Risks Factors For The Development Of Type 2 Diabetes Among Black Africans And Asians Aged 40-60 In The UK

Write the risks factors to diabetes type two development among adults black Africans and Asians aged 40-60 in the UK.

Defining Type 2 Diabetes

Diabetes mellitus has been recognised as a chronic disease that affects the process by which the human body uses glucose present in the blood. This long term metabolic disease is primarily characterised by increased concentration of sugar in the bloodstream, insulin resistance, and a comparative absence of insulin (American Diabetes Association 2014). Some of the most common symptoms of the metabolic disorder include frequent urination, increased thirst, fatigue and unexplained loss of weight. This chapter will contain an in-depth discussion on the pathophysiology of type 2 diabetes, it symptoms, the major research terms, aims and objectives that will provide an insight into the future course of the study.

There are certain biological terms that will be repetitively used for completion of this research. The terms are mentioned below:

BMI (Body Mass Index)- This is generally defined as the weight of a person in kilograms divided by the person’s height in meters square and is expressed in terms of kg/m2. Thus, BMI is a measurement of the body fat of a person, based on the weight and height, when applied to adult males and females (Flegalet al. 2013).

Acculturation- This refers to the process that encompasses psychological, social and cultural modifications that occur due to mixture of different cultures. Hence, acculturation comprises of the cultural modification of a person or group by familiarising to or derivingmannerisms from alternative culture. This merging between cultures is a direct result of protracted contact (Yoon et al. 2013).

Adequate fibre intake- Current intake of dietary fibres have been proposed to range from 25-30 grams of food per day (without any supplements). However, the recommended amount of fibre intake for males and females is an estimated 15 grams/day, which is about two-thirds of25 gram/day (Grooms et al. 2013).

Type 2 diabetes mellitus- Previously referred to as maturity onset diabetes or noninsulin-dependent diabetes mellitus (NIDDM) this condition most commonly affects people aged more than 30 years and is manifested by certain classic symptoms such as, polyuria (frequent urination), polyphagia (increased appetite), polydipsia (increased thirst) and sudden loss of weight (Brethaueret al. 2013).

Metabolic disorder- These disorders occur due to the onset of abnormal chemical reactions in the human body, which bring about an alteration of the metabolic processes. Some common symptoms that are concomitant with metabolic disorders are weight loss, jaundice, lethargy, and seizures.

Hyperglycaemia- Also referred to as high blood sugar, this condition is characterised by the circulation of an excess amount of sugar in the blood plasma. However, on an average chronic levels of sugar beyond 180–216 mg/dl are able to produce perceptible organ impairment over time (Chen et al. 2016).

Common Symptoms and Terms

Insulin resistance- This pathological condition occurs when the cells are not able to respond to the hormone insulin, secreted from the beta cells of the pancreas (Ye 2013). When the body generates insulin hormone, under circumstances of insulin resistance, the cells remain unaffected to the hormone and are incapable to use it as efficiently, resulting in high blood sugar.

Lifestyle factors- Some of the major lifestyle factors that are known to be crucial for the onset and development of type 2 diabetes include physical activity, obesity, urbanisation and stress.

Genetics- Most cases of type 2 diabetes involve a range of genes, each contributing individually to an increased likelihood of the person of becoming diabetic (Prasad and Groop 2015).

Black Africans- Black people is a collective term that is used to classify people based on the social systems of race and ethnicity, for describing individuals having dark skin, when compared to the Caucasians.

Asians- People who have descended from a large portion of the Asian population are called Asians and usually have origin in Southeast Asia, Far East, or the Indian subcontinent such as, China, Cambodia, India, Korea, Malaysia, Japan, the Philippine Islands, Thailand, Pakistan, and Vietnam.

Globally there were an estimated 392 million people in the year 2015, who had been diagnosedwith type 2 diabetes. This accounted for an estimated 90% of all diabetes cases.This in turn is comparable to approximately 6% of the entire world's population. Diabetes mellitus is now common both the developing and the developed regions of the world. However, it is relatively uncommon in the least developed nations (Voset al. 2016). Females appear to be at a larger risk as do specific ethnic assemblies, such as, the Pacific Islanders, Latinos, South Asians, and Native Americans. This higher susceptibility of the ethnic individuals can be accredited totheir heightened sensitivity to mannerisms of western lifestyle.

In the words of Adams and Butterly (2015) although, T2D was usually considered as a disease of the adults, it is progressivelybeen diagnosed amid children as well, along with their growing obesity rates. For an extended time, Africa was measured safe from numerous diseases that are named “diseases of affluence” that were widely prevalent in the Western world. Likewise, there was a period when Africa was supposed to be a landmass, comparatively free of diabetes mellitus diseases. South Africa is considered as one of the 32 countries that has been classified under the IDF African region. An estimated 425 million people are found to suffer from diabetes on a global scale (International Diabetes Federation 2018). Of them approximately 16 million persons reside in the AFR Region. Statistical reports expect this proportion to reach 41 million by the year 2045. Furthermore, there were an assessed 1,826,100 diabetes cases in South Africa in 2017.Diabetes mellitus is quite prevalent in Africa among the powerful and the wealthy, henceforth its title as the “disease of opulence,” is assumed to be correct. Further reports have provided evidence for the high prevalence of diabetes in the urban regions where people incline towards less physical activity, and generally consume a diet that contains high content of refined sugar and saturated fats (Anjanaet al. 2015).

Prevalence of Type 2 Diabetes

According to Hilaweet al. (2013) for Africans and their progenies, scientists have also noted that diabetics belonging to the Sub-Saharan African origin, who are found to exist in varied geographical environments could possibly add to the understanding of environmental and genetic mediators of the metabolic disease. In addition, studies have also shown that Asians are at greater risks of developing T2D, when associated with persons of European ancestry.Asians are more prospective of developing the metabolic disease, even under circumstances when they report lower BMI. This suggests that even though certain Asian population presently have a lesser occurrence of obese and overweight individuals, in comparison to the West, they have a unreasonably high proportion of individuals with diabetes (Chan et al. 2009). At present, around 60% of the world’s diabetic populace is Asian. Of them more than 113.9 million people with the condition reside in China, and make up an estimated 11.6% of the entire adult population.

Furthermore, Malik, Willett and Hu (2013) provided evidence for the presence of 65.1 million diabetics in India, with certain cities in South India comprising of approximately 20% of the nation’s diabetic population. National prevalence of the condition in Afghanistan, Korea, China, and Malaysia is 6.3, 7.3, 9.6, and 10.1%, respectively (Asian Diabetes Prevention Initiative 2018).

Owing to the high prevalence of T2D in the world, it is essential to get a sound understanding of the different factors that might make individuals more susceptible to the development of the metabolic condition. This problem has often been attributed to reduced physical activity, and alterations from conventional diet. There have been a plethora of studies that have explored the association between lifestyle choices and the presence of type 2 diabetes mellitus (Reis et al. 2011).

There is mounting evidence for the fact that regular consumption of refined carbohydrates that contains low amount of dietary fibre increases the risks for being overweight and obese and T2D (Ley et al. 2014). Whereas, Tremblay et al. (2010) also reported that a sedentary lifestyle was associated with increased risk for the condition. Hence, this research will aim to explore these factors, in relation to diabetes among the Africans and the Asians.

