Diets of Minority Ethnic Groups in The UK

BRI EF I N G PA P E R
Diets of minority ethnic groups in the UK: inuence on chronic disease risk and implications for prevention
nbu_1889 161..198
G. Leung and S. Stanner

British Nutrition Foundation, London, UK
Summary Introduction 1 Denitions of ethnic groups and demographics of minority ethnic groups in the UK 1.1 Denitions 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 prole and dietary habits of minority ethnic groups in the UK 2.1 Available surveys 2.2 Overview of the health proles 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 proles 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: g.leung@nutrition.org.uk
2011 The Authors Journal compilation 2011 British Nutrition Foundation Nutrition Bulletin, 36, 161198
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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 points 5 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 reect interactions between diet and other health behaviours, genetic predisposition 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 understanding 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 interventions in the UK targeting minority ethnic population groups. Further needs
Diets of minority ethnic groups in the UK
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assessment and better evaluation of nutritional interventions have been recommended to enhance the understanding of the effectiveness of different approaches amongst minority ethnic groups. This brieng paper will provide an overview of the health prole, 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 of their 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 the UKs population is made up of non-white minority ethnic groups. The largest of these groups were South Asians, Black African-Caribbeans and the Chinese. Population 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. Possible reasons 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 cultural differences have been identied as the two major barriers 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 by a wide variety of factors, which among others include income, socio-economic status, food availability and access, health, religion and dietary laws, food beliefs, amount of time available for food shopping or preparation, generation and gender. Acquiring a better understanding of the reasons underlying food choices by minority ethnic groups can help health professionals and educationalists to recognise the needs of minority ethnic groups and help them to make healthier food choices. The traditional dietary habits of minority ethnic groups vary widely between groups and compared with the mainstream population, but there is also heterogeneity within each group reecting differences in the regions of origin. Traditional diets may change because of 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 ethnic population groups, and well-evaluated nutritional interventions are needed to better understand the effectiveness of different approaches in these groups. However, priorities for nutritional interventions and research for different minority ethnic groups vary. This brieng paper will discuss the main health problems experienced by the largest non-white minority ethnic groups in the UK, provide an overview of traditional and current diets and review evidence for successful nutrition interventions.
1 Denitions of ethnic groups and demographics of minority ethnic groups in the UK

1.1 Denitions of ethnic groups and ethnicity
There are varying denitions for the terms ethnic groups and ethnicity, and these are often subject to much discussion. Carlson et al. (1984) dened an ethnic group or ethnic population as a group of people smaller in number than the majority categories and who by their customs, language, race, values, and group interests differ from the majority population. The UKs Economic Social Research Council (ESRC) referred ethnic groups as people of the same race or nationality with a long shared history and a distinct culture and dened ethnicity as the intangible quality, or sense of being, derived from that shared racial or cultural afliation (ESRC 2005). Membership of any ethnic group is subjective to the individual, and this self-perceived identity is based on different factors (Ofce for National Statistics, ONS 2003), such as:
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Table 1 Respective agencies that conduct censuses in the UK

Country England and Wales Scotland Northern Ireland Agency Ofce for National Statistics (ONS) The General Register Ofce for Scotland Northern Ireland Statistics and Research Agency (www.statistics.gov.uk) (www.gro-scotland.gov.uk) (www.nisra.gov.uk)
country of birth; nationality; language spoken at home; parents country of birth in conjunction with the individuals country of birth; skin colour; national/geographical origin; racial group; religion.
Table 2 Population by ethnic group in the UK, April 2001 (adapted from the ONS 2005)
% of minority ethnic population
Number White Mixed Indian Pakistani Bangladeshi Other Asian All South Asian or South Asian British Black Caribbean Black African Black Other All Black or Black British Chinese Other ethnic groups All minority ethnic population Total population 54 153 898 677 177 1 053 411 747 285 283 063 247 664 2 331 423 565 876 485 277 97 585 1 148 738 247 403 230 615 4 635 296 58 789 194
% of total population 92.1 1.2 1.8 1.3 0.5 0.4 4.0 1.0 0.8 0.2 2.0 0.4 0.4 7.9 100
Self-identied ethnicity was included in the UK census for the rst time in 1991. Because individuals may change the ways they view their cultural or ethnic identities, it is important to note that ethnicity is considered to be a shifting concept (Landman & Cruickshank 2001). The UK has a rich mix of cultures and culturally diverse communities. Some reect a long established history and heritage, but some are related to more recent changes 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 policies relating to diet and physical activity. Table 1 shows the respective agencies responsible for conducting the censuses in the four constituent countries of the UK. This paper makes use of the classications from the latest census in 2001 on minority ethnic groups in the UK, which are dened 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 reect their self-perceived identity. In 2001, non-white minority ethnic groups made up 7.9% of the UK population. The largest of these groups was South Asians (predominantly Indians, Pakistanis, Bangladeshi), followed by Blacks (predominantly Caribbeans and Africans), mixed and the Chinese (Table 2). Because the structure of the mixed population was highly heterogeneous, and specied mixed groups contain very different characteristics (ONS 2006b), this group is not considered further in this Brieng Paper, which will focus on the three largest non-white minority ethnic groups in the UK:
14.6 22.7 16.1 6.1 5.3 50.3 12.2 10.5 2.1 24.8 5.3 5.0 100.0
South Asians; Black African-Caribbeans; Chinese.
1.2 Demographics and characteristics of minority ethnic groups in the UK

Countries of origin South Asians originate from the Indian subcontinent, and the main subgroups in the UK are Indians, Pakistanis and Bangladeshis, with a smaller proportion through East Africa (including Kenya, Uganda and Tanzania). The Indian population is further differentiated into subgroups that mostly came from the Indian Punjab and Gujarat regions, while most Pakistanis are of Punjabi descent and most Bangladeshi are from the Sylhet district, in the north-east of Bangladesh. Caribbeans came from the numerous islands that constitute the West Indies, such as Jamaica, Barbados, Trinidad,
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Tobago, Saint Kitts and Nevis, Saint Lucia and Grenada; 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 Mainland China, with a smaller percentage from Malaysia, Vietnam, Singapore and Taiwan. Most non-white minority ethnic groups identied themselves in the 2001 census as British, with a smaller number as English, Scottish or Welsh (e.g. 76% of Bangladeshis identied 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 a younger age structure compared with the White population in the UK. Of the non-white minority ethnic groups, Black Caribbeans had the largest proportion of people aged 65 and over (11%), reecting the largescale migration of young labourers from the Caribbean to Britain in the 1950s (Fig. 1). Life expectancy of the UK population as a whole is increasing: the total number of people aged 85 and over in the UK reached a 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 County Council estimated a 4-year lower average healthy life
expectancy at birth for minority ethnic groups (65 years for Black and minority ethnic groups vs. 69 years for whites) based on local and Ofce for National Statistics (ONS) gures. This reects a need for better access for health services for minority ethnic groups (Knuckey 2008). Similar to the rest of the population, women from minority ethnic groups aged 65 and above generally outnumber men, with the exception of South Asian groups (Fig. 2). The demographics of some groups may have been affected by immigration waves. Geographic distribution and size of household The census in 2001 showed that the non-white population tended to concentrate in specic areas, with almost half of them living in London (45%) where they made up almost a third of the residents in the capital (29%) (Fig. 3). They also constituted a larger proportion of the population in England compared with Scotland, Wales and Northern Ireland (Table 3). Migrants arriving since the 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 was largely 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 households were larger than those of other non-white minority ethnic groups. Those headed by a Bangladeshi person
Under 16 White Mixed Indian Pakistani Bangladeshi Other South Asian Black Caribbean Black African Other Black Chinese Any other ethnic group 0 20 40
16 to 64
65 and over
60 Percentage
80
100
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.
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Males White Mixed Indian Pakistani Bangladeshi Other Asian Black Caribbean Black African Other Black Chinese Any other ethnic group 0 20 40 60 Percentage 80
Females
100
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.
North-east England North-west England Yorkshire and the Humber East Midlands West Midlands East England London South-east England South-west England Wales Scotland Northern Ireland 0 10 20 30 Percentage
Figure 3 Regional distribution of the non-white population in the UK, April 2001 (adapted from ONS 2005).
40
50
Table 3 Non-white population in the UK: by area, April 2001 (adapted from ONS 2005)
Country England Wales Scotland Northern Ireland Percentage 9.08 2.12 2.01 0.75
Religious beliefs Some ethnic and religious groups are closely related. For example, in the 2001 census, the majority of Pakistanis and Bangladeshis reported being Muslim (both 92%) and most Blacks reported being Christians (around 70%). However, other minority ethnic groups are more religiously diverse; for example, in 2001, almost half (45%) of Indians reported being Hindu, 29% Sikh and 13% Muslim. Around half of the Chinese reported no religion (53%) (Fig. 5). The dietary habits of certain minority ethnic groups may be largely dened by religious 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
were the largest, with an average of 4.5 people, followed by Pakistani and Indian households. These households were also more likely to contain at least one dependent child (dened as those aged 0-to-15 years or aged 16-to-18 years in full-time education and living with his or her parents) (ONS 2005) (Fig. 4).
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5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0
4.5 4.1 3.3 2.3 2.5 3.2 2.7 2.3 2.4 2.7 2.8
Household size (number of people)
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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.
White Mixed Indian Pakistani Bangladeshi Black Caribbean Black African Chinese Other Ethnic Group 0% Christian Buddhist 10% Hindu 20% Jewish 30% 40% Sikh 50% 60% 70% 80% No religion 90% 100%
Muslim
Bl
Any other religion
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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.
females from 16-to-59 years) with a degree qualication varied from group to group and the largest percentage of working age people without a degree qualication was from the Pakistani and Bangladeshi groups. According to the National Statistics Socioeconomic Classication, which measures socio-economic positions in society, low socio-economic status is characterised by being in routine and semi-routine occupations or unemployed for a long time, as this is associated with lower earning potential, job security
and career opportunities than managerial and professional occupations. The 2001 census reported that some minority ethnic groups were more likely to work in routine or semi-routine positions (e.g. 43% for Bangladeshi and 34% for Pakistani men respectively) (ONS 2006b). The Annual Population Survey found that unemployment rates for minority ethnic groups were also generally higher than the White British population average, with Bangladeshi, Black African and Black Caribbean men and Pakistani women topping
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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 unavailable for work) because they were students, looking after the family or home or classied as disabled in 2001 (ONS 2005).
Unemployment rates among minority ethnic groups were found to be higher than the mainstream population. Working-age men and women of minority ethnic groups were also more likely to be economically inactive (i.e. were students, looking after the family or home or disabled).
Key points
Denitions for ethnic groups and ethnicity vary. Ethnicity is a self-perceived identity and belonging to ethnic groups is subjective to the individual. Non-white minority ethnic groups made up 7.9% of the UK population in 2001. The three biggest groups were South Asians, Black African-Caribbeans and the Chinese (the mixed group is not discussed in this paper because its structure is highly heterogeneous and information about their health and dietary habits is more limited). Most non-white minority ethnic group members identied themselves as British. In the 2001 census, non-white minority ethnic groups had a younger age structure compared with the White population. Minority ethnic groups tend to be concentrated in specic 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 mainstream White population. Some ethnic and religious groups are closely related, and the dietary habits of some minority ethnic groups are inuenced by religious beliefs (see Section 3).
2 Overview of the health prole and dietary habits of minority ethnic groups in the UK
Health status is shaped by a multitude of factors, including the characteristics and behaviours of individuals and the physical, social and economic environment. These factors range from genetic predisposition, diet, lifestyle and psychological stress, to access to health services, housing conditions, education level and household income. Health inequalities, as dened by the World Health Organization (WHO 2010) as differences in health status or in the distribution of health determinants 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 show poorer 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 inequalities may be widening. For example, while rates of CVD have 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 these inequalities have been attributed to problems with access to health care. Language and communication and cultural differences have also been identied as major barriers to accessing health advice and treatment (Latif 2010).
Table 4 Unemployment rates by ethnic group and sex, 2004 (adapted from ONS 2006a)
Percentages (%) Great Britain White British Mixed Indian Pakistani Bangladeshi Other Asian Black African Black Caribbean Chinese Male 4.5 12.6 6.5 11.0 12.9 11.3 13.1 14.5 9.7 Female 3.7 11.6 7.7 19.7 12.6 7.0 12.3 9.1 7.1
2.1 Available surveys

