Abstract
Objective: To characterise the diet of South Asian males attending mosques in Burnley in order to focus intervention strategies to improve nutrition-related health in the community.
Design: Cross sectional survey of Muslim men in Burnley, Lancashire UK. Muslim men (n=141) aged 15-67 years who consented were recruited. Subjects completed a food and health questionnaire and a 24 hour dietary recall (repeated) and provided self-reported anthropometric data.
Results: Data revealed significant dietary under-reporting in the sample with a mean value of 78.0% of the estimated average intake (EAR) for energy specific to age group reported. Under-reporting was more likely as the body mass index (BMI) of subjects increased. Similar proportions of total energy were derived from protein but a greater percentage of energy was provided by total fat and a smaller proportion by total carbohydrate when compared with white British males. Saturated fatty acids constituted half the proportion of total food energy yet mono-unsaturated fatty acid intake was low in comparison. All (except the 46-67) year old age group consumed greater than 6g of salt a day.
Conclusions: The study identifies several areas with the potential for health improvement. Subjects should reduce total fat intake and redistribute fat intake to more favourable proportions, with more emphasis on monounsaturated fat sources. Further dietary modifications include reducing salt intake and increasing non-starch polysaccharide consumption. Access to mosques for use as a health assessment and promotion environment is an important avenue for ensuring effective communication of messages for Muslims.
Introduction
South Asian communities, originating from the Indian sub-continent: India, Pakistan, Bangladesh and Sri Lanka, are the largest ethnic minority group in Britain numbering 2.33 million, over 3% of the British population (1). Of this, Indians, Pakistanis and Bangladeshis comprise 29%, 16% and 5% respectively of the total non-white population of Britain. Growing evidence reveals that South Asians display disproportionately high rates of mortality and morbidity from coronary heart disease (CHD) and type 2 diabetes mellitus (2,3). Mortality from CHD is 50% higher (4) and the incidence of type 2 diabetes is 500% higher in South Asians than the general population of the UK (5, 6-8). Prevalence of cardiovascular disease (CVD) is increasing generally in the population, but significantly, the prevalence in Pakistani men doubled between 1999 and 2004, coronary heart disease or stroke prevalence reaching 41.1% in men aged over 55 years. Doctor-diagnosed Type 1 or 2 diabetes was almost 3 times more prevalent in Pakistani men than the general population (9). The reasons for this are yet to be fully established, but are undoubtedly multi-factorial, including genetic predisposition, diet and environment/lifestyle factors (10).
Epidemiological studies have reported a progressive increase in the risk of developing complications such as type 2 diabetes, hypertension and coronary heart disease with increasing BMI, particularly if the fat is located centrally (truncal adiposity) (11,12). The occurrence of a combination of obesity with other metabolic disorders, including hypertension, insulin resistance, cardiac hypertrophy and hyperinsulinemia has been termed “syndrome X” (13). It is well recognised that they are not merely co-morbid factors that occur secondary to obesity, but are part of an integrated metabolic syndrome.
A study examining the heterogeneity of CHD risk factors in Indians, Pakistanis, Bangladeshis and Europeans in Britain revealed that obesity was more common in Pakistanis and Indians than Bangladeshis, and that a higher proportion of Pakistani and Bangladeshi men had type 2 diabetes (22.4% and 26.6% respectively) than Indians (15.2%) (14). In addition Asians of Pakistani origin have a greater tendency for accumulation of truncal adiposity compared to Caucasians in the UK (15). Furthermore, a cross sectional comparison of children demonstrated that insulin resistance was present at a higher rate in South Asian compared to white children, in the absence of a concomitant increase in adiposity (16). Studies in adults have revealed that the classic complications of obesity are evident more frequently at lower body mass indexes (BMIs) in Asians compared to Caucasians (17,18). Mean BMI of Pakistani men (25.9kg/m²) is lower than the general population (27.1kg/m²) (19) despite this CVD prevalence is higher in this ethnic group than in Caucasians (9). Taken together, these studies suggest that South Asian people may be particularly sensitive to the metabolic consequences of obesity. Additionally, the UK Department of Health (20) reported a lower activity level in Asian populations as compared to the general population, as seen in less walking and less participation in sports and exercise per week (20).
Despite the potential impact of optimal nutrition on many of the risk factors for metabolic syndrome there has been relatively little research into the diet of South Asians, primarily due to a lack of tools available to examine dietary patterns. This is confounded by the diversity of dietary practices exhibited by these communities (21). Consequently this research sought to examine the dietary patterns of South Asian men, gaining access to this community via the novel route of their place of worship, four mosques located in the Burnley area. The aim was to establish a picture of the dietary pattern of this population with a view to developing subsequent interventions. Recruitment of participants from mosques and community venues ensured contact with this group South Asian men.
Methods
This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human participants were approved by the Department of Biological Sciences Panel for Ethical Review of Research, University of Chester. Written informed consent was obtained from all participants. Participants were checked for diet history using 24 hour recall, portion size using food atlas (23) and food frequency questionnaire validated for south Asians (22). Three researchers were assigned single roles to assess diet history, administer questionnaires and checking weight circumference respectively to prevent reporter’s bias. Height and weight were self reported measures.