What are the risk factors that make the Black Africans and Asians, aged 40-60 years. Living in the UK, more likely to get affected with type 2 diabetes?

Broad question

To determine the association between several environmental and genetic factors and the increased likelihood of T2D among the Black Africans and Asians in the UK, belonging to the age group 40-60 years.

Risk Factors for Type 2 Diabetes

Narrow questions

Objective 1- To analyse the social determinants that predispose the Asians and Black Africans to T2D

Objective 2- To identify correlation betweendiet, smoking and alcoholism with increase likelihood of suffering from T2D

Objective 3- To determine the association between physical activity and T2D development amid Asians and Black Africans

T2D is a chronic metabolic disease that is linked with a shorter life expectancy (Selvinet al. 2010). This can be attributed to several complications that occur in relation to the metabolic disease. Furthermore, the condition also increases the risk of suffering from cardiovascular diseases, including stroke and ischemic heart disease, risks of amputation in the lower limb, and elevated rates of hospitalisation of the patients (Centers for Disease Control and Prevention 2011).

Furthermore, T2D has been identified as one of the greatest contributors to kidney failure and nontraumatic blindness (Hsu et al. 2014). The disease also leads to the manifestation of increased risks for dysfunction in cognitive abilities and dementia, with a progress in time. Kong et al. (2010) opined that other complications that can arise if T2D remains untreated are sexual dysfunction, acanthosisnigricans, and frequent infections. This calls for the need of identifying the risk factors that will facilitate early detection and management of the condition.

The research will assist in unravelling the contributing factors and will therefore pave the way for novel management and prevention techniques. When the findings are utilised in evidence based practice, the overall health and quality of life of patients will get enhanced.

The chapter stated that T2D is a chronic metabolic condition and also elaborated on the widespread prevalence of the condition among Asians and Africans, besides discussing the research aims and objectives.

This chapter will contain exhaustive information on the different causal factors that increase the susceptibility of the Black Africans and Asians to acquire type 2 diabetes mellitus. This chapter will also contain a theoretical and conceptual framework for further illustrating the association between the variables identified from the scholarly articles.

According to Peer et al. (2014) the Africans, who rarely reported presence of diabetes symptoms have begun manifesting an upsurge in the condition and the prevalence of T2D among Africans aged 20–79 years is 4.9%. The major of diabetes are found to occur among individuals aged more than 60 years, with the highest proportion amid the middle aged (40-59 years). Diabetes figures in the AFR are expected to rise with the number of persons with the condition growing from 19.8 million 41.5 million (from 2013 to 2035), representative of 110% complete increase. This sudden increase in diabetes in Sub-Saharan Africans was attributed to an increase in age, with most information representing a peak at 65 years or older or between 55–64 years. Age has been established as a major risk factor for type 2 diabetes. This connotation suggests that, in Africa, the result of ageing of the populace on diabetes pervasiveness is now evident (Mbanyaet al. 2010).

Objectives of the Research

This was in accordance to the findings presented by Levitt (2008) who established a close correlation between the metabolic condition with increasing age and rapid urbanisation. Thus, older adults are found to be more likely to get affected with T2D, at or after the age of 65 years or with long term diabetes at middle age. In the words of Hu (2011) multifaceted interaction between the environment and the genes was found to act in the form of risk factors that drive the onset of T2D. The researchers elaborated on the fact that Asia accounts for more than 60% of the global diabetic population. In current decades, Asia has experienced rapid financial development, expansion, and changeovers in nutritional status as well. These have controlled an explosive upsurge in diabetes occurrence within a moderately short time. Furthermore, the article also drew a comparison of Asians with the western population and found the prevalence of obesity and overweight in Asia to be comparatively low. Nonetheless, it was identified to increase hurriedly, in parallel with commercial development and hasty urbanization.

This was further supported by statements from Noble et al. (2011) who established a close correlation of T2D with gender, ethnicity, age, and family history. A cross-sectional survey was also conducted in the rural South African Black community, the results of which identified the independent risk factors as alcohol ingestion (OR2.8), family history (OR3.5), waist circumference (OR1.1), serum triglycerides (OR2.3), systolic blood pressure (OR1.0), and total cholesterol levels (OR1.8). These findings were able to draw the conclusion that there occurs moderate prevalence of T2D in increased prevalence of total glycaemia disorders among the Black Africans and these people can be categorised into the domain of glucose intolerance (Motalaet al. 2008).

Within this, dietary habit and preferences has become one of the major risk factors for the upsurge in obesity and eventually in T2D. There are several studies have been conducted to determine the direct connection between increase in higher amount of sugary drink consumption, weight gain, cardiovascular diseases and type 2 diabetes mellitus.

As per Hu and Malik (2010) there are evidences that high caloric drinks have etiological role in determining the obesity associated epidemic and in the course of consumption, in incorporates incomplete compensation for energy in every meal it is consumed. Further due to increase in the dietary glycaemic load several changes such as inflammation, insulin resistance and impaired beta cell functions occurs and hence, dietary habits are one of the major risk factor for T2D. These risk factors are affecting Asian community more than any other communities due to the fact that Asian cuisine specifically south Asian cuisine is filled with sugary syrups and high carbohydrate food products and due to that their prevalence rate is higher than any other communities. as per the research conducted by Boggs et al. (2010) there are several epidemiological studies have been conducted that indicated to the fact that Asiatic communities are prone to diabetes type 2 risk factors and all the pathophysiology is visible among those communities. In this systematic review, the researchers collected researches from the MEDLINE database and includes studies like cohort study, large surveys, meta-analysis study, systematic review and others to determine the epidemiological evidence from those research articles about the number of diabetes affected people in Asia and it was found that in the year 2007, more than 110 million people were suffering from T2D and the rate of this disease was higher in younger and middle age generations due to their food, diet, sedentary lifestyle and economic conditions. On the other hand, African communities are also suffering from dietary imbalance, obesity and associated type 2 diabetes.

Complications of Type 2 Diabetes

Palmer et al. (2008) conducted a research to understand the relation between sweetened drink, overweight and type 2 diabetes and it to conduct the study more than 59,000 African women were involved in the study who were a part of the research from 1995 and from 1995 to 2001, they took part in questionnaire and survey questions. Within these only 43,000 women provided their diet and weight related data that helped to interpret that more than 2713 cases of diabetes type 2 was identified every year. further from their food intake it was determined that rate of type 2 diabetes mellitus was higher in people who consumed food products such as sugary and sweetened soft drinks, cold drinks, fruit drinks and others that independently affected the body mass index of the consumer.

