We’re fat. As a planet, we are bulking up, with nearly one-third of the Earth’s population estimated to be either overweight or obese. Turks are no different. More than one-third of those over the age of 15 can be classified as overweight, and Turkey, as the world’s 17th largest country, is overburdened by the health care costs that come with treating diseases associated with obesity, such as hypertension, musculoskeletal diseases, and diabetes. In fact, it is predicted that by 2035, Turkey will rank among the top ten countries for diabetes prevalence. Currently, about 10 to 12 percent of the country’s health care budget is spent addressing such obesity-related ills.
Of course, Turkey is well known as the land of kebabs, sweet lokum, baklava and now an expanding waistline. So what happens when Turks emigrate to distant lands, as they have done in large numbers since the 1960s? Do they slim down as they assimilate into their surrounding culture? Or do they remain overweight, as they continue to enjoy the food and cultural habits of home?
The statistics are startling. Turks take their fat with them. But more interestingly, they often experience a higher rate of obesity-associated diseases (such as gestational diabetes) than Turks who remain in their native country. Why this is so, and what can be done about it remains a bit of a mystery, although the evidence provides some important clues about how this problem might be resolved.
Why Turks are Overweight
The global standard for measuring obesity is based on calculating the body mass index (BMI), and a BMI value that equals or exceeds 30kg/m2 is generally accepted as an indicator of obesity. A landmark study of the obesity epidemic in Turkey took place in 1990, where the body weight, height and waist circumference was measured in nearly 200 adult males and females in 59 cities located in 7 geographical regions. This study reported an overall prevalence of 18.6%. When the same study was repeated 10 years later, there was a nearly 20% increase in prevalence. Recent data suggest that nearly 35% of Turks over 15 years of age are overweight. Related to the rise in overweight
A survey of 15,468 Turkish adults aged 30 years or older reported that only 3.5% engaged in regular physical activity (moderate intensity physical activity lasting at least 30 minutes a day for at least 3 times a week). Coupled with this is the documented reduction in consumption of fresh fruits and vegetables, especially in urban regions
—Turks aged 18 years and over eat only 1.7 portions of fresh fruit and 1.6 portions of fresh vegetables a day—which is far less than the recommended 5 portions per day of fresh fruits and vegetables. This is surprising given that Turkey is a Mediterranean country rich in all the ingredients for a healthy diet: fresh fruits and vegetables and readily available fresh fish.
Obesity Among Turkish Migrants
The statistics are startling when Turkish immigrants are studied within the context of various countries. Turkish immigrants are amongst the largest ethnic minority groups in many parts of Europe. Nearly 44% of all 10-year-old children with a Turkish background in Amsterdam are either overweight or obese—this is nearly double the Dutch average for this age group (1). This is in dramatic contrast with obesity rates of 12% in 7 to 12-year-olds reported in a survey of the indigenous Turkish population. In general, Dutch children with a Turkish background are noticeably more overweight than native Dutch children—this being evident at ages starting as young as 5 years old. It is thought that longstanding cultural habits that often result in overfeeding/overeating may be important in this setting, and the general belief that a chubby child represents a healthy child.
A survey conducted in 2000 in Amsterdam reported four-times higher rates of self-reported diabetes in Turkish migrants than native Dutch. These findings were confirmed by a clinical study that reported significantly higher rates of obesity and diabetes in young Turkish migrants. Important are the findings that Turkish migrants are twice as likely to be diabetic than ethnic Dutch and also tend to have a lower age of onset for the disease.
The story in Scandinavian countries is similar. Turkish migrant women in both Sweden and Denmark have four times the rates of obesity than age-matched women native to these countries. Similar data are also reported in Oslo, Finland where nearly half of Turkish migrant women are likely to be obese (BMI ≥ 30 kg/m2). And in Germany, only 16% of migrant Turkish women have a “healthy” body weight. Migrant Turkish females living in Germany for 17-21 years, which should allow for integration with local customs and habits, reported higher levels of markers of diabetes, such as glucose and HbA1c levels, and also for physical inactivity, than their male counterparts. In fact, migrant Turkish women are three times more likely to be diabetic than German women.
