A Systematic Examination of Food Intake and Adaptation to the Food Environment by Refugees Settled in the United States^,,,

Abstract

The United States is the largest refugee resettlement country in the world. Refugees may face health-related challenges after resettlement in the United States, including higher rates of chronic diseases due to problems such as language barriers and difficulty adapting to new food environments. However, reported refugee diet challenges varied, and no systematic examination has been reported. This study examined refugee food intake pre- and postresettlement in the United States and differences in intake across various refugee groups. We systematically reviewed relevant studies that reported on refugee food intake and adaptation to the US food environment. We searched PubMed for literature published between January 1985 and April 2015, including cross-sectional and prospective studies. Eighteen studies met inclusion criteria. Limited research has been conducted, and most studies were based on small convenience samples. In general, refugees increased meat and egg consumption after resettling in the United States. Changes in refugee intake of vegetables, fruits, and dairy products varied by socioeconomic status, food insecurity, past food deprivation experience, length of stay in the United States, region of origin, and age. South Asians were more likely to maintain traditional diets, and increased age was associated with more conservative and traditional diets. Despite the abundance of food in the United States, postresettlement refugees reported difficulty in finding familiar or healthy foods. More research with larger samples and follow-up data are needed to study how refugees adapt to the US food environment and what factors may influence their food- and health-related outcomes. The work could inform future interventions to promote healthy eating and living among refugees and help to reduce health disparities.

Introduction

Refugees are individuals who reside outside of their home country because of suffering, feared persecution, violence, and/or war. According to the United Nations Refugee Agency, there are 59.5 million forcibly displaced people worldwide (1). The United States is the largest refugee resettlement country, with an allocation of 70,000 admissions for the fiscal year 2015 (2).

Research indicates that US refugees have elevated rates of chronic diseases, including obesity, diabetes, hypertension, malnutrition, and anemia (3–5), compared with US-born residents or first-generation immigrants (6). Rates of chronic diseases vary within and across refugee groups by sex, region of origin, and length of stay in the United States (7–9). These health disparities may be attributable to refugee food intake and postresettlement as well as food-related acculturation. However, very limited research has examined dietary intake and health outcomes in postresettlement US refugees.

Refugees face many health-related challenges on arriving to the United States. First, refugees encounter language barriers: they need time to acculturate to unfamiliar language and food environments in the United States (10). Second, refugee beliefs and home-country culture, in conjunction with postresettlement socioeconomic status (SES; which is often lower), influence what types of food can be purchased and consumed (11). Third, limited information about foods, shopping, and recipes in the United States creates another barrier to purchasing healthy foods (12). Fourth, high intake of processed and energy-dense foods in the United States contributes to chronic disease risk (13). Indeed, refugee food intake and adaptation to the US food environment is a complex phenomenon.

In addition, there is limited understanding of what factors influence postresettlement food intake and how to best promote refugee health and nutrition. Given the national priority of eliminating health disparities (14), health promotion and empowerment of postresettlement refugees in the United States is necessary.

This study comprehensively examined food intake including status, changes, and adaptation to the food environment among refugees living in the United States based on published research. Specifically, we described refugee current food groups, knowledge and perception of foods in the United States, their changes after resettlement, challenges in food insecurity, ability to locate familiar foods, adaptation to food preparation environment in the United States, and differences in food intake between refugees from different countries of origin.

Methods

Literature search strategies.

We searched PubMed to identify original studies published between 1 January 1985 and 31 April 2015, evaluating food intake and adaptation to the food environment by refugees living in the United States. We used key words including “refugee,” “nutrition,” “diet,” “food,” and “United States.” The initial search yielded 80 articles, which were reviewed by two coauthors and resulted in 18 articles meeting inclusion criteria.

Study inclusion and exclusion criteria.

Studies meeting the following inclusion criteria were included in the review: 1) published in English, 2) studied US refugees, and 3) reported results regarding refugee dietary intake. Our study exclusion criteria included the following: 1) not relevant to refugee dietary intake and 2) studied refugees in other countries.

Data extraction.

We extracted information, including study sample descriptions, settings, and the study year. Outcome data varied across studies. FFQs and focus group discussions were considered useful measures of food intake and adaptation to the food environment, respectively. Three coauthors carried out the literature search and data extraction.

Results and Discussion

Main characteristics of the included studies

Study design.

The 18 included studies consisted of 17 cross-sectional studies and 1 cohort study (Table 1). Eleven studies recruited refugees by snowball (using existing subjects’ acquaintances) or purposive sampling, and 7 studies randomly selected participants. Only 3 studies included >200 participants; 10 included <50 participants. Studies were conducted since 1985, and most (14 studies) were reported over the past decade (Supplemental Figure 1).

TABLE 1.