Besides diet, active lifestyle, consumption of alcohol, smoking habits and sedentary lifestyle plays an important role in determining the degree of diabetes type 2 diabetes in Asian and African communities. Both of these communities are connected to its roots and hence their dietary preference and food choices are reflected from their dietary preferences. However, to compare the prevalence of T2D between African and Asian communities, researchers Tonstadet al. (2009) conducted a research to assess the prevalence of T2D in people with vegetarian diet and non-vegetarian diet. Further to conduct the study the researchers collected 22434 men 38469 women and they were provided with a food frequency questionnaire and their habits such as sleeping, TV watching, physical activities, their education, income and others were also assessed besides their food habits and it was found that people with sedentary lifestyle, less physical activities and non-vegetarian diet were more affected to type 2 diabetes or had more chances to develop this syndrome within their body. Further to more elaborate on the risk factor related to physical activity in both Asian and African communities, research study of Child Heart And Health Study England (CHASE) has been included in this discussion. It has been seen that childhood obesity has been increasing with greater extent in both of these communities and hence, researchers indicated to draw a parallel between their decreased physical inactivity and increasing obesity with risks related type 2 diabetes. In this process, the researchers looked for different ethnic groups within communities such as south Asian and black African and then compared their physical activity levels with emergence of obesity and type 2 diabetes.

In this research by Owenet al. (2010) a cross sectional study was carried out with 2049 children in different schools of the United Kingdom with Asian and African ethnicity. All these factors were measured for 7 days and after the research it was found that physical activities were strongly associated with negative diabetes type 2 results and in all ethnic groups with increased physical activity, it was seen that the rate of diabetes related risk factor is decreasing. Therefore, from this research, the researchers were able to draw a parallel between the physical activities and increased childhood obesity and increased risk of diabetes type 2. Sedentary lifestyle, activities of daily life is an important factor that affects the lifestyle of people and ultimately make them susceptible to obesity and increase their risks related to type 2 diabetes. In a research article by Krishnan, Rosenberg and Palmer (2008) researchers were keen to find out the results of sedentary lifestyle on the health and wellbeing of African community and in the process included 45,668 black women in the research, who used to spend maximum hours of their daily life in watching television and binge eating. Cox proportional hazards model were used in the process and it was found that within those 45,668 women, more than 3000 women were affected with type 2 diabetes and hence, it was determined that binge eating with sedentary and less active lifestyle is associated with obesity which ultimately increases the risk factor related to type 2 diabetes and hence, it is one of the primary risk factor related to emergence of type 2 diabetes mellitus in communities such as African and Asian.

Ntandouet al. (2009) also provided evidence for the fact that quality of diet and the presence of adequate physical activity are usually greater in the rural and semi-urban population, when compared to urban people living in Benin, Africa. Their findings was further supported by the fact that physical activity was quite protective for high blood pressure, obesity, and low levels of HDL-C. It was also suggested that micronutrient adequacy acts as an independent analyst of HDL-C and is subsequently associated with low risks of T2D and hypertension. The association between poverty (as a socioeconomic element) and development of T2D was also established by a cohort study that employed data from the Taiwan NHI database. Upon assessing the Asian people and their economic status, the researchers concluded that poverty was significantly associated with increased incidence of diabetes and inequality in care required for the metabolic syndrome in northeast Asian population, notwithstanding the presence of uniform health coverage for all people (Hsu et al. 2012).

Upon assessing the association between the metabolic syndrome and physical activity energy expenditure (PAEE) in Sub-Saharan Africans, Assahet al. (2011) stated that when compared with rural residences, urban houses were more associated with decreased PAEE, and elevated prevalence of T2D. This helped in confirming PAEE as a strong and independent factor that governs the onset of diabetes in adult Cameroonians. In the words of Peer et al. (2012) increased age, family history of the metabolic syndrome, increased BMI, better housing quality, and lower scores of sense of coherence (SOC) were associated increase in the likelihood of the prevalence of diabetes mellitus in the South Africans. The role of increase in urbanisation was also established with upsurge in the prevalence of diabetes in Korea, Singapore, Indonesia, Malaysia and the Philippines. Owing to the fact that urbanisation decreases physical activity among Asians, subsequently resulting in an increase in their body mass index and adiposity in upper body, the rapid socioeconomic progress in Asian countries were allied with the metabolic syndrome (Ramachandran, Ma and Snehalatha 2010).

The theoretical framework which will be applied in this scenario is the socio-economic status and its theory related to stratification (Heraclideset al. 2009). The core idea of this theory was associated to unity within the society so that the weaker and under-developed section of the society can also grow themselves to achieve all the fundamental rights (Auchinclosset al. 2009). This theory discusses about poverty, educational background, food and diet preferences which increases the risk related to type 2 diabetes in communities of African and Asian background due to the diversity present in their culture and cuisine. As per Hankonenet al. (2009), food and diet are one of the primary determinants that determine the increased risk of diabetes in people of these communities. Both of these communities are deeply rooted to their culture and hence, cuisines having sweet and carbohydrate rich sources are consumed in higher amount that increases the risk of obesity and eventually type 2 diabetes.

On the other hand, their less physical activity, sedentary lifestyle and other lifestyle disorders increases the chances of diabetes among the population (Wayne et al. 2015). The second determinant or educational attainment also determine the presence of diabetic risk factor among the population. it is noted from the data collected from WHO that Asian and African communities are among the populations where the rate of educational dropouts are in higher number and hence, such communities are not aware of the food or diet preferences which is important to save the, from the risk factor of diabetes (Shrewsbury and Wardle 2008). Therefore, due to the less attainment of education, a complete community suffer from the emergence of diabetes. Poverty is similarly linked to the risk factors of diabetes as increased poverty is associated to less availability of healthy food and therefore such people suffer from diabetes type 2 related risk factors (Walker et al. 2014).

                

Although there have been several studies that determined the association between type 2 diabetes and the primary risk factors, with respect to the Asian and African population, none of them addressed both the population together. This research will be a novel study where both the population will be taken into account, while drawing relevant answers to the individual research objectives. Furthermore, with an alarming increase in the numbers of Asians and Africans who are affected with T2D, the underserved and vulnerable populations in both the groups are most affected, with greater occurrence of the metabolic disease and its linked complications. Too often, the information found in relation to the risk factors of the condition are these individuals do not obtain the assistance they require to efficiently manage their diabetes. Furthermore, knowledge about the risk factors are often not utilised appropriately in real time settings such as, increasing access to healthy foods and creating safe provisions for physical activity. Hence, the research intends to conduct an extensive systematic review where the risk factors that make Black Africans and Asians more susceptible to T2D development, will be explored.

This chapter identified some of the chief risk factors that make Asian and African population more likely to suffer from type 2 diabetes.

Methodology is an important chapter of dissertation. It helps the researcher to choose the standard steps which will be used for conducting the research in order to achieve the aims and objectives of the research. Saunders and Rojon (2014) stated that the methodology of the research mainly helps in indentifying the philosophy underpinning specific research approach. Gough et al. (2017) further argued that the methodology of the systematic review depends on the research question and the type of research design. As stated in the chapter 1, Introduction, the aim of this research is to determine the risk factors, which make Black Asians and African more vulnerable in developing type 2 diabetes mellitus. Thus in order to work on the aim of the research, the researcher will try to abide by the objective rather than highlighting subjective realities. The chapter of methodology will mainly highlight the steps which the authors will be using while conducting qualitative thematic analysis. The approaches and the steps, which will be selected will be critically evaluated through critical justifications behind the selection along with detailed descriptions of the strength and limitations of other research approaches.

