Obesity is a global pandemic that is particularly problematic in the US [1]. Nationally, the risk of obesity for men and women is approximately 35% with the greatest prevalence and most rapid rates of increase noted among minority populations [2].  Obesity increases the risk of many other non-communicable diseases (NCDs) including coronary artery disease, diabetes, cancers, osteoarthritis, hypertension, and depression.

Although some refugees are obese prior to resettlement, particularly those from Iraq [3], refugees in general are more often underweight or at a normal body mass index (BMI) upon arrival in the US.  While some weight gain may be beneficial in those who are underweight, many refugees are gaining more weight than needed, resulting in an increased risk of chronic disease.  Previous studies in immigrants have demonstrated a trend towards higher BMI and elevated cardiovascular risk factors after 10 years of residence in the US with rates of obesity approaching that of US-born individuals after 15 years [4, 5]. The trend towards increased BMI is mostly due to dietary changes [6].

A recently completed longitudinal study of 356 refugees from Southeast Asia, Africa, and the Middle East documented significant weight gain for all three groups over a two-year timeframe.  Refugees from the Middle East had a significantly higher BMI on arrival (mean = 27) than those from Southeast Asia and Africa (mean = 21).  However, refugees from Southeast Asia and Africa experienced more rapid increase in BMI during the study period (1 BMI point increase per 3-month period).  This may have a significant clinical impact given that an increase in 1 BMI point in someone who is 5’6’’ corresponds to a six-pound weight gain [7].

Other research on refugees resettled in the US has demonstrated increased rates of chronic disease, including rates of obesity (46.8%) and hypertension (22.6%) [8] with other studies confirming the increased incidence of NCDs.  These studies have demonstrated that in certain refugee populations in the US, the prevalence of NCDs is now higher than that of infectious diseases, traditionally among the most prevalent disorders noted in refugees [3, 9].

Targeted public health interventions should be implemented for all refugee populations within the first year after arrival to decrease the risk of weight gain or poor growth and the complications that follow.  These interventions should include monitoring weight and height for all refugees and BMI for all those 2 years and older at the initial domestic health assessment as well as during follow-up visits. In addition, clinicians should provide education on healthy nutrition and referrals to nutrition support programs such as Women, Infants, and Children (WIC). Given the multi-factorial nature of obesity and the myriad of competing priorities facing healthcare providers, collaborations with public health advocates, resettlement agencies, community organizations, and governmental organizations are most likely to result in long-term success in addressing obesity among refugees.

Contributed by:

Marc Altshuler, M.D., Kevin Scott, M.D., and Beth Careyva, M.D.

References
1. Popkin BM, Adair lS, Wen Ng S. Global nutrition transition and the pandemic of obesity in developing countries. Nutrition Reviews 2011;70(1):3-21.
2. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of Obesity and Trends in the Distribution of Body Mass Index Among US Adults, 1999-2010. JAMA. 2012; 307(5): 491-497.
3. Ramos M et al. Health of Resettled Iraqi Refugees: San Diego County, California, October 2007–September 2009. MMWR. 2010; 59(49): 1614-1618.
4. Sanghavi Goel M, MCarthy EP, Phillips RS, Wee CC. Obesity among US immigrant subgroups by duration of residence. JAMA 2004;292(23):2860-2867.
5. Koya DL, Eged LE. Association between length of residence and cardiovascular disease risk factors among an ethnically diverse group of United States immigrants. SGIM 2007; 22:841-846.
6. Barcenas CH, Wilkinson AV, Strom SS, Cao Y, Saunders KC, Mahabir S, Hernandez-Valero MA, Forman MR, Spitz MR, Bondy ML. Birthplace, years of residence in the United States, and obesity among Mexican-American adults. Obesity 2007; 15(4): 1043-52.
7. Careyva B, Mills G, LaNoue M, Bangura M, de la Paz A, Gee A, Patel N. The impact of living in the United States on refugee patients’ body mass index scores. Submission pending.
8. Dookeran NM, Battaglia T, Cochran J, Geltman PL. Chronic disease and its risk factors among refugees and asylees in Massachusetts, 2001-2005. Prev Chronic Dis 2010;7(3):A51. http://www.cdc.gov/pcd/issues/2010/may/09_0046.htm
9. Chinitz D. International Health and Aid Policies: The Need for Alternatives. JAMA. 2012;308(8): 819-820.