Secondary Logo

Journal Logo

Diabetes Prevalence in Populations of South Asian Indian and African Origins: A Comparison of England and The Netherlands

Agyemang, Charlesa; Kunst, Anton E.a; Bhopal, Rajb; Anujuo, Kennetha; Zaninotto, Paolac; Nazroo, Jamesd; Nicolaou, Marya; Unwin, Nigele; van Valkengoed, Irenea; Redekop, William Kenf; Stronks, Kariena

doi: 10.1097/EDE.0b013e31821d1096
Diabetes: Brief Report

Background: We determined whether the overall lower prevalence of type II diabetes in England versus the Netherlands is observed in South-Asian-Indian and African-Caribbean populations. Additionally, we assessed the contribution of health behavior, body size, and socioeconomic position to observed differences between countries.

Methods: Secondary analyses of population-based standardized individual-level data of 3386 participants were conducted.

Results: Indian and African-Caribbean populations had higher prevalence rates of diabetes than whites in both countries. In cross-country comparisons (and similar to whites), Indians residing in England had a lower prevalence of diabetes than those residing in the Netherlands; the prevalence ratio (PR) was 0.35 (95% confidence interval = 0.22 to 0.55) in women and 0.74 (0.50 to 1.10) in men after adjustment for other covariates. Among people of African descent as well, diabetes prevalence was lower in England than in the Netherlands; for women, PR = 0.43 (0.20 to 0.89) and for men, 0.57 (0.21 to 1.49).

Conclusions: The increasing prevalence of diabetes after migration may be modified by the context in which ethnic minority groups live.


From the aDepartment of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; bSection of Public Health Sciences, Edinburgh Ethnicity and Health Research Group, Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh, United Kingdom; cDepartment of Epidemiology and Public Health, University College London, London, United Kingdom; dDepartment of Sociology, School of Social Sciences, University of Manchester, Manchester, United Kingdom; eInstitute of Health and Society, Newcastle University, Medical School, Newcastle, United Kingdom; and fInstitute for Medical Technology Assessment, Erasmus Medical Center, Rotterdam, The Netherlands.

Submitted 12 July 2010; accepted 4 March 2011.

Supported by a VENI fellowship (grant number: 916.76.130) awarded by the Board of the Council for Earth and Life Sciences of the Netherlands Organisation for Scientific Research.

Supplemental digital content is available through direct URL citations in the HTML and PDF versions of this article (

Correspondence: Charles Agyemang, Department of Public Health, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail:

Type II diabetes is more common in ethnic minority groups than in the European white populations.1–3 Unhealthy behavior following migration, obesity and adiposity, and early life exposures such as low birth weight, low socioeconomic position, genetic predisposition, and psychosocial stress have all been suggested as possible underlying factors.4–6

Although the risk of diabetes is comparatively high in most ethnic minority groups, the magnitude of the risk may vary between countries due to differences in national contexts. Ethnic minority groups living in industrialized countries with more diabetogenic environments may be more prone to diabetes than those living in countries with less diabetogenic environments. Recent diabetes prevalence estimates suggest marked differences among countries. For example, the age-standardized prevalence of diabetes in 2007 was 7.3% in the Netherlands compared with 4.0% in the United Kingdom.7 These findings are consistent with data from the Organisation for Economic Co-operation and Development, which show that Dutch people die more often from diabetes-related complications than their British counterparts.8 The reasons for these differences are unclear, but may relate, at least in part, to differences in national context in terms of health behavior and related factors such as obesity and adiposity, and differences in the health-related policy such as screening program. These differences may also affect ethnic minorities living in these countries. In addition, socioeconomic position, accessibility, and utilization of preventive services in the residing countries may also differ, and subsequently affect ethnic minority health outcomes in different ways.9,10

Although recent evidence7 shows clear differences in the overall prevalence of diabetes among European countries, it is unclear as to whether these differences are also seen among ethnic minority groups living in these countries. The aim of this study was therefore to examine ethnic differences in the prevalence of diabetes in 2 European countries, and to determine whether the lower prevalence of diabetes in the United Kingdom as compared with the Netherlands is also observed in the Indian and African-Caribbean populations living in these 2 countries. In addition, we assessed the contribution of physical activity, smoking, body sizes, and socioeconomic position to the observed differences between countries.

We hypothesized that the prevalence of diabetes would be higher in Dutch minorities than their English equivalents, as a reflection of the English and Dutch difference among whites, due to exposure to different national contexts. These differential exposures may affect ethnic minorities' health behavior and related factors in different ways, and subsequently lead to differences in the risk of developing diabetes (Fig. 1).