Main characteristics of the 18 studies included in this study regarding refugees’ food intake¹

Author, year (ref)	Study design2	Sampling method	Time of data collection	Region of origin or race	Current US living area	Sample size	Sex	Age, y	SES	Time lived in or acculturation to the United States
Dharod, 2015 (15)	II, FFQ	Snowball	Jun 2010 to Jul 2011	Montagnard (Vietnam)	North Carolina	42	F	Mean: 40 y	No formal education: 60%; household income ≤$500/mo: 39%; no health insurance: 66%; SNAP: 66%	Poor English proficiency: 88%
Anderson et al., 2014 (16)	SQ via FG, FFQ	Purposive3, snowball	Jul–Oct 2002	Sudan	Atlanta, GA	49 (households)	M, F	Child ≤3 y in each house; others: 68.9% from 21 to 30 y	Food insecurity: 37%; reported child hunger: 12%	Lived in the United States <4 y: 89.8%
Haley et al., 2014 (17)	FG, II	Snowball	NA	Burma	Worcester, MA	18	M, F	20–40 y	NA	NA
Peterman et al., 2013 (18)	FG, SQ	Random	Apr–May 2007 (FG);Sep–Nov 2007, Apr–Jun 2008 (SQ)	Cambodia	Lowell, MA	11 (FG); 160 (SQ)	F	30–65 y (FG); 35–60 y (SQ)	≤1 y of education: 24%; high school: 21%; employed: 58%; above the federal poverty rate: 15%; food security rate: 24%; current FSP: 30%	Lived in the United States: 19.3 ± 7.04 y; acculturation score5: 2.1 ± 0.7
Dharod et al., 2013 (19)	SQ via II, FFQ	Snowball	Oct 2006 to Dec 2007	Somalia	Lewiston, ME	195	F	Mean: 33.6 y	No formal education: 49%; mean household income<$1000/mo; food insecurity rate: 67%; current SNAP: 92%; current WIC: 75%	Poor English proficiency: 72%
CDC, 2011 (20) and Cuffe et al., 2014 (21)	Intervention study	Random	Dec 2007 to Nov 2008; Jun 2009 to Jan 2011; Sept 2010 to Jan 2011; NA	Bhutan	Minnesota, Utah, and Texas	99; 141; 326; 49	M, F	15–50 y; 17–65 y	NA
Peterman et al., 2011 (22)	FG, SQ, 24-h dietary recall	Random	2007–2008	Cambodia	Lowell, MA	11 (FG); 150 (SQ)	F	35–60 y	Education ≤1 y: 23%; some education: 54%; high school: 23%	Acculturation score5: 2.1 ± 0.7; lived in the United States: 18.7 ± 7.7 y
Vue et al., 2011 (23)	FG	Purposive3	NA	Hmong	Northern California	15	F	19–37 y	Living in low-income community	All speak English well
Rondinelli et al., 2011 (24)	FG, II	Random	Dec 2006 to Mar 2007	Afghanistan, Ethiopia, Iran, Iraq, Russia, Somalia, Sudan, Vietnam	San Diego County, CA	16 (refugees resettled in the United States; other nonrefugees were included)	M, F	37–54 y	<High school: 37%, no college degree	Lived in the United States: 3.0 y (interquartile: 1.3–4.0 y)
Peterman et al., 2010 (25)	FG, SQ	Random	End of 2010	Cambodia	Lowell, MA	11 (FG); 133 (SQ)	F	35–60 y	<High school: 82%	Acculturation score5: 2
Hadley et al., 2010 (26)	FG, SQ	Snowball through local resettlement agency	2006	Sierra Leone, Liberia, Ghana, Somalia, Togo, Russia (Meskhetian Turk)	Midwest of the United States	281	M, F	18–84 y	≥1 y of education: 79%; currently employed: 61%; household income <$500/mo: 25%; current FSP: 53%	Able to read English: 56%; lived in the United States: 8.0 ± 2.3 y
Patil et al., 2009 (27)	FG, SQ	Purposive3	NA	Mixed6	NA	157	F	18–74 y	≥High school education: 50%; household income <$1000/mo: 48%; current FSP: 50%; current WIC: 47%; currently employed: 59%
Willis and Buck, 2007 (28)	II, SQ, 3-d 24-h food diary	Purposive3	Jun 2005 to Feb 2006	Sudan (Dinka or Nuer)	NA	31 (II); 29 (SQ)	M, F	20–49 y	Some college and above: 42%; unemployed: 35%	Lived in the United States <5 y: 55%
Hadley and Sellen, 2006 (29)	SQ, FG	Snowball	NA	Liberia	Northeastern United States	33	F	Mean: 35.9 y	≥High school: 51%; <$1000/mo: 60%; food insecurity rate: 85%; child hunger: 42%; FSP: 51%; WIC: 54%; currently employed: 48%	All subjects had lived in the United States <5 y
Barnes and Almasy, 2005 (30)	II	Snowball	NA	Bosnia, Cuba, Iran	NA	31	M, F	19–71 y	High school: 65%; some college: 23%; employed in low-paying job: 58%	Fluent English: none; lived in the United States: 2.8 y (3 mo to 5 y)
Rairdan and Higgs, 1992 (31)	II	NA	NA	Hmong	Spokane, WA	13 (households)	M, F	NA	NA	NA
Story and Harris, 1989 (32)	II (including itemized food consumption)	Randomly selected from a school list	June 1984	Hmong, Cambodia	NA	60	M, F	28–69 y	Husbands employed: 23%; wives employed: 17%; FSP: 73%; WIC: 42%	All subjects had lived in the United States <5 y
Story and Harris, 1988 (33)	SQ (including itemized food consumption)	Randomly selected from Southeast Asian refugee high school students	Fall 1985	Vietnam, Hmong, Cambodia	Minneapolis, MN	207	M, F	High-school age; grades 10–12	No father at home: 56.5%; no mother at home: 34.5%; youth employed part time: 8%	All subjects had lived in the United States <5 y

¹FFQ, Food Frequency Questionnaire; FG, focus group interview; FSP, food stamp program; II, individual interview; NA, not available; ref, reference; SES, socioeconomic status; SNAP, Supplemental Nutrition Assistance Program; SQ, survey questionnaire; WIC, Supplemental Food Program for Women, Infants, and Children.