The main mode of study which is selected by the researcher for conducting this systematic review is qualitative research. According to Ross (2012), qualitative research helps in understanding complex phenomenon with the help of thematic analysis. It begins with observation followed by collection of data and thus helps in highlighting the pattern of data through generation of themes. This approach further helps in generation of new theories about the existing phenomenon (Ross 2012).

The research philosophy for this qualitative research is interpretivism. Bergh and Ketchen (2011) argued that intrepretivism research philosophy provides in-depth analysis of the small data by the use of meaningful theme. Bergh and Ketchen (2011) further argued that intrepretivism research philosophy is mainly suitable while handling secondary data. Since it is systematic review, intrepretivisim is the suitable research philosophy. Interpretivism is selected over positivism because positivism research philosophy mainly uses existing theory of develop the hypothesis and this is beyond the scope of research as new hypothesis is required to be generation.

Inductive research approach was selected for this qualitative research. Crowther and Lancaster (2012) stated that inductive research approach is associated with the qualitative research. It is concerned with the generation of the new theory emerging from the data. This is opposed to deductive research approach which is aimed towards testing theory. The generation of new theory through inductive research approach helps to compare data and thereby helping to conduct a thematic analysis. This will help to generate new theories centring the risk factors behind type 2 diabetes occurrence among Black Asians and Africans.

The research design selected was descriptive style research design. Ellis and Levy (2012) stated that descriptive type research design helps authors to illustrate the relationships between the cause and effect. This design is suitable for analysis the causes of developing type 2 diabetes among the Black Africans and Asians and its subsequent effect in comparison to explanatory and exploratory research design.

The main data which was used in this research is secondary data since it is systematic review in qualitative format. The data collection was done through the search of the literary articles in online electronic databases. According to Parahoo (2014), electronic databases, articles are articles are presented in an organised manner and this helps to researcher to spot the relevant data that coincides with the scope of the search. Parahoo (2014) further highlighted that online database helps to access huge secondary information about the topic from literary articles which are already published online. The online databases which are used for the data collection include Ovide, Cinhal, MedLine and Cochrane. Parahoo (2014) argued that before initiating the systematic review of literature, it is important t conduct a thorough search of the articles which are already published online. This helps the researcher reduce the chances of getting published duplicated work or in other words, it helps the researcher to work with a novel research aims and objectives. With this concept in mid, Parahoo (2014) conducted a literature search in the Cochrane database of Systematic Review with Keywords which are highlighted below. The search provided negative results and thus helped in the identification of the research gap in the literature. This helped in the reinforcement of the requirement of an extended systematic review over the research topic (Holloway and Wheeler 2010).

Name of database	Number of articles	Name of the selected articles
OVID	3	Assah, F.K., Ekelund, U., Brage, S., Mbanya, J.C. and Wareham, N.J., 2011. Urbanization, physical activity, and metabolic health in sub-Saharan Africa. Diabetes Care, 34(2), pp.491-496
		Boggs, D.A., Rosenberg, L., Ruiz-Narvaez, E.A. and Palmer, J.R., 2010. Coffee, tea, and alcohol intake in relation to risk of type 2 diabetes in African American women–. The American journal of clinical nutrition, 92(4), pp.960-966
		Hsu, C.C., Lee, C.H., Wahlqvist, M.L., Huang, H.L., Chang, H.Y., Chen, L., Shih, S.F., Shin, S.J., Tsai, W.C., Chen, T. and Huang, C.T., 2012. Poverty increases type 2 diabetes incidence and inequality of care despite universal health coverage. Diabetes care, p.DC_112052.
MEDLINE	9	Hu, F.B. and Malik, V.S., 2010. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. Physiology &behavior, 100(1), pp.47-54.
		Hu, F.B., 2011. Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes care, 34(6), pp.1249-1257.
		Levitt NS., 2008. Diabetes in Africa: epidemiology, management and healthcare challenges. Heart, 94(11), pp.1376–82.
		Mbanya, J.C.N., Motala, A.A., Sobngwi, E., Assah, F.K. and Enoru, S.T., 2010. Diabetes in sub-saharanafrica. The lancet, 375(9733), pp.2254-2266.
		Motala, A.A., Esterhuizen, T., Gouws, E., Pirie, F.J. and Omar, M.A., 2008. Diabetes mellitus and other disorders of glycaemia in a rural South African community: prevalence and associated risk factors. Diabetes care.
		Ntandou, G., Delisle, H., Agueh, V. and Fayomi, B., 2009. Abdominal obesity explains the positive rural-urban gradient in the prevalence of the metabolic syndrome in Benin, West Africa. Nutrition research, 29(3), pp.180-189.
		Owen, C.G., Nightingale, C.M., Rudnicka, A.R., Sattar, N., Cook, D.G., Ekelund, U. and Whincup, P.H., 2010. Physical activity, obesity and cardiometabolic risk factors in 9-to 10-year-old UK children of white European, South Asian and black African-Caribbean origin: the Child Heart And health Study in England (CHASE). Diabetologia, 53(8), pp.1620-1630.
		Palmer, J.R., Boggs, D.A., Krishnan, S., Hu, F.B., Singer, M. and Rosenberg, L., 2008. Sugar-sweetened beverages and incidence of type 2 diabetes mellitus in African American women. Archives of internal medicine, 168(14), pp.1487-1492.
		Peer, N., Kengne, A.P., Motala, A.A. and Mbanya, J.C., 2014. Diabetes in the Africa Region: an update. Diabetes research and clinical practice, 103(2), pp.197-205.
CINAHL	3	Peer, N., Steyn, K., Lombard, C., Lambert, E.V., Vythilingum, B. and Levitt, N.S., 2012. Rising diabetes prevalence among urban-dwelling black South Africans. PloS one, 7(9), p.e43336.
		Ramachandran, A., Ma, R.C.W. and Snehalatha, C., 2010. Diabetes in asia. The Lancet, 375(9712), pp.408-418.
		Tang, T.S., Brown, M.B., Funnell, M.M. and Anderson, R.M., 2008. Social support, quality of life, and self-care behaviors among African Americans with type 2 diabetes. The Diabetes Educator, 34(2), pp.266-276.

The search terms which were used for the search of the literary articles are highlighted in the table below:

Table: 1
Keyword 1	Key word 2	Keyword 3
Black Asians	Type 2 Diabetes	Risk Factors
OR/AND	OR	OR
Black Africans	Type 2 Diabetes Mellitus	Life style Factors
Keyword 1	Key word 2	Keyword 3
Black Asians	Type 2 Diabetes	Physical activity
OR/AND	OR	OR
Black Africans	Type 2 Diabetes Mellitus	Exercise

Boolean search operators (AND/OR) are used in order to conduct permutation and combination in the keywords. According to Robb and Shellenbarger (2014), Boolean operators help to draw relationships with the keywords used. Polit and Beck (2014) further highlighted that the use of Boolean search operator helps the researcher to refine the search of the articles through the electronic database. The use of Boolean search operator helped the author to save valuable time by reducing the number of overall hits. The total number of search results obtained by the use of the Boolean search operators helped the author to cross-check the relevancy of the extracted search results through scanning the tiles and abstracts of the articles.

