2.7 Gaps in data availability

Key points

Correspondence:Georgine Leung, Nutrition Scientist, British Nutrition Foundation, High Holborn House, 52-54 High Holborn, London

WC1V 6RQ, UK.

E-mail: [email protected]

2011 The Authors

Journal compilation 2011 Br itish Nutrition Foundation Nutrition Bulletin,36, 161198

161


2/38

3 Factors affecting food choice

Income and socio-economic status

Food availability and access

Awareness of healthy eating

Religious beliefs

Food beliefs Time and cooking skills

Generation and gender

Key points

4 Traditional diets of minority ethnic groups

4.1 Overview of traditional diets of minority ethic groups

South Asians

African-Caribbeans

Chinese

4.2 Dietary acculturation

4.3 Nutritional composition of ethnic-style cuisine

Key points5 Nutritional interventions and health promotion among minority ethnic groups

5.1 Effective nutritional interventions

5.2 Health promotion interventions to prevent problems associated with

fasting

5.3 Priorities for nutritional interventions and health promotion

5.4 Using behaviour change models

5.5 Current community initiatives

5.6 Catering for institutionalised individuals

5.7 Recommendations for future research, policy and practice

Key points

6 Conclusion

Acknowledgements

References

Summary According to the latest census, non-white minority ethnic groups made up 7.9%

of the UKs population in 2001. The largest of these groups were South Asians,

Black African-Caribbeans and Chinese. Studies have shown that some minority

ethnic groups are more likely to experience poorer health outcomes compared

with the mainstream population. These include higher rates of cardiovascular

disease (CVD), type 2 diabetes and obesity. The differences in health outcomes

may reflect interactions between diet and other health behaviours, genetic pre-

disposition and developmental programming, all of which vary across different

groups.

As is the case for the rest of the population, the dietary habits of minority ethnic

groups are affected by a wide variety of factors, but acquiring a better understand-

ing of these can help health professionals and educationalists to recognise the needs

of these groups and help them to make healthier food choices. Unfortunately, to

date, there have been few tailored, well-designed and evaluated nutritional inter-

ventions in the UK targeting minority ethnic population groups. Further needs

162 G. Leung and S. Stanner

2011 The Authors

Journal compilation 2011 British Nutrition Foundation Nutrition Bulletin,36, 161198


3/38

assessment and better evaluation of nutritional interventions have been recom-

mended to enhance the understanding of the effectiveness of different approaches

amongst minority ethnic groups.

This briefing paper will provide an overview of the health profile, dietary habits

and other health behaviours of the three largest non-white minority ethnic groups

in the UK, explore the factors affecting their food choices, provide a summary oftheir traditional diets and review the evidence base to identify the factors that

support successful nutrition interventions in these groups.

Keywords: minority ethnic groups, traditional diets, ethnic foods, South Asians, Black

African Caribbeans, Chinese

Introduction

According to the latest census, in 2001, 7.9% of theUKs population is made up of non-white minority

ethnic groups. The largest of these groups were SouthAsians, Black African-Caribbeans and the Chinese.

Population studies have shown that some minorityethnic groups are more likely to experience poorer

health outcomes compared with the mainstream popu-lation. These include higher rates of cardiovascular

disease (CVD), type 2 diabetes and obesity. Possiblereasons for the differences in health outcomes include

diet and other health behaviours, genetic predisposition

and developmental programming, as well as poorer

access and use of health care. Language and culturaldifferences have been identified as the two major barri-ers responsible for poorer access to health care for these

minority ethnic groups.As is the case for the rest of the population, the

dietary habits of minority ethnic groups are affected bya wide variety of factors, which among others include

income, socio-economic status, food availability andaccess, health, religion and dietary laws, food beliefs,

amount of time available for food shopping or prepa-ration, generation and gender. Acquiring a better under-

standing of the reasons underlying food choices by

minority ethnic groups can help health professionalsand educationalists to recognise the needs of minorityethnic groups and help them to make healthier food

choices. The traditional dietary habits of minority ethnicgroups vary widely between groups and compared with

the mainstream population, but there is also heteroge-neity within each group reflecting differences in the

regions of origin. Traditional diets may change becauseof acculturation, which is the assimilation of the habits

of the host country.

To date, few tailored and evaluated nutritional

interventions in the UK have targeted minority ethnicpopulation groups, and well-evaluated nutritional inter-ventions are needed to better understand the effective-

ness of different approaches in these groups. However,priorities for nutritional interventions and research for

different minority ethnic groups vary.This briefing paper will discuss the main health prob-

lems experienced by the largest non-white minorityethnic groups in the UK, provide an overview of tradi-

tional and current diets and review evidence for success-ful nutrition interventions.

1 Definitions of ethnic groups anddemographics of minority ethnic groups inthe UK

1.1 Definitions of ethnic groups and ethnicity

There are varying definitions for the terms ethnicgroups and ethnicity, and these are often subject to

much discussion. Carlsonet al. (1984) defined anethnic

grouporethnic populationas a group of people smaller

in number than the majority categories and who by theircustoms, language, race, values, and group interests

differ from the majority population. The UKs Eco-

nomic Social Research Council (ESRC) referred ethnicgroupsas people of the same race or nationality with along shared history and a distinct culture and definedethnicity as the intangible quality, or sense of being,derived from that shared racial or cultural affiliation

(ESRC 2005).Membership of any ethnic group is subjective to the

individual, and this self-perceived identity is based ondifferent factors (Office for National Statistics, ONS

2003), such as:

Diets of minority ethnic groups in the UK 163

2011 The Authors



4/38

country of birth;

nationality; language spoken at home;

parents country of birth in conjunction with the indi-viduals country of birth;

skin colour; national/geographical origin;

racial group; religion.

Self-identified ethnicity was included in the UK censusfor the first time in 1991. Because individuals may

change the ways they view their cultural or ethnic iden-tities, it is important to note that ethnicity is considered

to be a shifting concept (Landman & Cruickshank2001).

The UK has a rich mix of cultures and culturallydiverse communities. Some reflect a long established

history and heritage, but some are related to more recentchanges in society (e.g. immigration). Knowing more

about the ethnic make-up of the population enables a

better understanding of many social and economic

trends (ONS 2005) and helps inform health policiesrelating to diet and physical activity. Table 1 shows therespective agencies responsible for conducting the cen-

suses in the four constituent countries of the UK.This paper makes use of the classifications from the

latest census in 2001 on minority ethnic groups in theUK, which are defined as the population of a non-white

group. Because ethnic identity is a subjective concept,respondents were invited to select the ethnic group that

they consider themselves to belong to, in order to reflecttheir self-perceived identity. In 2001, non-white minor-

ity ethnic groups made up 7.9% of the UK population.

The largest of these groups was South Asians (predomi-nantly Indians, Pakistanis, Bangladeshi), followed byBlacks (predominantly Caribbeans and Africans),

mixed and the Chinese (Table 2).Because the structure of the mixed population was

highly heterogeneous, and specified mixed groupscontain very different characteristics (ONS 2006b), this

group is not considered further in this Briefing Paper,which will focus on the three largest non-white minority

ethnic groups in the UK:

South Asians;

Black African-Caribbeans; Chinese.

1.2 Demographics and characteristics of minorityethnic groups in the UK

Countries of origin

South Asians originate from the Indian subcontinent,

and the main subgroups in the UK are Indians, Paki-stanis and Bangladeshis, with a smaller proportionthrough East Africa (including Kenya, Uganda and Tan-

zania). The Indian population is further differentiatedinto subgroups that mostly came from the Indian Punjab

and Gujarat regions, while most Pakistanis are ofPunjabi descent and most Bangladeshi are from the

Sylhet district, in the north-east of Bangladesh. Carib-beans came from the numerous islands that constitute

the West Indies, such as Jamaica, Barbados, Trinidad,

Table 1 Respective agencies that conduct censuses in the UK

Country Agency

England and Wales Office for National Statistics (ONS) (www.statistics.gov.uk)

Scotland The General Register Office for Scotland (www.gro-scotland.gov.uk)

Northern Ireland Northern Ireland Statistics and Research Agency (www.nisra.gov.uk)

Table 2 Population by ethnic group in the UK, April 2001

(adapted from the ONS 2005)

Number

% of total

population

% of minority

ethnic

population

White 54 153 898 92.1

Mixed 677 177 1.2 14.6

Indian 1 053 411 1.8 22.7

Pakistani 747 285 1.3 16.1Bangladeshi 283 063 0.5 6.1

Other Asian 247 664 0.4 5.3

All South Asian or South

Asian British

2 331 423 4.0 50.3

Black Caribbean 565 876 1.0 12.2

Black African 485 277 0.8 10.5

Black Other 97 585 0.2 2.1

All Black or Black British 1 148 738 2.0 24.8

Chinese 247 403 0.4 5.3

Other ethnic groups 230 615 0.4 5.0

Al l minor ity ethnic population 4635296 7.9 100.0

Total population 58 789 194 100


2011 The Authors



5/38

Tobago, Saint Kitts and Nevis, Saint Lucia andGrenada; while Africans in the UK mainly originate

from Nigeria, Ghana, Somalia, Zimbabwe, Uganda,Sierra Leone and Kenya. The majority of the Chinese in

the UK have family roots from Hong Kong and Main-land China, with a smaller percentage from Malaysia,

Vietnam, Singapore and Taiwan. Most non-whiteminority ethnic groups identified themselves in the 2001

census as British, with a smaller number as English,Scottish or Welsh (e.g. 76% of Bangladeshis identified

themselves as British vs. 5% who said they were English,Scottish or Welsh) (ONS 2005).

