Tailoring lifestyle programmes for diabetes prevention for US South Asians

Formative qualitative research

The study team conducted FGDs to obtain a broad range of community beliefs6 about lifestyle behaviours among South Asian Americans. FGDs were stratified by sex and age (25–39 or 40+ years) to create homogeneous groups of participants, minimise hierarchy development that may reduce data quality and enable structured analytical comparisons.6 Trained moderators, matched to participants’ sex, used a semistructured interview guide to elicit conversation around lifestyle behaviours, barriers and motivators for exercise and healthy eating, and feedback on possible programme components. Moderators were not South Asian to encourage more detailed discussions, as would be needed when speaking to an outsider not familiar with their community.7 The interview guide was not based on an existing framework, but was instead based on concepts from research literature around diet and physical activity behaviours and key components of the DPP. FGDs (n=17, n=109, average group size 6.4 individuals), five with older females and four each with younger males, younger females and older males) lasted 60–90 min, were digitally recorded, and were held at locations familiar to participants (eg, Indian restaurants, temples). Meaning saturation was reached around key themes central to the research goals (see the Results section) with no new information or nuance arising during FGDs.8 All participants took a brief demographic survey before the discussion and received refreshments, parking validations and a gift bag. Participants were not contacted to provide further feedback after the completion of the FGDs.

The recordings were transcribed verbatim, deidentified and uploaded into MAXQDA (VERBI Software, V.10, V.11). The investigators developed codes based on a close read of the transcripts, and two analysts coded a subset of data independently to assess intercoder agreement. The researchers conducted a thematic analysis9 of the data by developing thick descriptions of core influences on diet and physical activity behaviours and diabetes prevention in the South Asian community. Structured comparisons (men vs women, younger vs older participants) identified contextual differences between subgroups. The researchers calculated means and frequency distributions for survey variables.

Intervention design

The SHAPE curriculum, like the DPP, included 16 weekly core intervention classes, followed by maintenance classes (taught weekly in SHAPE instead of monthly like the DPP), mirrored the topics covered in DPP lessons and encouraged participants to reach weight (7% wt loss) and physical activity goals (150+ min per week). Modifications to the DPP curriculum based on the FGD analysis and feedback from the community advisory board are described in the Results section.

Pilot intervention

South Asians aged ≥25 years with BMI >22 kg/m² (indicative of overweight/obesity in Asians10 and pre-diabetes (fasting glucose 100–125 mg/dL (impaired fasting glucose, IFG) and/or 2 hours postload glucose of 140–199 mg/dL (impaired glucose tolerance, IGT)11 were eligible for the pilot study. Individuals with diagnosed type 1 or type 2 diabetes or taking diabetes medication, currently pregnant or with a history of heart disease, serious illness or conditions that may impede or prohibit participation were excluded. Prescreening (n=117) was conducted in-person or over the phone and included demographic questions and the FINDRISC (Finnish Diabetes Risk Score) screening tool, a validated diabetes risk score,12 and at in person screenings, measures of height, weight and waist circumference. Individuals with a FINDRISC score of ≥11 were invited for baseline testing.

Baseline (n=55) and follow-up testing at months 4 and 6 were conducted at the Georgia Clinical and Translational Science Alliance Emory University Hospital Clinical Interaction Site. Testing included fasting blood draws to measure plasma lipids, insulin, glucose, A1C, complete blood count and blood chemistry; anthropometric measurements (weight, height, percentage body fat, waist and hip circumference, abdominal sagittal circumference and full body bioimpedance); blood pressure measurement; study questionnaires; a medical assessment and a 24-hour dietary recall. A 75 g oral glucose tolerance test with blood draws at 0, 30 and 120 min was done at baseline and month 6. Eligible participants (n=17) completed an exercise treadmill test13 to identify contraindications to unsupervised exercise; none were found.

Lifestyle classes of 3–8 participants were held at two locations across Atlanta on weekend days or weeknights. Participants selected their preferred class. Classes lasted about an hour, included a weight measurement and were led by a trained health educator.

