Diet and Physical Activity Interventions for People from Minority Ethnic Backgrounds in the UK: A Scoping Review Exploring Barriers, Enablers and Cultural Adaptations

Background Type 2 diabetes (T2D) and cardiovascular disease (CVD) are a global pandemic, driven by obesity, poor diet and physical inactivity. In the UK, the prevalence of T2D and CVD is higher in minority ethnic groups. Lifestyle prevention interventions can be effective but uptake amongst minority ethnic groups in the UK is low and the extent of cultural adaptations to increase engagement unknown. Aim To explore barriers, enablers and culturally adapted lifestyle interventions in UK minority ethnic groups. Methods Four electronic databases were searched from to January 2013–2023. Two independent reviewers carried out manuscript selection and data extraction. Barriers and enablers were mapped to the Capability + Opportunity + Motivation = Behaviour (COM-B) theoretical model. Intervention adaptations were linked to behaviour change strategies and reported within a Cultural Adaptation framework. Results Twenty-three studies were included, reporting barriers/enablers, culturally adapted interventions or both. Barriers and enablers mostly mapped to social and physical opportunity, and reflective motivation. Common adaptation strategies considered behavioural influences related to culture, values, religious beliefs and/or traditions. Most impactful strategies were associated with using credible sources of information and reorganising social and environmental contexts. Discussion and conclusions The current umbrella approach to preventative intervention delivery is unlikely to promote sustained participation in behaviour change amongst UK ethnic minorities. Engagement strategies for this population should consider key determinants such as social contexts, beliefs and cultural norms. Important research gaps include interventions investigating tailored interventions for Black populations, and the impact of negative social experiences (e.g., racism) on engagement