According to Aveyard (2014), having a stringent plan for conducting search of the literary articles helps to design a search protocol that has specific focus on the aim of the research. It also ensures that no additional time is wasted to check information that falls out of the scope of the study. Coughlan et al. (2013) also stated that the formulation of the inclusion and exclusion criteria while conducting search of the articles through the electronic database helps to save significant amount of time. Polit and Beck (2014) opined that framing of inclusion and exclusion criteria of the research must be done strategically. Proper selection of the inclusion and the exclusion criteria helps to mark the defined boundaries of the research. This type of selection approach also helps in reducing the number of irrelevant hits. In relation to this, Parahoo (2014) highlighted that inclusion and exclusion criteria must be clearly justified. For example, too specific exclusion criteria might exclude many relevant research articles which might be helpful for the research. On the other hand, selecting inclusion criteria which is too board might increase the overall time of scrutinising the selected search results.

The main inclusion and exclusion criteria which are used for the research are highlighted in the table below

Inclusion and Exclusion Criteria
Inclusion	Exclusion
Primary and secondary research	Editorials
Language: English	Other than English
Country: NA
Year of publication: 2008 to 2018 (last 10 years)	Year of publication: Before 2008
Population: Black Africans and Black Asians	Population: Study conducted other than Black Africans and Black Asians
Disease type: Type 2 Diabetes Mellitus	Disease type: Type 1 Diabetes Mellitus

Both primary and secondary research was included in this systematic review. This is because, inclusion of the only primary research might limit the total number of the articles which will coincide with the scope of the research. In the secondary article selection, systematic review over the randomised control trial was give first preference. According to Barton et al. (2015) systematic review of the randomised control trial is at level 1 of evidence. The year span for the selection of the research was selected for the past 10 years. Initially past 5 years was selected as the filter of the time span but it extracted very few articles which coincided with the scope of the research and research objectives. So in order to increase the overall sample size of the research, the time filter was extended for the last 10 years. Last 20 years was not selected as the time frame for the research paper selection because, Moher et al. (2015) stated that literary articles which are published long back (past 20 years) can be considered to be outdated as the field of science is ever evolving and only latest research must be preferred. Only type 2 diabetes is selected as the inclusion criteria and type 2 diabetes is excluded from the research because, type 1 diabetes as different pathology in comparison to the type 2 diabetes and type 2 diabetes analysis was the main research aim of the article (Ozougwu et al. 2013). Similar concept was utilised for the selection of the population group. English was selected as the main language of the research because, it is the international yet official language of the United Kingdom.

Data analysis was done through thematic analysis of the data. According to Vaismoradi, Turunen and Bondas (2013), thematic data analysis is one of the most common form of the data analysis in the qualitative research. It helps in examining, pinpointing and reporting patterns which are alternatively termed as themes. Vaismoradi, Turunen and Bondas (2013) further stated that theme are patterns across the set of data which are crucial in order to describe a phenomenon and are associated with specific research questions. The approach of the thematic analysis was down through 6 subsequent steps. The first step involves familiarisation with the data. This phase mainly deals with reading and re-reading of the data in order to get immersed and get familiar with its content. The second stage is known as coding. It deals with generating of succinct label or code to represent the data. The third stage is searching for relevant themes through codes. Then is review of the themes was done followed by defining and naming of the final selected themes and then noting down the final theme for the data analysis.

Sr/No.	Name of the author	Research Name	Journal Name	Year of Publication
1	Assah, F.K., Ekelund, U., Brage, S., Mbanya, J.C. and Wareham, N.J.,	Urbanization, physical activity, and metabolic health in sub-Saharan Africa	Diabetes Care	2011
2	Boggs, D.A., Rosenberg, L., Ruiz-Narvaez, E.A. and Palmer, J.R.,	Coffee, tea, and alcohol intake in relation to risk of type 2 diabetes in African American women	The American journal of clinical nutrition	2010
3	Hsu, C.C., Lee, C.H., Wahlqvist, M.L., Huang, H.L., Chang, H.Y., Chen, L., Shih, S.F., Shin, S.J., Tsai, W.C., Chen, T. and Huang, C.T.,	Poverty increases type 2 diabetes incidence and inequality of care despite universal health coverage	Diabetes care	2012
4	Hu, F.B. and Malik, V.S.,	Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence	Physiology &behavior	2010
5	Hu, F.B.,	Globalization of diabetes: the role of diet, lifestyle, and genes	Diabetes care	2011
6	Levitt NS.	Diabetes in Africa: epidemiology, management and healthcare challenges	Heart	2008
7	Mbanya, J.C.N., Motala, A.A., Sobngwi, E., Assah, F.K. and Enoru, S.T.,	Diabetes in sub-saharanafrica	The lancet	2010
8	Motala, A.A., Esterhuizen, T., Gouws, E., Pirie, F.J. and Omar, M.A.,	Diabetes mellitus and other disorders of glycaemia in a rural South African community: prevalence and associated risk factors	Diabetes care	2008
9	Ntandou, G., Delisle, H., Agueh, V. and Fayomi, B.,	Abdominal obesity explains the positive rural-urban gradient in the prevalence of the metabolic syndrome in Benin, West Africa	Nutrition research	2009
10	Palmer, J.R., Boggs, D.A., Krishnan, S., Hu, F.B., Singer, M. and Rosenberg, L.,	Sugar-sweetened beverages and incidence of type 2 diabetes mellitus in African American women	Archives of internal medicine	2008
11	Owen, C.G., Nightingale, C.M., Rudnicka, A.R., Sattar, N., Cook, D.G., Ekelund, U. and Whincup, P.H.,	Physical activity, obesity and cardiometabolic risk factors in 9-to 10-year-old UK children of white European, South Asian and black African-Caribbean origin: the Child Heart And health Study in England (CHASE).	Diabetologia	2010
12	Peer, N., Kengne, A.P., Motala, A.A. and Mbanya, J.C.,	Diabetes in the Africa Region: an update	Diabetes research and clinical practice	2012
13	Peer, N., Steyn, K., Lombard, C., Lambert, E.V., Vythilingum, B. and Levitt, N.S.,	Rising diabetes prevalence among urban-dwelling black South Africans	PloS one	2012
14	Ramachandran, A., Ma, R.C.W. and Snehalatha, C.,	. Diabetes in asia	The Lancet	2010
15	Tang, T.S., Brown, M.B., Funnell, M.M. and Anderson, R.M.,	Social support, quality of life, and self-care behaviors among African Americans with type 2 diabetes	The Diabetes Educator	2008

The main research ethics which is considered while conducting this systematic review include the studies which are selected followed the ethical guidelines. The researcher also took into consideration that the subjects over which the research was conducted did not included children or infants. The accurate reporting of the selected articles were also taken into ethical consideration (Parahoo 2014).

The main limitation of the research is its sample size. After the final scrutiny, the main articles which were selected for the research is 15. According to Billingham, Whitehead and Julious (2013) 15 can be regarded as a sample size for the conduction of the systematic review. Billingham, Whitehead and Julious (2013) stated that sample size prevents the generalization of the data.

