Type 2 diabetes prevention: population and community-level interventions

Evidence statement 1.5

Evidence of mixed effectiveness was found in relation to nutrition knowledge. One poor quality case series (-) found that a 10-week programme focused on translating dietary recommendations into practice, including guided hands-on food preparation, led to an increase in nutrition knowledge in two of the four intervention groups studied. No significant increase in nutrition knowledge was found in the other two groups.

Evidence statement 1.7

Evidence of mixed effectiveness was found in relation to fruit and vegetable intake. One reasonable quality prospective cohort study (+) found an overall increase in overall average fruit and vegetable consumption in both the community where a new food hypermarket had opened and the comparison community with no new hypermarket over 12 months. There was however no significant change in either groups in average fruit consumption, and an increase in only the comparison community in vegetable consumption. One poor quality case series (-) examining the impact of the introduction of a new large-scale food retail outlet over a 1-year period found an increase in fruit and vegetable consumption among those who switched to the new store, but not among those who did not. Among both switchers and non-switchers, those with low pre-intervention levels significantly increased their fruit and vegetable consumption.

Evidence statement 1.21a

There is evidence that information is more accessible and interventions more acceptable where key workers possess the appropriate knowledge, skills and personal attributes, such as empathy and trustworthiness.

One (+) evaluation found that trained lay workers were able to access and raise awareness in hard-to-reach groups through their knowledge of the community in which they were working, and their personal communication skills. Attributes of workers were found to be influential in three (all [+]) evaluations on the success of interventions. Other (four [+]) evaluations found that the skills of an intervention adviser facilitated the feeling of empowerment among participants, and that skills were learned through engaging the interest of the participants. As well as disseminating information in a meaningful way.

Evidence statement 1.21b

Three (all [+]) evaluations of included intervention studies found evidence that acceptability is increased when practical demonstrations make abstract concepts and scientific language more meaningful, and when progressive small steps are taken in terms of behaviour change.

Two (both [+]) evaluations reported suggestions made by participants that might increase acceptability. These were: the development of women-only classes and more activities at weekends to fit in with other commitments; free sessions, free childcare (especially in school holidays), free food, individual and group tailored recipes and useful enjoyable activities.

In one (+) evaluation there was evidence that male-only classes using creative ways to conceptualise weight management increased acceptability and motivation.

One exploratory study and one evaluation (both [+]) found that acceptability of a food educational intervention was increased by first exploring participants' needs in terms of topic content. Three evaluations (two [+] and one [++]) found that incentives such as access to free food increased motivation to participate in nutrition educational interventions. The experimental use of familiar and affordable food increased the acceptability of a food and health project.

There was evidence (one [+]) that interventions delivered by community members rather than health professionals tended to encourage community participation and meet local needs with an open and holistic agenda.

Evidence statement 1.21c

There is evidence that acceptability of interventions that aim to change behaviour is enhanced by the added value of social inclusion. Social interaction has a positive subjective effect on wellbeing as well as providing a shared forum for discussion of concerns.

Evaluation of a healthy living centre (one [++]) found that social inclusion was stated as one aim of the intervention, while another randomised controlled trial (RCT) qualitative evaluation (+) found that interactive Internet portals increased social capital for people with shared health issues. Social interaction was a positive and facilitating factor for participation in four interventions (all [+]) aimed at increasing physical activity, and one aimed at improving eating behaviours. Positive social aspects of the interventions included an informal atmosphere, the opportunity to chat and discuss with other participants, as well as humour.

Evidence statement 1.21d

There is evidence that interventions aimed at raising awareness of healthy behaviours are more acceptable when they are made appropriate to the target audience and have a positive image.

One (++) qualitative study found that young women will be less motivated to participate in sporting activities if the image associated with those activities, for example the required clothing, is perceived as negative. Two process evaluations found that participants held negative associations with the term 'healthy eating'. The group in one (++) study associated the term with government policy and the other (+) study groupregarded healthy eating as boring and not filling.