Age/sex distribution and life expectancy

The 2001 census found that non-white groups have ayounger age structure compared with the White popu-

lation in the UK. Of the non-white minority ethnicgroups, Black Caribbeans had the largest proportion of

people aged 65 and over (11%), reflecting the large-scale migration of young labourers from the Caribbean

to Britain in the 1950s (Fig. 1). Life expectancy of theUK population as a whole is increasing: the total

number of people aged 85 and over in the UK reacheda record 1.3 million in mid-2008 (ONS 2009); although

continuation of this trend will depend on fertility levels,

mortality rates and future net migration (ONS 2005,2006b). There are currently no data available for life

expectancy by ethnicity, but the Lancashire CountyCouncil estimated a 4-year lower average healthy life

expectancy at birth for minority ethnic groups (65 yearsfor Black and minority ethnic groups vs. 69 years for

whites) based on local and Office for National Statistics(ONS) figures. This reflects a need for better access for

health services for minority ethnic groups (Knuckey2008). Similar to the rest of the population, women

from minority ethnic groups aged 65 and above gener-ally outnumber men, with the exception of South Asian

groups (Fig. 2). The demographics of some groups mayhave been affected by immigration waves.

Geographic distribution and size of household

The census in 2001 showed that the non-white popula-tion tended to concentrate in specific areas, with almost

half of them living in London (45%) where they madeup almost a third of the residents in the capital (29%)

(Fig. 3). They also constituted a larger proportion of thepopulation in England compared with Scotland, Wales

and Northern Ireland (Table 3). Migrants arriving sincethe 1950s have been likely to settle relatively close to big

cities, which were their point of arrival (ONS 2005;Gilbert & Khokhar 2008). The continual growth of

minority ethnic groups in metropolitan areas waslargely the result of existing communities being joined

by new migrants and the birth of children (Rees &

Philips 1996).According to the 2001 census, South Asian house-

holds were larger than those of other non-white minor-ity ethnic groups. Those headed by a Bangladeshi person

0 20 40 60 80 100

Any other ethnic group

Chinese

Other Black

Black African

Black Caribbean

Other South Asian

Bangladeshi

Pakistani

Indian

Mixed

White

Percentage

Under 16 16 to 64 65 and over

Figure 1 Age distribution: by ethnic group in Great Britain, April 2001 (adapted from ONS 2005). Data are for Great Britain only because no relevant

information was provided by the census in Northern Ireland.


2011 The Authors



6/38

were the largest, with an average of 4.5 people, followed

by Pakistani and Indian households. These householdswere also more likely to contain at least one dependent

child (defined as those aged 0-to-15 years or aged16-to-18 years in full-time education and living with his

or her parents) (ONS 2005) (Fig. 4).

Religious beliefs

Some ethnic and religious groups are closely related. For

example, in the 2001 census, the majority of Pakistanisand Bangladeshis reported being Muslim (both 92%)

and most Blacks reported being Christians (around70%). However, other minority ethnic groups are more

religiously diverse; for example, in 2001, almost half

(45%) of Indians reported being Hindu, 29% Sikh and13% Muslim. Around half of the Chinese reported noreligion (53%) (Fig. 5). The dietary habits of certain

minority ethnic groups may be largely defined by reli-gious beliefs (see Section 3).

Education and employment patterns

The 2001 census showed that the proportion of people

of working age (males from 16-to-64 years and

0 60 80 100

Any other ethnic group

Chinese

Other Black

Black African

Black Caribbean

Other AsianBangladeshi

Pakistani

Indian

Mixed

White

Percentage

Males Females

20 40

Figure 2 Sex distribution of people aged 65 and over in Great Britain, by ethnic group, April 2001 (adapted from ONS 2005). Data are for Great Britain

only because no relevant information was provided by the census in Northern Ireland.

Northern IrelandScotland

WalesSouth-west EnglandSouth-east England

LondonEast England

West MidlandsEast Midlands

Yorkshire and the HumberNorth-west EnglandNorth-east England

Percentage

0 2010 30 40 50

Figure 3 Regional distribution of the non-white population in the UK, April 2001 (adapted from ONS 2005).

Table 3 Non-white population in the UK: by area, April 2001

(adapted from ONS 2005)

Country Percentage

England 9.08

Wales 2.12

Scotland 2.01

Northern Ireland 0.75


2011 The Authors



7/38

females from 16-to-59 years) with a degree qualifica-tion varied from group to group and the largest per-centage of working age people without a degree

qualification was from the Pakistani and Bangladeshigroups. According to the National Statistics Socioeco-

nomic Classification, which measures socio-economicpositions in society, low socio-economic status is char-

acterised by being in routine and semi-routine occupa-tions or unemployed for a long time, as this is

associated with lower earning potential, job security

and career opportunities than managerial and profes-sional occupations. The 2001 census reported that someminority ethnic groups were more likely to work in

routine or semi-routine positions (e.g. 43% for Bang-ladeshi and 34% for Pakistani men respectively) (ONS

2006b). The Annual Population Survey found that unem-ployment rates for minority ethnic groups were also

generally higher than the White British populationaverage, with Bangladeshi, Black African and Black

Caribbean men and Pakistani women topping

2.3 2.5

3.3

4.14.5

3.2

2.3

2.72.4

2.7 2.8

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Othe

rblac

k

Hou

seholdsize

(numberofpeople)

Whit

eMi

xed

Indian

Pakis

tani

Banglad

eshi

Othe

rAsia

n

BlackC

aribb

ean

Chine

se

Othe

rethn

ic

group

s

Black

Afric

an

Figure 4 Average household size by ethnic group in Great Britain, April 2001 (adapted from ONS 2005). Data are for Great Britain only because no

relevant information was provided by the census in Northern Ireland.

Other Ethnic Group

Chinese

Black African

Black Caribbean

Bangladeshi

Pakistani

Indian

Mixed

White

Christian Buddhist Hindu Jewish Muslim Sikh Any other religion No religion Not stated

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 5 Religious composition of ethnic groups in Great Britain, April 2001 (adapted from ONS 2005). Data are for Great Britain only because no relevant

information was provided by the census in Northern Ireland.


2011 The Authors



8/38

the list in 2004 (ONS 2006a) (see Table 4). In general,working-age men and women from minority ethnic

groups were also found to be more economically inactive(i.e. not actively seeking or unavailablefor work)because

they were students, looking after the family or home orclassified as disabled in 2001 (ONS 2005).

Key points

Definitions for ethnic groups and ethnicity vary.

Ethnicity is a self-perceived identity and belonging toethnic groups is subjective to the individual.

Non-white minority ethnic groups made up 7.9% ofthe UK population in 2001. The three biggest groups

were South Asians, Black African-Caribbeans and theChinese (the mixed group is not discussed in this paper

because its structure is highly heterogeneous and infor-mation about their health and dietary habits is more

limited). Most non-white minority ethnic group members iden-

tified themselves as British. In the 2001 census, non-white minority ethnic groups

had a younger age structure compared with the Whitepopulation.

Minority ethnic groups tend to be concentrated inspecific areas and big cities, close to where migrants

originally arrived. South Asian households were found to be larger than

those of other minority ethnic groups and the main-stream White population.

Some ethnic and religious groups are closely related,and the dietary habits of some minority ethnic groups

are influenced by religious beliefs (see Section 3).

Unemployment rates among minority ethnic groupswere found to be higher than the mainstream popula-

tion. Working-age men and women of minority ethnicgroups were also more likely to be economically inactive

(i.e.were students, looking after the family or home ordisabled).

