AWA: Academic Writing at Auckland

Introduction

Obesity is an issue of increasing concern in New Zealand and around the world. A recent survey found the prevalence of obesity in New Zealand adults to be 27.7% in men and 27.8% in women (University of Otago & Ministry of Health, 2011). However, obesity does not affect all New Zealanders equally. This essay will investigate the issue of obesity in Indian women in New Zealand.

Although the precise prevalence is not known due to the use of ethnic-specific definitions of obesity, it has been estimated that Indians in New Zealand are more than four times as likely as Europeans to be obese (Ministry of Health, 2006). Indian women in particular are at risk as nearly 53% are obese compared to 34% of Indian men. Obesity is of concern as a health issue because it is widely recognised as a significant risk factor for many chronic diseases including cardiovascular disease, diabetes and some cancers (Ministry of Health & Clinical Trials Research Unit, 2009). It is likely that the higher prevalence of obesity contributes to the high rates of some of these diseases amongst Indian women. Hospitalisation rates for ischaemic heart disease, for example, are twice as high amongst Indian women as rates in the general population (Ministry of Health, 2006). The reasons for the higher rates of obesity amongst Indian women in New Zealand remain unclear. However, South Asians in New Zealand have low intakes of fruit and vegetables and low participation in physical activity (Scragg, 2010).

This essay will begin with a brief history of Indian migrants to New Zealand and a description of some of the group’s socioeconomic and demographic characteristics. A review of the literature on obesity in Indian women will be presented followed by some examples of local attempts to address obesity. Finally, New Zealand policy relevant to obesity will be assessed for its responsiveness to the needs of Indian women. 

History and characteristics of Indians in New Zealand

Indians have been migrating to New Zealand for more than 100 years. However the immigration reforms of the late 1980s that encouraged skilled, educated migrants to settle in New Zealand led to an steady increase in the number and diversity of migrants from India arriving in New Zealand (Friesen, 2008).  At the time of the 2006 Census there were nearly 100,000 people in New Zealand who identified as belonging to the Indian ethnic group, of whom approximately half are women (Statistics New Zealand, 2006).  As shown in Table 1, the majority of Indian migrants to New Zealand have settled in the Auckland Region. The location of the Indian population in New Zealand has implications for service provision.

Table 1: Region of residence of Indian population in New Zealand

Source: Statistics New Zealand, 2006 Census

More Indian women are unemployed than Indian men. However, the majority of Indian women are in paid employment. The employment status of Indian men and women is shown in Table 2. The high participation of Indian women in employment could contribute to obesity as lack of time could act as a barrier to participation in physical activity and preparation of traditional foods.

Table 2: Employment Status by Sex of Indians in New Zealand

Source: Statistics New Zealand, 2006 Census

Overview of relevant literature

India is in a phase of nutritional transition (Griffiths & Bentley, 2001; Shetty, 2002). Nutritional transition is characterised by an increase in overall energy intake, increased proportion of energy from fat and increased intake of sugar alongside decreasing energy expenditure (Popkin, 2004; Satia, 2010).  As a result to these changes, the prevalence of overweight and obesity in India is increasing, and alongside the continuing high prevalence of under-nutrition this represents a double burden of disease (Balarajan & Villamor, 2009; Griffiths & Bentley, 2001; Shetty, 2002). Indian women appear to have higher rates of obesity than Indian men (Madrigal et al.). The overall prevalence of obesity in Indian women in India has been estimated at between 12 to 15% using ethnic-specific cut-offs, increasing from around 10% in 1999 (Balarajan & Villamor, 2009; Garg, Khan, Ansari, & Garg). In India, obesity is positively correlated with urban residence, higher socio-economic status and age (Ackerson, Kawachi, Barbeau, & Subramanian, 2008; Balarajan & Villamor, 2009; Garg et al.; Yadav & Krishnan, 2008). The prevalence of obesity is highest amongst women in the highest wealth quintile (30.5%) followed by women with higher qualifications (23.8%), women aged between 40-49 years (23.7%) and women living in cities (23.5%) (Garg et al.). While the pathways to obesity are complex, it is thought that some of the mechanisms by which these differences occur include a decrease in physical activity as a result of moving to non-manual occupations; increased exposure to food marketing; and increased access to calorie-dense foods (Ackerson et al., 2008).

While Indian women living in urban areas in India have increased exposure to such risk factors, those who migrate to Western countries appear to be at even greater risk of obesity. A meta-analysis investigating obesity in South Asian migrants found that the prevalence of obesity is higher amongst migrants than non-migrants (Madrigal et al.), while a study comparing an Indian migrant population in Britain with a similar population in India also found a higher prevalence of obesity in migrants than non-migrants (Patel et al., 2006).  However, an Australian study that compared risk factors for cardiovascular disease of Indian migrants to Australia with their relatives in India found that although the women in India had higher BMI, they also had higher prevalence of abdominal adiposity which could be a better indicator of the risk of disease associated with obesity. The findings in this case could have been due to both study groups being relatively well-off and therefore exposed to similar risk factors for obesity (Mahajan & Bermingham, 2004). Migration does seem to be associated with increased obesity in other migrant populations as well as South Asian Indians, and the links between migration, increasing exposure to a westernised environment and chronic disease risk are well established   (Misra & Ganda, 2007).