In the summary it can be stated that the systematic research with thematic analysis was conducted by 15 research articles selected through the online search of the articles in electronic databases. The search of the articles was done with the use of keywords under specific inclusion and exclusion criteria. The research design s descriptive, inductive research approach and interpretivisim research philosophy.

The purpose of this research was to identify the risk factors that make Asians and Black Africans aged 40-60 years, and residing in the Unite more susceptible to the development of type 2 diabetes mellitus, a metabolic syndrome. The major objectives of the research were to identify the different risk factors that were associated with an increased prevalence of T2D among the two ethnic population, by utilising evidences from available scholarly literature. This chapter will summarise the results obtained from the scientific literature and will further link them with the research objectives.

Study	Type of study	Population	Main results
Assahet al. (2011)	Cohort study	Sub-Saharan Africa	Urban dweller reported less PAEE than rural dwellers (44.2 ± 21.0 vs. 59.6 ± 23.7 kJ/kg/day, P < 0.001) and increased prevalence of diabetes (17.7 vs. 3.5%, P< 0.001).
Boggs et al. (2010)	Cohort study	African American women	Multivariable RRs for intakes of 1–3, 4–6, 7–13, and greater than 14 alcoholic drink per week compared to no consumption were 0.90 (95% CI, 0.82, 1.00); 0.68 (95% CI, 0.57, 0.81); 0.78 (95% CI, 0.63, 0.96); and 0.72 (95% CI, 0.53, 0.98), respectively. T2D was not related to intake of tea and decaffeinated coffee.
Hsu et al. 2012	Cohort study	Taiwan	T2D incidence in poor people was 20.4/1,000 person years (HR, 1.5; 95% CI, 1.3–1.7) and poor people showed a reduced likelihood of visiting any clinic for diabetes care (OR, 0.4; P < 0.001).
Hu and Malik (2010)	Epidemiological evidence	Asia and Africa	Intake of sweetened sugar beverages were related to gain of weight among Africans and Asians that directly increased their susceptibility of suffering from T2D, insulin resistance, and impaired function of the beta cells.
Hu (2011)	Review	Global	Increased physical activity and low consumption of refined carbohydrates, reduces risk of T2D. Cigarette smoking and moderate to heavy consumption of alcohol were also found to act as independent risk factors for the metabolic syndrome.
Levitt (2008)	Review	Africa	Westernisation of lifestyle, diet and urbanisation were related to the onset of T2D.
Mbanyaet al. (2010)	Systematic Review	Sub-Saharan Africa	Some of the risk factors for T2D onset were high age, sex (females), urbanisation, family history, western diet and less physical activity.
Motalaet al. (2008)	Survey	South African community	Some of the common risk factors were family history (OR3.5), waist circumference (OR1.1), alcohol consumption (OR2.8), serum triglycerides (OR2.3), systolic blood pressure (OR1.0), and high cholesterol (OR1.8);
Ntandouet al. (2009)	Cross-sectional study	Benin (Africa)	Presence of positive rural-urban gradient witnessed for inclusive prevalence of the metabolic disease (4.1%, 6.4%, and 11%,; P = .035). Urban areas manifested increased physical activity and improved diet quality, thus demonstrating low risks of T2D.
Owen et al. (2010)	Cross-sectional study	UK based population	High physical activity levels were related to low BP, low risks of T2D, and cardiometabolic diseases.
Palmer et al. (2008)	Cohort study	African American women	Higher intake of fruit drinks and sweetened beverages were related to increased incidence of T2D (1.31 and 1.24). Regular consumption of these drinks were related to an increased risk of developing T2D in African American women.
Peer et al. (2014)	Review	Africa	Impaired glucose tolerance, low income, lack of availability of optimal and affordable care services makes the African population more vulnerable to develop the disease.
Peer et al. (2012)	Cross-sectional study	Black Africans aged 25-74 years from Cape Town	Older age, family history of diabetes, increased BMI, low SOC scores and better home quality were positively correlated with T2D.
Ramachandran, Ma and Snehalatha (2010)	Review	Asia	Substantial upsurge in urbanisation rates, change in diet habits, reduced physical activity, and old age were directly allied with greater T2D prevalence among Asians.
Tang et al. (2008)	Cross-sectional study	African- Americans	Satisfaction with medical support, regular blood glucose monitoring, regular carbohydrate consumption, and a minimum 30 minutes of physical activity were identified as major risk factors.

Table 1- Summary of results

Assahet al. (2011) examined the independent correlation between free-living physical activity energy expenditure (PAEE) that was objectively measured and the metabolic disorder in African adults who lived in urban and rural Cameroon. The findings of this study can be associated with the social gradient that acts as a significant predictor of wellbeing and health, owing to the fact that African urban dwellers reported substantial low PAEE, when compared to their rural counterparts(44.2 ± 21.0 vs. 59.6 ± 23.7 kJ/kg/day, P < 0.001). This in turn was related to increased prevalence of the metabolic condition (17.7 vs. 3.5%, P < 0.001). 6.5 kJ/kg/day variance in PAEE, corresponding to 30 min/day of brisk walking, corresponded to a 13.7% reduced risk of the syndrome. Hsu et al. (2012) also established a correlation between T2D and social determinants of health where the attuned odds ratio (OR) for the underprivileged having diabetes was 2.2 (P < 0.001), in comparison to their middle-income counterparts.

The ORs for the deprived population with type 2 diabetes to obtain tests for low-density lipoprotein cholesterol, glycatedhemoglobin, retinopathy, and triglycerides were 0.4 (0.2–0.7), 0.6 (0.4– 0.9), 0.4 (0.2–0.9), and 0.5 (0.4–0.8), respectively. The research objective was also supported by three studies that identified urbanisation as a direct contributor to T2D development (Levitt 2008; Ramachandran, Ma and Snehalatha 2010; Mbanyaet al. 2010). Positive rural-urban gradient was another socioeconomic factor that was found to increase the prevalence of T2D among people living in Benin (Ntandouet al. 2009). Owing to poor socioeconomic status among most Africans, there exists a lack of access to affordable healthcare services that has been cited as a reason for developing T2D in another research (Peer et al. 2014). Peer et al. (2012) also confirmed that old age increases the possibility of Black Africans from being affected with T2D.  

Boggs et al. (2010) conducted a research that was helpful in establishing a connexion between intake of alcoholic drinks and T2D development. However, there was no association between the disease and intake of coffee or tea. The relation between diet (sweetened beverage consumption and refined carbohydrates) and T2D was also established by two other studies that focused on exploring these lifestyle factors (Hu and Malik 2010; Hu 2011). They suggested that consumption of sweetened sugar beverage was associated with a gain in weight by virtue of reduced satiety and an imperfect compensatory decrease in energy intake at succeeding meals next to the consumption of liquid calories. Cigarette smoking was recognised as an independent risk factor to prevalence of the disease by Hu (2011). Furthermore, Levitt (2008), Motalaet al. (2008) and Mbanyaet al. (2010) supported the same, by drawing a correlation between western diet, and alcohol consumption with diabetes mellitus. Westernisation of the lifestyle patterns were correlated with a reduction in the level of physical activities performed by the Africans, followed by an elevated intake of high fat or energy dense diet. This in turn was found to significantly contribute to an increased body mass index and a waist to hip ration, thus making the Black Africans more likely to suffer from the metabolic condition.