Government health surveys are carried out across the UK to 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 other factors related to health and wellbeing. However, few representative data are available regarding the health of minority ethnic groups from these surveys. The 2004 report, Health Survey for England: the health of minority ethnic groups provided the latest population-wide data set on the health of minority ethnic groups in England. The survey involved 6816 adults and 3298 children from minority ethnic groups. It was the second time that this survey focused on the health of minority
Aforementioned data are for Great Britain only because no relevant information was provided by the Census in Northern Ireland.
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ethnic groups, the rst being in 1999. Through questionnaire-based interviews, physical measurements and blood sample analysis, the survey assessed health and psychosocial wellbeing, CVD risk, tobacco use, alcohol consumption, obesity, blood pressure and physical activity and eating habits among the AfricanCaribbean, South Asian, Chinese and Irish groups throughout England. The report Black and Minority Ethnic Health in Greater Glasgow: A Comparative Report on the Health and Well-Being of African & Caribbean, Chinese, Indian and Pakistani People and the General Population by the National Health Service (NHS) Greater Glasgow is the largest data set to date on the health-related perceptions and behaviours of minority ethnic groups in Scotland. It is a comparative report based 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 the General Population Survey (n = 1802) collected in Greater Glasgow from 20042005. The health surveys from England and Scotland have been used in this 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.
mainly traditional Chinese medicine or acupuncture (Boreham 2006; Heim & MacAskill 2006; Natarajan 2006). Cardiovascular disease (CVD) CVD encompasses all the conditions concerning the heart and circulatory systems, the main forms being coronary heart disease (CHD) (including heart attack or angina) and stroke. CVD is a common cause of death in the UK, and its risk factors include increased blood pressure, 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 as smoking, physical inactivity, diets high in saturated fatty acids and/or low in fruit and vegetables, as well as non-behavioural factors, such as family history and ethnicity (British Heart Foundation 2010b). CVD is a major cause of mortality and morbidity in the general population and even more so in some minority ethnic groups. While total death rates for CVD have been falling in the UK since the early 1970s, the decline has been slower among minority ethnic groups. CVD is also a major cause of ill health and surveys suggest that morbidity from CHD is not falling and may be rising particularly among older people and in some minority ethnic 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 population, the overall prevalence of CHD and stroke in all minority ethnic groups is higher in those in the lowest income category (with the exception of Chinese women) and in men compared with women and increases with age (Mindell & Zaninotto 2006; NHS Health Scotland 2009). Coronary heart disease (CHD) According to the Health Survey for England, in 2004, men and women from Indian, Pakistani and Bangladeshi groups were more likely to suffer from CHD compared with the general population (agestandardised rates were around 30% to 140% higher for 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 Caribbean (0.77 for men and 0.91 for women) respondents also reported lower risk ratios compared with the general population. The risk for CHD differs for immigrants from different parts of the Indian subcontinent,
2.2 Overview of the health proles among adults from minority ethnic groups
Overall health According 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 own health as bad or very bad (relative risks range from 1.9 to 4). Pakistani men and women and Bangladeshi men had a higher chance of suffering from psychiatric disorders (over 50% higher compared with the general population) as assessed by a validated questionnaire that measured psychological wellbeing. The prevalence of limiting 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 Bangladeshi men compared with men in the general population, and approximately 20% to 60% higher for Black Caribbean, Bangladeshi and Pakistani women compared with women in the general population. In contrast, Chinese adults were less likely to report limiting long-standing and psychological illnesses compared with the general population. They were also more likely than other ethnic groups to have used complementary or alternative medicines and treatments, which were
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with the highest risk for those from Bangladesh, followed by Pakistanis, while Indians have the lowest risk (Bhopal et al. 1999). Wild et al. (2007) also showed that mortality rates for CHD were much higher for people born in East Africa, Bangladesh, Pakistan or India compared with those born in England and in Wales. The Health Survey for England found the prevalence of high LDL-cholesterol levels (3.0 mmol/l) among Indian and Pakistani respondents to be similar to those in the general population but low HDLcholesterol levels (<1.0 mmol/l) were more common in Pakistani men and Bangladeshi respondents in 2004 (Falaschetti & Chaudhury 2006; Mindell & Zaninotto 2006). It has been suggested that higher LDLcholesterol levels among South Asians may be caused by an increased acculturation of the diet because traditional diets are probably lower in saturated fatty acids (P. Whincup, personal communication) (also see Section 4). The lower risk of CHD among African-Caribbeans may be partly explained by their lower LDL-cholesterol levels. Levels of LDL-cholesterol have been found to be even lower in Africans than in Caribbeans, which may reect wider acculturation among Caribbeans, while the more recent African immigrants are more likely to consume traditional diets (P. Whincup, personal communication). The increased prevalence of CHD among adult minority ethnic groups may be tracked from childhood. The Child Heart and Health Study in England (CHASE), which examined the health of around 5000 primary schoolchildren of different social and ethnic backgrounds (including those of South Asian, Black African and Caribbean origin) from London, Birmingham and Leicester, showed that Black African children had lower LDL-cholesterol levels, while Caribbeans and South Asians had levels similar to, or higher than, White European children, which may impact on the risk differences for CHD in later life (Donin et al. 2010a) (see Section 2.6). Stroke People of African-Caribbean ethnicity are more likely to suffer from stroke compared with the general population. One of the main risk factors for stroke is hypertension (elevated blood pressure) (The Stroke Association 2008). The British Hypertension Society denes hypertension as systolic blood pressure of 140 mmHg and/or diastolic blood pressure of 90 mmHg (Williams et al. 2004). Based on this denition, the Health Survey for England found that African and Caribbean men were 20% to 40% more
likely to be hypertensive, and the risk was greater still for African and Caribbean women at around 60% to 70% higher than the general population in 2004 (Mindell & Zaninotto 2006). Although the prevalence of hypertension was not found to be as high for other minority ethnic groups as among African-Caribbean or mainstream white populations, other studies have shown that South Asian and Chinese groups were also more likely to suffer from stroke than the mainstream population (Lip et al. 2007). This observed difference in risk between minority ethnic groups and the general population has been attributed to the interaction between diet and other health behaviours, genetic predisposition and developmental programming (see Section 2.3). It is currently being debated whether socio-economic differences play a part in the ethnic variations in CVD risk (British Heart Foundation 2010a), but results from the CHASE study showed that ethnic differences in risk to be independent of socio-economic status (Whincup et al. 2010). As most studies including CVD risk assessments have been carried out on white Europeans in Western populations, Hippisley-Cox et al. (2007) recognised the importance of having more appropriate CVD risk assessment tools to account for ethnic and socio-economic differences and to provide more accurate measurements of CVD risk factors in these groups. Type 2 diabetes Rates of type 2 diabetes have been increasing rapidly in the UK, and this condition is now a major cause of premature illness and death, largely through the increased risk of CVD (Thomas et al. 2009). There are various risk factors for type 2 diabetes, which include family history, obesity, central fat deposition and ethnicity. The Health Survey for England found that type 2 diabetes was approximately three to four times more common in Indian, Pakistani and Bangladeshi men, while the condition was more than six times as common among Pakistani women than the mainstream population in 2004 (Mindell & Zaninotto 2006). The risk of developing type 2 diabetes for minority ethnic groups is higher at a younger age (from 25 onwards) compared with the White population (from 40 onwards) (Diabetes UK 2006). The prevalence of type 2 diabetes was also high among Black Caribbean respondents: twice as high for men and three times higher for women compared with the general population. Black African and Chinese respondents showed lower rates than other minority ethnic groups but were also found to be
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more likely to suffer from type 2 diabetes than the general population (Mindell & Zaninotto 2006, Fig. 6). These gures are supported by a greater prevalence of high glycated haemoglobin (Hb) (HbA1c) levels (dened as 7%) among all minority ethnic groups (except for Black African and Chinese women) (Mindell & Zaninotto 2006). High HbA1c levels are associated with micro- 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 childhood. The Ten Town Heart Health Studies (2005) observed a tendency to insulin resistance in South Asian children of 8-to-11 years (n = 227) and higher mean fasting glucose levels in South Asian children aged 13-to16 years compared with their white counterparts (Whincup et al. 2002, 2005). Following this nding, Whincup et al. (2010) investigated the ethnic differences in type 2 diabetes precursors in the much larger and more representative CHASE study and found that children 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 insulin and C-reactive protein than white Europeans, all of which are all precursors for type 2 diabetes. South Asian children 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 was observed for Black African-Caribbean children. This suggests that ethnic differences in precursors for type 2
diabetes and risk factors for CVD among children are similar to those observed among adults and supports scope for early prevention (Whincup et al. 2005, 2010). In a study of 129 14-to-17-year-olds in Birmingham, South Asian adolescents were observed to be less insulinsensitive than White European adolescents and had a higher percentage of body fat (Ehtisham et al. 2005). Obesity The common way to classify overweight and obesity is by using the body mass index (BMI), which equates to weight (kg) divided by height squared (m2). The international BMI cut-off points for classifying overweight and obesity are 25 kg/m2 and 30 kg/m2, respectively. In recent years, however, there has been much discussion about whether these are appropriate for minority ethnic groups in the UK because Asians (including South Asian and Chinese people) tend to have a higher body fat content for a given BMI, which is associated with higher morbidity and mortality risks compared with the white population (WHO Expert Consultation 2004). The available data show that increased risk for morbidity and mortality is 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. In the absence of universal agreement, the National Institute for Health and Clinical Excellence (NICE) continues to advise that the same thresholds for the general population should be used to classify overweight and obese (National Collaborating Centre for Primary Care 2006).
Men 10.0 Risk ratio, logarithmic scale 10.0
Women
2.0 1.0 0.5
2.0 1.0 0.5
0.1
0.1
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se ne hi hi s C de la ng Ba ani st ki Pa an an di fric A an
se ne hi hi s C de la ng Ba ani st ki Pa an an di fric A an In
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% condence limits.
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While the WHO Expert Consultation (2004) retained the international BMI cut-off points for overweight and obesity, it suggested public health action points at lower BMI cut-off points for the Asian population of 23 kg/m2 (overweight) and 27.5 kg/m2 (obesity), respectively. It should be noted that the term Asians represents a vast and diverse portion of the worlds population therefore the absolute risk for overweight and obesity is based on factors such as ethnic and cultural subgroups, degrees of urbanisation, 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 for obesity (30 kg/m2), the Health Survey for England found that participants from the Chinese and South Asian communities (except for Pakistani women) were less likely to be obese in 2004, but obesity prevalence may 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 used as indicators for central obesity, which is strongly associated with health problems such as insulin resistance, metabolic syndrome, CVD and type 2 diabetes (International Obesity Task Force 2004). Obesity is
dened as WHR 0.95 or WC 102 cm for men and WHR 0.85 for women or WC 88 cm. Using WHR, the Health Survey for England found that South Asians were likely to have similar prevalence of central obesity compared with men in the general population (with other groups showing a lower prevalence), while women from Bangladeshi, Black Caribbean and Pakistani groups were more likely to be centrally obese compared with those from the general population in 2004. Chinese participants had the lowest rates of central obesity (Hirani & Stamatakis 2006). The WHR was shown in the INTERHEART study to provide a better estimate of heart attack risk because of obesity in most ethnic groups (Yusuf et al. 2005). Figure 7 summarises the different 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 among minority 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
Men BMI30 kg/m2 Men WHR0.95

