Professor Kamila Hawthorne is a GP in Mountain Ash in the South Wales Valleys. She leads the Graduate Entry Medicine programme at Swansea University and is a member of the Bevan Commission and a nationally elected member of the Council of the RCGP.
Over the course of the Coronavirus pandemic, it has become increasingly clear that people from Black, Asian and Minority Ethnic backgrounds are more susceptible to falling seriously ill and dying from the disease.
The reasons for this are complex, and probably include both social and health-related factors, but scientists believe that one of these factors could be the increased prevalence of underlying medical conditions or ‘comorbidities’ in these groups.
These medical conditions include Type 2 Diabetes, Heart Disease, and metabolic syndrome. So let’s look at one of these - Diabetes - and try to understand why more BAME people are vulnerable.
What’s the picture at present?
In the 1980s, we realised that Type 2 Diabetes was more common in people of South Asian origin. The initial evidence came from a house to house survey in Southall, in London, which suggested that Type 2 Diabetes was up to four times more common in this ethnic group. We now know that it’s actually 6 times more common in people of South Asian origin than in people of European origin.
If we look at the population of the UK, South Asians make up 4% of the population but account for 8% of all known cases of Diabetes - and there are probably more who don’t even know they have it.
What’s more, South Asian people are also three times more likely to have heart disease - so there’s clearly something going on in their racial background or makeup that makes them more vulnerable to these diseases.
And that’s vital because if you’re diabetic and you get Covid-19, it’s likely that because of your high blood sugars, you deal with the infection less well than if you’re not diabetic.
Nature or nurture?
It’s a simple question with a complicated answer. There does seem to be some genetic predisposition here, and there is often a family history of Type 2 diabetes.
In the 1980s, one theory was that it had to do with the fact that first generation immigrants might have been born in their home countries as ‘small-for-dates’ babies.
We know that this increases the risk of developing chronic illnesses late in life - in particular, Type 2 Diabetes, heart disease and hypertension.
The theory is that being ‘small-for-dates’ could alter the way dietary fats and proteins are digested and processed, putting a strain on your pancreas which makes the insulin.
While the person remains slim, everything remains fairly stable, but if the diet becomes richer (as it often does on coming to the UK), the person becomes less able to make enough insulin to control blood sugar levels.
If the person also gains weight, this increases the resistance to the action of insulin, making blood sugars even higher, resulting in diabetes.
But then we see the same impact in second or third generation South Asian people - they also have that higher risk of developing Type 2 diabetes, when many of them were not small for dates.
So there must be additional factors that increase the chances of developing Type 2 Diabetes.
Essentially, it’s complicated. But what we think may also be happening is that people of South Asian origin are not processing or burning fat in quite the right way, increasing their insulin resistance.
That makes them accumulate fat centrally (around the abdomen), particularly around the liver and pancreas. This is called central obesity, which dramatically increases chances of developing Type 2 Diabetes.
The particular thing for South Asian people when it comes to weight is that instead of having a BMI of 25 or lower to be a healthy weight, they should have a BMI of 23 or less. So they have to be thinner in order to have the same insulin activity as European people.
The next question is what part is played by lifestyle - diet, exercise, cultural approaches to taking regular medication, and attending for regular check-ups for complications of diabetes.
It’s very easy to blame a South Asian diet, pointing at the many sweetmeats and fried foods that people eat.
In reality, there are many things in a South Asian diet that are very good for Diabetes.
People eat a lot of vegetables, they eat high fibre foods and many eat less meat or are vegetarian.
On the other there are also approaches to the way food is prepared - especially amongst the older generation, that unless there’s a good layer of oil on the surface of your curry it’s not tasty.
A diet that is high in fibre, and low in carbohydrates and fats is ideal.
What needs to be done?
We need to train people to cook in ways that are still traditional but are healthier. It’s not about living off boiled vegetables, it’s about learning how to enjoy your home food, cooked slightly differently to be healthier.
People who smoke should be encouraged to stop, as smoking increases the damage caused by diabetes.
Having regular screening for diabetic complications (for example eye and foot screening, and regular blood tests to make sure diabetes is well controlled) can also prevent blindness, circulation problems and kidney and heart disease.
In Wales, we need to know the communities that we’re serving, because otherwise you’ll give them information that’s not suitable or appropriate for them - or even information in the wrong language!
In Wales, minority communities make up a small percentage.
It’s something like 3 to 4% are from BAME backgrounds, whereas in England it’s more like 15 or 16%.
And I think that sometimes, the fewer BAME people there are in an area, the more difficult it is for them, because services are less likely to flex in their favour to enable them to access them appropriately.
And so because of a lack of culturally appropriate education, people don’t understand what they need to do to improve their health.
We know that in Wales, for example, diabetic retinal eye screening attendance is much lower in BAME areas than in other parts of Wales - and that’s probably because we are not getting across the message that eye screening is important.
We continue to need more and better communication between healthcare services and BAME communities, using interpreters and link workers if needed, to get across simple but vital messages about how to stay healthy and how to prevent diabetes.
Making it easier for people to access the services available, using familiar community centres and places of worship, as well as understanding why it is so important to control diabetes to prevent chronic illness and disability later in life is crucial.