By Anjanee Kohli, Registered Dietitian (reviewed by Harriet Smith, RD)
This blog post serves as information only, and does not substitute individualised advice from a Registered Dietitian.
The South Asian population in the UK
The South Asian (SA) population in the UK is increasing, with those identifying as Asian making up the second largest proportion of the population1. Although the prevalence of malnutrition amongst the SA population is unknown, 5.7% of the Asian population are aged 65 and over2, and it is well documented that the prevalence of malnutrition increases with age3. These figures are likely to have increased since the census was conducted, due to the UK’s aging population3.
Background to South Asian diets
Broadly speaking, SA eating patterns in the UK are influenced by the Western diet, although some SA groups (such as the elder generation) adhere to a strictly traditional diet4.
Breakfast is usually light, consisting of tea and biscuits or cake rusk. Curries are based on ingredients such as vegetables, beans and pulses and may contain some meat or fish. They are commonly served with rice, yoghurt and chapatis (made from flours such as chickpea, gram and wholemeal) at lunch and dinner. Desserts are occasionally consumed and may include kheer (rice pudding made with nuts and raisins) or halwa (a semolina pudding).
The energy content of these dishes is dependent on their preparation, and additions such as ghee or butter can increase the energy density of the dish. Energy-dense foods are typically eaten during times of celebration including Eid, Diwali and Vaisakhi. Popular savoury or sweet snacks include meat kebabs, samosas, barfi (milk-based sweets), mathri (flaky biscuits) and jalebi (deep-fried Indian sweets).
It is important to consider religious influences on the diet, as well as cultural and individual beliefs. Those who follow Islam only eat halal meat and exclude pork, whereas those who strictly follow Hinduism or Sikhism are commonly lacto-vegetarian. Practices such as fasting may be observed, with some individuals fasting for specific month(s) or days throughout the year. For example during Ramadan, those who follow Islam abstain from eating and drinking completely from dawn til dusk for a full month. In Hinduism, a full month's fast is observed during Shravan. An individual will only consume fruits, water, vegetables, nuts and salt once daily.
Nutrition support information: challenges in South Asian Populations
Rise in lifestyle diseases
Lifestyle diseases such as diabetes, obesity and hypertension in SAs are highly prevalent5. SAs are becoming more conscious of their lifestyle, and may pass on diet and lifestyle information amongst family and friends. Anecdotally speaking, this can be problematic when encouraging patients, relatives and carers of patients to fortify meals and snacks with high-energy, high-fat foods such as ghee, butter and cream. Healthcare professionals may need to educate the patient and carers about the importance of nutrition support in the context of malnutrition, and explain why it goes against typical healthy eating advice.
Living in multigenerational households is common in a close knit SA community4. The ‘key kitchen person’ (KKP) in the household is primarily responsible for meal planning, food shopping and cooking6. Food is an important component of social interaction in SA communities, so it’s likely that the KKP and senior members of the family will play key roles in meal preparation for the patient. It goes without saying, the KPP may be the patient themselves, which may mean that other relatives and household members will need to take on the food preparation and cooking duties.
Generally speaking, there is a stigma within the SA community about speaking out about mental health and other serious illnesses such as cancers due to a fear of burdening family members7. This can result in delays accessing support and healthcare services and/or poor compliance, which could lead to poor nutrition and health outcomes8.
Cultural and religious beliefs
In some parts of the SA culture, there are strongly held beliefs around food and its role in the management and prevention of disease. Some of these beliefs are based on Ayurveda; an alternative medicine system which stems from the Indian subcontinent9. Ayurvedic principles encourage cooking wholesome meals using specific ingredients, which can lead to negative connotations towards using pre-prepared foods. This may cause issues if a patient does not have the energy to cook and therefore needs to rely on ready meals. Some patients and carers may also have concerns as to whether the hospital or care home food choices are suitable for a SA diet.
Dietetic advice may not be readily understood if English is not the patient’s first language7. Some patients may bring relatives or carers to their appointments so that they can translate. It may also be necessary to arrange for the HCP to arrange for a translator to be present during the consultation. It may be useful to obtain dietary resources in suitable languages prior to the appointment.
A food first approach to nutrition support
Food fortification increases the calorie and protein content of foods consumed without increasing the volume, and is a particularly useful tool in patients who have a low appetite and experience early satiety. A ‘little and often’ approach is also useful and may involve offering nourishing meals, snacks and puddings to optimise nutritional intake. Tailoring the food first approach to suit SA’s dietary, cultural and religious needs may help improve compliance and acceptance of advice given8.
Below are some ideas for nourishing snacks and drinks as well as food fortification ideas.
