Diabetes is a chronic disease that interferes with the body’s ability to make or use insulin produced in the pancreas reducing the ability of the body to deal with glucose, or sugar, as a cell energy source (“International diabetes”, 2019). South Asians are one of the fastest growing populations in Canada, they are also at an increased risk of developing type 2 diabetes whether in a South Asian country or as migrants to another country (“South Asian Health”, 2015 & Biason, 2019). Type 2 diabetes is currently one of the leading causes of morbidity and death, but South Asians have rates higher of type 2 diabetes than other races (Gujral, 2013). Diabetes has many complications; kidney disease, heart disease, vascular disease, neuropathy and retinopathy all of which result in increased health care costs and poorer individual health outcomes (Gujral, 2013 & “International diabetes”, 2019). South Asians seem to be more genetically predisposed to developing type 2 diabetes (Gujral, 2013 & “South Asian Health”, 2015). This is thought to be related to the increased intra-abdominal fat accounting for increased insulin resistance as well as a metabolic syndrome that also contributes to insulin resistance (“South Asian Health”, 2015). The general lifestyle of South Asian’s is also changing leading to more inactivity and higher amounts of refined carbohydrates, saturated fats and sugars being eaten (Gurjal, 2013). It has been shown through evidence, that with changes to lifestyle, including physical activity and improved healthy food choices, type 2 diabetes can be prevented or delayed (“International diabetes”, 2019).
Healthcare in Ontario
Let’s consider the World Health Organization definition of health, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO). Clearly our goal is to have healthy individuals and being able to reduce a group’s chance of acquiring a chronic disease such as diabetes would be an important step towards that goal. In Ontario we are dependent on the Government of Ontario abiding by the conditions set forth by the Canada Health Act of 1984 to ensure that funding to the province continues to be provided by the Federal government. We are also currently challenged by a change in our provincial leader that has seen a dramatic reduction to public health funding as well as a dismantling of the overarching Local Health Integration Networks. The creation of a super-agency called Ontario Health and how it will allocate funds is yet to be fully understood at this time (Crawley & Janus, 2019). As you can see, we depend on both the Federal and Provincial governments for the funding that enters into the public health and hospitals.
Social determinants
How do we determine what areas to focus on in order to help reduce diabetes rates in the South Asian population? Health inequalities are generally based from the social determinants of health and as such they are best addressed at multiple levels of health rather than at the individual level alone (Agurs-Collins et al., 2019). The social determinants of health defined by the government of Canada to include: income and social status, employment and working conditions, education and literacy, childhood experiences, physical environments, social supports and coping skills, healthy behaviours, access to health services, biology and genetic endowment, gender, culture and race/racism contribute to health inequalities (Government of Canada, 2019). There are generally multiple causes of health inequalities and having multiple solutions to address those is key.
Social Ecological Model
If we look at the Ottawa charter, we want to be able to use health promotion as a tool to reduce social determinants and be able to create equality in health for all (WHO, 1986). A social-ecological multilevel approach to health looks to improve health and health inequalities from multiple levels. As stated by Sandro Galea “a multilevel approach to population health is predicated on the understanding that exposures at many levels of organization work together to produce health outcomes” (Galea, 2015). The multiple levels involved when considering optimal health solutions, according to the Centers for Disease Control and Prevention, includes the individual, relationship, community and societal (“The Social Ecological model”, 2019). A social ecological multilevel approach looks at working within a community to help craft solutions, unique to that community, at all levels within the community to help reduce inequalities and improve overall health. Figure 1 shows how the different levels overlap each other.
Figure 1. Social-Ecological Model. Adapted from Centers for Disease Control and Prevention 2019
Different cultural backgrounds can be a significant social determinant of health. Multilevel interventions that take into account the complex interaction that occurs across the different levels need to be constructed to help remove barriers.
Individual level
At this level we consider things such as genetics, race, age and education. Ultimately, we all have to be able to make our own choices but being able to make a choice rooted in sound information is important. Providing the individuals diabetes information about the increased risk for South Asians in a format that they will take in, such as pamphlets or radio ads in Punjabi, could be a plan.
Relationship level
Family connections as well as close friends create the influence at this level. We know that South Asian immigrants tend to live in multigenerational homes (“South Asian Health”, 2015). Being able to connect with the leaders in this group to share information about diabetes prevention and education helps create conversations with others in a trusted environment, reinforcing the information given at the individual level.
