Nutrition and Growth

Refugee Health Domestic Guidance

At a glance

During the domestic medical examination, refugees should have a nutrition examination that includes evaluation of anthropometric indices and laboratory testing to determine nutritional status, nutritional counseling, and referrals for treatment, if needed. Refugees with clinical or laboratory evidence of poor nutrition may benefit from a multivitamin or individual vitamin supplementation.

Background

Epidemiology of malnutrition in refugees

There are over 122 million people worldwide who have been displaced; included in this estimate are over 43 million refugees.1 Refugees enter the United States (U.S.) from numerous countries. Prior to arrival, most refugees reside in countries or territories affected by acute food insecurity and malnutrition.2 Even after arrival in the U.S., refugees can face challenges with food security and malnutrition. Studies suggest that many factors, including language barriers, socioeconomic status, cultural concerns, and lack of education on U.S. food purchasing and preparation can have an impact on nutritional status.345

Malnutrition includes both undernutrition (a deficiency of calories or essential nutrients that can be associated with developmental or cognitive delays) and overnutrition (an excess of calories or nutrients that can be associated with chronic medical conditions including hypertension, diabetes, and cardiovascular disease). Many studies of refugee populations evaluate undernutrition (wasting, stunting) before or after resettlement; however, increasingly studies are evaluating overnutrition (overweight and obesity) in refugees.678 The increased research on overnutrition is associated with the urbanization of the refugee experience before and often after resettlement; before resettlement, approximately 78% of refugees live in urban locations without access to humanitarian food programs traditionally provided in refugee camps.9 A systematic review of studies conducted between 2009 and 2020 reviewed the dietary intake and nutritional status of refugees resettled in non-camp settings worldwide. This review reported the prevalence of underweight was between 12% and 41% in refugee children. The prevalence of overweight and obesity varied across the included studies by gender and age, but the overall prevalence of overweight was between 9.1% and 65% and obesity was between 5.8% and 69%.2 Similarly, a cross-sectional analysis of overweight and obesity in U.S.-bound refugee adults between 2009 and 2017 found the prevalence of overweight/obesity increased steadily over the analysis period from 35.7% in 2009 to 44.7% in 2017.6 These estimates underscore the diversity of refugee populations and suggest that refugee populations may increasingly be at risk for both undernutrition and overnutrition.

Overview of Malnutrition

Malnutrition refers to deficiencies or excesses in nutrient intake, imbalance of essential nutrients or impaired nutrient utilization.10 It can be classified into three broad categories: undernutrition, overnutrition, and micronutrient deficiency. Malnutrition affects people across the lifespan with the greatest impact on infants, young children, pregnant people, people with disabilities, and elderly people. Refugees can be at increased risk for malnutrition because of many factors, including food insecurity, limited dietary diversity, increased risk of infection, chronic illness, and variable access to supportive nutrition programs.2

To identify malnutrition, clinicians can evaluate the relationship of anthropometric measurements, including weight and height (or length), to one another based on age and sex assigned at birth. The Centers for Disease Control and Prevention (ÐÇ¿ÕÓéÀÖ¹ÙÍø) and the American Academy of Pediatrics (AAP) recommend use of the World Health Organization (WHO) growth standards charts for children from birth to 2 years of age, and the ÐÇ¿ÕÓéÀÖ¹ÙÍø growth standards charts for children and adolescents from 2 – 19 years of age, to interpret anthropometric measurements. The ÐÇ¿ÕÓéÀÖ¹ÙÍø recommends the use of body mass index (BMI) categories to interpret anthropometric measurements in adults (see comment WHO/ÐÇ¿ÕÓéÀÖ¹ÙÍø growth charts) (Table 1 and Table 2).

Types of Malnutrition:

Undernutrition

Undernutrition can manifest as wasting, stunting, and underweight.

