The Role of Exercise

The Asian Indian community reflects what is known as `the healthy migrant effect' where the health of migrants deteriorates over time. As new migrants get accustomed to new food habits and a different lifestyle, certain related lifestyle health issues creep in. For instance, data suggests that Indians appear to have a higher prevalence of obesity than any other social groups in the country.

This is echoed in an analysis of the New Zealand Health Survey by Dr Robert Scragg, Associate Professor at the School of Population Health at the University of Auckland. While published a few years ago in 2005, according to Dr Scragg the findings still hold true for the Asian community.

While the overall lifestyle pattern of the Asian community is generally good since they are less likely to smoke or drink alcohol, the lack of physical activity is a likely cause for an elevated risk of diabetes and cardiovascular disease. Asian Indians have a higher prevalence of obesity compared to other Asians and this is a contributing factor to their increased risk of diabetes and heart disease.

Health experts working closely with the community unanimously share the opinion that this trend is a cause for concern. There is a need for an innovative approach to health communication if we are to deal with this trend effectively. There is a lack of evidence on the most effective community interventions and no recognized infrastructure to deliver Asian services in New Zealand,'' says Dr Ranjana Patel, Director of East Tamaki Healthcare Group. She speaks from the experience of running Arrogya, which literally means well-being, a health awareness programme aiming to raise levels of awareness in the community using existing points of gathering, like places of worship.

"An understanding of the community and working with an insight into the culture often yields better results. Often, when I work with the community I come across people who say they need to exercise more in order to keep fit in New Zealand. It didn't take them as much effort to work off excessive weight in their home country. Or that they find it hard to minimize the use of certain ingredients, like oil, for cooking if they are to move towards a healthier lifestyle,'' she says.

The preventive measures clearly are healthy eating and regular physical activity in order to reduce the risk of diabetes and heart disease. Finally, all the experts agree and recommend the old fashioned way of working up a sweat and exercising regularly as a way to leading a healthy and disease free life. (Patel, 2010)

Bollywood-style dance classes, based on the lavish dance numbers found in some films from India, have become a popular attraction among American exercisers, the Associated Press reports. The American Council on Exercise suggest that ethnic dancing styles like salsa, belly-dancing and now Bollywood-dancing is a major growth area for gyms and dance studios. Ensure "Green prescription" is discussed and offered to patient.


In migrants, the changes in diet, customs, physical activity, and socio-economic status bring potential stresses of varying degrees of magnitude. Urban stress is more marked in ethnic minorities than in local populations. The role of stress and constitution as causative factors in diabetes in Indians has been discussed more in the older literature than at present there is increasing interest in the concept of central nervous system control of insulin secretion, and with recent developments, a greater understanding of the interaction of stress, the nervous system, appetite control, and diabetes will be available.

Management of diabetes mellitus has been described as being the most complex of all common metabolic disorders. Type 2 diabetes, which is a disease of lifestyle, has an impact on all aspects of living: having to follow a schedule of diet, doing exercise regularly, taking medicines and getting tested periodically.

Stress can result in causing diabetes mellitus and might also contribute to difficulties in management. There is also evidence that chronic persistent stress may cause type 2 diabetes mellitus.

Cortisol and obesity are closely associated. Earlier studies suggested that in obesity, both secretion and clearance of cortisol are increased, resulting in normal or low circulating levels. Environmental stress and the pattern of cortisol secretion may both contribute to the pathogenesis of obesity.

Sexual dysfunction is an important expression of stress. Besides vascular and neural dysfunction leading to sexual dysfunction in men, stress can also result in reversible sexual dysfunction. Shift work and adverse work conditions also contribute to sleep disorders and sexual dysfunction.

Sleep disturbances are four times more common in diabetes mellitus compared to controls. The stress of having the disease, along with physical symptoms, psychosocial factors including shift work may all contribute to sleep disturbances. Women were shown to have more sleep disturbances than men (Sridhar and Madhu, 2001).

A review of the use of coping strategies in behavioral/psychosocial interventions revealed that problem-focused interventions are more common than emotion-focused interventions Research suggests that most clinicians know that emotional distress is common among their patients with diabetes and that this distress has a deleterious effect on diabetes outcomes, but fewer clinicians feel able to treat this distress Nevertheless, the health consequences of emotional problems are clear-cut; they are associated with poorer self-care behavior, poorer metabolic outcomes, morbidity, mortality, functional limitations, and poorer quality of life and the negative effects are not limited to diagnosable psychiatric disorders.