²Except for one intervention study (20, 21), all were cross-sectional studies.

³Purposive sampling: a nonrepresentative subset of some larger population under very specific characteristics or purpose.

⁴Mean ± SD (all such values).

⁵Acculturation was measured by using a scale that focuses on cultural orientation and values rather than behaviors or proxies for acculturation. The scale ranges from 1 to 5, with 1 representing identifying only with natives and 5 representing identifying only with Americans (10).

⁶Liberia, Ivory Coast, Burundi, Ethopia, Somalia, Kenya, Russia (Meskhetian Turk) (FG); Liberia, Somalia, Russia (Meskhetian Turk) (SQ).

Research methods and assessment of dietary intake.

Seven studies used qualitative approaches and included group or individual interviews. Five studies used dietary records (i.e., 24-h recall, FFQ, or food diary) to quantify the amount and/or frequency of foods consumed. Six articles used survey questionnaires without direct measurements of refugee food intake.

Participant characteristics.

Ten articles studied Southeast Asian refugees (Burma, Bhutan, Cambodia, Hmong, Vietnam), 4 articles studied African refugees (Sudan, Somalia, Liberia), and 4 articles had mixed samples of Southeast Asian, African, Middle Eastern, and Caribbean origin. Participants in 6 studies lived in the eastern United States (i.e., Massachusetts, Maine, Atlanta, and Minnesota); the remaining lived in California, Washington, Texas, and the Midwest.

Ten studies included both males and females, and 8 studies included females, exclusively. Three studies included children, while the majority included adults only (83%). Most study participants had low SES. Rates of participation in government-supported nutrition programs (i.e., Supplemental Food Program for Women, Infants, and Children, Supplemental Nutrition Assistance Program, etc.) were 30–92% as reported in 7 studies.

Among the 11 studies reporting length of stay in the United States or acculturation scores, most participating refugees had low acculturation or had lived in the United States <5 y. Most refugee participants [except 1 study (23)] were unable to speak or write in English. Interpreters assisted in data collection.

Main study outcomes.

The studies covered food intake–related topics, including major foods consumed, food preferences, food culture, and nutritional problems (i.e., food insecurity, vitamin deficiency, unhealthy eating behaviors,unfamiliarity with available foods in the United States, and obesity). Additional outcomes included the level of conservativeness (i.e., about traditional meals from the country of origin) and the need for knowledge and advice pertaining to healthy nutrition.

Changes in food intake between pre- and postresettlement in the United States

Seventeen studies described food intake changes after resettlement in the United States. After resettling, refugees increased energy intake with more consumption of meat, eggs, high-fat food, fast food, and soft drinks. Consumption of vegetables, fruits, and dairy products, however, exhibited discrepancies (see Tables 2 and 3).

TABLE 2.

Main research topics and findings of the 18 studies included in this study regarding refugees’ food intake¹