Evidence statement 1.22

There was qualitative evidence from two (both [+]) multi-method evaluations of changes in participants' and their family's eating behaviour, and also of a developing interest in cooking as well as increased feelings of wellbeing. In one of these evaluations, the use of fat in cooking had reduced.

Evidence statement 1.25

There is evidence that adopting healthy lifestyle behaviours can be influenced by existing attitudes toward health. One (++) qualitative study found evidence of a range of attitudes from actively seeking to improve health prospects to a disinterest in health issues. Another (+) interview and focus group study found a perceived lack of control over weight. Two rationales for excess weight included a flawed metabolism and genetics, neither of which were perceived as subject to change. There was evidence from one (+) interview study that for the mothers in the study, the five-a-day message was perceived as impractical and a joke. One focus group study (+) found that lack of exercise was generally not emphasised as a health risk factor by male and female blue-collar workers. In another focus group study (+), women of lower educational attainment were not clear about the links between food and health, often equating weight with health, and believed it was not good to be 'too healthy', although the long-term health of their children was considered important and related to food. Another focus group study (+) found that some mothers deliberately sought out cheap and healthy foods, however others were less concerned about the healthiness of their family meals.

Evidence statement 1.27

There is evidence that adopting healthy lifestyle behaviours can be influenced by current lifestyle. Two evaluations (both [+]) and one (+) interview and focus group study found evidence that commitments and responsibilities were seen as a barrier to participation in physical activity. There was also evidence that for some, existing activity around the home is sufficient. Participants cited lack of time, particularly if employed in work or looking after children, as a barrier to physical activity. There was evidence from one (+) qualitative study that parents regard 'stress', 'comfort eating' 'being stuck in a rut' and 'embarrassment' as reasons for not carrying out sufficient physical activity. Health professionals interviewed in the same study discussed the prevalence of mental health issues such as depression in the area, and its impact on health behaviours.

Evidence statement 1.28

There is mixed evidence that affordability has an impact on lifestyle behaviour change. One (+) qualitative study found that costs limited the extent to which deprived mothers could buy healthy food. Another (+) qualitative study exploring the beliefs of those living in new deal communities (NDCs) found a perceived lack of affordable goods in the local area, with public transport costs also regarded as prohibitive. Affordability in two studies was only an issue where buying extra food, or organic food might be considered. One (+) evaluation and one (++) qualitative study found that cooking different meals to suit the preferences of family members was considered too expensive. In one (+) evaluation there was evidence that low-income groups were resistant to change because of financial risk. In one (+) interview study with low income consumers and health professionals, both stated that pricing strategies were not regarded as helpful in encouraging healthy eating. However, health professionals held the view that healthy foods could be prioritised over convenience foods when shopping. One focus group study (+) identified the cost of food as a barrier to healthy eating due to its cost in relation to other priorities, marketing strategies and special offers not being placed on healthier foods and the waste generated by buying food that did not get eaten. Similarly, another focus group study (+) found that mothers would choose less healthy but cheaper options when shopping and wasting money on food that their families would not eat was a consideration. Expense was also reported by men as a barrier to healthy eating in another focus group study (++), although the authors did not explore this in detail.

There is evidence (one [+] study) that affordability may be addressed by including budgeting as a topic in nutrition educational programmes. Evidence from one (+) interview study showed cost as a perceived barrier to physical activity in disadvantaged groups for both consumers and health professionals. Transport to – and use of – facilities were both perceived as costly. Physical activity referral schemes were suggested as one way of overcoming the cost of using facilities.

Evidence statement 1.29

Evidence was found that environmental factors can be a barrier to improving nutrition. One (+) qualitative study found that a perceived lack of local amenities was a prohibiting factor in shopping for healthy foods. Access to food shopping was regarded as a barrier to healthy eating among women with lower educational attainment in one focus group study (+), in particular navigating round shops with pushchairs, coping with demanding children and bringing the shopping home on public transport and into high-rise flats. Evidence was also found that environmental factors can be a barrier to change in take-up of physical activity. One (++) qualitative evaluation found that fear of crime and feeling intimidated inhibited the motivation to participate in a new cycling initiative. One (+) qualitative study found that fear of attack prevented walking in certain areas. Another (+) evaluation showed that dark evenings and poor weather are barriers to physical exercise outdoors. One large-scale cross-sectional survey (+) found that active travel was associated with being younger, living in owner-occupied accommodation, travelling less than 4 miles to work, having access to a bicycle and not having access to a car, whereas overall physical activity was associated with living in social-rented accommodation and not being overweight.