In many countries outside India, including New Zealand, the prevalence of obesity and related diseases is higher in South Asians than in the general population (Gilbert & Khokhar, 2008; Lean et al., 2001; Ministry of Health, 2006). One of the mechanisms through which this increase is thought to occur is through acculturation. Acculturation is the process by which migrants adopt different aspects of their host culture, while dietary acculturation refers to changes in dietary patterns upon migration (Satia, 2010). Changes in patterns of physical activity are one probable consequence of migration from a developing country such as India to a developed country.  Levels of physical activity have been found to be lower amongst South Asian migrants to Western countries than those of European descent in the host country (Caperchione, Kolt, & Mummery, 2009; Daniel & Wilbur, 2011). Environmental factors such as safety; social isolation; and socioeconomic factors have been found to act as barriers to physical activity amongst Indian migrants to Britain (Caperchione et al., 2009). The determinants of participation in physical activity at an individual level appear to be complex and there is a lack of data comparing the physical activity of migrants with that of non-migrants for this group. However, it is clear that at the population level, people in Western, developed countries live a more sedentary lifestyle than those in developing countries such as India (Satia, 2010).

Dietary acculturation is also a complex phenomenon and there are many determinants of the dietary patterns of migrant populations and the level of dietary acculturation that takes place (Gilbert & Khokhar, 2008; Satia, 2010). However, similarly to the process of nutrition transition, a broad trend seems to be an increased consumption of energy-dense, processed foods that are high in sugar, fat and salt and a decrease in consumption of fruit, vegetables, and grains and legumes (Gilbert & Khokhar, 2008; Satia, 2010; Scragg, 2010).

People of South Asian descent also appear to have a higher risk of obesity related disease for a given BMI than people of European descent (Misra & Khurana, 2011). This could be because people belonging to Asian Indian ethnic groups have been found to have higher proportions of both total body fat and abdominal fat for a given body size compared to other ethnic groups (Misra & Khurana, 2011; Rush, Freitas, & Plank, 2009). Findings such as these have led the World Health Organization to recommend that lower BMI cut-offs should be used to determine obesity in Asian populations, including South Asians (WHO Expert Consultation, 2004).

There is very limited evidence evaluating the effectiveness of targeted interventions to address obesity in people of South Asian descent or other ethnic minorities (Netto, Bhopal, Khatoon, Lederle, & Jackson, 2008; Szczepura, 2011). Community-based interventions such as cookery clubs and health education sessions have shown improvements in knowledge of healthy diet and attitudes towards diet but it is unclear whether this translates into a reduction in obesity (Netto et al., 2008). Community-based, targeted initiatives to increase physical activity such as walking programmes have shown some success at improving fitness and changing behaviour but it is unclear whether the success was sustained over any period of time (Netto et al., 2008).

Local initiatives

Initiatives to address obesity in the Auckland Region include ACC ActiveSmart and services provided by the Sports, Recreation and Outdoors Trust (SPROUT).

ACC ActiveSmart is a free, online service provided by ACC that was developed in conjunction with the Ministry of Health, Snow Sports Council, Sport and Recreation New Zealand, the Heart Foundation, the Cancer Society and Fitness New Zealand (ACC ActiveSmart, n.d. -b). ACC ActiveSmart provides a training plan that is personalised to the needs of the individual. Individual needs are determined through completion of a short questionnaire that assesses current fitness and health status as well as well as individual goals. Currently plans are available for walking, running or cycling. A nutrition plan is also provided with the training plan. (ACC ActiveSmart, n.d. -a). The service is targeted at those who want to increase their physical activity levels without having to pay for gym memberships or excessive specialist equipment but who feel they need some advice and support to get started. This service could be useful for preventing obesity as well as helping those who are overweight or obese to lose weight. However the service is not targeted at any particular ethnic group and ethnic-specific guidance is unavailable. The training plans are only available in English.

SPROUT is voluntary, not-for-profit organization that aims to help “Every South Asian in New Zealand to achieve greater well being through balanced nutrition, sports, recreation and outdoor pursuits” (SPROUT, n.d.-a). SPROUT provides a number of services including BollyworX, HealthGuru and one-off events. BollyworX is a group fitness class that is delivered weekly in three locations across Auckland. The class is targeted at South Asians of all ages and consists of movements set to Bollywood and regional Indian music. Each class has several instructors and is provided in several different regional Indian languages. Entry is by gold coin donation. (SPROUT, n.d.-b).

HealthGuru is a lifestyle magazine targeted at the South Asian community. Published quarterly, the magazine provides culturally appropriate information about healthy eating, physical activity and healthy living (SPROUT, n.d.-c). Provision of such information is an important first step in addressing obesity in this group as it can contribute to raising awareness of the risks associated with obesity as well as help people to make changes to their lifestyles (SPROUT, 2010).