Author, year (ref)	Region of origin or race	Main research topics	Main findings	Direction of food intake changes
Dharod, 2015 (15)	Montagnard (Vietnam)	Characteristics of major food groups	Intake of meat, eggs, and dairy products increased, but plant protein, bean, and lentil intake decreased after resettlement (P ≤ 0.05 for all)	↑: chicken, pork, beef, egg, dairy products
			Those who experienced preresettlement hunger or received ≥$500/mo in SNAP were 3 times more likely to have high meat intake (P ≤ 0.05 for all)	–: fruits, vegetables
Anderson et al., 2014 (16)	Sudan	Food insecurity and its association with food expenditure and low-cost and/or high–nutrient density food consumption	Caregivers in food-insecure households reported significantly lessfrequent consumption of highcost foods (breakfast cereal, milk and dairy products, vegetables) but more frequent consumption of fresh meat than those in food-secure households (P < 0.05 for all)	↓: breakfast cereal, milk, other dairy products, vegetables in those with food insecurity
			Caregivers in households with child hunger consumed more servings of starchy cereals (rice, maize, pasta, semolina, couscous, maize porridge, noodles) and green leafy vegetables than those in food-secure households (P < 0.05 for all)	↑: fresh meat in those with food insecurity
Haley et al., 2014 (17)	Burma	Needs pertaining to nutrition and exercise information	There was difficulty finding foods that were familiar or that they knew were healthy	–: retained familiar food items and healthy foods
			They did not eat food that they were not used to
Peterman et al., 2013 (18)	Cambodia	Food insecurity issues in those with depression and lower income and acculturation scores	The risk of food insecurity increased with depression (OR: 3.7; 95% CI: 1.3, 11.1) and decreased with higher income (OR: 0.3; 95% CI: 0.1, 0.9), and higher acculturation scores (OR: 0.5; 95% CI: 0.2, 1.0)	–: retained familiar food items and healthy foods
		Difficulties transitioning to the US food environment	Those arriving in the United States in the 1980s had challenges with the shopping environment and anxiety around food, but those arriving in the United States in the 1990s–2000s easily found many Cambodian stores in the United States
Dharod et al., 2013 (19)	Somalia	Food insecurity and its association with meat, fruit, and vegetable consumptions and overweight and obesity	Food insecurity was associated with 80–82% lower consumption of fruits and green leafy vegetables (P < 0.05 for all)	↑: meat, eggs in those with child hunger
			The risk of child hunger increased with household consumption of egg (OR: 21.2; 95% CI: 7.8, 57.3) and meat (OR: 11.2; 95% CI: 1.4, 89.2) ≥1 time/d	↓: fruits, vegetables in those with household food insecurity
			Insecure families had poor dietary habits and high overweight and obesity rates (41% overweight, 24% obesity; P < 0.05 for all)
CDC, 2011 (20) and Cuffe et al., 2014 (21)	Bhutan	Vitamin B-12 deficiency and its related food intake	Past shortage of meat, egg, and dairy products in Nepal caused vitamin B-12 deficiency	↑: meat, eggs, and dairy due to CDC supplementation program
			After the intervention, 58% showed improvement in the vitamin B-12 blood test
			85% reported consuming more vitamin B-12–rich food
Peterman et al., 2011 (22)	Cambodia	Fruit, vegetable, and whole grain consumption and its association with levels of education and acculturation	Those with a higher education or acculturation or receiving nutrition advice were more likely to consume more fruits, vegetables, brown rice, and whole grains (P < 0.05 for all)	↑: fruits, vegetables, whole grains in those with higher acculturation scores in the United States and higher education level
			High-acculturation group seldom ate Asian sauce (P < 0.01)	↓: Asian sauce in those with higher acculturation scores
			Adolescent dietary preferences were influenced by American peers
			Fast food eaten ≥2 times/mo: 44% of families with children vs. 13% of those without children (P < 0.01)
Vue et al., 2011 (23)	Hmong	Perceptions about Hmong and American food culture	Rice was the main item for satiety and fresh ingredients of the Hmong diet	–: rice, fresh ingredients, especially in older generations
			Fast food and convenience foods changed their dietary habits because of convenience and low price
			Limited dietary changes among the elderly, while children’s diets were affected by television; much less consumption of traditional food among young generations
			They had many food options and an abundance of food available, and individuals could eat by desire (vs. need or hunger-only) in the United States
			Most of them were aware of increased rates of overweight and obesity among refugees
Rondinelli et al., 2011 (24)	Afghanistan, Ethiopia, Iran, Iraq, Russia, Somalia, Sudan, Vietnam	Factors influencing nutritional problems: past food deprivation, low acculturation or SES, unfamiliarity with available foods	The past food shortage, low acculturation or SES, and lack of knowledge contributed to poor eating habits and overeating after resettlement in the United States as food became more widely available	↑: overeating in those with previous food insecurity
			They were concerned about weight gain after resettlement in the United States
			A few felt uncomfortable with fruits and vegetables not typically in season and a large variety of food
			American culture and neighborhood environment influenced children’s food choices and physical exercise
Peterman et al., 2010 (25)	Cambodia	The association between past food deprivation or insecurity and the risk of unhealthy eating practices and being overweight or obese	93.6% of the respondents did not consume whole grains on the reference day	↓: whole grain
			Those with higher past food deprivation were more likely to eat high-fat meat (OR: 1.1; 95% CI: 1.0, 1.3) and to be overweight or obese (OR: 1.2; 95% CI: 1.0, 1.4)	↑: high-fat meat in those with previous food insecurity
Hadley et al., 2010 (26)	Sierra Leone, Liberia, Ghana, Somalia, Togo, Russia (Meskhetian Turk)	Difficulties in navigating the food environment	Difficulties in shopping (46%), cooking (63%), knowing store locations (40%), locating preferred foods (40%)
		The association between food insecurity and levels of income and education	The probability of food insecurity was inversely associated with household income (β: −0.28; SE: 0.13; P = 0.04) and having ≥1 y education (β: −0.98; SE: 0.49; P = 0.05)
			Those who had difficulties locating food stores were more likely to have food insecurity (OR: 2.5; P < 0.05)
Patil et al., 2009 (27)	Mixed2	Mechanisms of diets change in newly arrived refugees and immigrants by amount of time spent in the United States	The Liberians increased consumption in almost all food categories, especially in meat (86.1%), milk (84.2%), vegetables (78.2%), fruits (76%), and soda (72.3%)	↑: meat, milk, vegetables, fruits, soda in all groups
			The length of stay in United States was associated with more consumption of seasonings, hot drinks, vegetables, added sugar and sweets, oils, and milk	↑: seasoning, hot drinks, vegetables, sugar and sweets, oils, milk, and soda in those with higher acculturation scores
			The length of stay in the United States by Liberian caretakers was associated with their children’s fruit consumption
			Children of caretakers with difficulty speaking English were more likely to consume sodas and snacks and less likely to consume fruits
Willis and Buck, 2007 (28)	Sudan (Dinka or Nuer)	Refugees’ limited understanding of healthy US food and its impact on nutrient deficiency and related diseases	Fruit and vegetable intake did not meet the dietary guidelines and also decreased after reset-tlement in the United States	↓: fruits, vegetables, milk
			They had an unbalanced diet:	↑: high-protein foods (meat, egg, fish), high-starch foods, easy American foods, fast food, sweetened beverages
			No fruit (63% Nuer F, 56% Nuer M, 46% Dinka M)
			No raw or steamed vegetables (50% Dinka F, 46% Dinka M)
			No milk (38% Nuer F, 33% Nuer M, 54% Dinka M)
			Easy American and convenience foods (75% of energy resource among Dinka)
			All refugees shopped at American supermarkets, but they did not know the food items well
			They were unfamiliar with the US foods and their recipes but still consumed convenience foods and sweetened beverages in large quantities
			They found an abundance of food in the United States and were concerned about weight gain after resettlement in the United States
			Children did not prefer eating traditionally prepared food
Hadley and Sellen, 2006 (29)	Liberia	Household food insecurity and child hunger and associations with foods stamps, income, and education levels	Child hunger was significantly higher in a family with low income, low education, and food stamps (P < 0.01 for all)	↓: fruits, milk in children with hunger
			Daily intake of milk (P = 0.10) and fruits (P = 0.07) were marginally lower among households with child hunger
Barnes and Almasy, 2005 (30)	Bosnia, Cuba, Iran	Knowledge and perceptions of nutrition and healthy behaviors	They reported eating better since their arrival in the United States (F: 60%, M: 38%)	↑: energy, fat (hamburgers and French fries, etc.), sugar, and sweets
			All Cubans mentioned the abundance of available food in United States
			They perceived themselves to be consuming too much energy (60%), sweets (50%), or fats (19%), which increased after arriving in United States; 55% were overweight
Rairdan and Higgs, 1992 (31)	Hmong	Diet preference of natural and fresh foods without fertilizer and processed with preservatives	Hmong still ate their traditional foods of rice and vegetables accented with chicken, pork, fish, and beef	–: rice, vegetables (retained traditional diet)
			Hmong preferred to eat natural, fresh foods that had not been grown with or processed with preservatives	↑: carbonated beverages, fruit juices
			Some drank carbonated beverages or fruit juices as a substitute for water
Story and Harris, 1989 (32)	Hmong, Cambodia	Strong ties to native foods and traditional diets and their variation by age	Increased consumption of a variety of foods (see next column) except rice, oil, fresh vegetables, and tea (P < 0.05 for all)	–: rice, oil, fresh vegetables, and tea
			Most-preferred foods among adults: rice (100%), steak (97%), oranges (92%), bananas (90%), and apples (82%)	↑: sweets (soft drinks, candy, etc.), fats, dairy products, proteins, grains and starches, fruits, canned fruits and vegetables, frozen vegetables, coffee
			Least-preferred foods: cheese (53%), chocolate milk (48%), milk (38%), coffee (32%), and pizza (20%)	↓: fish
			42% of adults believed their children need to eat native food
			83% of adults preferred Hmong or Cambodian food
			75% of teenagers preferred both native and American food
			88% felt their diets in the United States were healthier than their diets in Southeast Asia
			The mean weight gain was 4.54 kg among 63% of respondents since resettling in the United States
Story and Harris, 1988 (33)	Vietnam, Hmong, Cambodia	Strong ties to native foods and traditional meals	Best-liked foods: all Asians, rice (88.8%); Cambodians, orange juice (57.4%); Hmong, chicken (77.6%), apples (75%), and bananas (64.7%); Vietnamese, soda (60.3%)	Like: rice, orange juice, chicken, apples, bananas, soda; dislike: cheese
			Disliked food: cheese (40.8%)
			Fruits: consumed regularly (i.e.,oranges or orange juice daily: 50%)
			Pizza and hot dogs weekly: 40%
			Sweets weekly: 50%
			Fast food: 30.6% Hmong, 18.9% Cambodians, and 13.3% Vietnamese
			Preferred their native foods: 38% Hmong, 91% Vietnamese, and 85% Cambodians
			Desired more American foods: 80% Hmong, 35% Vietnamese, and 43% Cambodian