Evidence statement 2.3

There was evidence from one (+) focus group study that acceptability of lifestyle change interventions can be increased by raising the cultural sensitivity of delivery. For example, the importance of avoiding Ramadan needs to be considered in the timing of delivery, and separate sessions for men and women need to be considered. There was evidence that flexibility around the timing of interventions as well as the bilingual abilities of staff were important. Learning to cook traditional foods in a more healthy way was one way to preserve cultural identity. In addition, advice (particularly one-to-one) and information that takes into account literacy levels and is encouraging were crucial to sustaining motivation to adopt a healthier lifestyle.

Evidence from one (++) focus group study that included suggestions from participants, showed that acceptability of a nutritional education intervention might be increased by: including free food, timing classes to suit those with childcare responsibilities, and providing a crèche or possibly holding the classes in schools. Evidence from one (+) needs assessment study showed that cook and eat sessions and weight management classes that were made freely available on a gypsy traveller site were valued by women residents for their non-threatening environment and as a forum for discussion of health issues – as well as a way to reduce social isolation. Lack of childcare facilities, transport issues and costs were barriers to off-site activity.

Evidence from an interview-guided questionnaire study (+) and one qualitative evaluation (+) included suggestions to increase the acceptability for Muslim Bangladeshi women who may wish to access a gym. Suggestions included the provision of women-only facilities, women-only sessions, swimming facilities for women, more walking physical activity facilities, fewer aerobic classes, Sylheti-speaking assistants, better transport and childcare facilities, less loud music, no inappropriate TV programmes and provocative music videos, and access to more local gyms. Evidence from one qualitative evaluation (+) of exercise on prescription (EoP) also identified lack of access to facilities, lack of childcare arrangements, as well as a limited choice of women-only sessions as barriers to attendance.

There was evidence from one (+) mixed method study that social interaction was a motivator for South Asian women attending a healthy eating and physical activity group. Some women also stated that they ate less when attending as they were not tempted to snack in the same way as when they stayed in the house.

Evidence statement 2.4

There was evidence from one (++) focus group study of lack of understanding between professional and lay groups in terms of Islamic teaching and its relation to healthy lifestyle practices. There was also evidence from the same study of communication difficulties arising from health literacy deficiencies in lay Bangladeshi people and cultural sensitivity deficiencies in professionals which obstruct appropriate health promotion messages.

Evidence statement 2.5

There was evidence from four focus groups and two interview studies that religious customs can become barriers or facilitators to lifestyle change. Change was more likely where participants believed they had some degree of free will. There was conflicting evidence regarding fatalism; in one (++) study health professionals spoke of fatalism as a barrier to health prevention in some black and minority ethnic groups. However, evidence from one (+) study suggests that while the occurrence of health conditions might be regarded as God's will, it is also, according to teachings, the responsibility of the individual to attempt to maintain good health and wellbeing.

There was evidence from three focus groups (one [++] and two [+]) and one (+) interview study and one qualitative evaluation (+) that healthy activities were acceptable provided they did not include aspects that were conflicting with religious teachings. One (++) focus group study showed evidence that some practices, such as eating Halal meat could limit the use of fast-food outlets.

Evidence statement 2.6

There was evidence from nine qualitative studies that cultural influences and issues of identity can be barriers or facilitators to lifestyle change.

There is evidence from one (+) focus group study that a nomadic identity influenced dietary choices for Somalians. As descendants of camel herders, diet in the UK continued to be influenced by the staple diet of meat with rice or spaghetti and a low consumption of fruit and vegetables which were less valued.