2 Overview of the health profile anddietary habits of minority ethnic groups inthe UK

Health status is shaped by a multitude of factors, includ-ing the characteristics and behaviours of individuals and

the physical, social and economic environment. Thesefactors range from genetic predisposition, diet, lifestyle

and psychological stress, to access to health services,housing conditions, education level and household

income. Health inequalities, as defined by the World

Health Organization (WHO 2010) as differences inhealth status or in the distribution of health determi-nants between different population groups, result from

the cumulative effects of these factors throughout life.Health inequalities have been found to exist among

many minority ethnic groups, as they tend to showpoorer health outcomes, e.g. higher rates of CVD and

type 2 diabetes, compared with the general population.There is also evidence that some of these health inequali-

ties may be widening. For example, while rates of CVDhave been falling among White Europeans in the UK

since the 1970s, the same rate of decline has not been

seen within minority ethnic groups. Some of theseinequalities have been attributed to problems withaccess to health care. Language and communication and

cultural differences have also been identified as majorbarriers to accessing health advice and treatment (Latif

2010).

2.1 Available surveys

Government health surveys are carried out across the UKto assess and monitor the health and nutritional status

of the population and to provide information regarding

the publics health and diet as well as the many otherfactors related to health and wellbeing. However, fewrepresentative data are available regarding the health of

minority ethnic groups from these surveys. The 2004report, Health Survey for England: the health of minor-ity ethnic groups provided the latest population-widedata set on the health of minority ethnic groups in

England. The survey involved 6816 adults and 3298children from minority ethnic groups. It was the second

time that this survey focused on the health of minority

Table 4 Unemployment rates by ethnic group and sex, 2004

(adapted from ONS 2006a)

Great Britain

Percentages (%)

Male Female

White British 4.5 3.7Mixed 12.6 11.6

Indian 6.5 7.7

Pakistani 11.0 19.7

Bangladeshi 12.9 12.6

Other Asian 11.3 7.0

Black African 13.1 12.3

Black Caribbean 14.5 9.1

Chinese 9.7 7.1

Aforementioned data are for Great Britain only because no relevant

information was provided by the Census in Northern Ireland.


2011 The Authors



9/38

ethnic groups, the first being in 1999. Throughquestionnaire-based interviews, physical measurements

and blood sample analysis, the survey assessed healthand psychosocial wellbeing, CVD risk, tobacco use,

alcohol consumption, obesity, blood pressure and physi-cal activity and eating habits among the African-

Caribbean, South Asian, Chinese and Irish groupsthroughout England. The report Black and Minority

Ethnic Health in Greater Glasgow: A ComparativeReport on the Health and Well-Being of African &

Caribbean, Chinese, Indian and Pakistani People andthe General Populationby the National Health Service

(NHS) Greater Glasgow is the largest data set to date onthe health-related perceptions and behaviours of minor-

ity ethnic groups in Scotland. It is a comparative reportbased on data from 960 individuals from the Chinese

Healthy Living Centre Study (n = 350), the Pakistani,Indian and the African & Caribbean Survey (n = 610)

and theGeneral Population Survey(n = 1802) collectedin Greater Glasgow from 20042005. The health

surveys from England and Scotland have been used inthis paper to provide an overview of the health and

nutritional status of minority ethnic groups in the UK.No comprehensive data set on the health of minority

ethnic groups are available in Northern Ireland or Wales.

2.2 Overview of the health profiles among adultsfrom minority ethnic groups

Overall healthAccording to the Health Survey for England in 2004,South Asian men and women and Black Caribbean

women in England were more likely to rate their ownhealth as bad or very bad (relative risks range from 1.9

to 4). Pakistani men and women and Bangladeshi menhad a higher chance of suffering from psychiatric disor-

ders (over 50% higher compared with the general popu-lation) as assessed by a validated questionnaire that

measured psychological wellbeing. The prevalence oflimiting long-standing illness (illnesses and disabilities

that are likely to affect a person over a period of time)

was about 20% to 50% higher for Pakistani and Bang-ladeshi men compared with men in the general popula-tion, and approximately 20% to 60% higher for Black

Caribbean, Bangladeshi and Pakistani women com-pared with women in the general population. In con-

trast, Chinese adults were less likely to report limitinglong-standing and psychological illnesses compared

with the general population. They were also more likelythan other ethnic groups to have used complementary or

alternative medicines and treatments, which were

mainly traditional Chinese medicine or acupuncture(Boreham 2006; Heim & MacAskill 2006; Natarajan

2006).

Cardiovascular disease (CVD)

CVD encompasses all the conditions concerning theheart and circulatory systems, the main forms being

coronary heart disease (CHD) (including heart attack orangina) and stroke. CVD is a common cause of death in

the UK, and its risk factors include increased bloodpressure, dyslipidaemia [high low-density lipoprotein

(LDL)-cholesterol and low high-density lipoprotein(HDL)-cholesterol levels], type 2 diabetes and obesity.

Other risk factors include behavioural factors such assmoking, physical inactivity, diets high in saturated fatty

acids and/or low in fruit and vegetables, as well asnon-behavioural factors, such as family history and eth-

nicity (British Heart Foundation 2010b). CVD is amajor cause of mortality and morbidity in the general

population and even more so in some minority ethnicgroups. While total death rates for CVD have been

falling in the UK since the early 1970s, the decline hasbeen slower among minority ethnic groups. CVD is also

a major cause of ill health and surveys suggest thatmorbidity from CHD is not falling and may be rising

particularly among older people and in some minorityethnic groups (e.g.in Pakistani men the prevalence rose

from 4.8% to 9.1% between 1999 and 2004 (Mindell& Zaninotto 2006). As with the mainstream popula-

tion, the overall prevalence of CHD and stroke in allminority ethnic groups is higher in those in the lowestincome category (with the exception of Chinese women)

and in men compared with women and increases withage (Mindell & Zaninotto 2006; NHS Health Scotland

2009).

Coronary heart disease (CHD)

According to the Health Survey for England, in2004, men and women from Indian, Pakistani and

Bangladeshi groups were more likely to suffer from

CHD compared with the general population (age-standardised rates were around 30% to 140% higherfor men and around 50% to 90% higher for women).

Black African respondents had the lowest risk ratio(0.27 for men and 0.15 for women), while the Chinese

(0.44 for men and 0.81 for women) and Black Carib-bean (0.77 for men and 0.91 for women) respondents

also reported lower risk ratios compared with thegeneral population. The risk for CHD differs for immi-

grants from different parts of the Indian subcontinent,


2011 The Authors



10/38

with the highest risk for those from Bangladesh, fol-lowed by Pakistanis, while Indians have the lowest risk

(Bhopal et al. 1999). Wild et al. (2007) also showedthat mortality rates for CHD were much higher for

people born in East Africa, Bangladesh, Pakistan orIndia compared with those born in England and in

Wales. TheHealth Survey for Englandfound the preva-lence of high LDL-cholesterol levels (3.0 mmol/l)

among Indian and Pakistani respondents to be similarto those in the general population but low HDL-

cholesterol levels (


11/38

more likely to suffer from type 2 diabetes than the generalpopulation (Mindell & Zaninotto 2006, Fig. 6). These

figures are supported by a greater prevalence of highglycated haemoglobin (Hb) (HbA1c) levels (defined as7%) among all minority ethnic groups (exceptfor Black African and Chinese women) (Mindell & Zani-

notto 2006). High HbA1c levels are associated withmicro- and macro-vascular complications and used as an

indicator of diabetes.The increased prevalence of type 2 diabetes among

adult minority ethnic groups may be tracked from child-hood. The Ten Town Heart Health Studies (2005)

observed a tendency to insulin resistance in South Asianchildren of 8-to-11 years (n = 227) and higher mean

fasting glucose levels in South Asian children aged 13-to-16 years compared with their white counterparts

(Whincup et al. 2002, 2005). Following this finding,Whincupet al. (2010) investigated the ethnic differences

in type 2 diabetes precursors in the much larger andmore representativeCHASEstudy and found that chil-

dren aged 9-to-10 years from minority ethnic groups(South Asian, n = 1306 and Black African-Caribbean,

n = 1215) had higher levels of HbA1c, fasting insulinand C-reactive protein than white Europeans, all of

which are all precursors for type 2 diabetes. South Asianchildren also had higher levels of triglycerides and lower

levels of HDL-cholesterol, which are both risk factors

for type 2 diabetes and CVD, while the opposite wasobserved for Black African-Caribbean children. This

suggests that ethnic differences in precursors for type 2

diabetes and risk factors for CVD among children aresimilar to those observed among adults and supports

scope for early prevention (Whincupet al. 2005, 2010).In a study of 129 14-to-17-year-olds in Birmingham,

South Asian adolescents were observed to be less insulin-sensitive than White European adolescents and had a

higher percentage of body fat (Ehtishamet al. 2005).