¹ref, reference; SES, socioeconomic status; SNAP, Supplemental Nutrition Assistance Program; ↑, increase; –, no change; ↓, decrease.

²Liberia, Ivory Coast, Burundi, Ethiopia, Somalia, Kenya, Russia (Meskhetian Turk) from focus group interview; Liberia, Somalia, Russia (Meskhetian Turk) from survey questionnaire.

TABLE 3.

Patterns of changes in dietary intakes of the refugees between post- and preresettlement in the United States¹

	Increased, post- vs. preresettlement	Studies reporting increases, n	Decreased, post- vs. preresettlement	Studies reporting decreases, n
Energy	Hmong (23), Liberian (27), mixed (30), mixed2 (24)	4	NR	0
Nutrients
Fat	South Asian (32), mixed (30)	2	NR	0
Food groups
Dairy products	Bhutanese (20), Montagnard (15), mixed (27)	3	Liberian3 (29), Sudanese2 (16), South Asian (32), Sudanese (28)	4
Eggs	Somalian3 (19), Montagnard (15), Bhutanese (20), Sudanese (28)	4	NR	0
Fast foods	Sudanese (28), mixed (30)	2	NR	0
Fruits	Cambodian4 (22), South Asian (32), Liberian (27)	3	Liberian3 (29), Somalian2 (19), Sudanese (28)	3
High-starch foods5	Sudanese (28), Sudanese3 (16)	2	NR	0
Meats	Bhutanese (20), Cambodian2 (25), Liberian (27), Montagnard (15), Somalian3 (19), Sudanese2 (16), Sudanese (28)	7	NR	0
Soft drinks6	Hmong (31), Liberian4 (27), South Asian (33), Sudanese (28), mixed (32)	5	NR	0
Sweets and candies	Liberian4 (27), South Asian (32), mixed (30)	3	NR	0
Vegetables	Cambodian4 (22), Liberian (27), Sudanese3 (16; green leafy vegetables only)	3	Somalian2 (19), Sudanese (28), Sudanese2 (16)	3
Whole grains	Cambodian4 (22)	1	Cambodian (25)	1

¹Results are based on reviewing all 18 studies, and only some studies reported on some of the food groups and nutrients. NR, not reported by the identified studies.

²Subject to past or current food insecurity.

³Subject to child hunger.

⁴Subject to acculturation or length of stay in United States or education level.

⁵Rice, maize, pasta, semolina, couscous, maize, porridge, noodle.

⁶Mainly sugar-sweetened beverages.