Back to Top | Article Outline


This study is a part of a project to develop approaches to cross-national comparisons as a basis for future multinational comparisons.9,11,12 The definition of ethnic groups and brief histories of migration have been given elsewhere.11,12

We used data from population-based surveys that collected standardized data on cardiovascular disease and risk factors in populations of Indian and African-Caribbean origin in England and the Netherlands. All studies were population-based health surveys with data on ethnic minority and white populations. Each collaborator agreed to provide anonymized individual participants' data on risk factors, anthropometry, lifestyle, socioeconomic position, and demographics. The UK data were obtained from the Health Survey for England13 and the Newcastle Heart Project.14 The data on the Dutch ethnic groups came from the SUNSET Study.2 Full details of the studies have been published elsewhere.2,13,14 The short descriptions of the studies and measurements are given in eAppendix 1 (

Diabetes prevalence rates were age-standardized using direct standardization for both sexes, with the standards being the age distribution of the total population. Prevalence rate ratios (PRs) of diabetes and their 95% confidence intervals (CIs) were estimated by means of Poisson regression with robust variance15 and adjusted for available individual factors associated with diabetes: physical activity, smoking, body sizes, and socioeconomic position.4–6 In addition, we adjusted all the analyses for year of survey because the time frame over which the studies were performed varied both within and between studies. All analyses were performed using STATA 9.2 (Stata Corp, College Station, TX).

Back to Top | Article Outline


Table 1 shows differences in the study characteristics between Dutch and English groups. Ethnic inequalities in diabetes were relatively similar in both countries. Among the English group, men and women of Indian origin had a higher prevalence of diabetes than their English white counterparts (Fig. 2). The differences did not change after further adjustment for other factors in both men and women (Table 2). English-African-Caribbean men and women also had a higher prevalence of diabetes than their English white counterparts (Fig. 2). After adjustment for other factors, the PRs were 1.97 (95% CI = 0.82 to 4.74) in men and 1.90 (0.78 to 4.65) in women. Among the Dutch group, both Indian-origin and African-origin men and women had higher prevalence rates of diabetes than their Dutch White counterparts.







Among whites, English men and women had lower prevalence rates of diabetes than their Dutch counterparts (Fig. 2). The PRs were 0.45 (0.24 to 0.84) in men and 0.45 (0.18 to 1.15) in women after other factors had been adjusted for (Table 3). Indian men and women residing in England also had lower prevalence rates of diabetes than their Dutch counterparts. After further adjustment for other factors, the PRs were 0.35 (0.22 to 0.55) in English-Indian women and 0.74 (0.50 to 1.10) in English-Indian men. Women of African-Caribbean origin in England also had a lower prevalence rate of diabetes than those in the Netherlands (PR was 0.43 [0.20 to 0.89]); for men, the PR was 0.57 (0.21 to 1.49).



Similar differences were also observed when fasting glucose was analyzed as a continuous variable (data not shown).

Back to Top | Article Outline


A few studies have compared prevalence of diabetes among African or Indian populations living in industrialized countries with people who remained in their countries of origin.16–18 The high prevalence of diabetes among ethnic minority populations living in industrialized countries had been largely attributed to transition to an industrialized lifestyle following migration, which is associated with most known risk factors.16,17 Studies examining ethnic minority populations living in different industrialized countries are, however, limited in number.19 In the present study, substantial variations still exist with Indian and African ethnic minorities in the Netherlands having higher diabetes rates than their English equivalent groups.

The reasons for these marked differences are unclear. Unmeasured factors such as diet and early life experiences, as well as unmeasured aspects of physical activity and socioeconomic position (eg, occupational class and income), may contribute. It is also possible that the relatively high prevalence of diabetes among Dutch ethnic minority groups may be related to the context in which they live. First, possible specific risk factors might be embedded in national policies and related national conditions. Exposure to lifestyle-related risk factors may be influenced by food production and marketing, urban design, health education, and transport; and these may differ between England and the Netherlands. Second, local traditions regarding food, as well as food policy, may also have an influence on ethnic minority diets.20 The rate at which dietary change occurs after immigration may largely depend on the national context; the availability of familiar foods and the migrant's level of contact with compatriots and their country of origin, or with the white populations, may all play a part. Third, diabetes guidelines and adherence to diabetes prevention advice such as smoking cessation varies widely between the 2 countries.10,21,22 The UK diabetes guideline, for example, has been shown to give more attention to ethnic minorities than does the Dutch diabetes guideline.10 Evidence from England also suggests that ethnic minority smokers attempt to quit as often as nonminority smokers.21 The Dutch data, by contrast, suggest that the majority of the Dutch-Indian and Dutch-African smokers were not motivated to quit smoking.22

There are limitations to this study. Data collection instruments in the 2 studies were designed independently. Differences in study methods might have introduced bias in the prevalence estimates. Nevertheless, all the studies used standardized methods and validated instruments, and the prevalence rates were consistent with other data.7 Additionally, we did not have data on all the important explanatory variables that might contribute to the observed differences, such as diet, psychosocial stress, and early-life exposures. Furthermore, we lacked valid data on other types of physical activity and socioeconomic position measures.