53 % 50 % 4 7% 48%
Men WC102 cm Women BMI30 kg/m2 Women WHR0.85

43% 39% 36%
Women WC88 cm
4 1%
3 7%
38%
38%
38%
32%
32% 30% 30% 28%
32%
33% 3 1% 30%
%
2 5% 2 5% 22% 19 % 17% 16 % 14 %
22% 20% 20% 17% 15% 12 % 8% 8% 6% 6% 17% 16 %
23%
23%
Black Caribbean
Black African
Indian
Pakistani
Bangladeshi
Chinese
General population
Figure 7 Prevalence of obesity among minority ethnic groups in England in 2004 (adapted from Hirani & Stamatakis 2006).
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smoke than those of a similar age in the general population (Wardle 2006). These health behaviour patterns are associated with an increased risk of diseases such as CVD and type 2 diabetes (see Section 2.4). Dietary habits, which vary according to minority ethnic group and within the groups themselves, are discussed in Section 2.5. II. Genetic predisposition Research has identied genetic polymorphisms that predispose South Asians to increased risk of type 2 diabetes and CVD, while other genes that offer protection against diabetes and insulin resistance to Caucasians do not appear to protect South Asians (e.g. PPAR gamma gene) (Radha & Mohan 2007). Recent studies suggest that polymorphism of the PCK1-gene is associated with an increased risk of type 2 diabetes among the Chinese in Shanghai (n = 650) and among South Asians in Birmingham (n = 903) (Dong et al. 2009; Rees et al. 2009). While environmental factors play a major role in the development 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 efciency as an explana-
tion for increased adiposity and metabolic disease risk in populations with South Asian ancestry. The researchers hypothesised that South Asians are adapted to climatic (heat) and other nutritional (e.g. low-calorie diet) exposures in the Indian subcontinent that favour the conversion of energy to the storage form adenosine triphosphate rather than heat. This may be disadvantageous when these groups migrate to Western countries if they become physically inactive and consume highcalorie diets. III. Developmental programming The most important environment that regulates gene functions and phenotype is the intrauterine environment because the structure and function of the developing fetus are heavily inuenced by maternal nutrition and the mothers metabolism. The fetal origins hypothesis, originally named the Barker Hypothesis (Barker 1995), suggests that low birthweight caused by nutritional deprivation and growth restriction in the uterus increases the 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 early life. This has been shown to increase the risk for type 2 diabetes among South Asian groups and hypertension
Perinatal factors: Maternal, neonatal and excess childhood adiposity/accelerated velocity of BMI change
Physical inactivity Hypertension
Dyslipidaemia
Abnormal body composition: Excess body fat, excess truncal subcutaneous fat, abdominal obesity, low muscle mass
High free fatty acid levels Fatty liver Muscle fat
Type 2 diabetes mellitus
Coronary heart disease
Imbalanced nutrition: High intakes of energy and fat, low intakes of fibre and omega-3 fatty acids
Decreased insulin sensitivity
High levels of C-reactive protein
High levels of pro-inflammatory cytokines Genetic factors

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 et al. 2007).
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among African-Caribbeans (Oldroyd et al. 2005). This is particularly so in countries going through a rapid economic and nutritional transition or when people from less developed countries migrate to developed ones where the greatest mismatch is observed between early nutritional deprivation and nutritional abundance in later life (Prentice & Moore 2005). Low birthweight is common among South Asian groups in the UK (Oldroyd 2005), which may help to explain why South Asians are susceptible to type 2 diabetes at a younger age and at a relatively lower BMI compared with Caucasians (Krishnaveni et al. 2009; Misra & Khurana 2009; Yajnik & Ganpule-Rao 2010). Low birthweight has also been associated with increased risk of hypertension among African schoolchildren (n = 2648) (Longo-Mbenza et al. 1999).
2.4 Smoking, drinking and physical activity habits

According 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 proportion of smokers (20%) in 2004. The proportion of female smokers from minority ethnic groups was markedly smaller, except for Black Caribbean female subjects (24%) with rates comparable with the general population (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) (Wardle 2006). All minority ethnic groups reported consuming less alcohol and were more likely to report being nondrinkers than the general population. The highest proportion of self-reported non-drinkers was the Pakistani and Bangladeshi groups (over 90% on average), likely for religious reasons (see Section 3). However, it was noted that alcohol consumption and smoking levels may be under-reported in surveys as these behaviours may be deemed as socially undesirable by participants (Heim & MacAskill 2006). There are very few published studies of objectively measured physical activity among minority ethnic groups in the UK. Minority ethnic groups, especially South Asians and Chinese populations, showed lower levels of self-reported physical activity compared with the mainstream population, particularly among Bangladeshi respondents (where only half of the Bangladeshi men and one-third of Bangladeshi women participated in physical activity at least once a week). The percentage of Bangladeshi respondents achieving the recommenda-
tion of at least 30 minutes of moderate intensity exercise on ve or more days a week was also low (around a quarter for men and 1 in 10 for women) (Stamatakis 2006). This trend may be attributed to the Bangladeshi culture as sports and games are not generally pursued by Bangladeshi adults. There is no word for physical activity in the Sylheti language (the most predominant dialect of British Bangladeshis), the closest translation of which is beyam, a Sylheti word that carries a negative connotation (Greenhalgh et al. 1998). A review by Fischbacher et al. (2004) highlighted the lack of crossculturally adapted questionnaires to assess physical activity patterns among South Asians to ensure quality and appropriateness. For example, surveys translated into various South Asian languages such as Hindu, Urdu or Punjabi by bilinguals whose dialects may differ according to education, age, socio-economic status and gender may introduce inconsistency. The translated surveys have also been found to be too formal and literary for less educated people and therefore difcult to complete. Thus, assessing physical activity using selfreported methods may be problematic, particularly among those individuals who are not uent in the English language. Koshoedo et al. (2009) reviewed the barriers to physical activity for minority ethnic groups, which include personal factors such as lack of motivation, socio-cultural barriers that are associated with lack of family support, as well as religious, language and cultural issues (e.g. inappropriate dress codes and negative perceptions of exercise) and environmental factors, including lack of information and access because of limited availability of women-only facilities, high cost of participation and insufcient time.
2.5 Dietary habits and nutritional status