Background
The global prevalence of Type 2 diabetes (T2D) has increased rapidly over recent decades [1,2], with 693 million adults predicted to have diabetes by 2045 [3].In the United Kingdom (UK), it is estimated that 5.5 million people will be living with diabetes by 2030 [4].The management of diabetes and its complications costs the UK National Health Service (NHS) approximately 10% of the total budget [5,6].
The prevalence of T2D is higher among minority ethnic groups in the UK [7,8].People of Asian, Black African and Caribbean ethnicities are two-to-four times more likely to have diabetes, develop T2D at lower weight thresholds, and are diagnosed 10-12 years earlier than people of White ethnicities [7,9].The risk of developing T2D depends on multiple non-modifiable and modifiable risk factors including age, family history, ethnicity, socioeconomic status, and being overweight or obese [10].Obesity accounts for approximately 80-85% of the overall risk of developing T2D and together with physical inactivity, is estimated to cause a large proportion of the global diabetes burden [11].In England, obesity affects 25.9% of the adult population, with the highest prevalence amongst those who identified as Black British (33.7%) [12].Other factors that can predispose minority ethnic groups to a higher risk of developing T2D include a higher genetic predisposition and enhanced susceptibility for cardio-metabolic complications in relationship to body composition [9,[13][14][15][16].
Minority ethnic groups in high-income countries such as the UK also suffer disproportionately from diabetes-related complications such as cardiovascular disease (CVD) [17].CVD is the most prevalent cause of morbidity and mortality in people with diabetes, affecting almost a third of people with T2D [18,19].
The prevention of T2D and related conditions (e.g.CVD) through early detection, lifestyle changes and obesity prevention are amongst the key priorities outlined in the NHS long term plan [20].In England, the NHS Diabetes Prevention Programme (NHS DPP) and the NHS Health Check are two main interventions designed to prevent T2D and CVD respectively.The NHS DPP, introduced in 2016, identifies people at high risk of diabetes and refers them to a 9-month behavioural change intervention primarily consisting of diabetes and lifestyle education and support to adopt a healthy diet, increase physical activity and reduce weight [21].The effectiveness of DPPs in delaying or preventing the incidence of T2D has been established by several randomised controlled trials conducted in Finland, India, US, China and Australia [22][23][24][25][26][27][28][29].A recent evaluation of the NHS DPP, which included a predominantly White population (~ 84%), has demonstrated effectiveness at reducing the incidence of T2D in people with prediabetes [30].However, NHS DPP outcome reports indicate that minority ethnic groups including Black and Asian populations are 25% less likely to complete the programme and have smaller HbA1c and weight reductions [31][32][33].The NHS Health Check, a CVD prevention programme introduced in 2009, is freely offered to adults aged 40-74 years every 5 years and encompasses a risk assessment, risk communication (risk of developing heart disease, stroke, T2D or kidney disease, over the next 10 years) and risk management through tailored advice on lifestyle improvement [34,35].A review of evidence from NHS Health Checks has demonstrated reductions in risk factors including BMI [36].However, like the NHS DPP, uptake of the NHS Health Checks is lower among minority ethnic groups [19,37].
The reduction of health inequalities in preventative programmes such as the NHS DPP and NHS Health Checks is amongst the key priorities of the NHS [20].NICE guidance and service specifications for both programmes recommend developing culturally adapted interventions to increase uptake amongst populations likely to benefit most including those from minority ethnic groups [38][39][40].Systematic review evidence of primary studies conducted in countries other than the UK, supports the effectiveness of culturally adapted prevention interventions for reducing/delaying the risk of developing T2D and CVD in ethnic minority groups [41][42][43][44].However, the majority of the research exploring culturally adapted prevention interventions for reducing/delaying the development of T2D has been done in minority groups in the US, mainly African or Asian Americans [41,[45][46][47], Latin Americans [48], and Hispanic populations [43].For CVD prevention, most adapted interventions in minority ethnic groups have been conducted in the US and China, and have focused on risk factors such as hypertension and smoking [44].
The growing burden of chronic diseases, specifically T2D and CVD, fuelled by the economic crisis and social inequalities [49], highlight the need for cultural adaptation of preventative interventions to target the specific barriers faced by ethnic minorities (33,34).However, the extent of cultural tailoring of preventative interventions and evaluation in UK settings is unknown and has not been synthesised.As such, there is an evidence gap related to effective cultural adaptation strategies for developing T2D and CVD prevention interventions in minority ethnic groups [44].
The aim of this scoping review is to report the extent to which barriers, enablers and culturally adapted lifestyle interventions (diet or physical activity) intended to prevent or delay the onset of T2D have been explored in people from an ethnic minority background in the UK.In order to gain a greater insight into this area, it is also necessary to draw on culturally adapted lifestyle interventions implemented to prevent related chronic diseases such as CVD and Obesity which have the same predisposing lifestyle risk factors i.e., poor diet and physical inactivity.The objectives of this review are to: (1) report the barriers and enablers to intervention uptake, participation, and completion of diet and physical activity behaviour change interventions among minority ethic groups in the UK and link these to the COM-B behavioural change framework [50]; (2) describe the adapted interventions and link these to a cultural adaptation framework [51] and behaviour change techniques [52].

Intervention Components
At the core, DPPs are behaviour change interventions targeted at dietary and physical activity behaviours [56,57].Therefore, lifestyle interventions with a diet and/or physical activity component with the aim of improving health outcomes, and which describe deliberate strategies used to enhance cultural relevance, were included.Diet components of interventions were defined as the manipulation of food or dietary intake directly (e.g., provision of food or nutritional supplement) or indirectly (e.g., nutrition education).Physical activity components of interventions were defined as the manipulation of physical activity directly (e.g., provision of exercise classes) or indirectly (e.g., education).The diet or physical activity components could be the sole focus of the intervention or delivered in conjunction with other components.As the national rollout of the NHD DPP in England was initiated in 2016, evidence on adaptations of the English DPP is anticipated to be low.Therefore, this review will include diet and physical activity interventions beyond those solely focused on diabetes prevention (e.g., those focused on CVD or Obesity prevention).

Information Sources
The following databases were searched from January 2013 to January 2023: MEDLINE, Embase, PubMed Central and Cochrane Library.Since the NHS DPP was nationally introduced in 2016, the date range allowed for inclusion of preliminary studies.Published studies, of any design, were considered for inclusion.Commentaries and non-empirical papers were excluded.Reference lists of all included articles were hand searched to check that all relevant papers are included.