Quantitative analysis was conducted in SAS, V.9.3 (SAS Institute). Descriptive analysis was conducted for all variables and baseline and 6 months values were compared using t-tests (for continuous variables) or X² tests (for discrete variables).

Focus group discussions

Focus group participants (n=109, table 1) were from India, Pakistan and Bangladesh and were primarily Hindu, but groups also included Muslims (22.9%), Christians (4.6%), Sikhs (3.7%) and Jains (3.7%). The top five languages spoken at home were Gujarati (40.4%), English (33.9%), Hindi (25.7%), Tamil (8.3%), and Urdu and Punjabi (6.4% each).

Barriers to a healthy lifestyle

Participants cited that unhealthy lifestyle behaviours in their community, including physical inactivity, diets high in fat and refined carbohydrates, large serving sizes and stress, where common. Immigration, strongly defined gender roles and the cultural importance of food (table 2) influenced diet and exercise choices. After immigrating to the USA, the abundance of inexpensive food, reliance on convenience food products and the profusion of cars and elevators made it easier for participants to eat less healthy diets and be more sedentary. Migration was especially detrimental to the diet of South Asian men because they lacked cooking skills and therefore relied on preprepared, frozen foods or restaurant meals, food choices that are often high in fat, sodium and calories.

Culturally prescribed gender roles also affect lifestyle behaviours. Men are expected to be ‘providers’ and women the ‘carers,’ with both prioritising their family’s needs above their own health. Male participants said they are expected to succeed academically, excel at work and save money, leaving little time for exercise. This emphasis on material success also manifested as valuing saving money now over saving health and healthcare dollars later; one older male said: ‘You’ll pay tons of dollars to the doctor, but if you say, here, to buy a gallon of milk it’ll cost you two dollars extra every day, you aren’t willing to do that and so we end up paying much higher value later on.’ South Asian culture dictates that women prioritise caring for their family and household over their individual needs and taking time to exercise for health, pleasure or other reasons is discouraged.

Participants described the integral role of food in South Asian culture, family life, socialising and celebrating. Although women are responsible for food preparation, they find it difficult to improve their families’ diet. Taste drives food choice, and ‘oil is the king… to make [food] taste, uh, delicious’ (Young Male). Participants in each group felt ‘healthy’ and ‘delicious’ were opposites, and people, especially men, felt that lowering the fat in South Asian food would make it less, or even unpalatable, palatable. Women report being called a ‘scrooge’ if they use less oil in cooking, particularly at social occasions, and attempts to lower fat or sodium were often met with resistance.

Overcoming barriers to healthy lifestyle behaviours

South Asians who make and maintain healthy lifestyle choices credit the support of friends and family. They sought out activities with social aspects (eg, group sports for young men, family walks for older participants, or exercise classes for women) to help them maintain motivation and/or had friends and family who encouraged them verbally or by example. Family was a motivator for and not a barrier to lifestyle improvement for healthy lifestyle adapters. They decided to exercise and follow a healthy diet to better care for family and prevent disease and disability to have more quality time with their loved ones. These participants were also motivated to disseminate healthy lifestyle knowledge to others in their family network. For example, one young man shared: ‘When I came [to the US], and when I educated myself, I brought this rule [for when my parents visited the US]: Okay, you have to eat this in the breakfast, eat this thing in the lunch, eat this, eat this thing in the dinner. And, after when they went back [to India], they’re still following it. So, if somebody is really strong in a family, they can probably bring this change.’ Women overcame their family’s reluctance to diet change by gradually altering foods and recipes (eg, slowing increasing spice while decreasing oil) without their family’s knowledge. These women reported that their families never noticed the changes and now enjoy healthier foods.

Suggestions for lifestyle interventions in the South Asian community

In all groups, participants felt strongly that an intervention like this was needed to prevent the spread of diabetes in the South Asian community. While most participants believed the intervention would be important for all age groups, younger men often discussed the intervention in terms of its importance for older South Asians.