No comprehensive data on nutritional status are available for minority ethnic groups. Although the UK-wide National Diet and Nutrition Survey (NDNS) is designed to be representative of the population, sample sizes for minority ethnic groups have not been sufcient to allow separate analysis (Scientic Advisory Committee on Nutrition, SACN 2008). With the exception of a few studies in recent years, there has been a fundamental lack of information on the eating habits of minority ethnic groups. A small amount of data on the eating habits and nutritional intake among minority ethnic groups are also available from the Low Income Diet and Nutrition Survey (LIDNS) (Nelson et al. 2007) and the Family Food Survey (Defra 2008), which uses a methodology based on the purchase of foods by households to estimate consumption levels.
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Intake of fruit and vegetables A diet rich in fruit and vegetables provides many health benets such as reducing the risk of CVD, type 2 diabetes and some types of cancer and maintaining a healthier weight. The WHO (2003) recommends the consumption of at least 400 g of a variety of fruit and vegetables a day. In the UK, this has been translated to at least ve portions (of 80 g each) of fruit and vegetables each day. Based on 24-hour recalls of food consumption, the Health Survey for England found that men and women from minority ethnic groups were more likely to report eating 5 A DAY compared with the general population in 2004 (see Table 5). Data from
Scotland (NHS Health Scotland 2009) showed that the proportion 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 Pakistani respondents). This is similar to the ndings from the Family Food Survey for 20052007, where the average consumption of fruit and vegetables was lower among South Asian groups than the mainstream white population. Men and women from African-Caribbean and Chinese groups consumed a larger portion of fruit and vegetables, which reect the characteristics of traditional 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 Craig et al. 2006; Fuller 2006)
Black Caribbean Men 5 portions or more (%) Mean number of portions Women 5 portions or more (%) Mean number of portions Boys 5 portions or more (%) Mean number of portions Girls 5 portions or more (%) Mean number of portions Black African Indian Pakistani Bangladeshi Chinese General population
32 3.9 31 3.9 19 3.0 19 2.9
31 3.7 32 3.8 18 3.3 20 3.2
37 4.2 36 4.4 22 3.4 18 3.1
33 4.3 32 4.0 19 3.0 16 3.0
32 3.8 28 3.6 22 3.1 21 3.3
36 4.4 42 4.9 15 3.3 24 3.6
23 3.3 27 3.9 11 2.5 12 2.6
Table 6 Average intake of energy, fat, saturated fatty acids, sugars, salt, dietary bre and fruit and vegetables by ethnic group, 20052007, based on household purchases, UK (adapted from Defra 2008)
Asian/Asian British (%) Consumption per person per day, total diet (i.e. including alcohol) Energy (kcal) Fat (g) (% total energy) Saturated fatty acids (g) (% total energy) Total sugars (g) Non-milk extrinsic sugars (g) (% total energy) Dietary bre Englyst (g) Sodium (g) Salt (g) Purchase per person per week Fruit (g) Vegetables (g)
Black/Black British (%)
Chinese and others (%)
White (%)
2203 91 (37.0) 30 (12.2) 107 66 (11.2) 14 1.8 4.5 1184 1188
2086 83 (35.9) 27 (11.5) 118 79 (14.2) 14 2.0 5.1 1587 1122
2036 89 (39.4) 29 (12.8) 103 63 (11.6) 14 2.1 5.2 1446 1288
2368 98 (37.1) 38 (14.4) 135 88 (13.9) 16 3.1 7.7 1322 1185
Excluding salt added at the table.
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Macronutrients In the UK, it is recommended that total fat should contribute 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 questionnaire and fat scores based on the frequency of consumption of certain foods, the Health Survey for England reported fat intake to be lower for men and signicantly lower for women from minority ethnic groups compared with the general 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 the amount of fat consumed by South Asians, but these have reported conicting results, which may be caused by different methods of assessments or limitations associated with sample size (Bush et al. 1999). Research has also shown differences in fat intakes within the same minority ethnic group, depending on the country of origin, which inuences cooking practices, income and other social factors (Landman & Cruickshank 2001) (see Section 3). The LIDNS (Nelson et al. 2007), which captured the dietary intakes of low-income groups (bottom 15% of material deprivation), contained a small amount of data on the nutrient intakes of adults from minority ethnic groups (n = 207). Ethnicity was self-dened using a questionnaire. Because the sample sizes for some groups were small, only limited analyses were made and statistical comparisons were only carried out between White and Asian men, and between White, Black and Asian women. White men had higher contributions to energy intake from saturated fatty acids (13.9%) than Asian men (12.1%).White women had higher contributions to energy intake from fat (35.5%) than Black (30.7%) and Asian (31.4%) women. Similarly, 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 a lower percentage contribution of non-milk extrinsic sugars to food energy (10.5%) than White men (15.0%). Similarly, Asian women had a lower percentage contribution of non-milk extrinsic sugars to food energy (10.0%) than White women (13.2%) and Black women (14.3%). The report Family Food in 2007 showed that although 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 for the Chinese (39.4%) and the proportion of total energy from non-milk extrinsic sugars was highest for Black minority ethnic groups (14.2%). However, the amount of saturated fatty acids remained highest for the White population at 38 g per day (14.4% energy). Estimated intakes of dietary bre for all groups were found to be lower than the recommended daily amount of 18 g for adults and minority ethnic groups consumed less dietary bre daily (14 g) compared with the White group (16 g) according to the Family Food Survey (Table 6) (Defra 2008). These gures are based on household purchases and therefore may explain the differences with the ndings 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 death from CVD (SACN 2003). According to the Health Survey for England, use of salt in cooking and addition of salt at the table without tasting the food was more common among minority ethnic groups than the general population 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 sample of African-Caribbean adults living in Staffordshire (n = 39), Earland et al. (2010) also reported high intakes of sodium at 3231 mg (8.1 g of salt) each day. However, both the LIDNS and Family Food Survey showed conicting results, reporting the highest salt intake among the mainstream White population compared with minority ethnic groups, which may be caused by the different survey methodology and not including salt added at the table in both reports (Nelson et al. 2007; Defra 2008) (see Table 6). Unfortunately, there is a lack of 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 but there was evidence of lower intakes of vitamin A, riboavin and folate in Black and Asian women compared with White women. Compared with their White counterparts, Black women and Asian respondents were also more likely to consume lower amounts of calcium. A total of 42% of Black women and 36% of Asian women had calcium intakes below the lower RNI (LRNI) compared with 8% of White women, suggesting inadequacy is likely.
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Iron status has been found to be low among certain minority ethnic groups as demonstrated by the low mean haemoglobin (Hb) levels. Dening anaemia as Hb < 12.0 g/dl, the Health Survey for England (Falaschetti & Chaudhury 2006) found that anaemia was more common among women than men in all groups and more common in minority ethnic groups, in particular South Asian and Black African groups in 2004 (see Fig. 9). Poor iron status has been widely reported among women of South Asian origin in the UK and has been linked to low birthweight in their offspring, which may increase the risk for poor health in future life (Thomas 2002). Vitamin D is the generic term for two molecules, ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3). Vitamin D2 is derived by ultraviolet (UV) irradiation of the ergosterol that is widely distributed in plants and in other fungi, whereas vitamin D3 is formed from the action of UV irradiation on the skin. The main circulating vitamin D metabolite is 25-hydroxyvitamin D [25(OH)D] is and it is the best indicator of clinical status, whereas 1,25(OH)2D is the active form of the vitamin. Vitamin D is the only nutrient where the main source is not diet but actually sunlight exposure. Vitamin D is mainly produced photochemically in the skin between April and September in the UK as a particular wavelength of sun intensity is required. Suboptimal vitamin D status among some minority ethnic groups because of physiological and lifestyle factors, e.g. those with darker skin and those who wear concealing clothing, has been widely reported in the UK. Government advice is for Black and minority ethnic groups to take supplementary vitamin D (SACN 2007); however, awareness of this recommendation among these groups
is poor (Lanham-New et al. 2011). Deciency in vitamin D impairs the absorption of calcium and phosphorus, which increases the risk of low bone density and reduced muscle function. Prolonged deciency of vitamin D results in osteomalacia in adults and rickets in children. The D-FINES (Vitamin D, Food Intake, Nutrition and Exposure to Sunlight in Southern England) study compared the vitamin D status of preand post-menopausal Caucasian and South Asian women (n = 223 Caucasians and n = 70 South Asians respectively) in Surrey. The researchers reported marked ethnic differences with 17.1% of South Asian women in the summer being vitamin D-decient [dened as 25(OH)D < 20 nmol/l], increasing to 58.1% in the winter, while no Caucasian women were vitamin D-decient during any season. In addition, the results of this study showed clear regional differences in vitamin D status, with lower vitamin D status in the north (Aberdeen) compared with the south of the UK (Surrey) (postmenopausal group only) (Mavroeidi et al. 2010). The study also investigated selenium intakes of South Asian (n = 55) and Caucasian women (n = 248). South Asian women were found to consume less selenium compared with Caucasian women, while intakes for both groups were found to be below the LRNI (Darling et al. 2010), which is of concern as an adequate intake is important for immune and thyroid functions and reproduction (British Nutrition Foundation 2001). Pregnancy and infant feeding practices Folic acid is needed to prevent neural tube defects such as spina bida in unborn babies (SACN 2006). Research shows that folic acid supplementation should be actively promoted to women from low-income families of African-Caribbean and South Asian backgrounds to help improve the health of a baby and reduce the risk of birth defects as these groups have been found to be less proactive in seeking information and less interested in detailed written resources (Health Education Authority 1999). Making these communications available in various South Asian languages would be likely to help engage specic subgroups. It is also important to improve knowledge of breastfeeding and healthy infant feeding and weaning practices among women from minority ethnic groups, e.g. discouraging the use of cows milk as the main drink until after 1 year and the uptake of sweet commercial foods. Dyson et al. (2006) found breastfeeding education during the antenatal period in informal small groups, with links to existing programmes, to be effective in increasing both the initiation and duration of breastfeeding among women
35 30 25 20 % 15 10 5
B ar lac ib k be an Bl ac k Af ric an
Men Women
an i
hi
Ba ng la
Figure 9 Prevalence of anaemia (Hb < 12.0 g/dl) among adults, by ethnic group and sex (adapted from Falaschetti & Chaudhury 2006).
po Ge pu ne la ral tio n
de s C
di
Pa ki
hi n
In
es e
an
st
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from minority ethnic groups. Ellahi et al. (2008) suggested 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 infant feeding practices and types of food for weaning. Healthy Start vitamins should also be encouraged to ensure that children and pregnant and breastfeeding women receive adequate vitamin D (as is necessary for the 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 at least 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 than White mothers. First- and second-generation minority ethnic groups were less likely to breastfeed than recent immigrants. It was found that for every additional 5 years spent in the UK, the likelihood of breastfeeding was reduced by 5%. The Infant Feeding Survey in 2005 (Bolling et al. 2007) found that mothers from minority ethnic groups had highest rates for exclusive breastfeeding at birth and breastfeeding at all ages up to 9 months. It also reported that these mothers tended to introduce solids later on average than White mothers: around 70% compared with 83% had introduced solids by 5 months. Chinese women were least likely to introduce solids by 4 months (40% compared with 51% for white mothers). The Millennium Cohort Study also found similar results with White mothers more likely to introduce solids earlier than those from minority ethnic groups (Grifths et al. 2007). Mothers from minority ethnic 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 to give pulses (32% compared with 16% of all mothers) and eggs (16% compared with 6%). Asian and Black mothers were signicantly less likely than other groups to 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 the infants diet. Asian mothers were also less likely to give their babies chicken and sh, suggesting that weaning onto a vegetarian diet is more common. Chinese mothers were particularly likely to provide rice or pasta but much less likely than other groups to give breakfast cereals to their babies.
The use of salt was most prevalent in the diets of babies of mothers from minority ethnic groups compared with the diets provided by White mothers. While only 5% of White mothers used salt at least occasionally, 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 mothers from each of these ethnic groups said that they used salt often, most saying they used salt only sometimes (Bolling et al. 2007). Babies need only a small amount of salt (less than 1 g a day up to 12 months) because their developing kidneys cannot cope with larger amounts of salt. The dietary intakes of children from minority ethnic groups are presented in Section 2.6.
2.6 Overview of the health proles and dietary and health 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 to suffer from a long-standing illness than boys and girls in the general population, although a larger proportion of Bangladeshi boys and Black Caribbean girls reported fair or bad health. Pakistani boys were found to have higher systolic 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 general population. Using BMI percentiles classication for children from the 1990 UK growth reference data (UK90) (which dened overweight as the 85th percentile and obesity as the 95th percentile), the Health Survey for England showed that in 2004, the prevalence of obesity for children (2-to-15 years) of most minority ethnic groups was not signicantly different with each other; but the rates for these groups were higher than those for the general population (19% boys, 18% girls), with the highest rates among Black African children (31% boys, 27% girls) followed by Black Caribbean children (28% boys, 27% girls), with the only exception being Indian boys (14%), Pakistani girls (15%) and Chinese children (14% boys, 12% girls) (Fig. 10) (Fuller 2006). The National Child Measurement Programme (NCMP) is the most robust data set on childhood obesity in the UK, which uses the UK90 data to measure the height and weight of children attending state-maintained primary schools in England in Reception (aged 4-to-5 years) and Year 6 (aged 10-to-11 years) annually. It was rst run in 2006/2007 and the latest gures (2008/2009) showed
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35 30 25 % 20 15 10 5 0
B a r la ib ck be an Bl ac k Af ric an hi i ta n se n po Ge pu ne la ra l tio n ia es In d is ad Pa k gl C hi ne
Boys Girls
Studies in England showed that children from South Asian groups were likely to have lower blood Hb levels than the mainstream population. Childhood anaemia (Hb < 11.0 g/dl) was also more common among children from South Asians groups than White children in England. This may be caused by early introduction (9 months) of cows milk as a main drink for infants and the prolonged use of bottle-feeding, which has been associated with higher milk consumption at the expense of other foods that are rich in iron (SACN 2009). Diet and health behaviour patterns In the Health Survey for England, information on smoking and alcohol consumption habits was collected from children aged 8-to-15 years based on interviews. In 2004, Indian and Chinese children were less likely to have smoked than those of the same age in the general population. The proportion of children from minority ethnic groups who reported ever having an alcoholic drink was generally lower than the general population, particularly among Pakistani and Bangladeshi boys (Fuller 2006). A larger proportion of children (5-to15 years) from minority ethnic groups achieved the recommended ve or more portions of fruit and vegetables a day (15% for Chinese and 22% for Indian and Bangladeshi children) compared with the general population (11%). The average number of portions of fruit and vegetables was also higher than within the general population (2.5 and 2.6 for boys and girls respectively) with the highest amount for Indian boys (3.4 portions) and Chinese girls (3.6 portions) (Table 5). Results from the Determinants of Adolescent Social Well-Being and Health study by the Medical Research Council, a multiethnic adolescent cohort of over 6500 pupils recruited from 51 schools across 10 inner London boroughs, showed that compared with White UK children, Black African-Caribbean children were more likely to skip breakfast and take part in other poor dietary practices and eat less than one portion of fruit and vegetables each day, while South Asian children had healthier diets (although a higher intake of zzy drinks) (Harding et al. 2008) (see Table 7). The CHASE Study (Donin et al. 2010b) compared the nutritional quality of diets of children from mainstream White and minority ethnic populations. Based on a 24-hour dietary recall, the study found that South Asian children (n = 558) reported a higher consumption of total energy and total fat (absolute and as a proportion of total energy intake) (mostly polyunsaturated) than White European children, which may contribute to the increased risk of obesity in some South Asian children;
Figure 10 Prevalence of obesity among children from minority ethnic groups (2-to-15 years) in England using BMI, 2004, Health Survey for England (adapted from Fuller 2006).
that the prevalence of obesity in some Asian groups, particularly children of Bangladeshi and Pakistani ethnicity, was as high as or higher than those from the Black groups contrary to the ndings from the Health Survey for England (The NHS Information Centre 2009). This may be caused by the additional breakdown of 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 measurement for population group comparisons (Nightingale et al. 2011). Using bioimpedance and skinfold thickness measurements, Nightingale et al. (2011) demonstrated that BMI underestimates body fatness in South Asian children but overestimates levels of body fat in Black African-Caribbeans (because African-Caribbean children are generally taller and BMI and height are often correlated in childhood/adolescence). Using these body fat measurements, Nightingale et al. (2011) found UK South Asian children to have higher adiposity levels and Black African-Caribbeans to have similar or lower adiposity levels when compared with White Europeans. Shaw et al. (2007) also reported that BMI criteria may not accurately identify ethnic differences in body fat among children, which should be taken into consideration when determining rates for overweight and obesity. Data for childhood obesity from the Health Survey for England showed similar patterns to those in 1999, although signicant increases were found for Black Caribbean and Bangladeshi boys in 2004 (Fuller 2006).
Ba n
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Boys (Reception) Boys (Year 6) Girls (Reception) Girls (Year 6)