Participants
Muslim men of Pakistani origin aged 15-67 years, who attended one of four mosques/community venues throughout Burnley, were selected using a purposive sampling strategy. A skip method (as applied in systematic random sampling) where every third participant was selected was employed in this study. Of the approximately 750 eligible participants at that time (this was calculated from average mosque attendance) 141 agreed to take part in the study. The sample size was calculated based on the use of the following provisions: a point biserial model to allow for t-tests and correlation (two tailed). Statistical power of 90% (i.e. 1 - β =0.9) was sought with a medium effect size ρ = 0.30 and Type I error (α =0.05) with non-centrality parameter δ of 3.28. The sample size computed was n= 109 with 25% retention rate calculates to total of n= 137 subjects and n=141 were therefore recruited to take part in this part of the study.
Apparently normal healthy males adults who met the inclusion criteria were recruited. The study was advertised and supported in the mosque and by the faith leader at prayer times, which helped promote the study and its acceptability for participants. Subjects participated in data collection on the way to Friday (Jumma) prayer or after prayer.
Access to subject
Bhopal et al. (24) when speaking of research with south Asians suggests that “outsiders who do not identify with the group will be viewed with suspicion and seen as a threat in that they may disturb members of the community and will question what it is the outsider wants”. However, the advantage of this approach is that “outsiders” can access such places often restricted for research and for health promotion purposes by bringing on board the necessary gatekeepers to the community. Access issues were overcome by undertaking a meeting organised with local mosque leaders and the project team with the researcher as an “outsider”. By engaging with mosque leaders, the researcher is seen as acceptable and the response rate to research is good.
Analysis
Data from 24 hour recalls was analysed using Compeat Pro Version 5.8.0 which uses established Department of Health dietary reference values (25)unless otherwise stated. Data were statistically analysed using SPSS version 18.0.
Discussion
Studies have revealed that the classic complications of obesity occur at a lower BMI in the South Asian population as opposed to the European population (17). Given that the pathologies associated with abnormal glucose metabolism and obesity are evident at lower BMIs than in Caucasian populations, this population of men of Pakistani origin from Burnley would benefit from reducing their BMIs to lower than 23.0 kg/m² as identified by the WHO as an additional cut-off representing increased risk in Asian populations (34).
Physical activity levels could also be tackled as they are particularly low in this as in other Asian populations (20) and it has been suggested due to the risk gradient for CHD observed in rural and urban Asian populations that physical activity may be the single most important factor in lowering CHD risk in South Asians (35) as often it is easier to increase physical activity for the person but harder to change the diet produced for the entire family. As described in this study, these subjects are consuming a greater amount of total fat and salt and a lesser amount of non-starch polysaccharide than is optimal for the prevention of non-communicable diseases including, in particular for this ethnic group, coronary heart disease and Type 2 diabetes. Lip et al. (36) showed that, using a questionnaire survey of weekly food purchasing habits and food preparation techniques of the food purchased in a week the highest quantity of fats in that food was found to be purchased by the Asian community (1409g/week per person) compared to the white population (1186g/week per person) in line with data outlined here. They also found that the consumption of butter, eggs and milk was significantly greater in Asians; with ghee consumption almost exclusively amongst this group. Cooking techniques also varied between the groups studied with grilling, boiling and poaching being higher in the white group and frying being the most popular amongst the Asian community (36).
This study highlights the potential for improving the diet in line with current Government recommendations (25) by reducing and redistributing total fat intake to more favourable proportions, with more emphasis on monounsaturated fat sources and with maintenance of low saturated fatty acid consumption. Salt intake should be reduced and non-starch polysaccharide consumption increased. These significant dietary changes could be elicited through the medium of a dietary intervention in the Mosques attended by these subjects and may provide reductions in the prevalence of risk factors for coronary heart disease and type 2 diabetes in this population. Smoking cessation advice could also be utilised as part of a holistic intervention programme. Although baseline smoking prevalence was not determined here, it is generally higher in Pakistani men (29%) than men in the general population (24%) (37).
Traditionally healthy eating messages for South Asian communities have been aimed towards women as they are seen as the ‘gatekeepers’ to the health of the family unit because, in the vast majority of cases, it is the women in the household that prepares the food for the family (38). Within the Muslim family women are seen as essentially subordinate to men and are required to assume responsibility for preparing and serving food while actually having very little control over the underlying patterns of provisioning and food selection where the men’s tastes and preferences prevail (38). This is often linked to the man’s economic power within the household; the higher his earning, in general, the greater his power in the family’s food choice (39). Targeting nutritional education information at women in order to change the dietary habits of the family towards a healthier pattern of consumption could be ineffective because of the lack of women’s power in the food choice of the family, where the man’s preferences are dominant. It is therefore, why within this study we are targeted men, treating them as the ‘gatekeepers’ to the health of the family (40).