Obesity

The common way to classify overweight andobesity is byusing the body mass index (BMI), which equates to

weight (kg) divided by height squared (m2). The interna-tional BMI cut-off points for classifying overweight and

obesity are 25 kg/m2 and 30 kg/m2, respectively. In recentyears, however, there has been much discussion about

whether these are appropriate for minority ethnic groupsin the UK because Asians (including South Asian and

Chinese people) tend to have a higher body fat contentfor a given BMI, which is associated with higher morbid-

ity and mortality risks compared with the white popula-tion (WHO Expert Consultation 2004). The available

data show that increasedrisk formorbidity andmortalityis generally observed with BMIs of 22 kg/m2 to 25 kg/m2

and high risk for 26 kg/m2 to 31 kg/m2 among Asians. Inthe absence of universal agreement, the National Insti-

tute for Health and Clinical Excellence (NICE) continuesto advise that the same thresholds for the general popu-

lation should be used to classify overweight and obese

(National Collaborating Centre for Primary Care 2006).

10.0

Men Women

2.0

1.0

0.5

0.1

10.0

2.0

1.0

0.5

0.1

BlackCaribbean

Risk

ratio,

logarithmicscale

BlackAfrican

Indian

Pakistani

Bangladeshi

Chinese

BlackCaribbean

BlackAfrican

Indian

Pakistani

Bangladeshi

Chinese

Figure 6 Prevalence of type 2 diabetes, by minority ethnic group (Mindell & Zaninotto 2006, with permission from the NHS Information Centre). General

population = 1.0; error bars indicate 95% confidence limits.


2011 The Authors



12/38

While the WHO Expert Consultation (2004) retained theinternational BMI cut-off points for overweight and

obesity, it suggested public health action points at lowerBMI cut-off points for the Asian population of 23 kg/m2

(overweight) and 27.5 kg/m2 (obesity), respectively. Itshould be noted that the term Asians represents a vast

and diverse portion of the worlds population thereforethe absolute risk for overweight and obesity is based on

factors such as ethnic and cultural subgroups, degrees ofurbanisation, social and economic conditions and diet

and other lifestyle factors.Obesity rates appear to differ between minority ethnic

groups. Using the international BMI cut-off point forobesity (30 kg/m2), the Health Survey for England

found that participants from the Chinese and SouthAsian communities (except for Pakistani women) were

less likely to be obese in 2004, but obesity prevalencemay be under-represented because of the suggested

lower BMI cut-off points for the Asian population(Hirani & Stamatakis 2006). Waisthip ratio (WHR)

and waist circumference (WC) have also been usedas indicators for central obesity, which is strongly

associated with health problems such as insulin resis-tance, metabolic syndrome, CVD and type 2 diabetes

(International Obesity Task Force 2004). Obesity is

defined as WHR 0.95 or WC 102 cm for men andWHR 0.85 for women or WC 88 cm. Using WHR,

theHealth Survey for Englandfound that South Asianswere likely to have similar prevalence of central obesity

compared with men in the general population (withother groups showing a lower prevalence), while women

from Bangladeshi, Black Caribbean and Pakistanigroups were more likely to be centrally obese compared

with those from the general population in 2004. Chineseparticipants had the lowest rates of central obesity

(Hirani & Stamatakis 2006). The WHR was shown intheINTERHEARTstudy to provide a better estimate of

heart attack risk because of obesity in most ethnicgroups (Yusufet al. 2005). Figure 7 summarises the dif-

ferent rates for obesity using BMI (30 kg/m2), WHR(0.95 for men and 0.85 for women) and WC

(102 cm for men and 88 cm for women).

2.3 Possible causes of increased disease risk amongminority ethnic groups

I. Health behaviour patterns

Some minority ethnic groups in the UK have been

shown to be less physically active and more likely to

2 5%

17%

14%15%

6%%6

2 3%

2 5%

16%

38 %

36 %

3 2%

17%

3 3%

22 %

19% 20 %

30 %

12%

8 %

3 1%3 2 %

38 %

20 %

2 8%

17%

8 %

23 %

37 %

3 2%

3 0%

3 9%

50 %

2 2 %

30 %

4 7%

53 %

3 8%

4 8 %

4 3 %

16%

4 1%

Generalpopulation

%

Men BMI30kg/m2

Men WHR0.95

Men WC102cm

Women BMI30kg/m2

Women WHR0.85

Women WC88cm

Black Caribbean Black African Indian Pakistani Bangladeshi Chinese

Figure 7 Prevalence of obesity among minority ethnic groups in England in 2004 (adapted from Hirani & Stamatakis 2006).


2011 The Authors



13/38

smoke than those of a similar age in the general popu-lation (Wardle 2006). These health behaviour patterns

are associated with an increased risk of diseases such asCVD and type 2 diabetes (see Section 2.4). Dietary

habits, which vary according to minority ethnic groupand within the groups themselves, are discussed in

Section 2.5.

II. Genetic predisposition

Research has identified genetic polymorphisms that pre-dispose South Asians to increased risk of type 2 diabetes

and CVD, while other genes that offer protectionagainst diabetes and insulin resistance to Caucasians do

not appear to protect South Asians (e.g. PPAR gammagene) (Radha & Mohan 2007). Recent studies suggest

that polymorphism of the PCK1-gene is associated withan increased risk of type 2 diabetes among the Chinese

in Shanghai (n = 650) and among South Asians in Bir-mingham (n = 903) (Donget al. 2009; Reeset al. 2009).

While environmental factors play a major role in thedevelopment of diabetes, genetic factors may explain

why minority ethnic groups, especially South Asians,show a higher prevalence of type 2 diabetes, compared

with the white population (Radha & Mohan 2007)(Fig. 8). Bhopal and Rafnsson (2009) also explored the

possibility of mitochondrial efficiency as an explana-

tion for increased adiposity and metabolic disease risk inpopulations with South Asian ancestry. The researchers

hypothesised that South Asians are adapted to climatic(heat) and other nutritional (e.g.low-calorie diet) expo-

sures in the Indian subcontinent that favour the con-version of energy to the storage form adenosine

triphosphate rather than heat. This may be disadvanta-geous when these groups migrate to Western countries if

they become physically inactive and consume high-calorie diets.

III. Developmental programming

The most important environment that regulates gene

functions and phenotype is the intrauterine environmentbecause the structure and function of the developing

fetus are heavily influenced by maternal nutrition andthe mothers metabolism. The fetal origins hypothesis,

originally named the Barker Hypothesis (Barker 1995),suggests that low birthweight caused by nutritional dep-

rivation and growth restriction in the uterus increasesthe lifetime risk for hypertension, type 2 diabetes, stroke

and CHD (Huxley et al. 2007; Whincup et al. 2008).The risk for these chronic diseases is further increased

with a rapid gain in fatness (catch-up growth) in earlylife. This has been shown to increase the risk for type 2

diabetes among South Asian groups and hypertension

Maternal, neonatal and excesschildhood adiposity/accelerated

velocity of BMI change

Excess body fat, excess truncalsubcutaneous fat, abdominal

obesity, low muscle mass

High intakes of energy and fat,low intakes of fibre and omega-3

fatty acids

Perinatal factors:

Abnormal body composition:

Genetic factors

Imbalanced nutrition:

Physical inactivityHypertension

Dyslipidaemia

Coronaryheart disease

Type 2diabetesmellitus

High free fatty acidlevels

Fatty liver

Decreased insulinsensitivity

High levels of pro-inflammatory cytokines

High levels ofC-reactive protein

Muscle fat

Figure 8 Complex interactions of genetic, prenatal, nutritional and other acquired factors in the development of insulin resistance, type 2 diabetes and CHD

in South Asians (adapted from Misra etal. 2007).


2011 The Authors



14/38

among African-Caribbeans (Oldroyd et al. 2005). Thisis particularly so in countries going through a rapid

economic and nutritional transition or when peoplefrom less developed countries migrate to developed ones

where the greatest mismatch is observed between earlynutritional deprivation and nutritional abundance in

later life (Prentice & Moore 2005). Low birthweight iscommon among South Asian groups in the UK (Oldroyd

2005), which may help to explain why South Asians aresusceptible to type 2 diabetes at a younger age and at a

relatively lower BMI compared with Caucasians (Krish-naveni et al. 2009; Misra & Khurana 2009; Yajnik &

Ganpule-Rao 2010). Low birthweight has also beenassociated with increased risk of hypertension among

African schoolchildren (n = 2648) (Longo-Mbenzaet al.1999).

2.4 Smoking, drinking and physical activity habitsAccording to the Health Survey for England, a larger

proportion of Pakistani (29%) and Bangladeshi (40%)men smoked compared with the general population

(24%), while the Indian subgroup had the lowest pro-portion of smokers (20%) in 2004. The proportion of

female smokers from minority ethnic groups was mark-edly smaller, except for Black Caribbean female subjects

(24%) with rates comparable with the general popula-tion (23%). South Asian females were least likely to

smoke (2 to 5%). Chewing of tobacco, a major risk for

oral cancer, was most prevalent among Bangladeshi

men and women (9% and 16% respectively) (Wardle2006).

