Stunting and Overweight Prevalence Among Resettled Yazidi, Syrian, and Iraqi Pediatric Refugees

Abstract

This cohort study compares growth abnormalities between Yazidi and non–Yazidi pediatric refugees.

Pediatric refugees face diverse health issues, including growth abnormalities, that can have serious long-term adverse health consequences for cognition, bone health, blood pressure, and more. In 2014, the terrorist group Daesh committed genocide against Yazidis, an ethnic and religious minority group in Iraq and Syria, displacing an estimated 200 000 people. The Canadian government resettled approximately 1500 Yazidi refugees between 2016 and 2017, prioritizing previously enslaved women and children. Many Yazidi children endured violence and prolonged starvation, yet the prevalence of growth abnormalities among them is unknown. We assessed growth indicators for resettled Yazidi and non–Yazidi pediatric refugees from Syria and Iraq.

Methods

We performed a retrospective cohort study at a specialized multidisciplinary refugee health clinic in Calgary, Alberta, Canada. The University of Calgary Research Ethics Board approved the study and waived the informed consent requirement because data were deidentified and posed minimal risk of harm. We followed the STROBE reporting guideline.

We included consecutive Yazidi patients aged 17 years or younger with intake appointments between March 2017 and October 2018. We created a 4:1 age- and sex-matched comparison group of non–Yazidi pediatric refugees from Iraq or Syria with intake appointments between February 2016 and October 2018. We manually reviewed electronic medical records to extract height, weight, and sociodemographic data.

We identified each patient’s age- and sex-specific growth characteristics according to World Health Organization Growth Charts for Canada at intake and assessed 4 outcomes: stunting, wasting, underweight, and overweight or obese (eTable in the Supplement). We used log binomial regression models to estimate risk differences for each outcome and assessed effect modification by age and sex for each model. A 2-sided P < .05 indicated statistical significance. We conducted statistical analysis using Stata, version 16 (StataCorp LLC), from October 2020 to July 2021.

Results

We included 112 patients in the Yazidi cohort and 449 in the comparison cohort, among whom 287 (51.2%) were girls and 274 (48.8%) were boys, with 407 (72.5%) aged 5 years or younger (Table 1). Overall, 189 patients (33.7%) had 1 or more abnormal growth indicators. Table 2 shows the age- and sex-standardized proportions of each growth indicator for each group and risk differences. We observed no effect modification by age or sex.

Table 1. Sample Characteristics.

Characteristic	Patients, No. (%)
	Overall (n = 561)	Yazidi cohort (n = 112)	Comparison cohort (n = 449)
Sex
Female	287 (51.2)	59 (52.7)	228 (50.8)
Male	274 (48.8)	53 (47.3)	221 (49.2)
Age, y
≤5	407 (72.5)	85 (75.9)	322 (71.7)
>5	154 (27.5)	27 (24.1)	127 (28.3)

Table 2. Proportion and Risk Differences of Growth Indicators in Yazidi and Comparison Cohorts.

Outcome	Patients, No. (%)			Risk difference (95% CI)	P value
	Overall (n = 561)	Yazidi cohort (n = 112)	Comparison cohort (n = 449)a
Stunting	70 (12.5)	21 (18.8)	49 (10.9)	0.08 (0.00 to 0.16)	.048
Wasting	12 (2.1)	NAb	NAb	NAb	NAb
Underweight	28 (5.0)	7 (6.3)	21 (4.7)	0.02 (−0.03 to 0.06)	.50
Overweight or obese	115 (20.5)	12 (10.7)	103 (22.9)	−0.12 (−0.19 to −0.05)	.001

Abbreviation: NA, not available.

^a Comparison cohort represents resettled refugee children from Syria or Iraq.

^b NA refers to data not presented due to cell count of fewer than 5 individuals.

Overall, 70 patients (12.5%) had stunted outcomes. The Yazidi cohort more frequently had stunted outcomes than the comparison cohort, with a risk difference of 0.08 (95% CI, 0.00-0.16; P = .048). A total of 115 patients (20.5%) had overweight or obese outcomes. The Yazidi cohort had less overweight or obese outcomes than the comparison cohort, with a risk difference of –0.12 (95% CI, −0.19 to −0.05; P = .001).

Discussion

Yazidi, Syrian, and Iraqi pediatric refugees had growth abnormalities at resettlement consistent with those described in other studies. The 12.5% of patients with stunted outcomes exceeded the 3% expected in a healthy population. We observed more stunted outcomes among Yazidis, likely due to the premigration atrocities they experienced, including forced starvation. More than one-fifth of the Syrian and Iraqi pediatric refugees had overweight or obese outcomes. Because longitudinal studies have suggested that the prevalence of obesity increases after resettlement in high-income countries, addressing identified weight issues is imperative for pediatric refugees’ long-term health.

The small sample was a study limitation. The health clinic served almost all Yazidi refugees in Calgary; thus, this cohort likely accurately represents a sample of resettled pediatric refugees. Given that few forcibly displaced Yazidi have been resettled, those who remain in refugee and internally displaced camps may have similar stunted outcomes.

These findings expose growth abnormalities among Yazidi and non–Yazidi pediatric refugees in comparable regions and provide knowledge for medical personnel who care for these populations. With only approximately 2% of global refugees resettled, data from this study likely reflect the high prevalence of growth abnormalities among pediatric refugees worldwide. Action to address these growth concerns is critical given their impact on physical and cognitive health.

Supplement.

eTable 1. WHO Growth Indicator Definitions