Causes for High Migrant Obesity Rates
High obesity rates in migrant populations are frequently attributed to the low socio-economic status and lack of integration. This was studied in Turkish migrant women between ages 18 and 56 in Vienna, Austria, using factors such as knowledge of the German language, duration of stay in Vienna, weight, height, and socio-economic position. The study focused on three important criteria: income, education, and occupation. A structured questionnaire was used to gather information on place of birth, reason for migration, education level, household size, number of rooms in household, education level of husband, income level, and occupation of husband.
This survey determined that the highest rates of overweight (44%) and obesity (35%) in migrant Turkish women correlated with low socio-economic status, while those classed as being from a high socio-economic status had lower rates of overweight (8%) and an absence of obesity. Education status correlated inversely with rates of overweight and obesity in this study. Fifty percent of women with no reading or writing skills were obese or overweight and these levels progressively decreased as those with reading or writing skills being less likely to be overweight (11%) or obese (6%). While there was a progressive decline in rates of overweight and obesity as the extent of knowledge of German increased, there was a surprising lack of impact related to the duration of stay in Vienna, with the rates of overweight and obesity being similar for new immigrants (staying <5 years in Vienna) and more long term residents (>20 years residence).
A curious finding is that Turkish migrant women are more likely to develop gestational diabetes, a form of glucose intolerance during pregnancy that carries increased long-term health risks, such as progression to type 2 diabetes for both mother and child. Obesity is an important confounder in the setting of gestational diabetes. Turkish migrant women are more likely to develop gestational diabetes (183 out of 1000 pregnancies) compared to native German women (138 out of 1000 pregnancies). Data on the prevalence of gestational diabetes within Turkey are scarce; an isolated study of 807 women in a northeastern city in Turkey reported values of 7% (59 out of 807 pregnancies).
What are some likely reasons for the higher rates of obesity in Turkish immigrants? For one, visiting Turkish homes comes with the obligatory generous hospitality of the host family—accompanied with an abundance of calorie-rich food, many pastries and sugary drinks, and where it is generally impolite for the guest to not partake in the offerings. Another reason is that Turkish migrants as a rule tend not to engage in sports, due to a self-imposed segregation from the local native population. Most women do not work outside of the home, and are thus more likely to lead a sedentary lifestyle. Housework, rather than sports, represents the bulk of physical activity and there is a general lack of knowledge of the health consequences of obesity.
Health Care Policies in Turkey: A Possible Way Forward
Access to health care services made significant strides in 2003 with the creation of the Health Transformation Program, which reorganized primary and secondary healthcare systems and also initiated a general health insurance scheme. Up until then, health care in Turkey was marked by major disparities in health care across various regions, with great variations in access, quality, and efficiencies. There is some evidence that this transformation in healthcare provision has paid off richly in terms of reduced infant mortality rates, increased life expectancy, and lower maternal mortality rates. The Health Transformation Program will go a long way in providing much needed data on the impact of diabetes and obesity in terms of economic burden for acute and chronic care of diabetic complications, and also loss of work-hours in the Turkish population (2).
The Ministry of Health set an Action Plan with targets for 2014:
- Reduce incidence, prevalence, and impaired glucose tolerance by 5% by 2020.
- Target at least 10% of the population for greater awareness of diabetes during the first 5 years.
- Reduce by 10% the number of patients unaware of diabetes and its complications during the first 5 years.
- Cost analysis reports of diabetes and its management to be published at the end of second year.
While such goals are laudatory, it is important to appreciate that payment of Turkish health care professionals is primarily a performance (delivery) based system—this means a greater tendency to focus on treatment rather than on prevention.