27.3% 26.0% 25.1% 23.2% 26.4% 26.2%
29.1% 26.4%
28.5%
22.2% 19.7% 18.0% 19.8% 16.8% 14.9% 14.9% 15.5% 15.1% 19.8% 18.9%
21.5%
17.7% 16.3% 16.0% 16.4% 13.9% 11.8% 11.0% 9.7% 8.1% 8.8% 12.5% 11.4% 10.6% 10.3% 10.6% 9.6% 8.6% 8.7% 10.5%
Black African Black other
Indian
Pakistani
Bangladeshi Asian other
Mixed
White British White other
Any other ethnic group
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 the Determinants of Adolescent Social Well-Being and Health study (n = 6599) (adapted from Harding et al. 2008)
Black Caribbean Boys 36.3 59.6 28.5 17.3 Girls 51.9 64.5* 26.3 26.9 Boys 20.5* 66.7 38.1 13.2 Pakistani/ Bangladeshi Girls 32.6* 56.9 36.7 15.1* Boys 29.1 73.2* 23.9 25.9 Girls 49.6 59.0 25.7 22.1
Black African % Not eating breakfast every day Consuming zzy drink most days 5 portions fruit and vegetables each day <1 portion fruit and vegetables each day Boys 44.9* 62.3 24.4 22.9 Girls 53.0* 55.5 24.3 27.8
Indian
White UK Boys 31.0 62.3 31.0 19.4 Girls 43.3 54.2 30.1 24.3
*P < 0.05 compared with value for White UK group.
while Black African-Caribbean (n = 560), especially African children reported lower intakes of saturated fatty acids than White European children. South Asian and African-Caribbean children consumed proportionally lower amounts of sugars and higher amounts of protein than White European children. In CHASE, Donin et al. (2010a) found the lower intake of saturated fatty acids among African children to explain their lower total and LDL-cholesterol compared with other groups (White European, Black Caribbean and South Asian). However, Black Caribbean and South Asian children were shown to have LDL-cholesterol levels similar to or higher than White European children. These patterns are broadly similar to the adult ndings
(see Section 2.5), reecting the fact that dietary habits from earlier years often track into adulthood. South Asian and Black African-Caribbean children also have lower dietary intakes of vitamin D and calcium, which may negatively impact on future bone health (Donin et al. 2010b). In addition, South Asian children have been shown to consume lower levels of vitamin C compared with their Black African-Caribbean and White European counterparts (Donin et al. 2010b) (Table 8). Physical activity related questions were asked in the Health Survey for England to assess childrens levels of walking, active play, sports and exercise (excluding those as part of the curriculum in school) and housework and gardening in the week prior to the survey. In 2004,
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Table 8 Nutritional composition of childrens diets from the CHASE study by ethnic group (adapted from Donin et al. 2010b)
South Asian (n = 558; 264 boys) (%) 8042/1911 76.9 (35.6) 27.3 (12.7) 258.5 (50.9) 101.2 (19.8) 12.8 65.7 (13.6) 2.9 196 73.9 1.4 699 9.4 0.12 Black African-Caribbean (n = 560; 261 boys) (%) 7665/1821 69.0 (33.2) 25.0 (12.0) 256.3 (53.0) 112.0 (22.9) 11.0 60.2 (13.3) 3.0 200 85.9 1.7 693 8.6 0.20 White European (n = 543; 271 boys) (%) 7634/1814 70.8 (34.5) 27.2 (13.2) 252.3 (52.1) 116.1 (23.8) 11.8 57.3 (12.7) 2.8 204 85.1 1.9 742 8.7 0.15
Consumption per person per day, total diet Energy (kJ/kcal) Fat (g) (% total energy) Saturated fatty acids (g) (% total energy) Carbohydrate (g) (% total energy) Sugars (g) (% total energy) Dietary bre (g) Protein (g) (% total energy) Vitamin B12 (mg) Folate (mg) Vitamin C (mg) Vitamin D (mg) Calcium (mg) Iron (mg) Haem iron (mg)
Pakistani children and Chinese girls were least likely to have walked for 5 minutes or more during the week. Participation of children from minority ethnic groups in active play was also lower compared with the general population. Girls were less likely to take part in sports and exercise than were boys, with lowest participation rates among South Asian girls, of whom, less than a quarter 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 intensity of at least 60 minutes every day, except for Pakistani boys (Department of Health 2004; Fuller 2006). Khunti et al. (2007) also observed widespread sedentary behaviour, both for South Asian and White European children, in inner city secondary schools in the UK, with almost half of the respondents (n = 3601) spending four or more hours per day watching television or videos or playing computer games. Results from CHASE comparing objectively measured physical activity levels in 9-to-10year-old British children of South Asian, Black AfricanCaribbean and White European origin showed British South Asian children to have the lowest levels. Black African-Caribbeans also had lower levels that White Europeans, and girls in all groups recorded less physical activity than boys (Owen et al. 2009).
2.7 Gaps in data availability

The Foresight report (2007) highlighted the lack of substantial health data sets for minority ethnic groups. SACN (2008) also described the lack of national data
available on the nutritional status of minority ethnic groups 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 focused on South Asians and African-Caribbeans, but there is relatively little information about the health and dietary habits of the Chinese population. Further studies on all non-White minority ethnic groups are essential to provide a better picture of their health and nutrition status. Apart from the Health Survey for England, there are insufcient population-wide data available to reect the general health status of minority ethnic groups in Northern Ireland, Scotland and Wales. Evaluations of the availability and quality of data on ethnicity and health in the UK have suggested the following problems: incompleteness of data, variability in the use of ethnic coding, lack of training for staff on ethnicity data collection and inadequate information technology systems for ethnicity information to be appropriately recorded and exchanged (Unal et al. 2003; Aspinall & Jacobson 2007; Bhopal et al. 2008). For example, the Scottish Ethnicity and Health Research Strategy Working Group set up by the NHS Health Scotland (2009) reported that ethnicity was rarely recorded on health service records and not on death certicates. Less than 20% of hospital admission records and cancer registration data had an ethnic code. The group published the Health in our Multi-Ethnic Scotland report, which provides priorities for action to ll the information gap that include recording the ethnic identity of every person registered with
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the NHS and maximising use of methods and links to data research on various health problems. A health survey focusing on the health of minority ethnic groups is expected to be carried out in 2011/2012 by the NHS Health Scotland.
Key points
Health and wellbeing vary signicantly between minority ethnic groups. In general, minority ethnic groups tend to show poorer health outcomes compared with the general population. Possible causes of increased disease risk among minority ethnic groups for a given level of exposure include health behaviour patterns, genetic predisposition and developmental programming. Language and cultural differences have been identied as the two major barriers to access to health care. According to the Health Survey for England (2004), a higher 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 be explained by higher LDL-cholesterol levels. On the contrary, African-Caribbeans tend to have lower LDLcholesterol levels, and this may be reected in their lower CHD rates. Adults from minority ethnic groups were 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 develop type 2 diabetes, with highest rates among South Asians, which may be caused by their higher risk of central fat deposition. Findings from CHASE suggested that the increased risk of CVD and type 2 diabetes of adult minority ethnic groups may be tracked from childhood. Obesity rates were higher for Black African and Black Caribbean adults, while Chinese and South Asian communities were less likely to be obese. However, it has been 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 the White population. In the Health Survey for England, fewer respondents from minority ethnic groups reported drinking alcohol compared with the general population. A greater proportion is likely to abstain for religious reasons. A larger proportion of minority ethnic groups met the recommendation of eating at least ve portions of fruit and 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 the general population according to the Health Survey for England, but other studies have shown conicting results. According to the Health Survey for England, use of salt in cooking and addition of salt at the table was more common among minority ethnic groups than the general population. Unfortunately, there is a lack of data based on urinary sodium levels. Low iron status has been found among women of many minority ethnic groups, and anaemia is more common in both adults and children in these groups compared with the mainstream population. Vitamin D deciency has been observed among minority ethnic groups in the UK, particularly in the winter months. Low selenium intakes have also been reported in South Asian groups. Folic acid supplementation, good infant feeding practices and Healthy Start vitamins should be encouraged in minority ethnic groups as well as the mainstream population. The Infant Feeding Survey in 2005 and the Millennium Cohort Study found that mothers from minority ethnic groups had highest rates for exclusive breastfeeding and they tended to introduce solids later, on average, than White mothers. Mothers from minority ethnic groups tended to use more salt in their babies diet. Childhood anaemia was found to be more common among children from South Asian groups than White children 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 population, with highest rates among Black African-Caribbean children. The only exception being Indian boys, Pakistani girls and Chinese children. CHASE found that South Asian children reported a higher consumption of total energy and total fat (absolute and as a proportion of total energy intake), which may account for the increased risk of obesity in this group, while Black African Caribbean children reported lower intakes of saturated fatty acids, which may reduce their 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 bone health in the future. Physical activity levels among adults and children from minority ethnic groups tend to be lower than among 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
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Ireland, Scotland and Wales. To reduce health inequalities, it is important to carry out national surveys on the health and nutritional wellbeing of minority ethnic groups, to identify the gaps in health service provision, develop suitable health initiatives and community strategies to reduce barriers to health care and encourage healthy lifestyle behaviours.
cooking fats, and this may create trans fatty acids, which are adverse for heart health (Landman & Cruickshank 2001).
Food availability and access

Traditional foods are not widely available, and many are only available in ethnic-style supermarkets located in specic regions of the UK (e.g. London). These foods are often more expensive because they are imported (Lawrence et al. 2007; Mintel 2009). However, for some members from minority ethnic groups, maintaining traditional food habits is of central importance and they are willing to purchase imported traditional foods even at a relatively high cost (Bush et al. 1999). While some supermarket chains in the UK offer ethnic-style food products (e.g. rice, noodles, soy sauce, chilli powder), the relatively small quantities sold may be inappropriate for family catering for certain minority ethnic 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 be available in the UK during certain times of the year; for example, 42% of Pakistani households consumed palak (a kind of spinach) in the summer compared with 19% of these households in winter (Kassam-Khamis et al. 2000).
3 Factors affecting food choice

The dietary habits of minority ethnic groups are inuenced by a range of factors, including income, socioeconomic status, food availability and access, health, religion and dietary laws, food beliefs, amount of time available for food shopping or preparation, generation and gender. Acquiring a better understanding of the reasons 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 educationalists, to understand more about the needs of minority ethnic groups and help them make healthier food choices.
Income and socio-economic status

The amount of disposable income available for families and individuals in minority ethnic groups to spend on food impacts on their dietary habits and the foods that they choose to eat. According to the 2001 census, people from minority ethnic groups were more likely to live in low-income households and rely on social security benets. Unemployment rates for some minority ethnic groups were also higher than the population average (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 been observed among South Asian communities in the UK. Lip et al. (1995) found that South Asian households in the UK of lower social classes were more likely to purchase foods that were higher in fat. In a study by Kassam-Khamis et al. (2000), which examined the nutritional quality of commonly consumed dishes among three South Asian Muslim groups (Bangladeshi, Pakistani and East African Ismaili), the Ismaili group appeared to be the most afuent of the three and ate dishes of lower fat content. Low income may prevent some families from being able to consume some traditional foods (see following section) and this may also affect diet quality. Concern has also been expressed that poorer Asian families are also more likely to reuse
Awareness of healthy eating

