Household Food Security, Dietary Intake, and Obesity Among a Sample of Recently Arrived Liberian Refugees Receiving Food Assistance

Year: 2005

Research Center: Department of Nutrition at the University of California, Davis

Investigator: Hadley, Craig

Institution: University of Michigan

Project Contact:
Craig Hadley
Robert Wood Johnson Health and Society Scholar Center
for Social Epidemiology
University of Michigan
1214 S. University, 2nd Floor
Ann Arbor, MI 48104-2548
Phone: 734-615-9215


Currently, 10 million individuals in the world meet the United Nation’s definition of a refugee—that is, an individual who is unable to return to his or her country of birth because of a well-founded fear of persecution. Refugees are typically individuals forced to flee their homes because of civil wars and are, therefore, exposed to violence, torture, and loss of family and assets. Each year, approximately 70,000 refugees are eligible to be resettled in the United States through the U.S. Department of State’s refugee resettlement program.

Most research on refugees who have resettled in western countries has focused on physical or mental health status at the time of entry. Studies focusing on other dimensions of health and well-being in the post-resettlement period are, however, lacking, which is unfortunate because many believe that resettled refugees may face barriers to entry into the health care system, quality housing, and quality dietary intake.

This study investigated several dimensions of health and well-being among a sample of West African refugees living in a medium-sized city in the Northeastern United States. The study focused on the social and economic determinants of household food insecurity.

Food insecurity occurs whenever adequate and safe foods are not available or the ability to acquire such foods is limited or uncertain. Conceptually, food insecurity is a more direct measure of inadequate or unreliable dietary supply than is low income because food insecurity more closely taps into the phenomena of interest. Food insecurity represents a public health concern and is a useful index of health and well-being because it is associated with poverty, ill health, poor dietary intake (e.g., low intake of fruits and vegetables), limited social capital, depressive disorders, and, paradoxically, overweight and obesity among females. Refugees resettled from developing countries are hypothesized to be at elevated risk of food insecurity because they initially face high levels of underemployment or unemployment, language barriers, shopping difficulties, and a tremendous shift in the budget and management of household resources. The study’s objective was to test for associations between measures of food insecurity and indicators of economic standing, knowledge, and practice of budget management strategies and measures of acculturation, including language ability and time since arrival.

A variety of ethnographic and survey methods were employed in this study. For the survey, a nonprobability sample was used and 101 West African caretaker-child pairs were enrolled (there were no refusals). At baseline, mean household size was five individuals, one to two of whom were under the age of 5. Caretakers were on average 30 years of age, with a range of ages 18-74. The women had been in the United States for an average of 22 months. Just over one-half of the women (59 percent) interviewed had a high school education or higher, and 57 percent were currently employed. One-half of caretakers reported the mean household income as less than $1,000 per month, and 64 percent reported their own income as less than $1,000 per month. Nearly all caretakers had participated in the Food Stamp Program (FSP) at some point since their arrival (98 percent), and about 48 percent were currently participants.

About 53 percent of caretakers’ responses indicated that they and members of their households had experienced periods of food insecurity during the 6 months before the interview. The 53 percent was comprised of 37 percent who experienced food insecurity with no indication of hunger and 16 percent whose responses to the USDA food insecurity scale indicated food insecurity with hunger. The mean food insecurity score on the continuous scale, indicating severity, was 3.6. The modified USDA scale showed acceptable internal consistency. A majority of caretakers (90 percent) responded that they had experienced food insecurity before arriving in the United States.

In bivariate statistical tests, the occurrence and severity of food insecurity was associated with both economic and sociocultural factors. Households that scored lower on several measures of financial security scored significantly higher on the food insecurity scale. Similarly, respondents who were currently participating in the FSP experienced greater food insecurity. Informal social support appeared to be protective against food insecurity, although the effect was weak. Two measures of acculturation, language use and shopping difficulty, were also associated with greater food insecurity. Respondents who reported difficulty with understanding people and who reported more difficulty shopping scored higher on the food insecurity scale. These bivariate relationships disappeared in a multivariate regression model when the time since arrival in the United States was entered as a factor. This commonly used measure of acculturation was the most important explanatory variable in this study and explained approximately 13 percent of the variation in food insecurity.

Other noteworthy results include:

  • The prevalence of overweight and obesity among caretakers approached 65 percent, which appears to be considerably higher than found in the sending population.
  • Participation in the FSP declined sharply with amount of time lived in the United States.
  • The share of the sample that reported being employed increased sharply with time in the United States.

Although based on a nonprobability sample, findings suggest that food insecurity is an important public health problem in this vulnerable population, particularly during the first year in the United States. The distribution of food insecurity is consistent with theoretically derived predictions and ethnographic reports from caseworkers and refugees. The results also highlight the important role that economics and acculturation appear to play in protecting against food insecurity. Confidence in the results is further enhanced by the concordance between these findings and the limited data from other groups resettled in other industrial countries. From a programmatic standpoint, the results suggest that traditional measures of self-sufficiency, such as employment, may not be reliable indicators alone. Rather, measures of income, coupled with measures of food insecurity, may provide a more accurate picture of the health and well-being of a family. Despite agency objectives of achieving self-sufficiency within the first 6 months, these data suggest that families may still be struggling 2 or 3 years after resettlement.

The prevalence and existence of food insecurity, as identified through qualitative and quantitative methodologies, also suggest that nutrition education programs should be further integrated into the resettlement orientation that all refugees are expected to undergo upon arrival in their new home. The Expanded Food and Nutrition Education Program (EFNEP), through its hands-on didactic approach, may be a useful program to promote money management strategies to ensure that food stamps reach through the whole month. The EFNEP, along with education geared towards dietary change, may improve food insecurity as well as intake of key micronutrients; the latter may be particularly important given high levels of iron deficiency anemia in sending countries. The data on overweight and obesity from this refugee sample also suggest worrisome trends that may be combated through behavioral change programs in the area of physical activity and dietary intake.