A (+) needs assessment with gypsy travellers found that some fruit and vegetables were eaten daily, as they were seen as relatively cheap. In particular, vegetables were favoured as they could be incorporated into daily cooking. However, while 60% of participants considered themselves as 'heavy', they also stated that the meal was often followed by a take-away in the evening.

Evidence from one (+) interview study suggested that traditional South Asian beliefs regarding the preventive attributes of certain vegetables in terms of ill health are part of a cultural identity, and that this might be taken on board by professionals when discussing health promotion. Dietary practices in the UK can involve experiences that are alien to traditional culture and identity However, one (+) qualitative study showed that food choices made by South Asian women can be informed by both traditional ('our' food) and Western ('your sort of foods') explanations in terms of 'good' and 'bad' effects upon the body so long as such explanations are complementary rather than in conflict.

Evidence was found in one (+) guided interview study, one (+) focus group study and one (+) needs assessment for differences between UK culture and non-Western culture in terms of the perception of physical activity as either 'separate' or 'integral' to daily routine. Physical activity as 'separate' incurred financial costs as well as often being organised in ways that are insensitive to different cultural values.

Evidence from one (+) study highlighted the belief that expending sweat is important for increased wellbeing; this influenced the practices that might be taken up in the UK where a cold climate limits sweat production.

There was evidence from one (+) guided interview study and two (one [+] and one [++]) focus group studies and one qualitative evaluation (+) that a limited command of the English language is a barrier to accessing information, as well as accessing activities and shopping facilities outside of the individual's neighbourhood.

There was evidence from one (+) interview study that some South Asians consider that nothing can be done to prevent diabetes if there is already a family history.

Evidence statement 2.7a

There was evidence from three (two [++] and one [+]) focus group studies that knowledge regarding risk factors is high in South Asian communities. However, evidence from one (+) focus group study of predominantly male Somali participants suggested a low level of knowledge. When knowledge levels were high, there was evidence from two (one [++] and one [+]) focus group studies that this does not always translate to practice in terms of healthy lifestyle. Evidence from one (++) focus group study suggested that education may be one way of overcoming restrictive practices.

Evidence statement 2.7b

Evidence from one (+) focus group study suggested that South Asian people in the UK would appreciate increased information on risk factors, advice and encouragement in order to motivate and sustain behaviour change.

There was evidence from one (+) focus group study that information and advice regarding physical activity came mainly from the media, role models, family and friends, the medical establishment (mainly hospitals) and to a limited degree, fitness campaigns.

Evidence statement 2.7c

There was evidence from one guided interview study and two focus group studies (one [++] and two [+]) and one qualitative evaluation (+) that a limited command of the English language is a barrier to accessing information, as well as activities and shopping facilities outside the neighbourhood.

Evidence statement 2.8

For South Asian and African populations in the UK, and especially first generation migrants, there was evidence from three (two [++] and one [+]) focus group studies that traditional fresh foods are not readily available locally and are expensive.

Evidence from one (++) focus group study showed that older people are less willing to travel beyond the immediate neighbourhood for food due to language barriers and fears for their safety. There is evidence from one (++) focus group study that the price of food is more of an issue for older people.

There was evidence from one (+) mixed method evaluation and one qualitative evaluation (+) that: distance from physical activities, lack of transport, fear of walking alone, having conflicting family commitments, not being able or willing to walk, ill health and cold weather were all barriers to attending a healthy eating and physical activity group. Having to travel to venues incurred extra costs even if physical exercise was on prescription, as for some South Asian women even a small financial contribution was reported as a barrier.

Evidence statement 2.9a

There was evidence from four (two [+] and two [++]) focus group studies that traditional South Asian cooking is associated with a high usage of fat, particularly for special occasions (which occur frequently) and that there is resistance to change such traditions. Indian men who wished to control their diet within a close-knit community where social events were common found it particularly difficult.

Evidence from one (+) focus group study showed that Somali cooking is associated with high meat and low fruit and vegetable content and again there is resistance to change. These traditions are part of the cultural identity and symbolic of prosperity and hospitality.