Thus, addressing emotional problems is a key health care intervention even if diabetes self-care is adequate, and all clinicians should be able to :

1. Identify patients who are suffering from diabetes-related distress.

2. Apply effective treatments to relieve diabetes-related distress.

3. Identify patients who are suffering from psychiatric disorders.

4. Refer patients for specialized mental health care when appropriate.

As with the behavior change support process, the emotional support process is a step-by-step approach, making it easy to implement. It is generally best to start with interventions that can be implemented during regular visits before considering more intensive interventions, which may require referral to a behavioral/psychosocial specialist. Of course, symptoms may be so severe that the clinician should refer for specialist intervention.

Identifying patients who suffer from diabetes distress

Diabetes-related distress is associated with less active self-care , therefore, one sign that patients may be distressed is an unwillingness or inability to engage in active self-management despite recognition of the need for change. Patients sometimes spontaneously express their diabetes-related distress, often in terms of demoralization about their ability to manage their diabetes.

Patients who are distressed can be identified by asking the following questions designed to assess specific sources of distress as well as the intensity of the distress:

Are you having trouble accepting your diabetes?

Do you feel overwhelmed or burned out by the demands of diabetes management?

Do you get the support you need from your family for diabetes management?

Do you worry about getting diabetes complications?

(Peyrot and Rubin 2007).


Vitamin D

Asian Indians who are vegetarian or vegan are more at risk of Vitamin D deficiency as this is mainly obtained from eating foods rich in Vitamin D such as oily fish. It is available in small amounts in eggs and dairy products, however, vegans do not consume these either. Vitamin D is also obtained through exposure to the sun, however, darker skinned people do not absorb this well, and culturally, many Indians, especially woman are well clothed during the day.

According to Von Hurst, Vitamin D deficiency can relate to muscle loss, cancer, heart disease, auto-immune conditions and type 2 diabetes. (Von Hurst 2009) Inflammation and vitamin D deficiency is also implicated in causing insulin resistance, the precursor of type two diabetes. Some research has shed light on a complex interaction between elevated free fatty acids and inflammatory cytokines seen in obesity activating Protein Kinase C (PKC) isoform theta. PKC Theta inhibits the Insulin Receptor. (Challem 2010) Another study also implicates Vitamin D deficiency as being associated with insulin resistance. ( Cheng, S., Joseph M Massaro, Caroline S Fox, Martin G Larson, et al. 2010)

For most people a daily supplement of vitamin D is required.

Vitamin B12

Vitamin B12 deficiency can be caused by:

1. Not consuming vitamin B12 containing animal foods such as meat, fish, eggs or dairy products (strict vegetarian and vegan diets)

2. Lack of intrinsic factor production due to atrophy of the gastric mucosa. The amount of intrinsic factor commonly decreases in the elderly. This is rare in younger people but pregnant/breastfeeding mothers can lack intrinsic factor, especially if the mother is older.

3. Some diseases of the stomach or small intestine can cause inadequate absorption of vitamin B12. A deficiency of vitamin B12 can lead to the development of megaloblastic anaemia (pernicious anaemia) and can cause neurological damage. Symptoms of anaemia include lethargy and loss of appetite. Symptoms of nerve cell damage may include numbness/tingling in hands and feet, sore tongue, poor muscle co-ordination, depression, irritability, memory loss and personality changes. In adults symptoms often develop slowly over several months or a year. With sub-optimal intakes of Vitamin B12 there may be no clinical symptoms of deficiency, but marginal B12 status can lead to elevated homocysteine levels, which is a risk factor for cardiovascular disease. It is noted that folate deficiency may co-exist with vitamin B12 deficiency. (Public Health 2005)

It is known that the diabetes medication Metformin can cause vitamin B12 deficiency in 10-30% of users. An annual check is advised. This predisposes vegetarian Asian Indians taking Metformin even further risk of deficiency. (Arrow Medsafe)

Insulin resistance should be suspected where deficiencies of other key nutrients like chromium, zinc and Essential Fatty Acids exist.(Karl, 2010)

Health Care or Wellness Plan

A Care Plan is developed collaboratively with the patient and the nurse or Doctor and records care, support and self management.

A Care or Wellness Plan may include:

1. Patient Condition

2. Goals and steps to get there

3. Medications and treatments

4. Expectations by everyone involved

5. Links to other health and support services

Highlight importance of regular check ups including the Annual Diabetes "Get Checked" (Adapted for Counties Manukau webhealth.co.nz)

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© 2010 De La Haye