Search Terms and Search Strategy
The search strategy was developed with a health librarian.Medical Subject Headings (MesH) terms from the National Library of Medicine were used to conduct the search and terms selected based on the population, intervention components and country.Search results were limited by language (English), Country (UK) and the last 10 years.

Study Selection
Initial title screening was conducted by TKC.Two reviewers then independently screened titles and abstracts (TKC and KK/JHP/SSO/CS/RC) followed by full text screening.Any uncertainties or disagreements about eligibility were resolved through discussion with a third reviewer.To be included, studies needed to meet all three inclusion criteria specified in A, one or both criteria specified in B, and none of the exclusion criteria:

Exclusion Criteria
Review articles; meta-analyses; studies conducted outside of the UK; and articles in languages other than English.

Data Charting Process
The following data were extracted by two independent reviewers (TKC and KK/JHP/SSO/CS/RC) and recorded on a standardised excel form.

Collating, Summarizing and Reporting the Results
The focus of this review was on identifying and describing interventions or programmes that included cultural adaptations for the prevention of T2D and related conditions (CVD and Obesity) and barriers and enablers to engagement.Therefore, only a brief description of clinical outcomes (where reported) is provided.

mapping Barriers and Enablers
Barriers and enablers identified from the included studies were mapped onto the COM-B (Capability + Opportunity + Motivation = Behaviour change) theoretical model to understand and categorise key factors influencing engagement in minority ethnic groups [59].The central principle of the COM-B model is that for any behaviour to occur there must be 'capability (C)' to do it; 'opportunity (O)' for it to occur; and enough 'motivation (M)' to perform it.Three reviewers (TKC, KK and RC) collectively mapped the barriers/enablers to the COM-B.Any disagreements/uncertainties were resolved by a fourth reviewer (FN).

Mapping Cultural Adaptations to Behaviour Change and Adaptation Framework
To guide understanding of the theoretical underpinning of adaptations used to date, adaptations to interventions identified were linked to specific Behaviour Change Techniques (BCT's) identified from a taxonomy of 93 Behaviour Change Techniques [50,52,59].BCT's are the active ingredient of an intervention (strategies) that can be used to change behaviour [52].Examples include goal setting, action planning, feedback, prompts and cues.Two reviewers (KK and RC) independently mapped the intervention adaptations.Any disagreements/uncertainties were resolved in consultation with TKC and/or FN.Adaptations linked to specific BCT's were reported within the six dimensions of the conceptual framework for tailoring prevention interventions [51]: Cultural adaptations; Cognitive adaptation intervention; Affective-motivational adaptation; Environmental adaptation; Adaptations of program content and Adaptations of program form effectiveness.

Synthesis of Results
Mapped barriers/enablers and cultural adaptations are presented in a narrative summary to summarise the characteristics of the included articles.

Search Results
A total of 13,670 records were identified, from which 2,271 duplicates were removed.Following initial title and abstract screening against the eligibility criteria, a total of 11,252 were removed before obtaining full text.One hundred and forty-one full text articles were retrieved of which 23 were eligible.The search process is presented in the PRISMA flow diagram in Fig. 1.

Study design and Characteristics
Twenty-three studies in total were included in the review, 14 reported barriers and enablers only, four reported the design and delivery of culturally adapted interventions, and five reported barriers and enablers in relation to a specific adapted intervention (see Table 1).

Barriers and Enablers
Barriers and enablers influencing the uptake or implementation of diet and physical activity behaviour change, were mapped onto the COM-B model [50] (See Table 2).For both barriers and enablers, the COM-B components most frequently mapped were Social or Physical Opportunity (e.g., prioritisation of social and cultural commitments), Reflective Motivation (e.g., conflicts between religious beliefs and health practices) and Psychological Capability (e.g., understanding the intensity of physical activity needed to achieve health benefits).The following sections will provide a description of specific barriers and enablers that studies reported as influencing engagement in lifestyle changes for each COM-B component.The components are arranged in descending order, according to the number of studies that reported related factors.