Community level
At this level, the workplace, schools and neighbourhoods compose the content. This level has the ability to make a big impact. 65% of South Asians state that they have a strong sense of community belonging (“South Asian Health”, 2015). Knowing that a deep connection exists with their own culture group, the ability to create an opportunity for educating a larger amount of the group awaits. A family health team could have a representative attend a social event to share diabetic information, other community members could share their journey of diabetes to help warn others of the complications from diabetes. A “South Asian Diabetes Prevention” working group might be created with influencers from the community, community business owners, the public health department, and the local hospitals. The public health department could work to make other recommendations such as the creation of a South Asian walking group to help individuals become more active.
Societal Level
In this last level we look at policies and law. The ability to add or change a law at the local, provincial or federal level can be an important piece of health promotion. For example, there has been a lot of talk about imposing a federal sugar tax to help reduce the intake of sodas and sugary junk food (Casey, 2019). We know that there is an increase uptake of eating fresh fruits and vegetables when they are more accessible (“South Asian Health”, 2015). The public health department might then work with the local councillors to pass a by-law requiring grocers to stock a percentage of their stores with fresh fruits and vegetables, ensuring that the community will have enough health food options in stock to support healthy eating. We also know that South Asians self-report lower activity levels than other groups (“South Asian Health”, 2015). The working group might also connect with the local councillors to support a better walking trail in the area to support safer walking outdoors, all while being supported by the work done at the hospital and by the family doctors such as tracking weight and blood sugars levels in hopes of earlier intervention.
Concluding thoughts
South Asian immigrants continue to be one of the fastest groups coming to Canada. They are genetically predisposed to be at a higher risk for developing type 2 diabetes and at a much younger age than their western born peers. Their diet and lifestyle are also changing, and not for the better. The multiple issues they face would be best served with a social ecological multilevel approach, increasing the odds that the health promotion delivered would be heard and adapted. We need to curb the sugar for this at-risk group to help better health for all.
References
Agurs-Collins, T., Persky, S., Paskett, E. D., Barkin, S. L., Meinssner, H. I., Nansel, T. R., Arteaga, S.S., Zhang, X., Das, R. & Farhat, T. (2019). Designing and Assessing Multilevel Interventions to Improve Minority Health and Reduce Health Disparities. American Journal of Public Health, January 2019. Retrieved October 20, 2019 from https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2018.304730
Biason, R. (2019). Young adults of South Asian descent face higher risks of prediabetes, diabetes: U of T study. U of T News. Retrieved October 21, 2019 from. https://www.utoronto.ca/news/young-adults-south-asian-descent-face-higher-risk-prediabetes-diabetes-u-t-study
Casey, L. (2019, May 29). University of Waterloo study suggests that sugar tax would reduce consumption. Global news. Retrieved October 28, 2019 from
Crawley, M. & Janus, A. (2019, February 26). Ford government creating Ontario Health Super Agency. CBC. Retrieved October 28, 2019 from https://www.cbc.ca/news/canada/toronto/doug-ford-ontario-health-super-agency-lhin-cancer-care-1.5032830
Fraser Health Authority (2015). South Asian Health Report. Retrieved October 28, 2019 from https://businessinsurrey.com/wp-content/uploads/2016/03/FHA_SouthAsianHealthReport_FINAL_20160606-1.pdf
Galea, S. (2015). The Determination of Health Across the Life Course and Across Levels of Influence. BU School of Public Health, Dean’s note. Retrieved October 28, 2019 from
Gujral, U.P., Pradeepa, R., Weber, M.B., Venkat Narayan, K., & Mohan, V. (2013). Type 2 diabetes in South Asians: similarities and differences with white Caucasian and other populations. Ann N Y Acad. Sci. 2013 Apr; 1281(1):51-63. Retrieved October 27 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715105/
International Diabetes Federation Care and Prevention. Retrieved October 28 2019 from https://www.idf.org/our-activities/care-prevention/type-2-diabetes.html
Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June-22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p.100) and entered into force on 7 April 1948. Accessed October 5, 2019.
The Social- Ecological Model: A Framework for Prevention. (2019). Centers for Disease Control and Prevention. Retrieved October 26, 2019 from https://www.cdc.gov/violenceprevention/publichealthissue/social-ecologicalmodel.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Foverview%2Fsocial-ecologicalmodel.html
World Health Organization (1986). Ottawa charter for health promotion. Retrieved from World Health Organization. Retrieved October 28, 2019 from https://www.who.int/healthpromotion/conferences/previous/ottawa/en/
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