Energy intake.

Liberian and Hmong refugees reported increased overall food consumption in the United States (23, 27). In a study of Bosnian, Cuban, and Iranian refugees, 60% reported consumption of excessive energy, in general: 50%, too many sweets and 19%, too much fat (30). Cuban, Cambodian, and Hmong refugees indicated that an abundance of available food (18, 23, 30) and a variety of cuisines in the United States (23) compared with near-starvation and restricted food availability in regions of origin and/or refugee camps contributed to excess food consumption (23).

Increased consumption of food items.

The most common foods with increased consumption were meat, eggs, and high-fat meat or fat, reported in 9 studies (15, 16, 19–21, 25, 27, 28, 30, 32). There were several reasons for elevated meat consumption: meat was more accessible, refugees worried about the high cost and reduced satiety of vegetables, and there were concerns about timely use of food stamps and the ability to keep foods fresh (15, 18, 29). For example, Sudanese caregivers in severely food-insecure households consumed affordable fresh meat more frequently but higher-cost and nutritious foods, such as milk and other dairy products, less frequently (P < 0.05) than those in food-secure households (16). This was additional evidence that government-supported nutrition programs, including food stamp provision, may have side effects on refugee health, diet, and food intake (34, 35).

Somalian refugee intake of eggs (OR: 21.20; 95% CI: 7.83, 57.34) and meat ≥1 time/d (OR: 11.21; 95% CI: 1.41, 89.19) was higher among households with child hunger (19). In addition, one study showed that a supplementary program for B-12 deficiency resulted in increased refugee consumption of meat, eggs, and dairy products (20, 21). Finally, a fairly common finding was that the consumption of sweets, sweetened beverages, fruit juices, and fast food increased in refugees after US resettlement (27, 28, 30, 31–33). The longer refugees lived in the United States, the more likely they were to consume added sugars, oils, seasonings, hot drinks, and vegetables (P < 0.05) (27).

Discrepancies in food items consumed.

Changes in refugee consumption of vegetables, fruits, and dairy products varied across studies. Specifically, Liberian, Somalian, and Cambodian refugees increased vegetable, fruit, whole-grain (22, 27, 32), and dairy consumption (15, 20, 21, 27), and they reported believing that vegetables and fruits were good for health (32). In addition, refugee caretakers reported increased fruit consumption in children with increased time in the United States (27). Refugees with household food insecurity reported lower intakes of vegetables, fruits, milk, dairy, and whole grains (16, 19, 29). For example, household food insecurity among Somali refugees was significantly associated with 80–82% lower consumption of fruits (OR: 0.18; 95% CI: 0.05, –0.67) and green leafy vegetables (OR: 0.20; 95% CI: 0.08, 0.51) (19).

Four studies reported no change in consumption of fruits or vegetables after US resettlement because of a preference for traditional diets (15, 23, 31, 32). Refugees also reported beliefs that children should consume native food (27, 32) to preserve culture (16, 23). In particular, South Asian refugees from Hmong, Burma, Cambodia, and Vietnam had strong ties to native foods (17, 32, 33). However, Cambodian adolescent dietary preferences were influenced by American peers (22). One study found that most adults preferred a traditional diet, whereas teenagers preferred a combination of native and US foods (32).

In summary, the majority of refugees experienced food intake changes after US resettlement. The amount and direction of changes varied based on refugee characteristics such as age, region of origin, past food deprivation experience, current SES, food insecurity status, and length of stay in the United States.

Challenges adapting to the US food environment

Food insecurity.

Eight studies addressed food insecurity, and 7 investigated its association with sociodemographic factors. Food insecurity rates varied across the 4 studies, ranging from 24% (18) to 85% (29) (see Table 4). These studies indicated low income, low education, low acculturation, shorter length of time in the United States, and language barriers as major factors leading to food insecurity among refugees. Further, refugees lacking knowledge about food outlet locations were 2.5 times more likely to report food insecurity (26). Depression was also associated with food insecurity among refugees (18).

TABLE 4.

Challenges in dietary intakes of the refugees after they resettled in the United States¹

Food insecurity	Varied food insecurity rates
	Cambodian: 24% (18), Sudanese: 37% (16), Somalian: 67% (19), Liberian: 85% (29)
	Major factors associated with food insecurity in the United States
	Depression: Cambodian (18)
	Low income: Cambodian (18), Liberian (29), Somalian (19), Sudanese (16), mixed (26)
	Low education: Liberian (29), mixed (26), Somalian (19), Sudanese (16)
	Limited access to employment: Liberian (29), Sudanese (16)
	Lack of knowledge in locating food outlets or in navigating food environments: Liberian (29), mixed (26)
	Short length of time spent in or low acculturation to the United States: Cambodian (18), Liberian (29), Somalian (19)
	Language barrier: mixed (26), Somalian (19), Sudanese (16)
	Consequences of past (in home country or refugee camp) or current food insecurity
	Overeating: mixed refugee groups (24)
	Consumed more starchy cereals and green leafy vegetables: Sudanese (16)
	More-frequent consumption of fresh meat: Cambodian (25), Somalian (19), Sudanese (16); of eggs: Somalian (19)
	Less-frequent consumption of dairy products: Liberian (29), Sudanese (16); of vegetables: Burmese (17), Somalian (19), Sudanese (16); of fruits: Burmese (17), Liberian (29), Somalian (19)
Difficulties locating familiar foods in the United States	Difficulties finding stores with desired food items: Cambodian (18), Liberian (29), mixed (26)
	Difficulties finding foods that were familiar or that they knew were healthy: Burmese (17), Liberian (29), Sudanese (16)
	Missed their own fruit or vegetable garden: Bosnian (30), Burmese (17), Cambodian and Laotian (32); own rice paddy: Cambodian and Laotian (32); own livestock: Cambodian and Laotian (32)
Unfamiliar with food items and food preparation in the United States	Unfamiliar with recipes of American foods: Liberian (29), mixed (26)
	Unfamiliar with ingredients of food items in packages: Sudanese (28)
	Uncomfortable with the fruits and vegetables not typically in season: mixed (24)
	Uncomfortable with pasteurized foods or preservatives: Hmong (31)

¹Results are based on reviewing all 18 studies; only 8 studies reported about food insecurity.