  • Wasting (low weight-for-length (height)):
    Wasting is often associated with acute or severe nutritional deprivation which can result from many factors, including acute significant food shortages11 and infectious conditions.10 Wasting disproportionately affects children younger than 2 years of age.12 It is associated with a higher risk of death if not treated.13
  • Stunting (low length (height)-for-age):
    Stunting is often associated with chronic or recurrent nutritional deprivation. It can affect child development from the early stages of conception until the third or fourth year of life, when the nutrition of the mother and the child are essential determinants of growth.11 Stunting can prevent children from reaching their physical and cognitive potentials.10
  • Underweight (low weight-for-age):
    Underweight is considered a proxy indicator for undernutrition if data on wasting are not available.11 Children who are underweight may experience stunting, wasting, or both conditions.10

Overnutrition

Overnutrition indicates elevated weight-for-height, and it can manifest as overweight or obesity. Overnutrition can increase risk for chronic health conditions including heart disease, stroke, diabetes, and some cancers.

Micronutrient Deficiency

Micronutrient deficiency is an inadequacy in availability of vitamins and minerals that are essential for bodily functions (e.g., proper growth and development) due to underconsumption or challenges with absorption or metabolism (Table 3). People affected by micronutrient deficiencies may have normal anthropometric measurements. Risk for micronutrient deficiency can be increased by many factors, including lack of dietary diversity, insufficient food supply, food supply with insufficient micronutrients, and infectious diseases (e.g., diarrheal illnesses).14

Table 1. Growth parameters defining malnutrition in children (birth to 19 years) in the United States

Table 1. Growth parameters defining malnutrition in children (birth to 19 years) in the United States
Nutrition Category Age birth - 2 yearsa, b

(World Health Organization definitions)

 Age 2-19 yearsc, d

(ÐÇ¿ÕÓéÀÖ¹ÙÍø definitions)
Wasting: low weight-for-length/height Weight-for-length less than-2 standard deviations (SD) of the WHO Child growth standards median  n/a
Stunting: low length/height-for-age Length-for-age less than -2 SD of the WHO Child growth standards median n/a
Underweight: low weight-for-age Weight-for-age less than -2 SD of the WHO Child growth standards median Body mass index (BMI) less than the 5th percentile for sex and age
Overweight/obesity: high weight-for-length/height Weight-for-length greater than+2 SD of the WHO Child growth standards median

Overweight: BMI 85th percentile to less than the 95th percentile for sex and age

Obesity: BMI 95th percentile or greater for sex and age

a. WHO Child Growth standards,

b. WHO Malnutrition in Children,

c. ÐÇ¿ÕÓéÀÖ¹ÙÍø Growth Charts, /growthcharts/cdc-growth-charts.htm

d. ÐÇ¿ÕÓéÀÖ¹ÙÍø Child and Teen BMI categories: /bmi/child-teen-calculator/bmi-categories.html

Table 2. Growth parameters defining malnutrition in adults (> 19 years) in the United States

Table 2. Growth parameters defining malnutrition in adults (> 19 years) in the United States
Nutrition Category Age > 19 yearsa
Underweight Body mass index (BMI) less than 18.5
Overweight/obesity

Overweight: BMI 25.0 to 29.9

Obesity: BMI 30.0 or greater

a. ÐÇ¿ÕÓéÀÖ¹ÙÍø Adult BMI categories: /bmi/adult-calculator/bmi-categories.html

Table 3. Micronutrient Deficiencies

Table 3. Micronutrient Deficiencies
Micronutrient/ (deficiency) Common Signs/ Symptoms associated with Deficiency a Refugee Populations associated with Deficiency
Iron

(iron-deficiency anemia)

 Infants/Children:
  • Impaired psychomotor and mental development,
  • cognitive impairment,
  • negative infant social-emotional behavior

Adults:

    • fatigue,
    • low productivity at work,
    • impairment of reproductive functions
 High rates of deficiency (54% - 85%) reported in refugee children from Syria, Jordan, the West Bank, the Gaza strip, Lebanon, and Thailand (Burmese) East Africa (Kenya), Nepal 15 16 17 18
Vitamin D