Evidence from two focus (one [++] and one [+]) group studies suggested that consumption of take-away food is common in second generation South Asian males and females as a change from traditional fare. Similarly, take-away meals were commonly used by Somalian males, particularly those living alone.

Some South Asian women are beginning to cook in more healthy ways. There were suggestions from one (+) focus group study that learning to cook traditional food in healthy ways may be beneficial to South Asian groups. Another focus group study (++) suggested that women from Zimbabwe were not used to cooking for themselves as in Africa, maids had done the cooking; having to cook in the UK was seen as time consuming.

Evidence statement 2.9b

There was evidence from two (both [+]) interviews and four (one [++] and three [+]) focus group studies and one qualitative evaluation (+) that in South Asian groups, physical activity was perceived as a part of normal life and that there was little time for formal or 'separate' sessions, due to work or childcare commitments.

In particular, evidence from one (++) focus group study suggested women were expected to stay home and look after children rather than enrol the help of others. Evidence from one (+) interview study suggested that older participants perceived that vigorous physical activity was unnecessary in the context of advancing age and that keeping active and mobile was preferable.

There was evidence from one (+) focus group study of variation in views of South Asian and black participants regarding the appropriate level of physical activity required to obtain benefits, depending on own level of activity. There was evidence from the same study among South Asian participants that partaking in physical activity could compensate for unhealthy eating or smoking.

Evidence from two interview studies (both [+]), three focus group (one [++] and two [+]) studies and one qualitative evaluation (+) suggests that vigorous activity such as aerobics was not acceptable to some South Asian participants, particularly females, for whom modesty and single-sex classes were important considerations. One (+) focus group study found that for some young people, however, going to the gym created a means of filling time, escape from social conditions and keeping up with fashion trends. There was evidence from one (+) focus group study of South Asian participants that partaking in physical activity could compensate for unhealthy eating or smoking.

There was also evidence from one (+) focus group study that encouraging sweating was important to some South Asian people. Evidence from one (+) focus group study and one guided interview study suggested that swimming and slow walking were preferred ways to remain active.

There is evidence from one (++) focus group study of a 'complex value hierarchy'. For example, choosing healthier options such as using less fat in cooking, and having to wear certain clothing for particular physical activities were seen as shameful and as more important than the benefits of a healthy lifestyle. In addition, as in white communities, support from families can act as a facilitator (if the new behaviour is integrated with the sense of self and one's own values without the control of others) or a barrier to changing health-related behaviours.

Evidence statement 2.10

There was evidence from five good quality (two [++] and three [+]) qualitative studies (three focus group and two interview studies) that body image expectations vary according to background and culture and often differ from those currently popular within the UK.

There is evidence from one (++) focus group study that body size can be positively or negatively associated with health and attractiveness, and attempting to reach an ideal body size can be a strong motivator for behaviour change. There was evidence from one (+) interview guided questionnaire that only 64% of overweight or obese Bangladeshi women classed themselves as overweight. There was evidence from one (+) interview study that weight management was more important for South Asian males than females, and a (+) focus group study found it important for young South Asian and black females.

Evidence was found for an association between being overweight and prosperity in one (+) focus group study with Indian, Pakistani and Indian participants. Changing dietary and physical activity patterns in old age was perceived as potentially weakening.

Having the 'right' body size was influenced by the media as well as some male views, and was important for attracting a partner for young South Asian and black females in one (+) focus group study.

In one (++) focus group study body size was found to be a stronger motivator for healthy behaviour changes than health issues.

Evidence statement 3.2

There is evidence from one (+) study that did not focus on low income or BME groups to suggest that the process of identifying and referring high-risk patients in primary care to an exercise scheme varies between general practices. GPs and practice nurse's methods of identifying and referring patients to an exercise scheme was ad-hoc and based on: patients asking about exercise themselves, chance discussion during consultations, requests for referral by another doctor, and asking patients to choose from a variety of behaviour change activities that might produce health benefits.