Although knowledge does not necessarily translate to behaviour change, awareness of healthy eating messages can impact on food choices of minority ethnic groups. Kassam-Khamis et al. (2000) observed that the most afuent Ismaili group (compared with other South Asian Muslim groups from Bangladesh and Pakistan) were found to be more conscious of healthy eating messages and ate foods that had lower fat content. In a qualitative study (n = 33), Lawrence et al. found that all respondents, 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 the link, and this was dependent on the cultural background. For example, Pakistani and Bangladeshi women appeared to have relatively good understanding of what methods of cooking are healthy and unhealthy, e.g. frying is not a healthy cooking method; while Zimbabwean respondents placed value on freshness and regarded frozen foods as less healthy (Lawrence et al. 2007). This reects the need for targeted messages and
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culturally appropriate resources on healthy eating for different minority ethnic groups.
Religious beliefs
Religious dietary laws have a direct impact on the eating habits of minority ethnic groups, especially South Asians (Muslims, Hindus and Sikhs) and AfricanCaribbeans (Rastafarians and Seventh-day Adventists). These rules were set to help followers demonstrate their faith by adhering to religious rites concerning diets, to communicate with God (e.g. saying thanks and blessings) and to develop discipline through fasting (Kearney et al. 2005). Depending on the religion, there are rules as to how, when and with what particular foods are eaten. 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 shows the foods allowed or prohibited for different religious groups. However, it is important to note that dietary practices 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 Pakistanis and Bangladeshis living in the UK are Muslims (ONS 2006b). The Koran, the religious text of Islam, outlines the foods that can be eaten (described as halal) and those forbidden (haram). Beef, lamb and chicken can only be eaten if the animal has been slaughtered by the
halal method, which means that the animal must be killed 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 sacriced to idols. 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 ve pillars of Islam, is practised during Ramadan and is believed to increase spirituality, improve self-discipline and awareness of the hardship experienced by people facing starvation. However, fasting may lead to headaches and dehydration (because of restrictions in uids and/or caffeine). Prolonged abstinence from food and drinks may also lead to lethargy and affect work performance. A study of 81 students in Tehran showed reductions in the concentrations of blood glucose and HDL-cholesterol and increases in LDL-cholesterol in healthy individuals during the period of fasting, which may be related to the biochemical response to starvation (Ziaee et al. 2006). Although children (before puberty), pregnant and lactating women, the elderly and those who have serious sickness can be exempted from fasting, many still choose to fast because of religious or social reasons, e.g. fear of stigmatisation, penalty from non-compliance. This is a particularly serious issue when followers are on oral medication or insulin therapy as fasting affects glycaemia. Therefore, these should be adjusted to co-ordinate with the time of the main meal. The EPIDIAR (Epidemiology of Diabetes and Ramadan) population-based study, which involved over 12 000 patients with diabe-
Table 9 A guide to religious and cultural inuences on diet (adapted from de Wet et al. 1995)
Seventh-day Adventist Church (with ns and scales) Rastafari Movement (to some) (to some) (to some)
Food/ drink Eggs Milk and yogurt Cheese Pork Beef Lamb Chicken Fish Alcohol Fasting
Muslims
Hindus (to some) (not with rennet) (to some) (to some) (with ns and scales) On special occasions to personal Gods
Sikhs (to some) (to some)
Buddhists (to some)
(to some) (not with rennet) Halal only Halal only Halal only (with ns and scales)
(to (to (to (to (to
some) some) some) some) some)
Ramadan: no food or liquid from sunrise to sunset
, acceptable; , not acceptable Halal means that the animal can only be eaten if it has been slaughtered in a particular way.
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tes from 13 countries with a sizable Muslim population, found that hypoglycaemic episodes during the month of Ramadan were signicantly more frequent compared with other months (Salti et al. 2004). Hindus The majority of Indians living in the UK are Hindus who came from the Gujarat region (ONS 2006b). Hindus do not eat beef because the cow is held in high regard and a symbol of abundance. Strict Hindus are vegetarian because they believe in reincarnation so the soul of an ancestor may be in an animal. Some Hindus may also avoid certain foods, such as domestic fowl, salted pork, milk, ghee, onions, garlic, eggs and coconut. Some devout Hindus fast on special occasions as a mark of respect to personal gods or as part of their penance. Diwali (or Deepavali, meaning row of lamps in Sanskrit), also known as the festival of lights, is an important 5-day festival occurring between October to November and celebrated by Hindus, Jains and Sikhs around the world. During this festival, sweet treats and confectionery (called mithai) made from coconut, cream and various types of nuts and some our-based savoury snacks are often eaten and offered as gifts. Sikhs The second largest religion among Indians in the UK is Sikhism, and most Sikhs originated from the Punjab region (ONS 2006b). Sikhs follow dietary laws from their Code of Conduct, Sikh Rehat Maryada, which states that Sikhs should refrain from food and drinks that may harm their body, e.g. alcohol, or ritually slaughtered meat, e.g. halal, kosher. Only vegetarian food is served at gurdwaras (the place of worship for Sikhs) so that everyone, regardless of their dietary restrictions, is able to enjoy free, communal food, which is called langar. Some older Sikhs may fast during full moon or specic feast days, but most are discouraged from fasting and going on pilgrimages. Rastafarians A small group of African-Caribbeans belong to the Rastafari Movement. Most Rastafarians are vegetarians or vegans because foods of animal origin, especially meat and sh, are considered as dead foods. Foods approved for Rastafarians are called Ital, which should be of vegetable origin and natural, without the addition of articial colours, avourings or preservatives. Because Rastafarians do not consume much, if any, meat, milk,
fats and oils, children born of Rastafarian parents have found to be of increased risk of low iron levels and of rickets, especially with prolonged breastfeeding, no vitamin supplementation and on a vegetarian diet low in vitamin D (Ward et al. 1982). Rastafarians avoid alcohol and some also avoid tea, coffee and other caffeinated drinks because these are considered to confuse the soul. Seventh-day Adventists Many Adventists are ovo-lacto vegetarians; therefore, they do not consume animal esh of any kind but will consume dairy and egg products. The vegetarian diet recommended by Adventists includes plenty of wholegrain breads, cereals, pasta, fruit and vegetables and moderate amounts of legumes, nuts and seeds. Some Adventists avoid food and drinks that contain caffeine; therefore, they do not consume tea and coffee. They also avoid alcohol. The Adventist vegetarian diet has been shown in a number of studies to be associated with the prevention of type 2 diabetes, heart disease, cancers and overall mortality. The Seventh-day Adventist cohort in America (Adventist Health Study 2), which compared Black (n = 14 376) and White Adventists (n = 42 378), found that although Black Adventists showed better health habits than non-Adventist Blacks, they were more likely to be overweight or obese and reported higher rates of hypertension and type 2 diabetes than the White Adventists, which maybe be caused by genetic predisposition and developmental programming (see Section 2.3). However, Black Adventists had lower rates of high serum cholesterol and myocardial infarction (Montgomery et al. 2007). Buddhists Most Buddhists in the UK are Chinese (ONS 2006b). Buddhists pledge to refrain from killing or injuring living creatures. Therefore, strict Buddhists follow vegetarian and vegan diets and also avoid the consumption of alcohol.
Food beliefs
Some minority ethnic groups hold traditional beliefs about food, health and views on body image that may conict with those based on scientic research; e.g. fat children are healthy. Obesity is sometimes seen as a symbol of afuence and success in some traditional, non-Western societies. It is important to address these cultural characteristics, as such beliefs may lead to par-
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ticular difculties when delivering interventions, such as those that combat obesity. South Asian communities (e.g. Indians, Pakistanis and Bangladeshis) perceive foods as hot and cold, which is related to beliefs on how foods affect the body systems, but not to the temperature of foods. Foods are chosen to counteract or complement a condition, e.g. u. This may be related to Ayurveda (science of life), which is the traditional medicine originating from the Indian subcontinent (de Wet et al. 1995). Chinese communities also consider balancing the yin (coldness) and yang (hotness) of the body as particularly important. Yu (2000) found that older Chinese people living in Glasgow reportedly applied their traditional values to determine whether Western food is healthy, e.g. because sh and chips are deep-fried and coffee is made from roasted beans, therefore believing that these foods could produce excessive heat and dryness and may cause harm to the body.
found that the younger generation of minority ethnic groups regarded itself culturally torn between ideas and attitudes of their elders and those of their peers from the mainstream population. The longer working hours and hectic lifestyle of the younger generation also led to irregular dietary habits, which may encourage them to eat more convenience foods (Mullen et al. 2006). Therefore, the needs for different generations of these groups, are likely to vary.
Key points
It is important to understand the different factors affecting the dietary habits of minority ethnic groups when designing health and nutrition interventions. These aspects include income, socio-economic status, food availability and access, health, religion and dietary laws, food beliefs, amount of time available for food shopping or preparation, generation and gender. The amount of disposable income available to spend on food will inuence dietary habits. There may be limited availability of traditional foods for minority ethnic groups in some areas, and these foods may be relatively expensive. Religious dietary laws set out the foods that are accepted and not accepted for different religious beliefs. Some religions also practise fasting. Traditional food beliefs are also strongly held by for some minority ethnic groups, which may have a direct impact on the food and drinks that individuals choose to eat or refrain from eating. Younger generations of minority ethnic groups are more likely to adopt the dietary habits of the mainstream population, for various reasons such as lack of time and cooking skills to prepare traditional foods, a way to conform to the British culture and a reection of independence from their parents.
Time and cooking skills

Lack of time to prepare food has a direct impact on food choice. Some women from minority ethnic groups (especially older women and rst-generation migrants) who do not work spend the majority of their time preparing and cooking meals, and this is considered an important daily task (Lawrence et al. 2007). Therefore, lack of time for food preparation is not a key issue for some families but may have an impact on the younger generation, such as young working women, who may have limited time for food shopping and preparation (see following section). In addition, if cooking has a central role in the family, traditional cooking skills are more likely to be passed down to younger generations. The lack of condence in traditional cooking skills may encourage a less traditional style of cooking.
Generation and gender

Older generations are more likely to follow traditional diets and less likely to change their dietary habits compared with younger generations. A qualitative study conducted in Bradford reported that rst-generation British Pakistanis were more reluctant to try any English foods compared with the second generation who perceived English foods as convenient, a way to conform to the mainstream British culture and a reection of independence from their parents. It also found that women of the rst generation were more adventurous compared with men, mostly because they wanted to share the same experience of consuming English foods with their children (Jamal 1998). A qualitative survey in Glasgow
4 Traditional diets of minority ethnic groups

4.1 Overview of traditional diets of minority ethnic groups
South Asians The basis of a traditional South Asian diet is starchy staples, such as rice and various types of bread, e.g. chapatti, roti (a thicker variant of chapatti) and paratha (unleavened) bread. These are often eaten with vegetables (e.g. okra, aubergines, courgettes, peas, onions), beans and pulses (dhals), meat or seafood in a curry.
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South Asian cuisine is also known for the wide range of herbs and spices used for avouring. Some types of food are only consumed during certain seasons. For example, some foods such as khadhi (a yogurt and chickpea soup) are viewed as warming foods and eaten more often in winter (Kassam-Khamis et al. 2000). The traditional diet of South Asian people contains large amounts of starchy foods, fruit, vegetables and pulses, which suggests that it is relatively high in bre and low in fat (Wyke & Landman 1997). However, the South Asian population in the UK is a heterogeneous group and there is wide diversity in the traditional foods they consume depending on a range of factors including where the family originated from and religious beliefs. For example, in a study on dietary habits of different South Asian groups, Indian Punjabis and Pakistanis were found to consume more wheat-based staples, such as roti and chapattis, while Indians originating from the drier Gujarat region tended to use millet traditionally but increased their wheat consumption after migrating to the UK primarily because of the cheaper cost and wider availability. Bangladeshis were found to consume mainly rice, as wheat was not traditionally cultivated in Bangladesh. They also often added extra vegetables to their dishes and consumed large quantities of fresh and salt water varieties of sh (Sheikh & Thomas 1994). Simmons and Williams (1997) compared the diets of South Asian religious groups from different regions and reported regular fasting to be most common among Muslims and Gujarati Hindus, reecting their religious dietary laws. However, there is considerable variation even within religious groups. For example, Punjabi Muslims were found to eat more paneer (a type of cheese) than Gujeratis. Kassam-Khamis et al. (1995) compared to the diets of South Asian Muslims originating from Bangladesh and Pakistan and Ismailis originating from the Indian Gujarat region via East Africa and that the Pakistanis consumed more varieties of dhals, such as channa (chickpea), masoor (lentils), mung bean and urad (black lentil); they also ate more sweet dishes than the other groups, e.g. kheer (rice with milk and sugar) and mithai. The Gujaratis were found to consume more fried foods. African-Caribbeans African-Caribbeans represent a vast heterogeneous group in the UK originating from a number of different countries. The types of traditional foods consumed vary widely between different subgroups. Those of African descent tend to base their meals on starchy foods, such as rice, plantains, cassava and fufu, native to Central
and Western Africa. Fufu is made by boiling starchy vegetables, e.g. cassava, plantain, yam and corn, until it becomes soft and paste-like, to be shaped into dumplings. Staples of the West Indian diet include rice, plantains (sometimes referred to as green bananas), yams and potatoes. A large variety of vegetables are also consumed, usually boiled or added to highly avoured soups and eaten with meat or sh dishes. Meat, such as lamb, beef, chicken, mutton and goat, are often heavily seasoned and deep-fried, with coconut cream occasionally added. Large amounts of tropical fruits, such as mangoes, breadfruits, fresh calloloo and avocados, are eaten if in season. Commonly eaten snacks include beef patties, salt sh fritters and fried dumplings (Sharma & Cruickshank 2001; Gilbert & Khokhar 2008). Table 10 shows some commonly consumed traditional foods of the African-Caribbean population in the UK. Sharma and Cruickshank (2001) highlighted the importance of understanding the terms used for describing different foods when analysing African-Caribbean diets, e.g. sterilised milk is called steri and pasteurised whole milk is called plain milk. Boiled rice is referred to as plain rice, and rice is usually consumed with pulses to produce what Jamaicans call rice and peas (often kidney beans or gunga peas), while Barbadians call it peas and rice (often black-eyed beans or pigeon peas). Potatoes refer to all types including sweet potatoes, and white bread is made from a sweeter and rmer dough than the European type.
Table 10 Description of some traditional foods eaten by African-Caribbean people in the UK (adapted from Sharma & Cruickshank 2001)
Food Hard dough Cornmeal porridge Description Dense white bread. Cornmeal our added to hot milk (sometimes with condensed milk), avoured with fresh nutmeg, vanilla, sugar and salt. Canned or fresh green leaves (such as spinach), boiled or steamed with salt sh, onions and oil. Also called chayote, this is a gourd with a similar appearance as green pear, but has a slightly hairy and lighter skin. Deep-fried batter with salt sh/salted cod, which is purchased dried and soaked overnight to remove salt or boiled to rehydrate before cooking. Semi-circular or oval-shaped pastry lled with seasoned minced beef or vegetables. Deep-fried or boiled dough made with white our. Also called Johnny cake. Different variations available, e.g. nutritionally enriched milk drink and malt energy drink.
Callaloo Cho Cho
Salt sh fritter
Pattie Fried dumplings Punch
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Furthermore, different foods may be eaten on specic days. Commonly eaten foods on Saturdays include West Indian soup, typically a one-pot meal with large pieces of starchy carbohydrate, such as yam or sweet potatoes with meat and boiled dumplings. Fried plantain may be consumed for Sunday breakfast, while cornmeal porridge and canned fruit salad in syrup and homemade punch are often eaten at other times on Sundays. Foods such as ackee and salt sh are expensive and therefore tend to be reserved for special occasions (Sharma & Cruickshank 2001). Chinese There are marked differences between the types of foods consumed and cooking styles in various parts of China. Wheat products, such as noodles or buns, are more commonly consumed as staple foods in northern China, while rice is typical for southern China. Rice is also used to produce beers, wines and vinegars. Chinese dishes are often packed with lots of green, leafy vegetables, e.g. pok choi, choi sum and Chinese broccoli (also called Chinese kale or kai lan), gourds/melons, e.g. winter melons (also called wax gourd), bitter gourds, hairy gourds and watermelons and fungal-type vegetables, e.g. Shitake mushrooms and dried black fungus. Different types of meat, poultry and seafood are commonly eaten, depending on where the dish is originated from. Fish is often served as a whole to symbolise prosperity. Tea, which was rst cultivated and drunk in China, is a common drink among the Chinese, both on its own or at meal times. Although milk and dairy foods are not traditionally consumed as part of the diet, these have become more common constituents of a Chinese diet, reecting the increased use of Western foods. The Chinese diet has a heavy reliance on soya milk and other soya products, such as bean curd (tofu) and its derivatives. In addition to other types of fruit common to the rest of the population, the Chinese also consume a variety of fruits that are widely cultivated in the Asian continent and the subtropics, such as watermelon, white pears (also called ya li), nashi pears, lychee, longan, kumquat, dragon fruit, starfruit (also called carambola), bell fruit (also called lian wu), guava, mangoes and papayas. The type of cooking reects regional characteristics and changes from province to province, e.g. Cantonese in Southern China, Shanghainese in Eastern China, Sichuanese in South-western China and Pekinese in Northern China. Dim sums, are small snacks served in Cantonese cuisine. These are savoury or sweet food items in bite-sized portions, such as dumplings, buns
and rice rolls with various meat or vegetable-based llings. A range of cooking techniques, which include boiling, steaming, poaching, braising, stir-frying and deep-frying, are used in Chinese cuisine. Traditionally, the Chinese eat with chopsticks and most dishes are prepared in bite-size pieces to make it easier to pick up and eat directly. Soups (or broths), which often use ingredients with perceived medicinal properties to balance the yin (coldness) and yang (heat) of the body, are particularly important. It is a common practise to eat together and share a couple of dishes with other people at a meal occasion to symbolise harmony and togetherness. Special foods are eaten at different times of the year. For example, ingredients with names that symbolise good luck and fortune are eaten at Chinese New Year e.g. the pronunciation of sh is similar to abundance in Chinese; therefore, eating sh is seen to bring about abundance in the coming year. The word for tangerines in Chinese sounds similar to fortune and they are frequently consumed or displayed on plates or as plants around the house as ornaments. Sweets and seeds are often eaten to symbolise happiness and fertility, respectively. The Lantern Festival, which takes place on the 15th day of the Chinese New Year, is celebrated by eating glutinous rice dumplings. During the Mid-Autumn Festival (also known as Moon Festival in Western countries), moon cakes, a traditional cubical Chinese pastry with a thin crust and lotus seed paste with egg yolk in the middle, are usually eaten in small wedges with Chinese tea.
4.2 Dietary acculturation