A more recent development has been the launching of the “Turkey Diabetes Program 2015-2020” in a draft format. This program will target school children through improved educational strategies by encouraging imams to discuss the importance of a healthy lifestyle, better nutrition, and greater physical activity. It is important that this messaging targets both genders and spans all age groups. An interesting development is the focus on sporting events with high public interest—such as soccer matches—where visual and audio broadcasts on diabetes and its risk factors will be made. These events will also afford opportunities to promote mobile applications on diabetes education.
Helping Migrants Slim Down
Migration negatively impacts the incidence and prevalence of obesity and type 2 diabetes; this is the case for most ethnic groups. This repopulation is generally associated with increased affluence, more urbanized lifestyles, and a greater vulnerability to environmental influences on health. So it is tempting to speculate that specific health guidelines targeting ethnic migrant groups would yield benefits. A detailed study concluded that such programs are more likely to succeed if they are culturally tailored and aimed at a community level; important to consider in this context are religious beliefs, awareness of language/ dialects spoken, social norms, levels of education, and extent of integration.
An example of a success story comes from “The Mosque Campaign”—targeting cardiovascular risk factor awareness to first-generation female Turkish migrants in Austria (3). This innovative initiative used a Turkish-language based approach to increase awareness of cardiovascular disease prevention strategies. The approach taken was to “fan-out” health care workers to 28 local mosques in Tyrol over a three-year period. Nearly 2500 first generation Turkish migrant women completed a cardiovascular-risk awareness questionnaire, and also had access to private medical consultations that included blood pressure screening. It is important to note that most of the participants did not avail themselves of the free access to health care services offered in Austria, however, the outreach program led to increased awareness of cardiovascular disease. Clearly for such campaigns to be successful, some level of buy-in from community and religious leaders would be essential. Areas to target would be classes in a healthy lifestyle that includes cooking classes, encouraging more physical activity for women within their religious and cultural practices, and also engaging children in outdoor sports, walking to school, and recognizing healthy food choices at home and in public spaces.
Of interest is that migrant Turkish children are more likely to have a sedentary lifestyle compared to native children from Western and Central Europe. It is unclear what the underlying reasons for this could be, since separating migrant cultural habits from socioeconomic constraints is difficult. It has been proposed that the educational level of the mother may be an important determinant. Thus greater awareness of nutritional choices would he helpful, since the Turks get nearly half of their daily calories from bread—and much of the remainder from foods rich in dairy, sugar, salt, and fat, with little consumption of fresh produce.
There are several questions worth considering when examining whether Turkish migrants differ in obesity/diabetes rates compared to the native Turkish population. Migrant Turks appear more likely to suffer from higher obesity rates than Turks in Turkey. Are these high rates related to urbanization rather than migration—in which case one would expect that someone from remote regions of Turkey moving to urban city centers within Turkey would also acquire the characteristics of a migrant? Or, conversely, do urbanized Turks moving to remote areas in Turkey or other countries experience a drop in obesity rates?
These questions are still open for further study, but the data are very clear about one thing: obesity has become a major health crisis among Turkish migrants, calling for more education and health initiatives to combat a growing problem.
- J. K. Ujcic-Voortmen, C. A. Baan, J. C. Seidell, A. P. Verhoeff, “Obesity and cardiovascular disease risk among Turkish and Moroccan migrant groups in Europe: A systematic review,” Obesity Review, vol. 13, no. 1, pp. 2-16, 2012. doi: 10.1111/j.1467-789X.2011.00932.x. Epub 2011 Sep 26
- M. Tatar, “Management of diabetes and diabetes policies in Turkey,” Globalization and Health, vol. 9, no. 16, 2013.
- A. Bader, D. Musshauser, F. Sahin, H. Bezirkan, M. Hochleitner, “The Mosque Campaign: A cardiovascular prevention program for female Turkish immigrants,” Wien Klin Wochenschr, vol. 118, no.7–8, pp. 217–223, 2006.