All minority ethnic groups reported consuming less

alcohol and were more likely to report being non-drinkers than the general population. The highest pro-

portion of self-reported non-drinkers was the Pakistaniand Bangladeshi groups (over 90% on average), likely

for religious reasons (see Section 3). However, it wasnoted that alcohol consumption and smoking levels may

be under-reported in surveys as these behaviours may bedeemed as socially undesirable by participants (Heim &

MacAskill 2006).

There are very few published studies of objectivelymeasured physical activity among minority ethnicgroups in the UK. Minority ethnic groups, especially

South Asians and Chinese populations, showed lowerlevels of self-reported physical activity compared with

the mainstream population, particularly among Bang-ladeshi respondents (where only half of the Bangladeshi

men and one-third of Bangladeshi women participatedin physical activity at least once a week). The percentage

of Bangladeshi respondents achieving the recommenda-

tion of at least 30 minutes of moderate intensity exerciseon five or more days a week was also low (around a

quarter for men and 1 in 10 for women) (Stamatakis2006). This trend may be attributed to the Bangladeshi

culture as sports and games are not generally pursued byBangladeshi adults. There is no word for physical activ-

ity in the Sylheti language (the most predominantdialect of British Bangladeshis), the closest translation of

which is beyam, a Sylheti word that carries a negativeconnotation (Greenhalgh et al. 1998). A review by

Fischbacher et al. (2004) highlighted the lack of cross-culturally adapted questionnaires to assess physical

activity patterns among South Asians to ensure qualityand appropriateness. For example, surveys translated

into various South Asian languages such as Hindu, Urduor Punjabi by bilinguals whose dialects may differ

according to education, age, socio-economic status andgender may introduce inconsistency. The translated

surveys have also been found to be too formal andliterary for less educated people and therefore difficult

to complete. Thus, assessing physical activity using self-reported methods may be problematic, particularly

among those individuals who are not fluent in theEnglish language. Koshoedo et al. (2009) reviewed the

barriers to physical activity for minority ethnic groups,which include personal factors such as lack of motiva-

tion, socio-cultural barriers that are associated with lackof family support, as well as religious, language and

cultural issues (e.g.inappropriate dress codes and nega-

tive perceptions of exercise) and environmental factors,

including lack of information and access because oflimited availability of women-only facilities, high cost ofparticipation and insufficient time.

2.5 Dietary habits and nutritional status

No comprehensive data on nutritional status are avail-

able for minority ethnic groups. Although the UK-wideNational Diet and Nutrition Survey(NDNS) is designed

to be representative of the population, sample sizes forminority ethnic groups have not been sufficient to allow

separate analysis (Scientific Advisory Committee on

Nutrition, SACN 2008). With the exception of a fewstudies in recent years, there has been a fundamentallack of information on the eating habits of minority

ethnic groups. A small amount of data on the eatinghabits and nutritional intake among minority ethnic

groups are also available from the Low Income Diet and

Nutrition Survey(LIDNS) (Nelsonet al. 2007) and theFamily Food Survey (Defra 2008), which uses a meth-odology based on the purchase of foods by households

to estimate consumption levels.


2011 The Authors



15/38

Intake of fruit and vegetables

A diet rich in fruit and vegetables provides many healthbenefits such as reducing the risk of CVD, type 2 dia-

betes and some types of cancer and maintaining ahealthier weight. The WHO (2003) recommends the

consumption of at least 400 g of a variety of fruit andvegetables a day. In the UK, this has been translated to

at least five portions (of 80 g each) of fruit and veg-etables each day. Based on 24-hour recalls of food con-

sumption, the Health Survey for England found thatmen and women from minority ethnic groups were

more likely to report eating 5 A DAY compared with thegeneral population in 2004 (see Table 5). Data from

Scotland (NHS Health Scotland 2009) showed that theproportion of Chinese (54%) and African-Caribbean

(44%) respondents achieving 5 A DAY was highest,above the general population at 34%, and was lower

among South Asians (33% of Indian and 19% of Paki-stani respondents). This is similar to the findings from

the Family Food Survey for 20052007, where theaverage consumption of fruit and vegetables was lower

among South Asian groups than the mainstream whitepopulation. Men and women from African-Caribbean

and Chinese groups consumed a larger portion of fruitand vegetables, which reflect the characteristics of tra-

ditional diets of these groups (Craig et al. 2006; Heim &MacAskill 2006; Defra 2008) (see Tables 5,6).

Table 5 Adults and childrens daily fruit and vegetable intake in England, by ethnic group and sex (adapted from Craigetal. 2006;

Fuller 2006)

Black Car ibbean Black Afr ican Indian Pakistani Bangladeshi Chinese Gener al population

Men

5 portions or more (%) 32 31 37 33 32 36 23

Mean number of portions 3.9 3.7 4.2 4.3 3.8 4.4 3.3

Women

5 portions or more (%) 31 32 36 32 28 42 27


Boys

5 portions or more (%) 19 18 22 19 22 15 11


Girls

5 portions or more (%) 19 20 18 16 21 24 12


Table 6 Average intake of energy, fat, saturated fatty acids, sugars, salt, dietary fibre and fruit and vegetables by ethnic group, 20052007,

based on household purchases, UK (adapted from Defra 2008)

Asian/Asian

British (%)

Black/Black

British (%)

Chinese and

others (%) White (%)

Consumption per person per day, total diet ( i.e. including alcohol)

Energy (kcal) 2203 2086 2036 2368

Fat (g) (% total energy) 91 (37.0) 83 (35.9) 89 (39.4) 98 (37.1)Saturated fatty acids (g) (% total energy) 30 (12.2) 27 (11.5) 29 (12.8) 38 (14.4)

Total sugars (g) 107 118 103 135

Non-milk extrinsic sugars (g) (% total energy) 66 (11.2) 79 (14.2) 63 (11.6) 88 (13.9)

Dietary fibre Englyst (g) 14 14 14 16

Sodium (g) 1.8 2.0 2.1 3.1

Salt (g) 4.5 5.1 5.2 7.7

Purchase per person per week

Fruit (g) 1184 1587 1446 1322

Vegetables (g) 1188 1122 1288 1185

Excluding salt added at the table.


2011 The Authors



16/38

Macronutrients

In the UK, it is recommended that total fat shouldcontribute an average of 33% of daily total energy

(when alcohol is included), of which no more than 10%should come from saturated fatty acids, while non-milk

extrinsic sugars should not contribute more than 10%of daily total energy (Department of Health 1991).

Using a self-completed food frequency questionnaireand fat scores based on the frequency of consumption of

certain foods, the Health Survey for England reportedfat intake to be lower for men and significantly lower for

women from minority ethnic groups compared with thegeneral population, with lowest intakes among Indian,

Chinese and Black African men and Black Caribbean,Bangladeshi and Pakistani women in 2004 (Craig et al.

2006). Smaller studies in the UK have examined theamount of fat consumed by South Asians, but these have

reported conflicting results, which may be caused bydifferent methods of assessments or limitations associ-

ated with sample size (Bush et al. 1999). Research hasalso shown differences in fat intakes within the same

minority ethnic group, depending on the country oforigin, which influences cooking practices, income and

other social factors (Landman & Cruickshank 2001)(see Section 3).

TheLIDNS(Nelsonet al. 2007), which captured the

dietary intakes of low-income groups (bottom 15% ofmaterial deprivation), contained a small amount of

data on the nutrient intakes of adults from minority

ethnic groups (n = 207). Ethnicity was self-definedusing a questionnaire. Because the sample sizes forsome groups were small, only limited analyses were

made and statistical comparisons were only carried outbetween White and Asian men, and between White,

Black and Asian women. White men had higher con-tributions to energy intake from saturated fatty acids

(13.9%) than Asian men (12.1%).White women hadhigher contributions to energy intake from fat (35.5%)

than Black (30.7%) and Asian (31.4%) women. Simi-larly, White women had higher contributions to energy

intake from saturated fatty acids (14.0%) than Black

(10.8%) and Asian (11.7%) women. Asian men had alower percentage contribution of non-milk extrinsicsugars to food energy (10.5%) than White men

(15.0%). Similarly, Asian women had a lower percent-age contribution of non-milk extrinsic sugars to food

energy (10.0%) than White women (13.2%) and Blackwomen (14.3%).