(Rickets/ osteoporosis)
  • Muscle weakness,
  • bone pain,
  • joint deformities,
  • bowed or bent bones
 High rates of deficiency reported in refugees from sub-Saharan Africa, Middle East, Asia, 19 20
Vitamin A
  • Poor night vision,
  • Bitot spots (areas of abnormal squamous cell proliferation and keratinization of the conjunctiva),
  • xerophthalmia (corneal or conjunctival dryness),
  • keratomalacia (corneal softening),
  • corneal perforation,
  • permanent blindness
  • Impaired bone growth,
  • dry skin and hair,
  • impaired humoral (antibody-mediated) and cell-mediated immune response (results in increased risk of infection)
 High rates of deficiency reported in refugees in Nepal, North and East Africa (Kenya), and among Iranian, Iraqi, Palestinian and Sudanese refugees in Jordan 15 16 21
Zinc
  • Growth retardation,
  • loss of appetite,
  • impaired immune function
  • hair loss,
  • diarrhea,
  • delayed sexual maturation,
  • impotence,
  • hypogonadism in males (zinc aids in gonad development, testosterone production, and spermatogenesis) 22.
  • Weight loss,
  • delayed healing of wounds,
  • eye and skin lesions,
  • taste abnormalities,
  • lethargy
 High rates of deficiency reported in Burmese refugees in Thailand and refugees of Karen ethnic origin, (from Myanmar) in Thailand 23 24
Vitamin B-12 or Cobalamin Nonspecific symptoms:
  • fatigue,
  • decreased concentration and memory,
  • irritability,
  • depression.

Neurologic symptoms:

  • diminished vibratory sensation and proprioception (ability to sense body movement and position);
  • weakness,
  • numbness or tingling of the extremities,
  • impaired sense of smell,
  • loss of coordination,
  • ataxic (uncoordinated) gait
 High rates of deficiency reported among Bhutanese refugees: 64% at overseas medical screenings and 27% at domestic medical screenings 25
Vitamin B-3 or Niacin/

Tryptophan

(Pellagra)
  • Symmetric photosensitive dermatitis (e.g., Casal's necklace (hyperpigmentation or erythema around the neck),
  • butterfly-shaped rash on the face,
  • "glove-like" rash on hands,
  • diarrhea,
  • stomatitis (inflammation of mucous membranes of the mouth)

Neurologic symptoms:

  • irritability,
  • anxiety,
  • apathy,
  • tremors,
  • peripheral neuritis (inflammation of nerves in peripheral nervous system—outside the brain and spinal cord),
  • dementia 26
 Outbreaks reported among refugees and internally displaced people in Angola, Ethiopia, Malawi, Nepal, Swaziland, Zimbabwe and the former Zaire. 27
Iodine

(Thyroid disease)
  • Impaired mental function,
  • delayed physical development,
  • hypothyroidism,
  • goiter,
  • growth and developmental abnormalities.
 High rates of deficiency reported in populations from South Asia and sub-Saharan Africa 28.

 

 
Vitamin B-1 or Thiamine

(Beriberi)
  • Loss of appetite,
  • constipation,
  • fatigue,
  • irritability,
  • memory loss,
  • peripheral neuropathy (damage to nerves in peripheral nervous system),
  • muscle weakness and pain,
  • areflexia (absence of deep tendon reflexes),
  • foot drop,
  • tachycardia (rapid heartbeat),
  • heart failure
 Outbreaks reported in Cambodian refugees in Thailand; Bhutanese refugees in Nepal; Liberian refugees in Guinea, Eastern Ethiopia and in Djibouti. Refugees in Thailand and SE Asia, camps 29 30 31 32
Vitamin C

(Scurvy)
  • Ecchymoses (bruising or bleeding under the skin),
  • petechiae (pinpoint-sized spots due to bleeding under the skin),
  • bleeding gums,
  • hyperkeratosis (thickening of the outer layer of skin),
  • impaired wound healing

Systemic symptoms:

  • weakness,
  • malaise,
  • joint pain and swelling,
  • edema (fluid retention),
  • depression,
  • neuropathy (nerve damage)
 Outbreaks reported in refugee camps: Somalia, Bhutanese refugees in Nepal, Ethiopia, Kenya, Somalia, and Sudan 33 34.