Policy relevant to obesity

Addressing obesity was a priority of the previous Labour government who introduced broad, national level policies such as Healthy Eating Healthy Action (HEHA) (Ministry of Health, 2003). However, the current Government has different priorities HEHA is now somewhat out of date. Current New Zealand policy aimed at addressing obesity includes the Clinical Guidelines for Weight Management in New Zealand Adults (Ministry of Health & Clinical Trials Research Unit, 2009) at the national level and the Counties Manukau Strategic Plan (Counties Manukau District Health Board, 2010) at a more local level.

The Clinical Guidelines for Weight Management in New Zealand Adults (the Guidelines) are intended to be used by primary care and community health providers (Ministry of Health, 2006). The Guidelines provide an overview of obesity in New Zealand including prevalence, inequalities, associated health risks and benefits of losing weight; give advice on assessment of obesity; and presenting the evidence on the effectiveness of different weight loss strategies for individuals. The focus is very much on weight loss and maintenance rather than preventing obesity.

The Guidelines (Ministry of Health & Clinical Trials Research Unit, 2009) identify South Asians in New Zealand as a group at high risk of obesity and improving weight management outcomes in this group is a stated priority. The importance of culturally appropriate service provision is emphasised and five good practice points are suggested for improving responsiveness to South Asian people as well as Maori and Pacific peoples. These are based around the idea that service providers should attempt to understand and connect with the deeper values and beliefs of their patients and consider how these values and beliefs affect their patients’ lives. These considerations should then be taken into account when considering weight-loss strategies. The Guidelines also emphasise that further research investigating obesity in South Asian groups is urgently needed.

As a policy intended to address obesity in New Zealand, the Guidelines are somewhat responsive to the needs of South Asians. A short paragraph providing some background information about cultural practices relevant to obesity amongst South Asians in New Zealand that avoided excessive stereotyping could have been a useful addition to the Guidelines. The Guidelines also do not provide any information that is specific to South Asian women. However, as the higher prevalence of obesity amongst South Asians in New Zealand has only recently begun to emerge as a problem, perhaps there is more scope for such information provision in the future once more is known about the issue.

Approximately 25% of Indians in New Zealand live in Manukau (Statistics New Zealand, 2006). The Counties Manukau District Health Board’s ‘Creating a Better Future’ Strategic Plan (the Plan) is intended to support the development and implementation of initiatives aimed at improving four key health problems in Counties Manukau: diabetes; cardiovascular disease; cancer; and chronic respiratory disease. These four health issues are seen as sharing four common risk factors:  tobacco use; poor diet; lack of physical activity; and excessive alcohol use (Counties Manukau District Health Board, 2010). As diet and physical activity are directly related to obesity, the policy is relevant to this issue. The Plan  (Counties Manukau District Health Board, 2010) takes a broad approach and is aimed at “reducing the risk factors for these diseases [identified above], slowing disease progression and improving health while building capacity and capability in the workforce and community and a sustainable whole of society approach" (p. 3). The Plan emphasises that to effectively address diseases such as obesity, initiatives that are aimed at prevention and initiatives aimed at addressing existing disease are both needed. Reducing inequalities is also an important goal of the Plan.

South Asians are identified in the Plan as a group that is disproportionately affected by the burden of disease in the four areas identified above. The differing needs of this group are also acknowledged. Physical activity and nutrition in South Asians in particular are identified as an area where there is significant potential for improvement in Counties Manukau (Counties Manukau District Health Board, 2010). This policy is therefore responsive to the needs of the South Asian community. While again there is no direct reference to South Asian women, the need for gender to be considered as the program develops is identified (Counties Manukau District Health Board, 2010).

Conclusions

The purpose of this essay was to investigate obesity in Indian women in New Zealand. Indian women in New Zealand are at high risk of obesity and as a result are at increased risk of suffering from a number of serious chronic diseases including diabetes, cancer and cardiovascular disease. It appears that people of South Asian descent have a higher risk of disease for a given body weight than people of European descent and obesity seems to affect South Asian women more frequently than South Asian men. There is evidence that obesity is influenced by the changes in lifestyle that can occur on migration to a Western country such as New Zealand through the mechanism of acculturation.

There has been some attempt to address obesity in Indian women in New Zealand with provision of targeted initiatives such as SPROUT although not all services have considered the needs of the South Asian community. Services appear to be targeted at increasing physical activity more than improving diet and there is a need for initiatives that support Indian women to improve their nutritional status. New Zealand policy relevant to obesity is responsive to the needs of the South Asian community in general.

More research is desperately needed to determine the determinants of the high rates of obesity amongst Indian women and the barriers to a healthy lifestyle that exist for this group. Initiatives to address the problem also need to be investigated as there is a lack of evidence about what works for addressing obesity in Indian populations. However, while targeted initiatives have a role to play, the underlying determinants of obesity need to be addressed at a macro level. Improving public transport, making cities more walk-able, restricting fast-food advertising and increasing the affordability of healthy foods are universal initiatives that if undertaken could help reduce obesity in Indian women as well as the population as a whole.

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