Exploring the Social Determinants of Health in Nutrition Care for South Asian Communities: A Narrative Review
Publication: Canadian Journal of Dietetic Practice and Research
17 January 2025
Abstract
The South Asian (SA) diasporic communities in Canada experience a greater burden of diabetes and cardiovascular disease (CVD) compared to white populations. Nutrition interventions often focus on individual behaviours and fail to consider that the social determinants of health (SDH) have a greater impact on chronic disease risk. A narrative review was conducted to identify the SDH in nutrition care interventions for the SA diaspora in Canada. The final analysis included fourteen articles from which SDH were identified and categorized based on the Social Ecological Model (SEM). The study analysis yielded the following needs in dietetic practice based on the SEM: (1) intrapersonal – need for language appropriate services, and representation of cultural foods and non-Western health perspectives in dietary guidelines, (2) interpersonal – understanding family and friends as social supports, (3) community – incorporating peer and community leader influences, (4) institution – importance of faith-based locations as community hubs, and client workplaces as a barrier to attending appointments, and (5) policy – advocacy for transportation and childcare access, adequate and secure income, and equitable care. These findings urge dietitians to move beyond cultural awareness, sensitivity, and competence to practicing cultural safety and humility in their practice, which is integral to providing equitable care.
Résumé
Les communautés diasporiques sud-asiatiques (SA) du Canada sont plus touchées par le diabète et les maladies cardiovasculaires (MCV) que les populations blanches. Les interventions nutritionnelles sont souvent axées sur les comportements individuels et ne tiennent pas compte du fait que les déterminants sociaux de la santé (DSS) ont un plus grand impact sur le risque de maladies chroniques. Une revue narrative a été menée afin d’identifier les DSS dans des interventions de soins nutritionnels destinées à la diaspora SA au Canada. L’analyse finale incluait quatorze articles où des DSS ont été identifiés et catégorisés sur la base du modèle socioécologique (MSE). L’analyse issue de l’étude a mis en lumière les besoins suivants dans la pratique de la diététique basée sur le MSE : (1) intrapersonnels – besoin de services linguistiquement adaptés et d’une représentation des aliments culturels et des perspectives de santé non occidentales dans les directives nutritionnelles, (2) interpersonnels – compréhension que la famille et les amis sont des soutiens sociaux, (3) communauté – intégration de l’influence des pairs et des leaders communautaires, (4) établissement – importance des lieux confessionnels en tant que carrefours pour les communautés, et des lieux de travail des clients en tant qu’obstacle à la participation aux rendez-vous, et (5) politiques – plaidoyer pour l’accès au transport et à la garde d’enfants, à un revenu adéquat et fixe, et à des soins équitables. Ces résultats révèlent que les diététistes doivent aller au-delà de la conscience, de la sensibilité et de la compétence culturelles et intégrer dans leur pratique la sécurisation culturelle et l’humilité, des aspects cruciaux de soins équitables.
INTRODUCTION
The South Asian (SA) population includes diverse individuals originating from India, Bhutan, Pakistan, Nepal, Sri Lanka, and Bangladesh [1–2]. The SA diaspora is a subgroup that migrated to the Caribbean, Africa, Europe, Canada, the Middle East, and other parts of Asia and the Pacific Islands [1]. In Canada, the South Asian population reached 2.5 million in 2021 and is projected to increase to 5 million by 2041 [3–4]. The majority of South Asians reside in Toronto, Ontario, and Vancouver, British Columbia [5]. This population is disproportionately impacted by chronic diseases compared to their white counterparts (referring to those with European ancestry) [6–13], with SA adults having an 8.1 times higher prevalence of developing type 2 diabetes (herein referred to as diabetes) [8]. The latter exacerbates the prevalence of cardiovascular disease (CVD) [9–17].