Social Opportunity [60-78]
Amongst South Asian communities, the high frequency and lengthy duration of social events (e.g., weddings, ceremonies etc.) associated with consumption of food high in fat and sugar, was cited as a barrier to making lifestyle changes.These events, integral to South Asian culture, were prioritised over other activities such as exercise.Social norms in relation to gender roles and expectations were also cited as a barrier.For women, the expectation to prioritise family and domestic responsibilities, limited time available to engage in structured physical activity.Men felt they could not make healthy dietary decisions as it was the role of the women to shop for groceries and prepare food.
Religious and cultural norms amongst South Asian, African and African Caribbean communities (alongside their British background) were also cited as important determinants.For example, adherence to some religious beliefs (e.g., forbidding alcohol consumption and moderate food consumption) was cited to promote a healthy lifestyle, whilst other religious practices (e.g., fasting) were seen as potential barriers to maintaining regular attendance   Gender roles and expectations • Domestic pressures and expectation for women to prioritise family and domestic duties (e.g., family care and cooking) leading to lack of opportunity to participate in physical activity/sports • Lifestyle change was seen as particularly difficult for women, the demands of family life and work were prioritised above selfcare • Social restriction for women in some communities e.g., Bangladeshi • The tendency for women in the family to be the main cooks, affecting the ability for men to make changes to diet and leading to a perceived lack of control over their food shopping and preparation and participation in physical activity.The prescription of modesty in some cultures and religious beliefs also meant that women were less likely to participate in lifestyle interventions with mixed genders.Availability of intervention sessions for specific genders, e.g., women-only exercise facilities, was viewed as an important enabler.Socio-economic challenges were cited as barriers for engaging in lifestyle interventions, particularly amongst African and African Caribbean participants.Experiences of racism, prejudice and discrimination were viewed to have a direct effect on socio-economic positioning, health status and well-being.Such experiences were seen to have a direct effect on participants willingness to engage in health promotion activities.In addition, the pressure of adverse social circumstances, e.g., unemployment, affected capacity to engage in behaviour changes.As such, consideration of socio-economic circumstances including access to employment, relevant education, health care and good housing, with equality and fairness was seen as a catalyst to enabling participation in lifestyle interventions.

Physical Opportunity [60-63, 65-78]
Location and session timing were important determinants, where delivery of interventions in convenient and trusted local facilities (e.g., places of worship) and ease of access as part of usual routines (e.g., physical activity/exercise venues adjacent to schools) facilitated engagement.The use of local and informal settings such as homes and places of worship, were important for facilitating a safe, culturally acceptable and trusted space.
Engagement in positive dietary and physical activity changes was constrained by financial insecurity and poverty stresses.The cost of public transport was frequently cited as a barrier to accessing interventions.Environmental barriers included poor weather limiting outdoor activities, high number of fast-food outlets and availability of cheap (highly processed) food near peoples' homes.The provision of free or subsidised exercise facilities/sessions, access to affordable and nutritious food and safe and well-maintained environments were seen to incentivise participation.

Reflective Motivation [60-63, 65-71, 73-78]
Barriers and enablers mapped to this category, were shaped by reflections on self-perceptions, and social, cultural and religious experiences and beliefs (reported under Social Opportunity).Cited barriers included lack of confidence (e.g., a negative perception of appearance while exercising), fear of exacerbating pre-existing health conditions, and for women, concerns of personal safety whilst exercising outside the home or travelling to intervention venues.Purposeful social grouping was therefore important.The motivational effects of sharing attempts at health promoting activities with family, friends and community peers were identified as important for both engagement and promoting greater confidence amongst participants.
Religious views about disease (e.g., diabetes) were sometimes stated as a barrier.For example, an external locus of control in which illness was perceived as 'God's will' or a punishment as the result of sin or karma, and for which a health intervention would not change the outcome.In South Asian communities, the higher prioritisation of academic achievement over sports engagement during childhood and adolescence, was cited as a barrier.These are important considerations when developing interventions for secondgenerationversus first generation participants.In addition, except for yoga, there is limited exposure to health promotional messages for physical activity for older generations who primarily watch Asian television channels.