Despite these limitations, the analysis provides useful information on Dutch and English-Indian and African-Caribbean populations. The findings suggest that the increasing prevalence of diabetes following migration may be modified by improving the context in which ethnic minority groups live. Further studies could explore the role of national context, also taking into account unmeasured or mismeasured factors. Analysis of international datasets on diabetes and cardiovascular disease in multiethnic populations constitutes a potentially important strategy.9,19 The success of this approach requires cross-standardization of studies across countries.

Back to Top | Article Outline


1.Oldroyd J, Banerjee M, Heald A, Cruickshank K. Diabetes and ethnic minorities. Postgrad Med J. 2005;81:486–490.
2.Bindraban NR, van Valkengoed IG, Mairuhu G, et al. Prevalence of diabetes mellitus and the performance of a risk score among Hindustani Surinamese, African Surinamese and ethnic Dutch: a cross-sectional population-based study. BMC Public Health. 2008;8:271.
3.Jenum AK, Holme I, Graff-Iversen S, Birkeland KI. Ethnicity and sex are strong determinants of diabetes in an urban Western society: implications for prevention. Diabetologia. 2005;48:435–439.
4.Agyemang C, Addo J, Bhopal R, de-Graft Aikins A, Stronks K. Cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe: a literature review. Global Health. 2009;5:7.
5.Cruickshank JK, Mbanya JC, Wilks R, Balkau B, McFarlane-Anderson N, Forrester T. Sick genes, sick individuals or sick populations with chronic disease? The emergence of diabetes and high blood pressure in African-origin populations. Int J Epidemiol. 2001;30:111–117.
6.Sniderman AD, Bhopal R, Prabhakaran D, Sarrafzadegan N, Tchernof A. Why might South Asians be so susceptible to central obesity and its atherogenic consequences? The adipose tissue overflow hypothesis. Int J Epidemiol. 2007;36:220–225.
7.Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87:4–14.
8.Organisation for Economic Co-operation and Development (OECD). Accessed November 25, 2008.
9.Agyemang C, Kunst AE, Stronks K. Ethnic inequalities in health: does it matter where you have migrated to? Ethn Health. 2010;15:216–218.
10.Manna DR, Bruijnzeels MA, Mokkink HG, Berg M. Ethnic specific recommendations in clinical practice guidelines: a first exploratory comparison between guidelines from the USA, Canada, the UK, and the Netherlands. Qual Saf Health Care. 2003;12:353–358.
11.Agyemang C, Kunst AE, Bhopal R, et al. A cross-national comparative study of blood pressure and hypertension between English and Dutch South-Asian and African origin populations: the role of national context. Am J Hypertens. 2010;23:639–648.
12.Agyemang C, Kunst AE, Bhopal R, et al. A cross-national comparative study of smoking prevalence and cessation between English and Dutch South Asian and African origin populations: the role of national context. Nicotine Tob Res. 2010;12:557–566.
13.Erens B, Primatesta P, Prior G, eds. Health Survey for England. The Health of Minority Ethnic Groups 1999. London: TSO; 2001.
14.Bhopal R, Unwin N, White M, et al. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study. BMJ. 1999;319:215–220.
15.Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21.
16.Cooper RS, Rotimi CN, Kaufman JS, et al. Prevalence of NIDDM among populations of the African diaspora. Diabetes Care. 1997;20:343–348.
17.Bhatnagar D, Anand IS, Durrington PN, et al. Coronary risk factors in people from the Indian subcontinent living in west London and their siblings in India. Lancet. 1995;345:405–409.
18.Chow CK, McQuillan B, Raju PK, et al. Greater adverse effects of cholesterol and diabetes on carotid intima-media thickness in South Asian Indians: comparison of risk factor-IMT associations in two population-based surveys. Atherosclerosis. 2008;199:116–122.
19.Nazroo J, Jackson J, Karlsen S, Torres M. The Black diaspora and health inequalities in the US and England: does where you go and how you get there make a difference? Sociol Health Illn. 2007;29:811–830.
20.Gilbert PA, Khokhar S. Changing dietary habits of ethnic groups in Europe and implications for health. Nutr Rev. 2008;66:203–215.
21.Bush J, White M, Kai J, Rankin J, Bhopal R. Understanding influences on smoking in Bangladeshi and Pakistani adults: community based, qualitative study. BMJ. 2003;326:962.
22.Nierkens V, Stronks K, de Vries H. Attitudes, social influences and self-efficacy expectations across different motivational stages among immigrant smokers: replication of the Ø pattern. Prev Med. 2006;43:306–311.

Supplemental Digital Content

Back to Top | Article Outline
© 2011 Lippincott Williams & Wilkins, Inc.