Majority of the literature on SAs attribute the higher rates of diabetes and CVD to biomedical and behavioural risk factors [18]. Studies report SAs in Canada are more susceptible to diabetes due to their fetal programming [18], have a higher amount of visceral fat and fatty acids, lower HDL-cholesterol levels, and greater insulin resistance compared to whites [12, 18]. They also state SAs engage in less physical activity, have a high-caloric, fat diet, and low fibre intake [12, 18], which is postulated to occur through acculturation in Westernized countries [19–20]. Thus, diet and physical activity are often seen as modifiable risk factors for diabetes and CVD [2, 21–27]. However, these studies illustrate a white normative and pathologizing perspective on diet when making comparisons to other cultures [28–31]. This ignores the broader societal context and creates a discordance with nutrition recommendations in Canada [28, 32]. The individualistic focus disregards how chronic disease is influenced by the social determinants of health (SDH); the interplay of social, economic, and cultural aspects that affect an individual’s or population’s health status, which creates a circumstantial disadvantage for certain groups [33–37]. Current research suggests that the Social Ecological Model (SEM) is commonly utilized to map SDH (Figure 1). This model serves as a guiding framework to determine the causes of public health nutrition issues and to propose strategies for change [38–41, 46]. A key SDH for SAs and their chronic disease risk is racism [15, 35–37, 42]. SAs and other ethno-racial groups are met with white normativity in societal structures, including in nutrition care [28, 31, 35, 47].
Figure 1.
Figure 1. Key Social Determinants of Health organized into the five levels of the Social Ecological Model.
Adapted from the Centers for Disease Control and Prevention State Health Equity Toolkit [48].
There is limited literature supporting the influence of the SDH in nutrition care interventions for SAs, which ignores health inequities in this population. The aim of this narrative review [43–45] was to explore SDH in nutrition care interventions for diabetes and CVD in the SA diaspora residing in Canada, and to propose equity-informed recommendations for dietitians working with this population.
METHODS
Search strategy
For this narrative review, MEDLINE, CINAHL, and Scopus databases were searched in November 2021, using the following keywords: “nutrition education”, “nutrition counsel*”, “nutrition intervention*”, “family care”, “peer program”, “Bangladesh”, “India”, “Nepal”, “Pakistan”, “Sri Lanka”, “Bhutan”, “South Asia”, “Canada”, “culturally sensitive”, “culturally appropriate”, and “cultural safety”. Selection criteria included peer-reviewed journal articles that focused on SA adults residing in Canada with ancestral origins from Nepal, Bhutan, Pakistan, Bangladesh, India, or Sri Lanka, and nutrition interventions for SAs with type 2 diabetes and/or CVD. Articles were excluded if they included SAs residing outside of Canada or SAs with type 1 diabetes; if they were conferences or poster abstracts, letters, commentaries, editorials, and presentations; written in a language other than English; and were published before the year 2000 (previous 20 years to reflect the increase in diversity of SAs in Canada).
Data collection and synthesis
Two authors (SB and CB) screened articles by title and abstract. Descriptive phenomenology was used to chart key study information for studies meeting the eligibility criteria. The analysts (SB and CB) applied thematic analysis to independently identify relevant SDH in the articles and grouped them into the five SEM levels (Figure 1) [41, 46–48]. Analysts then compared their categorization, and disagreements were resolved by consensus.
RESULTS
The search generated a total of 957 articles, and fourteen articles met the eligibility criteria and were included in the final analysis (see Supplementary Figure1 for PRISMA Flow Diagram). The Supplemental Table summarizes key characteristics of the final studies. Included articles were published between 2009 and 2021 and had a sample size ranging from 9 to 184 participants. The majority (12/14 (86%)) were qualitative studies with semi-structured interviews and focus groups being the most common data collection method. Eleven (79%) focused on diabetes and three (21%) on CVD. The reviewed articles revealed several SDH that demonstrate how the individual is interconnected with different parts of society and how these interactions influence health [38, 47]. These SDH highlight how dietitians can improve nutrition care for SAs with diabetes and CVD in Canada. Table 1 includes a summary of the key findings.
Table 1.
Intrapersonal
Intrapersonal factors encompass an individual’s knowledge, attitudes, and beliefs [41]. Several studies in this review identified language, cultural foods, and health perspectives as central to an individual’s well-being. Language is a primary SDH for the SA diaspora [18]. In initial diabetes appointments, SAs report experiencing anxiety due to language barriers; with the fear of misunderstanding their practitioner’s recommendations and not being understood themselves [49–50]. When SA clients and dietitians spoke the same language, it increased the client’s engagement and comfort level in education sessions [51–53]. Resources in both English and the clients’ primary language were also beneficial to support understanding of nutrition management for diabetes and CVD [51, 54].