The link with the research objective was confirmed by Owen et al. (2010) and Palmer et al. (2008) where influence of diet, and alcohol consumption were found to make people more susceptible to T2D onset. Diet that encompasses healthy eating plan (r = .280, P < .05) and even carbohydrate spacing (r = .367, P < .01) were also related to T2D development (Tang et al. 2008). Contrary to these findings, Ntandouet al. (2009) reported that urban areas were associated with better diet, thus lowering the risk of Africans from developing T2D.

The association between sedentary lifestyle and reduced physical activity was established in several scientific articles discussed in the review. Tang et al. (2008) suggested that African-Americans who performed different physical activities for a minimum of 30 minutes each day (r = .296, P < .05) reported better glucose tolerance and enhances self-care behaviour related to T2D. A connexion was also established between physical activity and T2D incidence among Asians in another review (Ramachandran, Ma and Snehalatha 2010). The fact that high levels of physical activity were significant contributors to low risks of obesity, cardiovascular complications and diabetes mellitus, helped in linking the findings of another cross-sectional study with the research objective (Owen et al. 2010). Increased physical activity were also found correlated to reduced risks of T2D susceptibility among people living in Benin (Africa) (Ntandouet al. 2009). This in turn was supported by results published by Mbanyaet al. (2010) and Hu (2011) who were successful in citing a sedentary lifestyle as a major risk factor for T2D development.

The chapter illustrated the link between the research objectives and the findings that were presented in the scientific articles discussed in the literature review. The articles suggested that some of the most common risk factors that made Asians and Black Africans more likely to acquire type 2 diabetes mellitus were increase in age, urbanisation, poor socioeconomic background, smoking, high consumption of alcohol, less physical exercise and dietary habit that comprises of high carbohydrates and fats.

This chapter contains information about outcomes of the research conducted and compares it to other scholarly articles on the same topic. The discussions will be presented in accordance to each research objective and will be followed by a summary of important findings.

Social determinants of health and wellbeing are referred to as conditions where an individual takes birth, grows, and lives, thus determining the chances of maintaining and upkeeping good health. Some of the major social determinants of health are the social gradient, early life, unemployment, social support, food and addiction. Walker et al. (2014) conducted a systematic review and presented results that were in accordance to those obtained from the articles incorporated in the review. Educational status and economic stability were identified as the major social determinants, which directly affected the susceptibility of a person to suffer from type 2 diabetes. The review further supported the fact with the prevalence of lower socioeconomic status, people were more prospective to have greater HbA1c levels. This can be accredited to the fact that community disadvantage, financial distress, and educational attainment established momentous impacts on the blood glucose levels of the population.

Walker et al. (2014) in a later study also confirmed the results presented in the review by producing adequate evidence for the significant connotation for blood glucose levels and income (β=−0.66, CI: − 1.30 to − 0.16), education [β=−0.72, 95% confidence interval (CI): − 1.36 to − 0.08], diabetes distress (β=0.43, CI: 0.14 to 0.72), and self-efficacy (β=−0.12, CI: − 0.15 to − 0.08). Hence, the results were in accordance to the fact that socioeconomic issues were most often related to diabetes consequences and psychological influences, precisely self-efficacy and apparent stress being most often linked with quality of life and self-care. The validity of the results discussed in the previous chapter can be further confirmed by the strong evidence that factors such as, depression, social sustenance, self-efficacy, and professed stress, show unswerving relations with quality of life, self-care, and glycaemic control. Furthermore, certain neighbourhood factors, such as, social cohesion, neighbourhood aesthetics food insecurity, and have also been related with glycaemic control.

Azimi-Nezhadet al. (2008) also established a relation between urbanisation, educational attainment and diabetes mellitus. It was stated that urbanisation of Iran population, concomitant with the relocation of persons from rural to urban zones might be held responsible for the ever-increasing pervasiveness of type 2 diabetes mellitus. Urbanisation was found to report the maximum odds-ratio (OR) (2.73), (p< 0.001, 95% CI; 1.89–3.92). Furthermore, ageing had a significant connotation with T2D, with an OR of 1.052 (p< 0.001, 95% CI; 1.029–1.074).

Jack, Jack and Hayes (2012) also conducted a study, the findings of which were in accordance to the results presented above. Upon exploring the social determinants of health and diabetes related health disparities, the researchers found that the inhabitants of minority societies are more probable to be subjected to limitations in their access to vegetables, quality fruits, and other effective food options owing to lack of transportation facilities, high costs, and lack of availability. The authors also argued that placement of outlets of food service is strongly allied with the racial distribution and wealth of the neighbourhood, with several individuals belonging to the minority populaces existing in low-income districts, compared to wealthier areas. Martínez-González et al. (2008) also supported the link between T2D onset and dietary habits by providing evidence for the fact that patients who showed adherence to Mediterranean diet reported lower risks of T2D development. A two point upsurge in adherence scores was related with a 35% relative decrease in the danger of diabetes (incidence rate ratio 0.65, 0.44 to 0.95), thus associating between T2D and dietary habits. Upon assigning patients with T2D to different groups that varied in the carbohydrate and fat intake, it was found that fasting glucose was found to be higher (p= 0.041), followed by a low 2-h postload glucose (p= 0.010) among patients subjected to a 12 month long, low-GI diet. This helped in confirming the role that dietary habits play on the development of T2D among people.

Mohan et al. (2009) also conducted a research, the results of which were consistent with the findings presented in the thematic analysis. The study illustrated that intake of refined grains was positively allied with the jeopardy of T2D development (OR 5·31 (95 % CI 2·98, 9·45); P < 0·001). In the multivariate model, following an adjustment for latent confounders, glycaemic burden (OR 4·25 (95 % CI 2·33, 7·77); P < 0·001), whole carbohydrate (OR 4·98 (95 % CI 2·69, 9·19), P < 0·001), and glycaemic index (OR 2·51 (95 % CI 1·42, 4·43); P = 0·006) were related with T2D, thus confirming carbohydrate rich diet as a major risk factor. Another cohort study also presented results that were in accordance to the aforementioned findings and suggested that high intake of protein was linked with amplified risk of T2D (HR-1·27 for highest linked with lowest quintile; 95 % CI; 1·08, 1·49; P for trend = 0·01). On the other hand, likelihood for the incidence of T2D was inversely related with increased consumption of cereals and fibre-rich bread (HR 0·84; 95 % CI 0·73, 0·98; P for trend = 0·004) (Ericson et al. 2013). 

Han, Lim and Kim (2012) also supported the link between smoking and T2D by providing associations of diabetes and smoking with periodontitis as, diabetics OR = 1.21, 95% CI = 0.82 to 1.77 and current smokers, OR= 1.40, 95% CI= 1.02 to 1.90. Results presented by Baliunaset al. (2009) were also useful in confirming alcohol consumption as a risk factor for T2D where relative risk for T2D was deleterious at 60 g/day alcohol intake (1.01 [0.71–1.44]) and  50 g/day alcohol (1.02 [0.83–1.26]), for men and women, respectively.

