Diabetes mellitus in Chinese people living in the UK

Britain’s Chinese population originates mainly from Hong Kong, China and other regions of the Far East. Many of these people migrated in the 1950s, ’60s and ’70s, but there was also a great influx just before 1997, when Hong Kong was taken back by China.

Many of these people are restaurant owners, waiters or chefs. As a result, families tend to be widely dispersed, rather than grouped in small, clearly defined areas within the community. The usual practice, when Chinese people came to Britain, was for them to move to new areas without existing restaurants, so as to reduce the competition (Oxfordshire County Council Social Services and Oxfordshire Health, 1995).

Language, religion and work patterns
The first generation of Chinese immigrants were educated in China and often have a poor grasp of the English language, both when speaking and reading. Many of their offspring, however, have been educated in the UK and have a good command of English as well as one of the Chinese dialects. Cantonese is the most common dialect in Hong Kong, and thus is the language spoken by the majority of Chinese people in Britain. However, the number of Chinese people speaking Mandarin is increasing.

Many Chinese dialects exist, originating from the different areas of China. Each is pronounced very differently and Chinese people who speak one dialect will not necessarily be able to understand a different one. However, the written language – Chinese – is always the same. Unfortunately, the younger generation of Chinese people tend not to read or write Chinese very well.

The Chinese community does not have a single religion to connect it: Chinese people may worship as Buddhists, Christians, Taoists or ancestral worshippers, or have no faith at all (Oxfordshire County Council Social Services and Oxfordshire Health, 1995).

Chinese people are hard working and work long hours. They tend to rise late and go to bed late, often because they work in the catering business. As a result, they may have little family life. This situation is exacerbated by the fact that different parts of the family may have settled in different areas of Britain, or indeed in different countries. 

All of these factors, along with language difficulties, mean that many individuals in the Chinese community are socially isolated. 

Prevalence of diabetes in Chinese people
There is remarkably little information available on the prevalence of diabetes in Chinese people. Although Pickup and Williams (1997) report that prevalence is low in mainland China, Pan (1996) suggests that the prevalence of diabetes in China is increasing. Twenty years ago it was estimated to be 0.9%; however, today approximately 2.5% of Chinese people have diabetes. It is known that the prevalence of type 2 diabetes is high in other parts of the world, and that it tends to rise as body mass increases (Pickup and Williams, 1997). 

In Britain, in the author’s experience, the majority of Chinese people with the disease have type 2 diabetes. The prevalence is about the same as that of childhood diabetes, which is 4 per 1000 (0.4%). The number of Chinese people with diabetes in Britain is therefore relatively small.

Marks (1996), however, quoted figures of 5% for the proportion of Chinese people in Britain diagnosed with diabetes and 4.1% for those with undiagnosed diabetes (these figures are derived from her personal communication with a diabetologist, and not from published epidemiological studies). Clearly, therefore, more accurate information on the number of Chinese people with diabetes in Britain is needed. 

Health care
In the author’s area (Kent), when Chinese people realise they are not well, they tend to go to China-town to visit a Chinese herb shop, rather than to their GP. This is because they are more at ease conversing in their own language and consequently more able to explain their symptoms. The Chinese herb shop provides advice as well as medicine.

Within the conventional healthcare system, wealthy Chinese people are most likely to use a private medical service. Unfortunately, in the author’s experience, instead of receiving education and advice about changing lifestyles, patients tend to be prescribed diabetic medication immediately, with little or no explanation about how it works or how to take it properly.

When patients finally present to NHS diabetes clinics, their diabetes is often poorly controlled or they are on maximum doses of oral hypoglycaemic agents, and they have little or no information or knowledge of diabetes.

Lack of understanding of the disease and the language difficulties compound the situation, making Chinese people very wary and suspicious of any treatment.

Food
Most Chinese people originating from the Far East do not like the Western diet; Chinese food is different from European food in many respects. A Chinese meal usually consists of many dishes, from which everyone helps themselves. It contains fish, meat, vegetables and rice or noodles and is therefore healthy. 

However, the Chinese like to snack. Sugar water, which is a Chinese snack, contains varieties of pulses or root vegetables stewed with large quantities of sugar. It is delicious, but people with diabetes obviously have to be very careful about the amounts they consume. Tian Sing, a Chinese breakfast that consists of small parcels of a variety of ‘goodies’, also tends to be high in starch and sugar.

If dietitians and other healthcare professionals do not understand the Chinese food culture and cannot fully comprehend the situation, it will be very difficult for them to get the diet right, and even more difficult to get the patients to eat healthily. One way that non-Chinese health professionals could perhaps learn more about the Chinese diet is by visiting a Chinese supermarket and casting their eyes over the produce on offer.

Patient education
It is important to provide Chinese patients with adequate explanations of the treatments for diabetes and their potential side-effects, to ensure that they continue with medication. For example, in the absence of adequate education, some people stop taking insulin once they learn of its connection with hypoglycaemia. 

The dose of insulin should be as low as possible initially and not be increased until the patient is able to show that he/she understands the relationship between insulin, blood glucose levels and hypoglycaemia. The scenario described above (see box) demonstrates a typical problem associated with insufficient patient education.

The lesson from this patient, and from many others, is that the nurse needs to take special care to ask pertinent questions when dealing with people from a different culture, in order to obtain an accurate picture of the situation. 

Many Chinese people, however, are reluctant to take advice from people with a cultural background that is different from their own. In order to gain the confidence of Chinese patients, non-Chinese nurses should first try to understand their patients’ culture. Using interpreters who speak the relevant dialects and providing diabetes education materials in Chinese are obvious strategies that could be tried, but unfortunately there is very little available. Since most older people can read Chinese, it may be worth considering translating existing written material. It would be particularly useful if audio or video tapes, in a familiar dialect such as Cantonese, could be produced.

Conclusion
The Chinese have been described as the ‘invisible community’, partly because they do not live in small geographical areas within our towns and cities, and partly because there is so little information available on their health needs. 

There is no accurate information on the number of Chinese people with diabetes in Britain. However, Chinese people with diabetes are no different from people with diabetes from other races: they develop complications, and so need information, education and screening.

Nurses’ exposure to this group is small and hence there are difficulties in achieving an understanding of their culture and health practices. It is also difficult to acquire relevant educational material. Consequently, it is not easy to help Chinese people manage their diabetes effectively. 

This is an area of diabetes care where gathering information would be of enormous benefit to patients and would also give us a much clearer picture of the needs of this often forgotten community.