Moreover, cultural foods form an integral part of nutrition care [32, 55–56]. Studies indicated that SAs believed their cultural foods were a barrier to change [32, 53, 57–58]. Clients often were not given culturally appropriate diabetes education, and felt obliged to convert Western recipes into their respective cultures, and educate the dietitian [57]. In contrast, dietitians who considered their clients’ culture, increased their own awareness of culturally appropriate resources, and sought advice on cultural influences from colleagues which improved client care [58].
With common educational resources and their cultural adaptability, Mian and Brauer [51] found that clients suggested alternatives to the plate method, such as the thali; food served in small bowls on a round tray, and a more accurate measurement tool, such as a katori; a standard size metal bowl (approximately 150 ml). Education tools should also include visual representations of SA foods [51]. Although these findings are not universal across SAs, it is the dietitian’s role to inquire further about clients’ cultural foods when providing education [58].
Lastly, among health perspectives, a belief for some SAs is the notion of “cure vs. control”; that diabetes could be cured when glycemic control is achieved, thus leading to ceasing diabetes treatment and management [51]. Likewise, cultural views on using specific foods for diabetes management via phytotherapy, such as bitter melon, reduced clients’ adherence to medication [51, 57]. Additionally, faith and spirituality were important for some SAs post-myocardial infarction (MI), as they reported it being as or more significant than Western health care; it was how they understood and coped with accepting their condition [59]. Similarly, among older generations, there may be distrust in Western medicine and preference for Ayurvedic medicines [49]. Religious fasting is a key component for some Muslim and Hindu clients, with differences between and within these groups [51]. Community members described how healthcare providers focused on the negative impacts of fasting [60]. Culturally appropriate guidelines, created through practitioner–client collaboration, should focus on maintaining health while fasting (e.g., consider the amount and timing of foods consumed) [51, 54, 60].
Interpersonal
The interpersonal level refers to an individual’s family and friends and their influence on an individual’s dietary patterns, behaviour, and lived experiences [41]. Family was a key source of diabetes-related information for SAs, which decreased their likelihood of utilizing dietitian services [50]. For instance, SAs with gestational diabetes highly valued family knowledge, especially generational knowledge from elders (e.g., mother, mother-in-law, or grandmother) and sisters [58]. They often sought emotional and physical support from family members who already provided nutrition advice during pregnancy [57]. Additionally, SAs stated that a primary challenge in implementing dietary changes at home was that food was made for the entire family, and meal preparers needed to assist with implementing dietary changes [52, 59]. Family was described as an “externality” that should be included in diabetes education and management for SAs [52]. For example, when dietitians included a family member in diabetes appointments, it increased client adoption of dietary recommendations [51]. Family is also a facilitator for cardiac rehabilitation participation as they were found to be major social supports, through promoting client attendance and attending sessions with clients [61].
Moreover, collectivistic cultural norms for SAs during social gatherings with family and friends were a challenge, as they had to balance dietary changes for diabetes or CVD [51–52, 59]. As traditional foods were prepared with specific ingredients [58], clients perceived that foods high in sugar and fat were readily available and socially encouraged, and it was considered culturally impolite to refuse these meals [59]. Furthermore, SAs with gestational diabetes found it challenging to consider dietary changes and food preferences while preparing meals [58].
Community
The community level encompasses an individual’s secondary social networks [41]. For SAs, community members provide social support and nutrition advice [50, 58, 60–62]. When fasting during Ramadan, informal peer counseling provided by current Muslim clients with diabetes to new clients was more effective than patient education provided by dietitians [60]. Patients learned they were allowed to check blood sugars or break their fast if hypoglycemic [60]. Dahal and colleagues [49] also emphasize that a trusted community member is key in providing diabetes education and navigating services for SAs. A community leader was seen as a knowledge broker that bridged the healthcare system, and there was also more comfort in speaking with those that had similar cultural experiences [49]. A diabetes education and support program that trained peer leaders (with diabetes or who were diabetes caregivers) to provide behavioural and emotional support to SAs found that this improved diabetes distress levels [62]. However, clients suggested that aside from social support, it was equally important for peers to be knowledgeable about nutrition recommendations for diabetes [62].