Link between physical activity and T2D prevalence was confirmed by Healy et al. (2008) who stated that regardless of the time that people spent in moderate-to-vigorous physical activity, significant associations were found between T2D and sedentary lifestyle. This was in accordance to another research activity where structured exercise training were related to a decrease in the HbA_1c level (−0.67%; 95% confidence interval [CI], −0.84% to −0.49%; I², 91.3%), in comparison to control participants. Structured resistance training (−0.57%; 95% CI, −1.14% to −0.01%; I², 92.5%) and aerobic exercise (−0.73%; 95% CI, −1.06% to −0.40%; I², 92.8%) were found to create a significant impact on the blood glucose level of individuals, thus correlating physical activity with T2D (Umpierreet al. 2011).

This was also in accordance to the findings presented by Andrews et al. (2011) where glycaemic control manifested noteworthy improvements among patients who were subjected to an intervention of diet, combined with physical activity (−0·33%, −0·51 to −0·14; p<0·001), in comparison to those randomised to the control group (Andrews et al. 2011). Wilmot et al. 2012 also supported the findings and stated that high sedentary time were directly responsible for an estimated 112% upsurge in the relative risk of type 2 diabetes (RR 2.12; 95% CrI; 1.61, 2.78), followed by 90% intensification in the danger of cardiovascular death (HR 1.90; 95% CrI; 1.36, 2.66). The results presented in the previous section are also supported by those presented by Cichoszet al. (2013) who elaborated on the fact that people diagnosed with T2D spent suggestively extra time engaged in inactive or sedentary doings during the day, with an average time of 926 (44) vs 898 (70) min, p< 0.001). 

Hence, the chapter was able to correlate the evidences discussed in the thematic analysis with additional scientific suggestions from other scholarly literature, thereby confirming the reliability and validity of the research results.

Conclusions and Recommendations

Finally, in this chapter, briefreviewof the findings and interpretation will be presented on the risk factors of developing type 2 diabetes amongst adult black Africans and Asians aged between 40 years to 60 years old. This chapter will contain conclusions of this study’s findings, related recommendation to overcome the risk factors and brief summary of the chapter. This sections are stated below.

Conclusions

From the discussion in above chapter, it can be safely stated that type 2 diabetes mellitus is high prevalent chronic disease worldwide and there are many risk factors which can lead to early onset of type 2 diabetes mellitus amongst middle aged black Africans and Asians, living in the UK, belonging to the age group 40-60 years. This risk factors can be broadly classified into two groups which are socio- economic situations and life style choices. In case of socio- economic situation, poverty and urbanization are two risk factors which affect the condition most. On the other hand, dietary habits, smoking, obesity, binge drinking, sedentary lifestyle and lack of physical exercises are all amongst life style choices which play a substantial role in the onset of type 2 diabetes mellitus. Evidence from the above chapter suggests that poverty can affect the onset of this disease immensely and it can some time two folds the risk of occurrence.

Along with that, poor people are very much likely get complications such as blindness, organ failure due to sustained effect of the type 2 diabetes. Women from low income category have a much higher prevalence rate in comparison with the woman from high income category. Interestingly, data from the above discussion shows that urbanisation also have increases the risk of having type 2 diabetes especially in Southern Asia. Here, older aged males are more likely to be affected by the type 2 diabetes which is in clear contrast with previous argument where woman from low income area have the highest risk of getting type 2 diabetes.

Furthermore, as mentioned above, lifestyle choicesalso present a huge threat of getting type 2 diabetes. Dietary habits such as consumption of large amount of sugary food or highly refined fibrecan lead to the onset of the disease. Many studies have reported that the consumption of highly refined fibre instead of whole grain fibre increases the incidence rate of type 2 diabetes. Research has also showed that consumption of dietary fibre can reduce the chance of getting type 2 diabetes significantly. Similar like refined fibre, academic paper also showed that eating of excessive amount of sugary food can influence the occurrence of type 2 diabetes. Additionally, consumption of highly refined fibre also plays a hand in this matter as all carbohydrates are essentially metabolized as sugar by the body. Along with that, binge drinking increases the risk of having type 2 diabetes multiple times as it causes insulin resistance in the body and insulin resistance is one of the vital metabolic effect leading to type 2 diabetes. Binge drinking, even once in a week, extends the insulin resistance of the body. Just like the dietary habits, smoking too plays a significant role as causing agent of type 2 diabetes. Smokers have difficult time to control their diabetes in comparison with non- smokers as smokers have trouble with their insulin dosing.

Apart from that, smokers with diabetes are much more likely suffer additional health issues such as kidney or heart disease. Obesity can be the end product of all of the above harmful detriments (lifestyle choices) and unsurprisingly this too influence the risk of getting type 2 diabetes. Studies have shown that most of the patients suffering from type 2 diabetes are obese. Researchers also argued that raise in worldwide obesity rate is closely knitted with the raise in prevalence rate of type 2 diabetes globally. Lastly, similarly like all the above risk factors, sedentary lifestyle and lack of physical exercise plays a substantial role as a risk factor to the occurrence of type 2 diabetes mellitus. Physical activity is important to the control of diabetes and sedentary life style and lack of physical life style neglect this aspect.

Academic paper published by researchers have shown that physical activity has closely related with the occurrence of type 2 diabetes and physical activity plays a role in preventing the occurrence of type 2 diabetes. In a nutshell, it can be said no single risk factor is individually responsible for the occurrence of type 2 diabetes and many of the risk factor are interrelated like urbanisation directly involved in dietary habits change and lack of physical activity due to less open space. Therefore, to conclude, it can be said that type 2 diabetes mellitus is multi-faceted problem and to thwart its insurgence a multi-pronged approach is needed by the concerned bodies and organisations.

Diabetes is a global issue and has many reasons for its occurrence. Researchers, doctors and academics have suggested few recommendations which can help prevent the type 2 diabetes mellitus. First of all, most important component of type 2 diabetes prevention plan is physical activity and it is recommended by all the healthcare professionals. Physical exercise can be of different type and it can be running, jogging, biking, swimming and walking. American Diabetes Association suggests physical movement in every thirty minutes and it can be anything from torso twists to leg lifts to walking in corridor(American Diabetes Association 2018).

Another important recommendation for type 2 diabetes is to manage individual dietary habits. Dietary habits can help an individual to have healthy live as well as it will prevent an individual from being an obese. Awareness should be raised amongst the population particularly in poverty area about the harmful effect of type 2 diabetes mellitus and its contributing risk factors such as smoking, binge drinking and dietary habits (Ley et al.2014). UK based policies should be implemented where a city or locality will be bound to have open spaces for physical activity. Ultimately, a guideline or recommendation only useful if they are implemented in our daily life and support and willingness from an individual to policy maker is needed to keep global emergence of type 2 diabetes mellitus at bay.

This concluding chapter demonstrates all the findings regarding the risk factors of type 2 diabetes mellitus in a concise and brief manner along with why they are considered as a risk factors. After the concluding remark, few brief recommendations are provided which can be implemented to prevent the onset of type 2 diabetes mellitus.

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