Studies have shown some traditional diets to change after migration through the process of acculturation (the assimilation of habits to that of the host country). This change has generally been associated with poorer eating habits, especially in younger generations. Secondgeneration offspring of former migrants are likely to adopt mainstream dietary patterns, with higher fat intakes and lower vegetable, fruit and pulse consumption compared with their rst-generation parents (Landman & Cruickshank 2001; Gilbert & Khokhar 2008) (see Section 3). These changing dietary habits, alongside insufcient levels of physical activity, which is common among minority ethnic groups (see Sections 2.4 and 2.5), may impact on the health of these minority ethnic groups.
4.3 Nutrition composition of ethnic-style cuisine

The latest edition of the Composition of Foods (2002) by McCance and Widdowson is the UK-wide nutrient
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data set that provides information on the nutrition content of over 1200 commonly consumed foods in the UK, including levels of fat, sodium, bre and carbohydrates, vitamins and minerals. The report, Immigrant foods (1985) was published previously as a supplement that contains the nutrition information of commonly consumed foods and recipes for cooked dishes with regard to the traditional diets of migrants from the Indian subcontinent, the West Indies and Hong Kong. A small amount of data on ethnic foods is available from the European Food Information Resource Synthesis report: Ethnic Groups and Foods in Europe (Church et al. 2006). As ethnic-style foods and cuisine are getting increasingly popular (Leung 2010), it may be useful to refresh the nutrient data set and amalgamate the ndings with the main report to gain a better understanding of the nutritional composition of these foods, which may be eaten by both the mainstream population and minority ethnic groups in the UK.
sumed and cooking styles across China. Special foods are eaten at different times of the year. Traditional diets may change because of acculturation, which is the assimilation of the habits of the host country. This has been associated with a less healthy diet that is higher in energy, fat and salt and lower in fruit and vegetables, which may be impacting on the health of the younger generation. There is a need to include ethnic-style cuisine in nutrient datasets to gain a better understanding of the nutritional composition of these foods.
5 Nutritional interventions and health promotion among minority ethnic groups

As previously highlighted, minority ethnic groups in the UK suffer from health inequalities compared with the mainstream white population, commonly attributed to the interaction between health behaviour patterns, genetic predisposition and developmental programming. Language and communication (such as poor interpretation services) and cultural differences (such as varying perspectives and beliefs on health) have been identied as the major barriers to health care (Latif 2010). As highlighted in Section 2, high LDL-cholesterol levels have been found in South Asian adults and children, which may contribute to their increased risk of CHD in later life. South Asians have a relatively high proportion of body fat and are more likely to be centrally obese and suffer from type 2 diabetes. Key dietary messages for South Asians should, therefore, include reducing the energy content of their diet and keeping their intake of saturated fatty acids below recommended targets. In contrast, Africans have lower LDLcholesterol levels that may protect them against CHD, but they are more likely to suffer from stroke. AfricanCaribbeans are also as likely to be obese as the general population so they should be encouraged to reduce the energy content of their diet. Reducing salt intake, as advised for the population as a whole, should also be encouraged among minority ethnic groups because they have been found to add more salt to foods (at the table and in their cooking) than the general population according to the Health Survey for England in 2004. High salt intakes may be associated with the higher risk of hypertension among these groups. High rates of anaemia and suboptimal vitamin D status have been found among some minority ethnic groups in the UK (see Section 2.5). Although mothers from minority ethnic groups reported highest rates for exclusive breastfeeding and they tended to introduce solids later on
Key points
The traditional dietary habits of minority ethnic groups vary widely but there is also heterogeneity within each group reecting different countries of origin and/or native regions. A variety of other factors inuence their food choices, e.g. religion and food availability. The traditional South Asian diet consists of staples, such as rice and bread, eaten with vegetables, beans and pulses (dhals), meat or seafood in a curry. It also features a wide range of herbs and spices for avouring. The foods commonly eaten also vary by season and between those from different regions and religious groups. The traditional African-Caribbean diet includes a range of starchy foods including rice, plantains, cassava, fufu, yams and potatoes. Various vegetables are also consumed with meat or sh dishes as well as different tropical fruits. Commonly eaten snacks include beef patties, salt sh fritters and fried dumplings. Understanding the terminology used when assessing the diets of this group is important because the names of dishes may differ between subgroups and from those used by the mainstream population. Wheat products, such as noodles or buns, are commonly consumed as staples in northern China, while rice is typical for southern China. Chinese dishes are often packed with lots of green, leafy vegetables and fungaltype vegetables. There tends to be a reliance on soy milk and other soy products, such as bean curd (tofu) and its derivatives. A variety of fruits are also consumed. There are marked differences between the types of foods con-
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average, they appeared to be more likely to add salt to weaning foods and should be advised about the dangers of too much salt in early life (see Section 2.5). As shown in Section 4, acculturation has generally been associated with poorer eating habits including higher fat intakes and lower fruit and vegetable consumption, especially in younger generations. These changing dietary habits, coupled with widespread physical inactivity among minority ethnic groups, are negatively impacting on the health of both adults and children within these groups. The National Patient Survey in England showed that South Asian and Chinese groups were less likely to give positive responses regarding their experiences with the NHS (Healthcare Commission 2008). The NHS Greater Glasgow report (Heim & MacAskill 2006) found that Chinese users were least likely to have made use of health-care services and reported the lowest levels of satisfaction with service providers, while South Asians and African-Caribbeans were more positive about service provision, with satisfaction levels comparable with those of the general population. Chau (2008) suggested that the low take-up rate in health and social care services among Chinese people may be caused by the relatively conservative nature of the community, difculties in communicating with health professionals about traditional health beliefs (e.g. that a sore throat is caused by excessive internal heat) and negative experiences with interpretation services. There has been a lack of tailored and evaluated nutritional interventions in the UK to target minority ethnic population groups. For interventions to be successful, they need to be targeted to the individuals dietary habits, which are inuenced by various factors (see Section 3). In designing health and nutritional interventions, health professionals need to understand the cultural concerns for each minority ethnic group and their subgroups to ensure services and interventions are delivered effectively. Using a trusted and recognised community worker and having health professionals who speak the language have also been suggested to help enhance the outcome of these interventions.
probably associated with their success. Although the report did not specify which ethnic groups the studies targeted, of all the interventions, 64 focused on disadvantaged communities and 13 took place in low- and middle-income countries. Each study was rated on three primary outcome measures, psychological changes, behavioural changes and physical and clinical changes, and categorised as effective, moderately effective, promising/insufcient evidence, minimally effective, insufcient evidence/not shown to be effective or not reported/not measured. The authors concluded that there is no one-size-ts-all approach for selecting interventions but made a few observations for successful interventions that are important to consider when designing studies for many groups, including minority ethnic groups: multi-component interventions that are adapted to the local context were the most successful (e.g. school programmes with interventions targeting the school environment, its food services and the classroom curriculum); interventions that used the existing social structures of a community (e.g. schools) reduced barriers to implementation; interventions that involved participants in the planning and implementation stages were more effective (e.g. community leaders in community- and religionrelated programmes). In the UK, Stockley (2009), on behalf of the Food Standards Agency (FSA) Wales, published a review of 17 evaluated nutritional interventions carried out between 1999 and 2008 targeting minority ethnic groups. The studies were mainly carried out in the community (n = 12), with others being in schools, health centres, places of worship and takeaway outlets. However, most of the studies were rated as being of weak scientic quality, mainly because of low numbers, the absence of control groups and the use of self-reported measurements, which may have introduced inaccuracy. Despite the weak scientic evidence base, the review highlighted a few key characteristics to successful nutritional interventions in minority ethnic groups, which are included in Table 11. The WHO (2009) report identied religious settings as an effective means to deliver dietary and physical activity interventions. Often, the outcome is enhanced when religious leaders and congregational members used pastoral support and spiritual strategies as well as group education sessions and self-help strategies. Places of worship have also been shown in other studies as a favourable means for delivering nutritional inter-
5.1 Effective nutritional interventions

The WHO published a review in 2009 of evidence-based interventions of diet and physical activity that aimed to reduce the risk of chronic non-communicable diseases (Anderson et al. 2009). This review divided 261 studies (published between 1995 and 2006) by their settings (including those carried out in religious settings) and life course stages and summarised the evidence of the effectiveness of these interventions to identify the factors
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Table 11 Key characteristics to successful nutritional interventions (adapted from Stockley 2009)
Tailoring interventions to specic minority ethnic groups, addressing cultural acceptability, appreciating different forms of behaviours and using appropriate languages. Understanding the lifestyles of different minority ethnic groups and targeting subgroups, e.g. men and women; young people, adults and older adults. Recognising the relationships between individuals, families and households for appropriate delivery. Reinforcing changes in knowledge, behaviours and attitudes by using a variety of activities that may be based on behaviour change models. Involving a trusted and recognised community worker for communitybased projects and health professionals from the same ethnic background who may also speak the language of the target group. Using approaches such as community development and peer education that have proven relatively successful.
5.2 Health promotion interventions to prevent problems associated with fasting