Institution
The institution level highlights how organizations influence the individual [41]. One article reported that places of worship, such as temples, had limited opportunity for individuals to specify how or what food was prepared and served, since food practices are steeped in traditions [59]. Avoiding the dining area at temples was not appropriate, as it led to decreased socialization and potential isolation [52]. Although Tang and colleagues [62] agreed that faith-based locations provide social support to SAs, they noted it was not appropriate to deliver lifestyle modification interventions due to the availability of foods higher in fat, sugar, and salt. However, the authors’ [62] interpretation of foods offered at SA faith-based locations stigmatizes SA foods as “unhealthy” [39, 63–64]. Religious institutions are community hubs and prime locations for promoting services and offering peer support [52, 59, 61–62].
Additionally, employers were a barrier to accessing care for SAs. A few studies found the inability to take time off work to attend diabetes or cardiac education sessions was connected to financial limitations [51, 61]. To mediate this issue, Banerjee and colleagues [58] found that cardiac rehab programs offering evening sessions were more convenient, and preferred over other timings or nearby locations. This indicates that dietitians must be flexible in timing sessions to accommodate those clients with stricter work policies [51, 61].
Policy
The SEM’s final section focuses on social structures and systems that influence policy-level decisions, which in turn impact individual health [44, 45, 41]. Limited access to dietitian services due to inconvenient locations [51] or transportation needs [50, 53, 61] was identified as a barrier to diabetes and cardiac care. Childcare issues [50] and additional costs not covered by Ontario’s health insurance or other insurance providers were also of concern among SAs seeking diabetes care [50, 65]. Gucciardi and colleagues [66] reported that the cost of lancets and strips for diabetes discouraged daily self-monitoring among SAs, which had an adverse impact on goals for dietary management. Furthermore, the cost of eating a nutritious diet was a key barrier in Toronto for those in the South Asian Diabetes Prevention Program [53], and was an important predictor of diabetes self-management [65]. This suggests the need to address food insecurity among this population. Consequently, precarious employment and having a low income was more common among recent SA immigrants compared to non-racialized Canadian-born clients [50]. Although only one of the articles found that SAs experienced discriminatory and inequitable treatment by healthcare providers, this is a significant determinant for adopting diabetes self-management behaviours, such as eating a nutritious diet [65].
DISCUSSION
This is the first narrative review to utilize the SEM as a guiding framework to highlight the role of the SDH in nutrition care for SAs with diabetes and CVD in Canada. The SEM can encourage dietitians to address the SDH in their practice [33–34, 38]. The following SDH were identified in this review: language, cultural foods, health perspectives, family and friends, peers and community leaders, faith-based locations and workplaces, transportation, childcare, income, and, discrimination and inequitable care.
Studies in other countries on SAs have also demonstrated the SDH found in this review. A systematic review identified native language use, culturally specific resources, and family involvement as primary SDH for diabetes management [64]. As well, dietary changes for CVD management in SAs were difficult to maintain unless there was family support [67]. SAs perceived advice from peers as familiar and meaningful, while advice from clinicians was unfamiliar and devoid of cultural meaning [68–69]. Another study identified that dietary interventions to prevent diabetes in SAs, tend to be extrapolated from evidence found from non-SAs, and align with guidelines not developed for them [70]. Evidently, the need for co-created community-level interventions for SAs spans across different countries [64, 67–70].
Furthermore, workplaces were identified as a barrier for dietary change as many SAs report struggling financially [51, 61]. SA taxi drivers stated that financially supporting their families was a priority when deciding between attending a healthcare appointment and working; causing them to decide between health or earning an income [71]. This reflects the systemic issue of working a lower-wage and precarious job that lacks both work flexibility and income security [72–73]. The intersection between nutrition care and income is also evident through the prevalence of food insecurity (FI) [72–73]. Although only a few studies in this review discussed FI [53, 65], the prevalence of FI among SAs is high [18, 72, 74]. SAs account for 15.7% of FI households in Canada compared to 13.2% for white households [72]. Racialized and low-income groups are more likely to experience FI [72–75], resulting in poorer health [75–76], and a higher risk for diabetes and CVD-related complications [72, 77–81]. A study discussed service provider perspectives on two SDH, employment and income, for diabetes management in SAs [82]. It emphasized that racism impacts access to equitable employment, which further perpetuates income insecurity for SAs [83]. Racialized income inequality, along with structural barriers to education attainment, contribute to the experience of FI for SAs [68, 80–84]. A multi-level policy approach targeting systemic racism in education and employment can ultimately improve the health of the SA diaspora in Canada [72, 82].