Psychological Capability [60-63, 66, 70-78]
The lack of knowledge about UK physical activity guidelines and how to exercise at required intensities, was stated as a barrier which led to a mismatch between participants and health professionals conceptual understanding and contextualisation of physical activity.Thus, clearly defining the intensity of physical activity needed to achieve health benefits, including real-life examples was identified as a key enabler.
Education and health literacy (e.g., a good understanding of T2D, its complications, risk factors and the role of diet and physical activity in reducing its effects) was identified as an important enabler for engaging in heathy behaviour changes especially amongst older generations in Sikh and Hindu communities.
A lack of culturally appropriate dietary advice was a barrier to knowing how to make appropriate dietary changes.Traditional food plays a central role in South Asian, African and African Caribbean communities.It is considered by some to be part of their ethnic identity.The exclusion of their traditional foods in conceptualisations of what constitutes a healthy diet was perceived by some as a form of social exclusion, where only White British values and beliefs about healthy lifestyle are promoted.Thus, the provision of appropriate education and advice that reflected participants identity, values and beliefs and displaying positive images and information supportive of such beliefs and values were important for encouraging change.
Automatic Motivation [66, 70-74, 76, 78] Fear of consequences including diabetes, medication, and diabetes complications were motivators to lifestyle changes.Socio-economic disadvantages and challenges were associated with feelings of anger and disrespect and negatively affected the willingness to participate in lifestyle interventions.In addition, for migrant African ethnic minorities using health promotion services, the presence of mainly English-speaking health care providers and the lack of translators added to anxiety and discomfort.References to other cultures and beliefs during recruitment, sessions, and engagement strategies were seen to promote cultural acceptance leading to participants feeling comfortable, safe, happier, and less isolated.
Physical Capability [61,63,65,71,72,78] The lack of intervention resources in different languages including health providers and health information, limited attendance in lifestyle interventions especially for African migrants.The lack of experience in how to exercise at an intensity that is moderate or vigorous was cited as a barrier, as was co-morbidities which hindered undertaking physical activities.

Linking Cultural Adaptations to Behaviour Change Techniques
The following sections provide a description of intervention adaptations which have been linked to strategies known to influence change (BCT's) [52].The adaptations and their strategies have been grouped and reported within dimensions of a framework of cultural adaptations [51] (See Table 3).

Affective-Motivational Adaptation and Cultural Adaptations
Affective-motivational adaptation and cultural adaptations were the most frequently reported dimensions of the adaptation framework.Cultural adaptations are defined as tailoring the intervention to meet a community's worldview and lifestyle.Affective-motivational adaptations include those related to gender, ethnic background, values, traditions, religious background, and socioeconomic status.Adaptations in these categories primarily utilised strategies such as using credible sources, social support and/or restructuring the social environment.For example, five of the nine reported interventions matched participants ethnic background, culture, traditions and language with that of the intervention provider.Other adaptations considered religious and cultural backgrounds by deleting foods on information leaflets deemed as taboo to Muslims (e.g., pork and ham) [80,81] and providing women only intervention sessions [74].The family influence in South Asian families was integrated by providing social support in the form of recruiting family clusters, specifically the family cook, instead of targeting just the individual.Two interventions, one of which was conducted in a deprived area, also considered participants' socio-economic status by providing a material incentive in the form of free or subsidized access to intervention activities.
Environmental Adaptations [53,57,60,64,[69][70][71][72] Seven interventions included environmental adaptations which relate to ecological aspects of the community primarily aimed at restructuring the physical and social environment.Adaptations included intervention delivery in venues which were local, convenient, and familiar (e.g., community halls).Other adaptations restructured the social environment by intervention delivery in venues associated with participants values and beliefs (e.g., religious venues).Social support was provided by credible sources which participants viewed as non-judgemental (e.g., home or nongym settings).One intervention [67] used prompts/cues as a strategy of recruitment prioritising telephone over postal communication.