The minority ethnic community is made up of many religious groups, some of which practice fasting. Fasting during Ramadan has been raised as a challenge for healthcare professionals because of the health effects of long periods of abstinence from food and water. Although some people are exempted from fasting, many still choose to fast for religious or social reasons (see Section 3). Health professionals may wish to establish links with local mosques and work with religious leaders beforehand, such as having a pre-Ramadan assessment (especially for high-risk population groups, e.g. diabetic patients) and take the opportunity to educate patients on healthy eating during fasting periods in order to deliver appropriate advice for this period. The Department of Health published the Ramadan Health Guide: A Guide to Healthy Fasting booklet (Communities in Action 2007) with the aim of helping people understand the health issues related to fasting, ways to make informed choices, minimise complications and maximise the benet of the fast. Some information is also available in different languages. Because some other religious groups (e.g. Sikhs and Hindus) fast on different levels and occasions, health professionals should gain a thorough understanding of clients religious and cultural background before providing advice.
vention among certain minority ethnic groups. For example, the British Heart Foundations Social Cooking Project (Zaidi et al. 2008) involved recruiting and training local peer facilitators to work with specic minority ethnic communities on a salt awareness programme to teach healthier cooking and shopping skills. The project was run by dietitians in 15 places of worship in Birmingham, Bradford, Cardiff, London and Watford. It focused on raising heart health awareness, specically the impact of high levels of salt used in Hindu and Sikh social cooking at temples and gudwaras and provided practical help to reduce the salt used by these groups. It also held seminars to encourage worshippers to implement the low salt messages at home. Of the 12 places of worship that took part in the evaluation, all of them reported at least the target of a 5% reduction in the amount of salt used in social cooking, with six of them reporting a 10% reduction. There was pressure from the congregation not to cook bland food, but the message of making gradual changes was emphasised. Clear rapport was shown between the dietitians, cooks and management committee members, and this was viewed as essential for the success of the project. Project objectives may need to be exible to account for the differences between each place of worship. To provide longterm guidance on salt reduction, bespoke printed visual and reading materials are required to support the project outcome. Further research is needed to investigate if the means of religious settings is able to encourage positive changes to other areas such as a higher uptake of fruit and vegetables and a reduction in saturated fatty acids within the diets of minority ethnic groups.
5.3 Priorities for nutritional interventions and health promotion

A needs analysis was conducted by the Health Education Authority (2000) regarding food and nutrition information resource needs for minority ethnic groups. The needs of each group have been identied as follows: South Asians There was a perception of a lack of understanding among health professionals of the various cultures and eating habits among subgroups in the South Asian community. Having a health professional who speaks the language and translated resources have been shown to be important to enhance the outcome of nutritional interventions for this group. Older South Asian women are often responsible for preparing household meals; therefore, targeting this group may be a good way to promote healthier cooking. South Asians usually have large households and interventions may have a greater impact if they target the household as a whole rather than as individuals. In addition, interventions should also consider the various factors that affect food choice,
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e.g. the importance of good hospitality, which may involve the use of ingredients that are high in fat (Bush et al. 1999). African-Caribbeans African-Caribbeans were found to have good knowledge and awareness of what constitutes a healthy diet, but this did not necessarily translate to behaviour. Involving a community worker, health professional or facilitator who is trusted and recognised is important to support the receptiveness of nutritional interventions and update health services (Stockley 2009). Chinese Very few interventions have been carried out to explore the dietary needs of the Chinese. This group perceived a widespread lack of understanding from health professionals of their culture. The group is insular in nature, and there is a high reliance on traditional health remedies, which may result in low uptake of advice from mainstream health professionals (Chau 2008). Given that many Chinese people in the UK work long irregular hours in the catering sector, health professionals could make use of catering outlets as a means for delivering nutritional interventions. Other recommendations to encourage a healthier lifestyle include, having Chinesespeaking health professionals and Chinese community centres working in partnership with other voluntary or statutory organisations to launch events or projects (Chau 2007).
exercise classes and CHD and diabetes awareness sessions to encourage lifestyle change. Of the 137 returnees with data at baseline and follow-up, 69 (50.4%) reported an increase in their motivational stage. The women self-reported reductions in salt intake, consumption of fried foods and the amount of oil used, and the increased use of healthier cooking methods, such as grilling, baking and steaming were reported. Signicant reductions in weight (0.61 kg), systolic and diastolic blood pressure (3.7 and 3.15 mmHg respectively), cholesterol (0.19 mmol/l) and triglycerides (0.29 mmol/l) were also found in the follow-up sample (Matthews et al. 2007; Netto et al. 2007).
5.5 Current community initiatives

Apnee Sehat (since 2008) Apnee Sehat (our health in Punjabi) is a community project aimed to promote health among South Asians, by increasing awareness and targeting specic needs of the community, through delivering more culturally appropriate services and education, supporting behavioural change and identifying risk factors for various diseases, such as CVD, cancer and diabetes. Based in Coventry, the activities by Apnee Sehat are being held in various local venues, including health and community centres and places of worship, such as Sikh gurdwaras. Resources on healthy living are available online and it also organises healthy lifestyle education sessions, structured diabetes education sessions, healthy cooking lessons, shopping tours and signposting physical activity opportunities (including yoga, walking, gym and dancing) to promote health. Evaluation of this programme (Coe 2009) by the University of Warwick reported increased awareness, understanding, satisfaction, engagement and self-reported evidence of behavioural change, following screening at their local GP and education sections on shopping and cooking. Education and empowerment were found to be the fundamental approach to Apnee Sehat, and the principles of Apnee Sehat were reported to be transferable to other community groups in the UK to promote health (www.apneesehat.net). The Ismaili Nutrition Centre (since 2009) The Ismaili Nutrition Centre is a resource featuring a library of recipes of foods with African, Central and South Asian and Middle Eastern origin, which are supported with nutritional information and healthy eating tips, as well as Eating for Health, a regular column
5.4 Using behaviour change models

Few nutritional interventions in minority ethnic groups have used behaviour change models. The Khush Dil (happy heart in Hindi) (2002) (n = 304) project adopted the Stages of change model, which consists of a ve-stage continuum (pre-contemplation, contemplation, preparation, action, maintenance) related to a persons readiness to change and community development approaches. This project was designed to develop and test methods for a locally based, culturally sensitive, CHD prevention and control service for South Asians. It aimed to identify people with CHD risk factors (including diabetes) for primary prevention, and those with established CHD for secondary prevention, and offer culturally appropriate information and practical support. Services included health visitor-led screening, dietetic clinics to provide one-to-one nutritional support, practical activities such as cookery workshops,
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written by a resident dietician. The site draws on the ndings of the South Asian Food Survey, which was a research project that investigated the nutrient content of foods commonly consumed by various South Asian groups living in the UK. The site recipe nder allows users to input their dish preferences with regard to their ingredients and nutritional values according to the Food Standards Agency (FSA) trafc light system (www.theismali.org/nutrition).
5.6 Catering for institutionalised individuals

Ensuring appropriate and accessible choices of meals for patients from minority ethnic groups in hospitals and other institutions is essential to avoid nutritional problems. Health professionals and catering staff in clinical settings may wish to: develop protocols to record patient information relating to diet and cultural and religious requirements on patient and nursing records; provide menus in appropriate languages with details of ingredients available upon request; allow relatives the freedom to bring in food from home and provide sufcient storage and heating facilities for such food, within health and safety guidelines, and in consultation with hospital staff; offer adequate training for dieticians and catering staff in assessing and delivering appropriate diets (Equality Commission for Northern Ireland 2007).
to consider boosting numbers of minority ethnic participants in dietary interventions for the mainstream population so that conclusions relating to minority ethnic groups can be drawn out; to make appropriate and validate evaluation tools for specic minority ethnic groups, e.g. food intake measurement techniques and various terminology used for dishes; to include theoretical bases, e.g. behaviour change models, to structure the intervention; to assess cost-effectiveness and sustainability of interventions; whether the results can be applied more generally to relevant minority ethnic groups (in addition to effectiveness in changing behaviour, nutritional status or attitudes).
Key points
Language and communication problems and cultural differences have been identied as the major barriers to accessing health care for minority ethnic groups. Nutritional interventions for minority ethnic groups should consider the cultural concerns of each minority ethnic group and their subgroups. Minority ethnic groups represent a heterogeneous section of the population and there have been few tailored nutritional interventions in the UK to target specic groups. Places of worship have been shown to be useful venues for health promotion, and working with religious leaders, management committee members and chefs may aid rapport. Having a community worker, health professional or facilitator who is trusted and recognised and possibly speaking the language can enhance the outcome of nutritional interventions. Targeting South Asian households as a whole rather than individuals or focusing on older women, who are often the ones responsible for meal preparation, can aid the promotion of healthier cooking practices. The Chinese community is an insular group and relies on traditional health remedies. Because Chinese people usually work long hours in Chinese restaurants or takeaway, using these outlets as a means of delivering nutritional interventions may encourage them to make healthier changes to their diet. Using behaviour change models can be a useful way to tailor intervention and structure attitudinal evaluation. It is important to consider the religious and cultural concerns of patients in hospitals and other institutions
5.7 Recommendations for future research, policy and practice

The FSA review (Stockley 2009) recommended further research on needs assessment and better evaluation of nutritional interventions for minority ethnic groups. Health/nutrition population surveys should also routinely include minority ethnic groups to avoid marginalisation, provide a better overview of their health/ nutrition status and inform gaps in service provision. All health promotion interventions should be formally evaluated to better understand the effectiveness of these for minority ethnic groups through the collaboration of practitioners, communities and researchers. The FSA review (Stockley 2009) also made six recommendations for the evaluation of future dietary interventions in minority ethnic groups: to include rigorous and appropriate research methodologies; to collaborate with other agencies or groups to increase the funding if it is insufcient to include a good evaluation;
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by providing appropriate menus, resources and adequate training for health-care professionals and catering staff. There are a few community initiatives in the UK that provide culturally appropriate resources for minority ethnic groups, which encompass messages about healthy eating, physical activity and smart shopping. More nutritional interventions are recommended together with appropriate evaluation.
Acknowledgements
The Foundation wishes to thank members of the Foundations Scientic Advisory and Industrial Scientists Committees who have kindly commented on the contents of this Brieng Paper. It is also very grateful to Professor Peter Whincup for his detailed comments on the contents of this paper.
Conict of interest
The authors have no conict of interest to disclose.
6 Conclusion
The UK has a rich mix of cultures and culturally diverse communities. The three biggest minority ethnic groups are South Asians, Black African-Caribbeans and the Chinese in the UK. Population studies have shown that some minority ethnic groups are more likely to experience poorer health outcomes compared with the mainstream population, such as higher rates of CVD, type 2 diabetes and obesity. The differences in health outcomes may reect the interaction between diet and other health behaviours, genetic predisposition and developmental programming, which vary across different groups. Language and communication problems and cultural differences have been identied as major barriers involved in the access to health care for some minority ethnic groups. These issues should be addressed to better deliver health and nutritional interventions to these groups. Acquiring a better understanding of the reasons underlying food choices by minority ethnic groups can help health professionals and educationalists to recognise the needs of minority ethnic groups and help them to make healthier food choices. Traditional diets may change because of acculturation, which is the assimilation of the habits of the host country. Therefore, the needs of different generations are likely to vary. Unfortunately, to date, there have been few tailored, welldesigned and evaluated nutritional interventions in the UK targeting minority ethnic groups. It has been recognised that for interventions to be successful, they need to be culturally appropriate. Adopting good practice in hospitals and other institutions is important to provide appropriate catering and adequate support for minority ethnic groups. Further needs assessment and better evaluation of nutritional interventions have been recommended to better understand the effectiveness of these for minority ethnic groups. Routinely including minority ethnic groups in health/nutrition population surveys would also help to avoid their marginalisation and better identify gaps in service provision and future priorities for dietary interventions.
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