Culture was an underlying theme in this review, as every culture has food-related values and beliefs [18, 88]. SAs value community and the need to preserve culture through traditional foods [18]. This ties directly into their well-being and how they interpret nutrition advice from healthcare providers [18]. The SDH in this review highlights the current status of Canadian dietitians’ cultural awareness, sensitivity, and competence when working with SAs. Providing culturally appropriate care encompasses awareness, acknowledgement, recognition, and respect around the differences between and within cultures [89]. Cultural competence focuses on the practitioners’ attainment of skills, knowledge, and attitudes to work respectfully with all cultural groups [89]. However, dietitians must foster cultural humility and safety to provide inclusive and equitable care to SAs [89]. Cultural humility is a lifelong process of self-reflection and accountability, allowing clinicians to acknowledge their biases, stereotypes, and prejudices [89]. Cultural safety takes a strength-based approach to culture in care; it considers the social, political, and historical context of care, and requires clinicians to practice cultural humility; and is only determined by the individual and their community [89].
Limitations
This review excluded SAs that originated from countries outside of SA, such as the Caribbean or Africa, as they may be considered a subgroup of the SA diaspora [1]. As well, SAs are discussed as a homogenous group in order to develop a general discourse [90] on SDH for nutrition care in this diaspora. However, it is important to recognize the diversity within SA communities, including differences in migration histories [90] and varying definitions of “healthy eating” [63, 91]. Future research should focus on discovering community-specific SDH for nutrition care.
Moreover, SAs in hospital settings were excluded, as dietary recommendations vary significantly between inpatient and outpatient care. Also, this review did not group findings based on immigrant status, which is a SDH that affects one’s ability to navigate a new environment [92–94]. Further investigation should explore this SDH in nutrition care for SAs.
Furthermore, this is not a systematic review, and therefore may lack the comprehensive and systematic nature of searching in all available databases, and did not include an assessment of study quality and certainty of the evidence. Nevertheless, narrative reviews provide a more focused understanding on a specific topic [45]. Lastly, the majority of literature found focuses on health behaviour change and disregards systemic inequities, such as classism and racism. Further research should assess these facets to highlight their pivotal role in nutrition care.
Recommendations
The following are equity-informed recommendations for dietitians working with SAs in Canada.
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Include family in client sessions [51–52, 58–59, 61], create collaborative, community-driven nutrition interventions [94–95] (e.g., through informal peer counseling, peer groups, or designated community leaders) [49, 58, 60–62] and utilize faith-based locations as community hubs for disseminating education [53, 59, 61–62].
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•
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RELEVANCE TO PRACTICE
As Registered Dietitians, the SDH identified in this review present avenues for improving nutrition care for SAs with diabetes and CVD in Canada. These SDH reflect dietitians’ current cultural awareness, sensitivity, and competence when working with this population. However, the SEM as a guiding framework has highlighted that dietitians should focus on the SDH and implement strategies that consider cultural humility and safety. These equity-informed recommendations are a starting point for dietitians to improve their practice. As the SA population increases in Canada, dietitians must be prepared to utilize their clients’ strengths to provide the highest level of care.
Source(s) of financial support
There are no funding partners for this project, and none of the organizations had any role in the project design, analyses, interpretation of data, or writing of the manuscript.
Acknowledgements
None.
Footnote
1
Supplementary data are available with the article through the journal Web site at Supplementary Material.
Conflicts of interest: The authors declare that there are no competing interests.
Author contributions: SB and CB reviewed the data, completed the analysis, and wrote the manuscript. ATB and AM conceptualized the study and supervised the project. All authors have critically reviewed the results, revised this manuscript, and have approved the final manuscript.
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Canadian Journal of Dietetic Practice and Research
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Editor: Naomi Cahill
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SharminiBalakrishnanMPH, RD, CristinaBeneaMPH, RD, AnanyaBanerjeePhD, and AnishaMahajanPhD, MPH, RD. Exploring the Social Determinants of Health in Nutrition Care for South Asian Communities: A Narrative Review. Canadian Journal of Dietetic Practice and Research.
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https://doi.org/10.3148/cjdpr-2024-024
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