The report Family Food in 2007 showed thatalthough the absolute consumption of fat and non-milk

extrinsic sugars was highest for the White population,

the proportion of total energy from fat was highest forthe Chinese (39.4%) and the proportion of total energy

from non-milk extrinsic sugars was highest for Blackminority ethnic groups (14.2%). However, the amount

of saturated fatty acids remained highest for the Whitepopulation at 38 g per day (14.4% energy). Estimated

intakes of dietary fibre for all groups were found to belower than the recommended daily amount of 18 g for

adults and minority ethnic groups consumed less dietaryfibre daily (14 g) compared with the White group (16 g)

according to the Family Food Survey (Table 6) (Defra2008). These figures are based on household purchases

and therefore may explain the differences with the find-ings from the NDNS.

Micronutrients

It is recommended that consumption of salt should not

exceed 6 g per day (lower for children under 11 years).A high salt intake raises the risk of high blood pressure,

which increases the risk of stroke and premature deathfrom CVD (SACN 2003). According to the Health

Survey for England, use of salt in cooking and additionof salt at the table without tasting the food was more

common among minority ethnic groups than the generalpopulation in 2004 (Craig et al. 2006), which may be

associated with the higher risk of hypertension among

these groups (see Section 2.2). From a small sampleof African-Caribbean adults living in Staffordshire

(n = 39), Earlandet al. (2010) also reported high intakes

of sodium at 3231 mg (8.1 g of salt) each day. However,both theLIDNS and Family Food Survey showed con-flicting results, reporting the highest salt intake among

the mainstream White population compared withminority ethnic groups, which may be caused by the

different survey methodology and not including saltadded at the table in both reports (Nelson et al. 2007;

Defra 2008) (see Table 6). Unfortunately, there is a lackof data based on urinary sodium levels for these groups.

According to the LIDNS (Nelson et al. 2007),average daily intakes of all vitamins from food sources

were above or close to the Reference Nutrient Intakes

(RNI) for men and women from all ethnic groups butthere was evidence of lower intakes of vitamin A, ribo-flavin and folate in Black and Asian women compared

with White women. Compared with their White coun-terparts, Black women and Asian respondents were also

more likely to consume lower amounts of calcium. Atotal of 42% of Black women and 36% of Asian women

had calcium intakes below the lower RNI (LRNI) com-pared with 8% of White women, suggesting inadequacy

is likely.


2011 The Authors



17/38

Iron status has been found to be low among certainminority ethnic groups as demonstrated by the low

mean haemoglobin (Hb) levels. Defining anaemia asHb


18/38

from minority ethnic groups. Ellahi et al. (2008) sug-gested that interventions should also target partners,

mothers and mothers-in-law for breastfeeding support,as South Asian women have reported pressure from

surrounding family members with regard to infantfeeding practices and types of food for weaning.

Healthy Start vitamins should also be encouraged toensure that children and pregnant and breastfeeding

women receive adequate vitamin D (as is necessary forthe mainstream population) (Ellahi et al. 2008).

The Millennium Cohort Study, (Hawkins et al. 2008),which was conducted in England in 20032005, found

that mothers from minority ethnic groups (n = 2110)were more likely to initiate breastfeeding than white

mothers (n = 6478) (86% vs. 69%) and continue for atleast 4 months (40% vs. 27%). Highest of these groups

were the Black participants (95% started breastfeeding),and the group with the lowest rate was the Pakistani/

Bangladeshi group at 76%, which was still higher thanWhite mothers. First- and second-generation minority

ethnic groups were less likely to breastfeed than recentimmigrants. It was found that for every additional

5 years spent in the UK, the likelihood of breastfeedingwas reduced by 5%. The Infant Feeding Surveyin 2005

(Bollinget al. 2007) found that mothers from minorityethnic groups had highest rates for exclusive breastfeed-

ing at birth and breastfeeding at all ages up to 9 months.

It also reported that these mothers tended to introducesolids later on average than White mothers: around

70% compared with 83% had introduced solids by 5

months. Chinese women were least likely to introducesolids by 4 months (40% compared with 51% for whitemothers). The Millennium Cohort Study also found

similar results with White mothers more likely to intro-duce solids earlier than those from minority ethnic

groups (Griffiths et al. 2007). Mothers from minorityethnic groups were also less likely to feed their babies a

number of foods including dairy products, potatoes,bread, fat spreads, cooked vegetables and fruit.

However, Asian mothers were more likely than others togive pulses (32% compared with 16% of all mothers)

and eggs (16% compared with 6%). Asian and Black

mothers were significantly less likely than other groupsto give their infants meat regularly (29% and 33%compared with 57% overall). A total of 41% of Asian

and 37% of Black mothers never included meat in theinfants diet. Asian mothers were also less likely to give

their babies chicken and fish, suggesting that weaningonto a vegetarian diet is more common. Chinese

mothers were particularly likely to provide rice or pastabut much less likely than other groups to give breakfast

cereals to their babies.

The use of salt was most prevalent in the diets ofbabies of mothers from minority ethnic groups com-

pared with the diets provided by White mothers. Whileonly 5% of White mothers used salt at least occasion-

ally, this proportion was 32% for Asian mothers, 26%for those of Chinese or other ethnic origin and 23% for

Black mothers. However, no more than 5% of mothersfrom each of these ethnic groups said that they used salt

often, most saying they used salt only sometimes(Bollinget al. 2007). Babies need only a small amount of

salt (less than 1 g a day up to 12 months) because theirdeveloping kidneys cannot cope with larger amounts of

salt. The dietary intakes of children from minorityethnic groups are presented in Section 2.6.

2.6 Overview of the health profiles and dietary andhealth behaviour patterns of children from minority

ethnic groups

Overall health

The Health Survey for England found that in 2004,

children from minority ethnic groups were less likely tosuffer from a long-standing illness than boys and girls in

the general population, although a larger proportion ofBangladeshi boys and Black Caribbean girls reported fair

or bad health. Pakistani boys were found to have highersystolic blood pressure than children of other minority

ethnic groups and the general population (Fuller 2006).

Black Caribbean and Black African children were

more likely to be obese compared with the generalpopulation. Using BMI percentiles classification for chil-dren from the 1990 UK growth reference data (UK90)

(which defined overweight as the 85th percentile andobesity as the 95th percentile), the Health Survey forEnglandshowed that in 2004, the prevalence of obesityfor children (2-to-15 years) of most minority ethnic

groups was not significantly different with each other;but the rates for these groups were higher than those for

the general population (19% boys, 18% girls), with thehighest rates among Black African children (31% boys,

27% girls) followed by Black Caribbean children (28%

boys, 27% girls), with the only exception being Indianboys (14%), Pakistani girls (15%) and Chinese children(14% boys, 12% girls) (Fig. 10) (Fuller 2006). TheNational Child Measurement Programme (NCMP) isthe most robust data set on childhood obesity in the UK,

which uses the UK90 data to measure the height andweight of children attending state-maintained primary

schools in England in Reception (aged 4-to-5 years) andYear 6 (aged 10-to-11 years) annually. It was first run in

2006/2007 and the latest figures (2008/2009) showed


2011 The Authors



19/38

that the prevalence of obesity in some Asian groups,

particularly children of Bangladeshi and Pakistani eth-nicity, was as high as or higher than those from the

Black groups contrary to the findings from the HealthSurvey for England (The NHS Information Centre

2009). This may be caused by the additional breakdownof Asian subgroup available within the NCMP data

(National Obesity Observatory 2011) (Fig. 11).

However, BMI is a marker of relative weight rather than

adiposity and is considered to be an unreliable measure-ment for population group comparisons (Nightingaleet al. 2011). Using bioimpedance and skinfold thickness

measurements, Nightingale et al. (2011) demonstratedthat BMI underestimates body fatness in South Asian

children but overestimates levels of body fat in BlackAfrican-Caribbeans (because African-Caribbean chil-

dren are generally taller and BMI and height are oftencorrelated in childhood/adolescence). Using these body

fat measurements, Nightingale et al. (2011) found UKSouth Asian children to have higher adiposity levels and

Black African-Caribbeans to have similar or lower adi-

posity levels when compared with White Europeans.Shaw et al. (2007) also reported that BMI criteria maynot accurately identify ethnic differences in body fat

among children, which should be taken into consider-ation when determining rates for overweight and

obesity. Data for childhood obesity from the Health

Survey for Englandshowed similar patterns to those in

1999, although significant increases were found forBlack Caribbean and Bangladeshi boys in 2004 (Fuller

2006).

Studies in England showed that children from SouthAsian groups were likely to have lower blood Hb levels

than the mainstream population. Childhood anaemia(Hb


20/38

while Black African-Caribbean (n = 560), especially

African children reported lower intakes of saturatedfatty acids than White European children. South Asian

and African-Caribbean children consumed proportion-

ally lower amounts of sugars and higher amounts ofprotein than White European children. In CHASE,Doninet al. (2010a) found the lower intake of saturated

fatty acids among African children to explain theirlower total and LDL-cholesterol compared with other

groups (White European, Black Caribbean and SouthAsian). However, Black Caribbean and South Asian

children were shown to have LDL-cholesterol levelssimilar to or higher than White European children.