- Sweet options such as cake rusk, biscuits, mishri, shakar paray (these can be bought in bulk from Indian sweet shops) and mithai (Indian sweets)
- Savoury options include bombay mix, matti and dried or roasted nuts or chickpeas
- Hot savoury snacks include pakora (bhajis made from various vegetables), meat kebabs, spring rolls and samosa (these can be filled with minced meat, paneer or vegetables)
- Puddings such as rice pudding (or kheer) fortified with cream, condensed milk, full fat milk and/or ground or crushed nuts. Handesh: Deep fried date molasses, sugar, flour and water.
- Having the yoghurt-based drink, lassi, between meals is a good nourishing snack or drink. This can be fortified with ground nuts, full fat milk or cream
- Consider making chai or chaa with full fat or condensed milk, sometimes referred to as Adeni tea
- Badam milk: This is an Indian milk drink flavored with soaked almonds, cardamom & saffron. It can be fortified with milk powder or ground almonds.
- Nimbu paani is a spiced drink similar to a still lemonade. It is made with freshly squeezed lemon, black salt and sugar. This is a good alternative to milk-based nourishing drinks and can be fortified with extra sugar and golden syrup.
- Oil and ghee can be added to vegetable dishes and curries, or parathas during the cooking process
- Sweet dishes can be fortified with cream, condensed milk, honey or sugar, and crushed or ground nuts
- Vegetarian dishes such as aloo mattar (potatoes and peas) or saag/paalak (spinach) can be fortified by adding vegetarian sources of protein such as paneer or tofu
A traditional SA diet can take time and energy to prepare. The information below may help patients with or at risk of malnutrition who do not have the energy, time or resources to prepare nourishing meals and snacks at home.
- Speak to relatives if they live in a multigenerational household: see if other household members can help with the food preparation and cooking
- Use frozen or convenience foods: you can buy authentic tasting frozen curries and pakoras from supermarkets
Batch cook to save time: Tarka is the base of curries, consisting of onions, tomatoes, dried spices, garlic, ginger and chilli. This can be prepared in advance, frozen and adapted to different dishes.
- Make "all-in-one" dishes, and fortify them:
- Stuffed parathas (with potatoes, leftover curry or keema)
- Biryani made with meat or paneer
- Khichdi an easy-to-prepare one-pot daal and rice
- Ask about special menus or bringing in food from home: Some hospitals have South Asian menus available, including halal menus
- Buy staples (atta, rice, pulses, tinned tomatoes) in bulk
- Encourage the patient or carer to make a daily snack box: for individuals with limited mobility, this is a useful way to encourage them to eat often, while promoting independence.
- If the patient follows a vegetarian diet, focus on including vegetarian sources of protein at every meal or as a snack, including tinned pulses, paneer, tofu, nuts, seeds and eggs (if these are eaten).
Ethnicity-facts-figures.service.gov.uk. Available at: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/population-of-england-and-wales/latest [Accessed 25th August 2020]
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Elia, M. (2015).The Cost Of Malnutrition In England And Potential Cost Savings From Nutritional Interventions. [online] BAPEN and National Institute for Health Research Southampton Biomedical Research Centre, pp.1-5. Available at: https://www.bapen.org.uk/pdfs/economic-report-short.pdf [Accessed 25th August 2020].
Bi, S. (2012). Fit As A Fiddle. [online]. Age UK. Available at:https://www.ageuk.org.uk/Documents/EN-GB/FaithGood%20Practice%20GuideWEB.pdf?dtrk=true [Accessed 25th August 2020]
Leung, S., Stanner, S (2011). Diets of minority ethnic groups in the UK: influence on chronic disease risk and implications for prevention [online]. Nutrition Bulletin. 36(2): pp.161-198. Available at:https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-3010.2011.01889.x [Accessed 26/08/2020].
- Keller Brown, L. and Mussell, K.. Ethnic and Regional Foodways in the US. 5th Ed. Knoxville: The University of Tennessee Press; 2001.
Memon A, Taylor K, Mohebati LM, et al.Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England.BMJ Open (2016).Available at:https://bmjopen.bmj.com/content/bmjopen/6/11/e012337.full.pdf [Accessed 01/09/2020]
BAPEN. (2018).Introduction To Malnutrition. [online] Available at: https://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?start=4 [Accessed 20th August 2020].
Narayanasamy, A. andNarayanasamy, M. Ayurvedic medicine: an introduction for nurses. British Journal of Nursing (2013). 15(21). Available at:https://www.magonlinelibrary.com/doi/pdf/10.12968/bjon.2006.15.21.22378 [Accessed 31/08/2020]