Cognitive Adaptations and Adaptations of Program Content [53, 59, 64, 69-72]
Adaptations of program content involve the adapting visuals, examples, scenarios, and activities.Cognitive adaptations involved tailoring information processing characteristics such as language and age/developmental level.Five studies included cognitive and program content adaptations, with the PODOSA trial reporting the most adaptations.These adaptations included 1) modification of participants traditional high-calorie dishes to meet nutritional recommendations while retaining their original appearance, flavour and textures; 2) modification of information leaflets to match participants spoken language; 3) tailoring pictorial and written examples of physical activity and diet leaflets (e.g.Swapping 'Western foods' with traditional South Asian dishes such as chapati with lamb and spinach); 4) tailoring patient information leaflets on diabetes from literal to spoken language, (e.g., diabetes also called sugar disease).The strategies behind these modifications primarily worked to highlight the discrepancy between current and behavioural goal, provide participants with instructions on how to perform a behaviour and provide information about health consequences from a credible source by restructuring the social environment and adding objects to the environment e.g., pedometers.

Adaptations of Program Form Effectiveness [67, 80, 81]
Adaptations of program form effectiveness involves altering the program structure and goals, which have a potential

Discussion
This review reports the extent to which barriers, enablers and culturally adapted lifestyle interventions (diet or physical activity) intended to prevent or delay the onset of T2D and related conditions (i.e., CVD and Obesity) have been explored in UK minority ethnic populations.This review was conducted in the context of low uptake and completion rates amongst minority ethnic groups in English nationwide interventions for preventing diabetes and CVD [19,32,33,37].The findings show that in the recent decade, studies in this population have largely focused on exploring barriers and enablers, rather than culturally adapting interventions [76,78].
Our scoping review has highlighted barriers and enablers related to social opportunity (i.e., social norms and cues that can encourage or discourage behaviour change) and reflective motivation (high cognitive processes, such as beliefs, values and goals) [50], as strong determinants of behaviour change for UK minority ethnic groups.Our findings align with previous UK research which identified social norms and values in South Asian, African and Caribbean communities' cultures as important enablers to engagement in lifestyle and self-management programmes [83,84].For example Moore et al., reporting the development of a culturally sensitive self-management support programme for people diagnosed with T2D for UK African and Caribbean communities [84], also found that even in the presence of adequate levels of knowledge, motivation to perform healthy diabetes-related self-management behaviours may be limited by specific cultural beliefs and cultural/social norms.The integral role and influence of social and cultural experiences and beliefs amongst South Asian, African and African Caribbean communities therefore needs adequate consideration when tailoring interventions for UK minority ethnic populations.
Our scoping review has highlighted three key strategies for addressing social and cultural barriers to engagement for minority ethnic groups including: using credible sources (e.g., matching participants ethnic background and language with that of the intervention provider); providing social support (e.g., family, peers, mentors); and restructuring the social environment (e.g., deleting foods on information leaflets deemed as taboo to Muslims).Such strategies aim to meet the community's worldview and lifestyle as well as consider participants gender, ethnic background, values, traditions, religious background, and socioeconomic status [51].Our findings reflect those of a 2024 systematic review, which although focused on diabetes prevention programmes with no geographical restrictions, also highlighted social support and the implementation of culturally appropriate programmes that considered specific needs, values and preferences of diverse populations as the most common mechanisms that increase engagement [85].
A key recommendation from this review would therefore be for UK interventions aimed at preventing T2D and related conditions to incorporate engagement strategies aimed at both addressing the highlighted social and cultural barriers.A 2023 narrative review of evidence from the NHS DPP highlighted that despite existing service specifications recommending adapting intervention to local population, there were still shortfalls in addressing the needs of diverse populations, including minority ethnic groups [86].A separate qualitative evaluation described current efforts of adapting the programme, which largely focused on providing developed course materials in different languages, as inadequate for increasing equity of access.Although our scoping review has identified a few barriers within psychological capability (e.g., language and health literacy) and enablers (e.g., dietary advice accommodating a more diverse and international food diet), there is a strong indication that strategies to address barriers related to social and cultural aspects are stronger determinants of behaviour change for UK minority ethnic groups even in the presence of adequate knowledge [84].
Physical opportunity, which encompasses environmental cues and resources, such as time or money, has also been identified as an important determinant for participation among UK ethnic minorities.Our previous work undertaken in a largely White British population, indicated physical opportunity (i.e., convenient location and flexible intervention session times e.g., evening classes) to be the most important determinant for engagement in the NHS DPP [87].However, rather than focusing on location proximity, the findings of this review emphasise that for minority ethnic groups, strategies that focus on other aspects of physical opportunity such as culturally acceptable, trusted and safe venues and locations are more important for positive behaviour change.In addition, the design of such strategies would need input from community or religious leaders/champions with adequate understanding of settings considered as a safe and culturally acceptable.
Our scoping review has also highlighted the importance of considering socio-economic positioning when developing interventions for minority ethnic groups in the UK.This resonates with previous research which has highlighted the relationship between ethnicity and socioeconomic status [88,89].Highlighted strategies resonates with other research which suggest using adaptations to address economic barriers and financial constraints including the provision of incentives such as free/affordable programmes and monetary rewards [85].However, implementing such strategies is a UK context where programmes such as the NHS DPP and NHS Health checks are already nationally funded, would need to utilise different approaches e.g., providing food vouchers to support maintenance of healthy diets.
Finally, an important finding in this review is the need to consider the role of social experiences (e.g., racism and discrimination) that foster mistrust and lead to disengagement, in efforts to increase uptake in lifestyle intervention for minority ethnic groups.This scoping review suggest using more person-centered strategies to intervention delivery, which aim to build trust and understanding, could be vital for continued engagement.However, more work needs to be done to explore how this could be delivered within context that largely implement group-based interventions.