These patterns are broadly similar to the adult findings

(see Section 2.5), reflecting the fact that dietary habits

from earlier years often track into adulthood. SouthAsian and Black African-Caribbean children also have

lower dietary intakes of vitamin D and calcium, which

may negatively impact on future bone health (Doninet al. 2010b). In addition, South Asian children havebeen shown to consume lower levels of vitamin C com-

pared with their Black African-Caribbean and WhiteEuropean counterparts (Donin et al. 2010b) (Table 8).

Physical activity related questions were asked in theHealth Survey for Englandto assess childrens levels of

walking, active play, sports and exercise (excluding thoseas part of the curriculum in school) and housework and

gardening in the week prior to the survey. In 2004,

18.0%

14.9%

9.7%

11.8%

15.1%

12.5%

10.6%9.6%

10.6%

13.9%

25.1%

23.2%

26.2%

29.1%

26.4%

22.2%

18.9%

21.5%

28.5%

16.3%

14.9%

8.1%

11.0%11.4%

8.8%

10.3%

8.6% 8.7%

10.5%

27.3%26.4%

15.5%

19.7% 19.8%

16.8%

19.8%

16.0%16.4%

17.7%

26.0%

Any otherethnic group

%

Boys (Reception)

Boys (Year 6)

Girls (Reception)

Girls (Year 6)

Black African Black other Indian Pakistani Bangladeshi Asian other Mixed White British White other

Figure 11 Prevalence of obesity among children from minority ethnic groups in Reception and Year 6 England, NCMP, 2008/2009 (The NHS Information

Centre 2009).

Table 7 Dietary behaviours of South Asian, African-Caribbean and White UK children from theDeterminants of Adolescent Social Well-Being

and Health study(n = 6599) (adapted from Harding etal. 2008)

%

Black African

Black

Caribbean Indian

Pakistani/

Bangladeshi White UK

Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls

Not eating breakfast every day 44.9* 53.0* 36.3 51.9 20.5* 32.6* 29.1 49.6 31.0 43.3

Consuming fizzy drink most days 62.3 55.5 59.6 64.5* 66.7 56.9 73.2* 59.0 62.3 54.2

5 portions fruit and vegetables each day 24.4 24.3 28.5 26.3 38.1 36.7 23.9 25.7 31.0 30.1


21/38

Pakistani children and Chinese girls were least likely tohave walked for 5 minutes or more during the week.

Participation of children from minority ethnic groups inactive play was also lower compared with the general

population. Girls were less likely to take part in sportsand exercise than were boys, with lowest participation

rates among South Asian girls, of whom, less than aquarter had taken part in sports and exercise over the

previous week. Children from minority ethnic groups

were less likely than children in the general population to

be active at the recommended levels of moderate inten-sity of at least 60 minutes every day, except for Pakistaniboys (Department of Health 2004; Fuller 2006). Khuntiet al. (2007) also observed widespread sedentary behav-iour, both for South Asian and White European children,

in inner city secondary schools in the UK, with almosthalf of the respondents (n = 3601) spending four or more

hours per day watching television or videos or playingcomputer games. Results from CHASE comparing

objectively measured physical activity levels in 9-to-10-year-old British children of South Asian, Black African-

Caribbean and White European origin showed British

South Asian children to have the lowest levels. BlackAfrican-Caribbeans also had lower levels that WhiteEuropeans, and girls in all groups recorded less physical

activity than boys (Owenet al. 2009).

2.7 Gaps in data availability

The Foresight report (2007) highlighted the lack of sub-stantial health data sets for minority ethnic groups.

SACN (2008) also described the lack of national data

available on the nutritional status of minority ethnicgroups and recommended improved monitoring and

health initiatives for this sector of in the population.Within the health and dietary data available for

minority ethnic groups, much research has been focusedon South Asians and African-Caribbeans, but there

is relatively little information about the health anddietary habits of the Chinese population. Further studies

on all non-White minority ethnic groups are essential toprovide a better picture of their health and nutrition

status.Apart from theHealth Survey for England, there are

insufficient population-wide data available to reflect the

general health status of minority ethnic groups inNorthern Ireland, Scotland and Wales. Evaluations of

the availability and quality of data on ethnicity andhealth in the UK have suggested the following problems:

incompleteness of data, variability in the use of ethniccoding, lack of training for staff on ethnicity data col-

lection and inadequate information technology systemsfor ethnicity information to be appropriately recorded

and exchanged (Unal et al. 2003; Aspinall & Jacobson

2007; Bhopal et al. 2008). For example, the ScottishEthnicity and Health Research Strategy Working Groupset up by the NHS Health Scotland (2009) reported that

ethnicity was rarely recorded on health service recordsand not on death certificates. Less than 20% of hospital

admission records and cancer registration data had anethnic code. The group published the Health in ourMulti-Ethnic Scotlandreport, which provides prioritiesfor action to fill the information gap that include record-

ing the ethnic identity of every person registered with

Table 8 Nutritional composition of childrens diets from the CHASE study by ethnic group (adapted from Donin etal. 2010b)

Consumption per person per day, total diet

South Asian

(n = 558; 264 boys) (%)

Black African-Caribbean

(n = 560; 261 boys) (%)

White European

(n = 543; 271 boys) (%)

Energy (kJ/kcal) 8042/1911 7665/1821 7634/1814

Fat (g) (% total energy) 76.9 (35.6) 69.0 (33.2) 70.8 (34.5)

Saturated fatty acids (g) (% total energy) 27.3 (12.7) 25.0 (12.0) 27.2 (13.2)

Carbohydrate (g) (% total energy) 258.5 (50.9) 256.3 (53.0) 252.3 (52.1)

Sugars (g) (% total energy) 101.2 (19.8) 112.0 (22.9) 116.1 (23.8)

Dietary fibre (g) 12.8 11.0 11.8

Protein (g) (% total energy) 65.7 (13.6) 60.2 (13.3) 57.3 (12.7)

Vitamin B12 (mg) 2.9 3.0 2.8

Folate (mg) 196 200 204

Vitamin C (mg) 73.9 85.9 85.1

Vitamin D (mg) 1.4 1.7 1.9

Calcium (mg) 699 693 742

Iron (mg) 9.4 8.6 8.7

Haem iron (mg) 0.12 0.20 0.15


2011 The Authors



22/38

the NHS and maximising use of methods and links todata research on various health problems. A health

survey focusing on the health of minority ethnic groupsis expected to be carried out in 2011/2012 by the NHS

Health Scotland.

Key points

Health and wellbeing vary significantly betweenminority ethnic groups. In general, minority ethnic

groups tend to show poorer health outcomes com-pared with the general population. Possible causes of

increased disease risk among minority ethnic groupsfor a given level of exposure include health behaviour

patterns, genetic predisposition and developmentalprogramming. Language and cultural differences have

been identified as the two major barriers to access tohealth care.

According to theHealth Survey for England(2004), ahigher proportion of Pakistani and Bangladeshi adults

reported suffering from a limiting long-standing illness.South Asian respondents were more likely than the

general population to suffer from CHD, which may beexplained by higher LDL-cholesterol levels. On the con-

trary, African-Caribbeans tend to have lower LDL-cholesterol levels, and this may be reflected in their

lower CHD rates. Adults from minority ethnic groupswere more likely to suffer from a stroke, with highest

rates amongst African-Caribbeans; this may be linked to

their higher salt intakes.

Minority ethnic groups are more likely to developtype 2 diabetes, with highest rates among SouthAsians, which may be caused by their higher risk of

central fat deposition. Findings from CHASE sug-gested that the increased risk of CVD and type 2 dia-

betes of adult minority ethnic groups may be trackedfrom childhood.

Obesity rates were higher for Black African and BlackCaribbean adults, while Chinese and South Asian com-

munities were less likely to be obese. However, it hasbeen suggested that obesity cut-off points should be

lower for Asian groups as they tend to have a higher

body fat content for a given BMI compared with theWhite population. In the Health Survey for England, fewer respondents

from minority ethnic groups reported drinking alcoholcompared with the general population. A greater pro-

portion is likely to abstain for religious reasons. A larger proportion of minority ethnic groups met the

recommendation of eating at least five portions of fruitand vegetables a day (although relatively low intakes of

vitamin C have been reported in South Asian children).

They also tended to have a lower fat intake than thegeneral population according to the Health Survey for

England, but other studies have shown conflictingresults. According to theHealth Survey for England, use

of salt in cooking and addition of salt at the table wasmore common among minority ethnic groups than the

general population. Unfortunately, there is a lack ofdata based on urinary sodium levels.