Faith groups can often access communities that mainstream services find difficult to reach and British Government has for some time considered developing closer links with faith groups for formulating public health policy (42). Darr (41), from the Muslim Health Network UK, suggests that “aside from being a place for prayers, a mosque is where people meet friends, where they are counselled [for example on bereavement] where marriages are arranged……”. Thus the use of a mosque as a health promoting place is an extension of this.
More recent literature reports successful interventions to promote health initiatives amongst minorities. Ghouri (43) describes how a Muslim community, was encouraged to become involved in its own health care by holding a health fair at its mosque organized by the Minority Ethnic Health Inclusion Project, in collaboration with the Local Health Care Co-operative, and in cooperation with Edinburgh Central Mosque. The focus was primarily on diabetes, high blood pressure, healthy eating and oral hygiene, as well as providing information on cancer and local community services, 200 men and 120 women participated.
Ludwig et al. (38) in a study of Muslim Pakistani women in the UK report that women participants identify barriers to improving health to include the influence of Islam, and culture. It therefore seems appropriate that this aspect could be directly explored through the mosque venues.
Grace (44), reports a study which explored lay beliefs and attitudes, religious teachings and professional perspectives in relation to diabetes prevention in the Bangladeshi community in Tower Hamlets, London. Contrary to the views of health professionals and previous research, poor knowledge was not the main barrier to healthy lifestyle choices. Rather the desire to comply with cultural norms, particularly those relating to hospitality, conflicted with efforts to implement healthy behaviours. Considerable support from Islamic teachings for diabetes prevention messages was provided by religious leaders, and faith may have an important role in supporting health promotion in this community. Some health professionals expressed outdated views on community attitudes and were concerned about their own limited cultural understanding.
Limitations
Under-reporting
Under-reporting of energy intake was common in the sample. The percentage of subjects with a EI:BMR ratio 1.2 or below (the value accepted to denote under-reporting) was 92.8%. This is a high percentage of under-reporting but a similar value of 84% (69%-100%) from this ethnic group has been reported in another study (21). It was found that subjects with higher BMIs and larger waist circumferences were significantly more likely to under-report (rs=-0.24, n=139, p=0.004 and rs=0.17, n=149, p=0.049 respectively). Nationally the National Diet and Nutrition Survey found that over all age groups energy intakes ranged from 93-94% in British white males comparable to figures here of 65.6-83.3%. The NDNS notes that these differences could be due to overestimates of energy requirements or an inadequate energy intake but are more likely due to mis-reporting low intakes as suggested by the doubly labelled water experiment employed to investigate the validity of the 7-day diet record method used at the outset of the NDNS survey. This could also be attributed to memory limitations (33).
The technique using a validated FFQ and a series of health related questions based on recall are generally considered to be a good indicator of approximate intake when more accurate techniques cannot be employed (45). Only one 24 hour recall was elicited as in the small sample size, it was felt that reducing the drop-out rate was a priority over acquiring more dietary information, despite the suggestion that multiple days of 24 hour recall may be optimal even when compared to multiple day food records (33). Recall bias and lack of precision in determining food quantities consumed are also issues that must be taken into consideration with data elicited using this method. However, this method has been used in other studies as it is considered less burdensome than prospective methods such as weighed intake and food diaries. Additionally the accurate nutritional analysis of composite South Asian foods has only recently become available (46) and was not integrated into the software used for the current analysis. Similarly no facility was available for the distinction between intrinsic and extrinsic sugars or the composition of polyunsaturated fat consumed. Due to purposive sampling this study professes no external validity but as it was not the objective of the report to achieve this, only to characterise the diet of a small sub-population, this is hence not considered a limitation.
In conclusion, it is widely recognised that health beliefs differ across cultural groups and that health professionals, if they are to provide appropriate health care, need to be sensitive to the diversity of these beliefs. It is observed in the paper that there are concrete lifestyle factors like ratio of PUFA:MUFA:SFA, fiber intake, salt intake, physical activity and using the family approach and reduce the influence of genetic predisposition to curb the burden of metabolic disorders among south Asians. The good news is the numbers are not drastically high and with appropriate education the numbers can change and positively influence health outcomes. A continuing health service challenge is to develop programs and services that will reduce barriers to health care and facilitate preventative practices. This study characterises a community’s dietary behaviour for subsequent health interventions and shows how engaging community leaders is effective for health research suggesting a similar route to be a promising way to deliver health messages. The mosque can then be utilised as a health-promoting environment for ensuring effective communication of messages but bringing the gate keepers on board is essential. In the 2011 census for England and Wales Muslim was the third-most popular category, with numbers rising from 1.5 million (3%) to 2.7 million (4.8%) over the 10 years since the census in 2001. Thus, this is an important group to engage. Strong participation by the community in this study shows that people from ethnic minorities are interested in their health and will participate in health-related activities arranged for them. The success of this project indicates that different groups and organizations within the community can work together to provide services to minority ethnic groups. The potential for collaborative working between health educators and religious leaders should be explored further, and the cultural competence of health professionals addressed.
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