Evidence from one (+) evaluation of healthy living centres acknowledges the challenges of identifying groups at risk. Hard-to-reach groups might be reached in small numbers at community events or eventually be motivated to engage with initiatives through word of mouth from relatives.

Evidence statement 3.3

Evidence from one (+) survey study that evaluated the contribution of nurses to targeting health and social need suggests that in order to be able to empower high-risk groups to make choices about adopting healthy lifestyles, health professionals require a deep understanding of the cultural and religious beliefs and economic influences within the communities with which they are working.

One (+) evaluation highlighted the need for practitioners to take into account the realities of the people they are targeting. For example, making it clear that low-income groups do not require expensive clothing to engage in a community physical activity initiative.

Evidence statement 3.4

Evidence from one (+) qualitative study of nurses' attitudes identified two discourses in relation to health promotion with disadvantaged groups. One was associated with the philosophy of holism that nurses were exposed to during training, resulting in empathy for the disadvantages that low-income groups face in attempting to achieve a healthy lifestyle. The other discourse reflects personal values, and beliefs that individuals must take responsibility for their own health. This tension may need addressing when practising health promotion in a culturally sensitive way.

Evidence statement 3.6

Evidence from two evaluations (one [+] and one [++]) suggests that the training of lay workers to identify and disseminate health promotion messages to members of their community is a way of reaching hard-to-reach and high-risk groups.

One (+) evaluation in which 11 women (seven of Pakistani, two of Indian and two of Chinese origin; of Muslim, Hindu and Christian religious backgrounds) undertook formal training to become community health workers (CHWs) provides evidence that lay workers trained by health professionals can identify target groups within the community and deliver health messages in a culturally sensitive way in an appropriate language. Knowledge of the communication channels in a community assisted in the success of the initiative. For example, in this study, younger women were targeted for training as they are relied upon in the community for passing on information.

Evidence from a qualitative evaluation (++) study that explores the role of the lay food and health worker suggests a consensus of opinion that the primary role for lay workers is the encouragement of dietary change by making complex messages more credible and culturally appropriate. A proactive strategy for lay workers to identify and contact at-risk individuals is to create lists of contacts within the community and introduce themselves to those on the list.

One (+) evaluation of healthy living centres highlighted a difference in focus between lay workers, who considered the larger social picture, and health professionals, whose focus was more on outcomes such as improved fruit and vegetable intake.

Evidence statement 3.7

One (-) evaluation of peer education training as part of a community health promotion programme (Project Dil), provides evidence of a high level of uptake and enthusiasm from those engaged in peer education. The project was designed to improve the effectiveness of primary and secondary prevention of coronary heart disease in volunteer Leicestershire general practices with a high percentage of South Asian patients. Peer education was reported to facilitate health promotion within a range of organised community events.

Evidence from one (+) evaluation suggests that fostering a team spirit and sharing experiences was a key facilitator in training lay workers. However, there is evidence from the same study that scheduled activities prevented lay workers from having time to participate.

Evidence statement 3.8

One (+) evaluation of lay worker training provides evidence that target groups within the community increased their knowledge as a result of lay worker activity, and found the cultural sensitivity of health promotion messages an important factor in helping to make changes in dietary practice.

Expert papers

Expert paper 5: 'CPD and training, enabling professionals to practice effectively and confidently'.

Expert paper 6: 'BME groups, diet and risk of type 2 diabetes'.

Expert paper 7: 'Developing population level guidance – CVD, the Foresight Report.'

Expert paper 8: 'Dietary strategies for the prevention of pre-diabetes'.

Expert paper 9: 'Low income groups and behaviour change interventions'.

Expert paper 10: 'Adapting health promotion interventions for BME communities'.

Expert paper 11: 'Health policy and health.'

Expert paper 12: 'Ismaili Nutrition Centre'.

Expert paper 13: 'Environment and physical activity'.

Expert paper 14: 'Nutritional food labelling current thinking and practice'.

Expert paper 15: 'Fiscal policy instruments to improve diet'.