Difficulties in locating familiar foods.

Although the US food environment provides a myriad of food choices, Burmese refugees, especially during the initial US resettlement period, had trouble locating familiar or healthy foods (17). In a study of Liberian refugees, child hunger was most likely to be present in households in which mothers reported difficulty navigating and understanding the American food environment (29). In addition, 63% of refugees reported not knowing how to cook American foods, and 40% reported difficulties finding stores with desired foods (26).

Nevertheless, the level of difficulty in adapting to the US food environment was inconsistent across studies and refugee groups. In one study, although 12% of refugees reported difficulty locating desired foods, the majority reported that locating preferred foods was unproblematic (27). Difficulties navigating the food environment varied by arrival date in the United States. For example, Cambodian refugees arriving to the United States in the 1980s faced challenges providing acceptable meals for themselves in the new shopping environment: this unfamiliar US food led to anxiety around food. However, Cambodians arriving in the 1990s and 2000s found familiar foods in Cambodian stores that had emerged in the United States (18).

Uncomfortable within the US food preparation environment.

Despite the abundance of food, not all refugees reported comfort with the food preparation environment in the United States. For instance, while all Sudanese respondents shopped at American supermarkets, most indicated discomfort or unfamiliarity with ingredients in packaged foods (e.g., bread) (28).

South Asian refugees reported discomfort with foods that were pasteurized or contained preservatives (31). Refugees were uncomfortable with the availability of fruits and vegetables not typically in season; most had never seen such a variety of food in their lifetime (24). Because most refugee families in Cambodia, Laos, Bosnia, and Cuba owned rice paddy lots, vegetable gardens, and/or livestock, they were accustomed to conveniently and readily accessing seasonal fruits, vegetables, grains, and fresh protein (17, 30, 32). These families reported challenges finding desired foods in the United States.

Public health implications

Overconsumption and obesity.

Several researchers reported issues pertaining to refugee food overconsumption. Liberian refugees reported increased food consumption after resettling in the United States (27). Although unfamiliar with American foods, Sudanese refugees reported 75% of total energy from high-protein, high-starch, or convenience foods. They also consumed sugar-sweetened beverages in large quantities and fewer than recommended fruits and vegetables (28). Hmong respondents reported that access to fast and convenience foods changed their dietary habits (23). Patil et al. (16) found that meat and dairy comprised a greater portion of total daily energy in the United States (12% and 10.4%, respectively) than in Liberia and Somalia (≤3% for both).

One study found that, given increased availability and accessibility to food, multiple refugee groups consistently overconsumed (including high-fat meats) in the United States, which was likely associated with past food deprivation in the country of origin (24). For example, Cambodian refugees with higher past food-deprivation scores were more likely to report eating fatty meats (OR: 1.14 for every point increase on the 9- to-27-point food-deprivation measure) (25).

This type of unhealthy diet (e.g., convenience and fast foods, fatty meats, and sugar-sweetened beverages) was associated with refugee overweight and obesity (25). Several studies reported refugee concerns about excessive energy intake (30), overweight, and obesity (19, 23–25, 28, 30). Indeed, they were aware of the expanding waistlines in their communities. Only 1 study addressed underweight and vitamin B-12 deficiencies among refugees (20, 21).

Perceptions and knowledge of healthy diet.

Several studies investigated whether refugees perceived foods in the United States compared with home country as healthy and whether they had accurate knowledge about healthy diets (see Table 5). This information may inform future interventions.

TABLE 5.

Future research needs for better food adaption among refugees resettled in the United States¹

Concerning overconsumption and obesity	Increased food consumption in almost all food categories: Liberian (27)
	Increased consumption of high-protein and high-starch foods, sugar-sweetened beverages: Sudanese (28)
	Consumption of convenience and fast foods in large quantities: Sudanese (28), mixed (30)
	Increased overweight and obesity: Cambodian (25), Hmong (23), Somalian (19), Sudanese (28), mixed (24, 30)
Perceptions and knowledge of healthy diet	Not aware of or wanted to learn the healthy food in the American grocery stores or how to prepare American meals: Burmese (17), Liberian (29), Sudanese (25), mixed (26)
	Considered that foods or diets improved since arrival in the United States: mixed (30, 32)
	Considered their diets less healthy after resettlement in the United States: Hmong (23), Sudanese (16), mixed (30)
	Foods perceived as healthy—fruits: mixed (30); vegetables: mixed (30, 33); oranges: mixed (33); food items with less fat and/or sugar: mixed (30); small food portion size: mixed (30); boiled water: Hmong (31); whole grains: Cambodian (25); beef: mixed (33); chicken: mixed (33); traditional or native diets: Hmong (23), Sudanese (16) [including Asian fruits, Asian vegetables, Asian herbs: Cambodian (22); including rice: mixed (33)]; fresh, natural, and wholesome ingredients: Hmong (23), mixed (30); minimal use of fat and meat: Hmong (23); without use of preservatives: Hmong (31)
	Foods perceived as unhealthy—high energy food: mixed (24); fat: Cambodian (25); sugar: mixed (30); dairy products: mixed (33); soda: Burmese (17); fast food: Cambodian (25); smoking: Burmese (17); tap water: Hmong (31)
What refugees need in the United States and from intervention programs for healthy eating	Cooking classes, or knowledge of the healthy food items and their recipes in the United States: Burmese (17), South Asian (32), Liberian (29), Sudanese (28), mixed (26)
	Understanding of their neighborhood environment: Liberian (29), mixed (24, 26, 27)
	Knowledge of how to best use resources including food stamps: Cambodian (18), Liberian (29), Montagnard (15)
	Information about how to participate in exercise: Burmese (17), mixed (30)
	Health care providers’ help with their diet: Cambodian (25)
	Support with the cost of fruits and vegetables: Hmong (23), Somalian (19), Sudanese (16), mixed (30)