Strengths and Limitations
This is the first scoping review to identify barriers and enablers to uptake and engagement in diet and physical activity interventions for UK minority ethnic groups and consider potential strategies for cultural adaptations.The review provides recommendations for strategies to promote uptake, based on empirical evidence and theoretical underpinning.The incorporation of behaviour change theory provides a base for developing culturally tailored interventions for preventing T2D and related conditions in UK ethnic minority populations.The findings of this review, although primarily focusing on the UK setting, could be relevant for consideration in other high income European countries where DPPs are provided (e.g., Finland) including.A limitation of the study is the low representation African and African Caribbean populations in the included studies.Ethnic minority groups comprise 18% of the UK population, with Asian ethnic groups comprising 9.3% of the population followed by Black ethnic groups (4.0%) [90].Most studies included in this scoping review have been conducted in South Asian populations, highlighting limited evidence for African and African Caribbean populations [83].In addition, most research to date has focused on English cities with the greatest diversity (i.e., London, Leicester, Manchester) [91].However, with recent [91] expansion of ethnic communities across other regions in England and Wales [91], it is important to ensure that research exploring diabetes prevention extends beyond these cities to many formerly non-diverse regions and also targets other high risk groups including Black African and African Caribbean ethnic groups [83].

Conclusion
A theory-informed examination of barriers and enablers to engagement in lifestyle interventions amongst UK minority ethnic groups has identified the central role of family, culture, beliefs, and socio-economic circumstances in determining behaviour change.The findings have identified the most impactful strategies for behaviour change as those providing information from credible sources and social support as well as restructuring the social and physical environment.This can be implemented by delivering interventions in environments considered by participants to be local, convenient, safe and culturally acceptable.Important research gaps include investigating tailored prevention interventions for African and African Caribbean populations and exploration of the influence of negative social experiences e.g., racism and prejudice on engagement with diabetes prevention interventions. the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
[58] Barriers and enablers or cultural adaptation.(1)Exploringculturaladaptation of lifestyle interventions defined as modifications that are responsive to the cultural needs of a local community and tailored to a cultural group's traditional world views[58].Interventions were considered culturally tailored if indicated in the text and/or if the cultural tailoring/adaptation