Low iron status has been found among women ofmany minority ethnic groups, and anaemia is more

common in both adults and children in these groupscompared with the mainstream population.

Vitamin D deficiency has been observed amongminority ethnic groups in the UK, particularly in the

winter months. Low selenium intakes have also beenreported in South Asian groups.

Folic acid supplementation, good infant feeding prac-tices and Healthy Start vitamins should be encouraged

in minority ethnic groups as well as the mainstreampopulation. TheInfant Feeding Surveyin 2005 and the

Millennium Cohort Study found that mothers fromminority ethnic groups had highest rates for exclusive

breastfeeding and they tended to introduce solids later,on average, than White mothers. Mothers from minor-

ity ethnic groups tended to use more salt in their babiesdiet. Childhood anaemia was found to be more common

among children from South Asian groups than Whitechildren in England, which may be caused by the early

introduction of cows milk as a main drink.

Obesity rates among children from minority ethnic

groups were higher than those for the general popula-tion, with highest rates among Black African-Caribbeanchildren. The only exception being Indian boys, Paki-

stani girls and Chinese children. CHASE found that South Asian children reported a

higher consumption of total energy and total fat (abso-lute and as a proportion of total energy intake), which

may account for the increased risk of obesity in thisgroup, while Black African Caribbean children reported

lower intakes of saturated fatty acids, which may reducetheir risk of CHD in later life. However, these children

also have lower intakes of vitamin D and calcium from

their diets, which may be risk factors for poor bonehealth in the future. Physical activity levels among adults and children

from minority ethnic groups tend to be lower thanamong the general population, and they are more

unlikely to reach the recommended level for health.Activity levels are lower in girls compared with boys in

all groups. There is a lack of national data on the health and

nutritional status of minority ethnic groups in Northern


2011 The Authors



23/38

Ireland, Scotland and Wales. To reduce health inequali-ties, it is important to carry out national surveys on the

health and nutritional wellbeing of minority ethnicgroups, to identify the gaps in health service provision,

develop suitable health initiatives and community strat-egies to reduce barriers to health care and encourage

healthy lifestyle behaviours.

3 Factors affecting food choice

The dietary habits of minority ethnic groups are influ-

enced by a range of factors, including income, socio-economic status, food availability and access, health,

religion and dietary laws, food beliefs, amount of timeavailable for food shopping or preparation, generation

and gender. Acquiring a better understanding of thereasons underlying food choices and the reasons for

acceptance or non-acceptance of particular foods by

different minority ethnic groups can help nutritionists/dieticians, as well as other health professionals and edu-cationalists, to understand more about the needs of

minority ethnic groups and help them make healthierfood choices.

Income and socio-economic status

The amount of disposable income available for familiesand individuals in minority ethnic groups to spend on

food impacts on their dietary habits and the foods thatthey choose to eat. According to the 2001 census,

people from minority ethnic groups were more likely tolive in low-income households and rely on social secu-rity benefits. Unemployment rates for some minority

ethnic groups were also higher than the populationaverage (see Section 1.2). A low income may restrict

food choice by limiting selection to cheaper foods,which are sometimes of poorer quality (e.g. higher in

saturated fatty acids, sugar and salt). This has beenobserved among South Asian communities in the UK.

Lipet al. (1995) found that South Asian households inthe UK of lower social classes were more likely to pur-

chase foods that were higher in fat. In a study by

Kassam-Khamis et al. (2000), which examined thenutritional quality of commonly consumed dishesamong three South Asian Muslim groups (Bangladeshi,

Pakistani and East African Ismaili), the Ismaili groupappeared to be the most affluent of the three and ate

dishes of lower fat content. Low income may preventsome families from being able to consume some tradi-

tional foods (see following section) and this may alsoaffect diet quality. Concern has also been expressed that

poorer Asian families are also more likely to reuse

cooking fats, and this may create trans fatty acids,which are adverse for heart health (Landman & Cruick-

shank 2001).

Food availability and access

Traditional foods are not widely available, and manyare only available in ethnic-style supermarkets located

in specific regions of the UK (e.g.London). These foodsare often more expensive because they are imported

(Lawrence et al. 2007; Mintel 2009). However, forsome members from minority ethnic groups, maintain-

ing traditional food habits is of central importance andthey are willing to purchase imported traditional foods

even at a relatively high cost (Bush et al. 1999). Whilesome supermarket chains in the UK offer ethnic-style

food products (e.g. rice, noodles, soy sauce, chillipowder), the relatively small quantities sold may be

inappropriate for family catering for certain minorityethnic groups with relatively large households (e.g.

South Asians) that favour the custom of bulk buying(Bush et al. 1999; Lawrence et al. 2007). In addition,

because of seasonal variability, some foods may not beavailable in the UK during certain times of the year; for

example, 42% of Pakistani households consumedpalak(a kind of spinach) in the summer compared with 19%

of these households in winter (Kassam-Khamis et al.2000).

Awareness of healthy eatingAlthough knowledge does not necessarily translate tobehaviour change, awareness of healthy eating messages

can impact on food choices of minority ethnic groups.Kassam-Khamis et al. (2000) observed that the most

affluent Ismaili group (compared with other SouthAsian Muslim groups from Bangladesh and Pakistan)

were found to be more conscious of healthy eating mes-sages and ate foods that had lower fat content. In a

qualitative study (n = 33), Lawrenceet al. found that allrespondents, which were girls and young women of

African and South Asian descent, recognised the link

between food, cooking methods and health. However,only a number of them had a good understanding of thelink, and this was dependent on the cultural back-

ground. For example, Pakistani and Bangladeshi womenappeared to have relatively good understanding of what

methods of cooking are healthy and unhealthy, e.g.

frying is not a healthy cooking method; while Zimba-

bwean respondents placed value on freshness andregarded frozen foods as less healthy (Lawrence et al.

2007). This reflects the need for targeted messages and


2011 The Authors



24/38

culturally appropriate resources on healthy eating fordifferent minority ethnic groups.

Religious beliefs

Religious dietary laws have a direct impact on the eating

habits of minority ethnic groups, especially SouthAsians (Muslims, Hindus and Sikhs) and African-

Caribbeans (Rastafarians and Seventh-day Adventists).These rules were set to help followers demonstrate their

faith by adhering to religious rites concerning diets, tocommunicate with God (e.g. saying thanks and bless-

ings) and to develop discipline through fasting (Kearneyet al. 2005). Depending on the religion, there are rules

as to how, when and with what particular foods areeaten. Some foods are completely prohibited, while

others may be eaten occasionally or in small amounts(Sheikh & Thomas 1994; Gilbert & Khokhar 2008).

Fasting is also common in some faiths. Table 9 showsthe foods allowed or prohibited for different religious

groups. However, it is important to note that dietarypractices may vary for religious subgroups within a

particular faith and also with the degree of devotion.

Muslims

According to the 2001 census, over 90% of Pakistanisand Bangladeshis living in the UK are Muslims (ONS

2006b). TheKoran, the religious text of Islam, outlines

the foods that can be eaten (described as halal) and

those forbidden (haram). Beef, lamb and chicken canonly be eaten if the animal has been slaughtered by the

halal method, which means that the animal must bekilled by slitting its throat and then have all the blood

drained from its body and slaughtered by a Muslim.Haram are foods that are forbidden in Islam, which

include pork, blood, alcohol and meat sacrificed toidols. During the month of Ramadan, the ninth month

of the Islamic calendar, Muslims refrain from eating,drinking and smoking from sunrise to sunset. Fasting,

one of the five pillars of Islam, is practised duringRamadan and is believed to increase spirituality,

improve self-discipline and awareness of the hardshipexperienced by people facing starvation. However,

fasting may lead to headaches and dehydration (becauseof restrictions in fluids and/or caffeine). Prolonged absti-

nence from food and drinks may also lead to lethargyand affect work performance. A study of 81 students in

Tehran showed reductions in the concentrations ofblood glucose and HDL-cholesterol and increases in

LDL-cholesterol in healthy individuals during the periodof fasting, which may be related to the biochemical

response to starvation (Ziaee et al. 2006). Althoughchildren (before puberty), pregnant and lactating

women, the elderly and those who have serious sicknesscan be exempted from fasting, many still choose to fast

because of religious or social reasons, e.g. fear of stig-matisation, penalty from non-compliance. This is a par-

ticularly serious issue when followers are on oralmedication or insulin therapy as fasting affects glycae-

mia. Therefore, these should be adjusted to co-ordinate

with the time of the main meal. The EPIDIAR(Epide-

miology of Diabetes and Ramadan) population-basedstudy, which involved over 12 000 patients with diabe-

Table 9 A guide to religious and cultural influences on diet (adapted from

diets of minority ethnic groups in the uk

Documents