Interpretation of ethnicity-specific data: increased risk versus increased utilisation

It was with great pleasure we read the article by Robson et al titled ‘NHS Health Checks: an observational study of equity and outcomes 2009–2017’.¹ We would like to offer additional contributions regarding explanations for the findings and differences between ethnic groups. It is difficult to ascertain whether ethnic disparities in incidence of disease between attendees and non-attendees are due to underlying higher risk of disease in these groups or the result of the NHS Health Check. It is well established that Black and South Asian patients have increased risk of hypertension and diabetes compared with White patients, and that ethnicity-specific body mass index (BMI) cutoffs should be utilised. It would be important to understand the risk of incident disease in attendees versus non-attendees within each ethnic group.

Interestingly, in a recent 2021 Lancet article, study authors found that adjusted incidence of type 2 diabetes occurred at far lower BMI in South Asians (BMI of 23.9) and Black Caribbeans (BMI of 26.0) compared with White patients with BMI of 30.0.² Additionally, at comparable BMIs, Bangladeshis had the highest risk of type 2 diabetes, followed by Pakistanis and Indians. This is in line with the ethnic differences in NHS Health Check attendance rates, potentially offering an explanation for South Asians’ high attendance rates.

Lastly, Eastwood et al, in a June 2021 article assessing UK ethnic differences in statin initiation, found that time to initiation of statins was longest for South Asians, followed by Black patients.³ They also found that South Asians and Black patients were significantly less likely to initiate statins compared with European patients.³ This disparity in the overall primary care setting may overestimate the ethnic differences seen in attendees versus non-attendees. Overall, we believe the authors of this paper make a strong case regarding the low uptake and effectiveness of the NHS Health Checks and that more targeted, culturally sensitive cost-effective approaches should be considered. Further studies should keep in mind the different comorbid risk factors as well as changing national guidelines and ethnicity-specific guidance that may influence findings.