¹Suggestions are based on our review and interpretation of findings from all 18 studies.

Healthy foods.

Burmese refugees reported neither knowing which foods were healthy in US stores nor how to prepare meals with those foods (17). Multiple refugee groups wanted to learn more about healthy foods in the United States (17, 26, 28, 29). In 2 studies, refugees reported improvements in diets since US resettlement (30, 32); however, more refugees considered US diets less healthy than preresettlement diets (16, 23, 30, 31). Perceived healthy foods included fruits (30), oranges (33), vegetables (30, 33), whole grains (25), beef (33), chicken (33), boiled water (31), and foods with less fat and sugar (30) or small portion size (30). South Asian refugees believed that traditional diets (16, 23) were healthy because they included less meat and more vegetables (23), Asian fruits and vegetables, Asian herbs (18), and rice (33). More than two-thirds of Hmong refugees reported Hmong food to be healthier than American food because of the frequent use of fresh ingredients, minimal use of fat and meat (23), and no preservatives (31).

Unhealthy foods.

Refugees considered high energy, fat (25), sugar, dairy products (33), tap water (31), soda (17), and fast food (25) to be unhealthy. Further, they believed American food choices were unhealthy because they were less “natural” or “wholesome” (30); however, they acknowledged US foods as more cost beneficial (27, 30, 32). One article reported refugees’ believing dairy products were unhealthy because they can gain fat from dairy products (33).

Health knowledge-behavior gap.

Even when refugees had knowledge about healthy diets and physical activity, they did not necessarily translate knowledge into healthy behavior. One study reported that only 13% of refugees studied felt they ate generally healthy diets in the United States (30). They also reported difficulties locating preferred foods (24, 27, 29). Lack of healthy food options in the past shaped their dietary habits and food choices poorly after resettlement (24). For example, 32% of Bhutanese refugees had vitamin B-12 deficiencies, likely due to a scarcity of meat, eggs, and dairy in their Nepal diets (20).

Participants reported wanting to change diets with health care providers’ help, but they also indicated they would not voluntarily limit high-fat meat intake (25). In addition, several researchers found that refugees were unfamiliar with preventive health care, although they expressed a desire to improve dietary knowledge (36–38).

Insights for future study and intervention.

Several studies collected self-reported refugee needs. Data suggested that refugee health and nutrition could be improved by learning: 1) what are healthy foods in the United States (17, 26, 28, 29), 2) recipes in the United States (17, 26, 28, 29), 3) food market locations (24, 26, 27, 29), 4) how to participate in exercise (17, 30), and 5) how to utilize resources including food stamps (15, 18, 29). More than half of the Hmong and Cambodian interviewees expressed interest in taking American food cooking classes (32). Future intervention efforts must help educate and empower refugee adaptation to the US food environment.

There are limitations in the current literature regarding refugee food intake after US resettlement. First, available studies are limited by small sample size (<300), variable methodological designs (i.e., type and quality), sampling approaches, data collection, and analyses. Most studies obtained limited data, which is likely because of language challenges and funding constraints. Some studies included multiple ethnic groups yet neither reported specific characteristics of the region of origin nor reported results by regional characteristics. Finally, most studies used convenience sampling; thus, findings may not be representative or generalizable.

Nevertheless, studies of refugee dietary intake provided important information regarding food intake, dietary changes postresettlement, and beliefs and barriers to healthy nutrition among resettled US refugees. Variables influencing between-group and longitudinal differences in postresettlement food intake and needs included SES, age, sex, food insecurity, past food deprivation, length of time in the United States, and region of origin. Future research with strong methodological designs will help us better understand these unique, diverse, and underserved refugee populations.

Our findings have several public health implications. First, there are large between-group differences in dietary intake and needs. Second, changes in food intake and adaptation to US food environments after resettlement vary across age and SES groups. Third, effective and sustainable nutrition and health education programs are needed to help refugees maintain healthy diets and good health. Resettled refugees and their children are likely to become part of the US population. Therefore, promoting health in this diverse, underserved population is a critical component of our national priority to reduce health disparities.

Conclusion

Our comprehensive examination revealed considerable variation in refugee food intake and postresettlement dietary changes in the United States. The patterns varied considerably across refugee groups. Future research is needed to investigate associations between refugee diet changes and related risk factors and health consequences. There is a special need for effective nutrition and public health intervention programs for refugees. To effectively target a critical health disparity in the United States, health promotion programs will need support and coordination from multiple sectors of American society.