In terms of class logistics, most participants agreed that English language classes would be preferable, reporting that most US South Asians, except for a few older individuals, spoke English: ‘Everybody knows English. We will say 99.9 percent know English and do understand what you are talking about’ (Older Male). Online content could be used to support in-person classes, but the majority of participants felt in-person classes would be most effective because they build peer support and create a culture of accountability. In particular, participants felt that in-person exercise instruction was required; ‘I think-I-there’s always the social aspect of it, too. I mean, I’m not talking to anybody necessarily, but when you’re around people, it kinda motivates you’ (Younger male). All groups reported that classes should be near participants’ homes at familiar locations. Young men favoured worksite-based programs, and women in both age groups stated that childcare should be provided. Class instructors could be ‘anybody’ as long as they were ‘the best qualified person,’ although some female participants suggested that a South Asian dietician might be needed to provide dietary guidance.

In terms of content, participants in all groups reported a need for nutrition information for South Asian foods. Younger participants requested that the class include information on foods from a variety of cuisines ‘because our generation will eat everything’ (Younger Woman). Several participants stressed that there should be specific dietary advice for vegetarians and non-vegetarians, as it was felt these diet patterns differed significantly. Although women reported an interest in cooking demonstrations and recipe books, these ideas were less appealing to the male groups. Younger men and women described the need for quick cooking Indian recipes and cooking techniques. Women reported a desire for exercise classes that taught a variety of exercise types, for example, yoga, aerobics and even sports, which they felt would appeal to younger South Asian men. Except for older women, all groups reported a need to tailor exercise classes specifically based on the participant characteristics (eg, older adults or families).

Intervention design

Based on the results of the FGD and community advisory board feedback, changes were made to the intervention protocol and the DPP curriculum. A planned control group was removed from the study design as it was deemed unnecessary given the strong evidence for the D PP and advisement that it would affect recruitment and community interest in the study. Modifications from the DPP are shown in table 3. These include adapting dietary examples and advise to be more culturally relevant, enabling social support for lifestyle changes, encouraging participants to build support for healthy changes and providing a strong foundation for exercising. The SHAPE curriculum was based on the lesson plans used in the original DPP study;4 since that time, some of these changes have also been independently added to the National DPP (eg, classes are now all group based).

Pilot intervention trial results

Of the 55 people screened, 22 were eligible for the SHAPE pilot study (clinicaltrials.gov NCT01084928) and 17 consented to participate. Participants and non-participants were similar except participants felt they were at low risk for a serious disease (52.9% vs 28.9%, p=0.037) and presented more often with isolated IFG (iIFG, 41.2% vs 2.6%, p=0.0002) or IFG+IGT (35.3% vs 5.3%, p=0.0035). Pilot participants were 76.5% male with a mean age of 46.9±12 years and had some college or higher education. Mean BMI was 28.9+/-6.1 kg/m², and 41.2% had isolated IGT, 17.7% had iIFG and 35.3% had IFG+IGT (35.3%). One participant with normoglycaemia was included in the classes but not in programme assessments at his request and because he could provide valuable input on the feasibility of the programme among young men.

Nine pilot intervention participants returned for 6-month follow-up testing. Two participants dropped out of the pilot, one for health reasons not related to the study and the other citing a lack of interest in continuing the programme. Of the remaining participants who declined attending follow-up testing visits (n=4), they cited the inconvenience of travelling to and parking at Emory University and difficulty taking time off work as reasons. Eleven participants attended more than half of the active intervention period classes, and eight participants attended at least half of the maintenance period classes.

As shown in table 4, five of the nine study participants attending 6-month testing had reverted to normoglycaemia. Mean weight, BMI, waist circumference and abdominal sagittal circumference all decreased, although none of these improvements reached statistical significance. Participants also had a slight decrease in systolic blood pressure and showed marked improvements in cholesterol, low-density lipoprotein and triglycerides. Results are similar when the analysis is restricted only to individuals with 6-month follow-up data (data not shown).