a. National Institutes of Health (NIH) Dietary Supplement Fact Sheets:

Overseas Pre-Departure Nutritional Screening

Nutritional assessment is not a required component of the overseas pre-departure examination. Prior to departure for the United States, refugee children may have measurements of height, weight, and head circumference (infants) performed. These measurements can be obtained either in the refugee camp setting or during the panel physician examination. The refugee may have records of measures and plots on either local or international standardized growth charts. The records can be located in their "International Organization for Migrations (IOM) bag", the blue and white medical bag containing their health information. When available, these records are useful as an historical record of the child's growth. Depending on the pre-departure setting, measurements from a single point in time, rather than serial measurements, may be the only recorded anthropometric information. Often, refugees who originate in camp settings, especially children, have benefited from supplemental feeding programs, which have resulted in catch-up growth and likely will decrease the degree of acute malnutrition observed in resettled children.35 However, increasingly refugees are not originating from camps but rather from urban settings where they do not receive supplemental feeding or nutrition programs.9

Nutrition Evaluation during the Domestic Medical Examination

RefugeesA should receive a comprehensive examination within 90 days of arrival. The goal of the domestic screening for nutritional status is to identify those with nutritional deficiencies that require further evaluation and/or treatment. In addition, when specific issues in populations are identified (e.g., a report of vitamin B12 deficiency in large numbers of Bhutanese refugees),25 clinicians can provide feedback to the State and ÐÇ¿ÕÓéÀÖ¹ÙÍø authorities. Clinician feedback may lead to initiation of an investigation and possible overseas pre-departure evaluation and/or preventive health interventions.

Prior to conducting the domestic medical examination, clinicians should review overseas medical records for information on pre-departure nutritional assessments. If nutritional screening was conducted overseas during the panel physician examination, nutritional status will be documented in the "Remarks" section of the U.S. Department of State form 3026 (DS-3026: Medical History and Physical Examination Worksheet). Anthropometric parameters will be indicated under the "medical history and exam findings" section of the form. Medical documentation, including form DS-3026 may accompany the refugee and can be accessed electronically through ÐÇ¿ÕÓéÀÖ¹ÙÍø's Electronic Disease Notification system (EDN).

Medical History and Physical Examination

A standard comprehensive medical history will provide important insight into the risk for malnutrition and the etiology for the malnourished state that may be observed in the newly arrived refugee.

Relevant medical history for assessing risk factors and signs/symptoms of nutritional deficiencies includes:

  • Review of Systems: A complete review of systems with particular attention to a history of chronic diarrhea, wasting, weight loss, skin rashes, and vision or hearing difficulties.
  • Past Medical History
    • Birth history (pediatric refugees): any history of fetal growth restriction, prematurity, or small-for-gestational-age birth weight in a setting where catch-up growth may not have been possible due to poor dietary resources. This may lead to a better understanding of the etiology for poor growth parameters and risk for micronutrient deficiencies.
    • Past hospital admissions, surgical procedures, blood transfusions, and major infections such as meningitis, severe malaria, or frequent or severe diarrhea.
    • A history of failure to thrive, hospitalization for nutritional issues, enrollment in a supplementary feeding program, or feeding children with special formulas or packaged foods may indicate known history of malnutrition.
  • Dietary, Family, and Social History
    • Past periods of food insecurity or social and/or economic duress.
    • A history of limited consumption of fruits, vegetables, and meat (depending on cultural norms) may provide insight into access to healthy diversity of foods or cultural or religious food exclusions and may heighten suspicion for micronutrient deficiencies.
    • A history of supplement intake of specific micronutrients, such as vitamin A, iron, or zinc, as frequently provided in many settings in the developing world, may decrease the likelihood of current deficiency.
    • For young children, current or past breastfeeding is important when providing counseling or information to the resettling family.

Anthropometric measurements of weight and height/length should be done on all newly arriving refugees. Accurate measurements of weight, height/length, and age are essential for identifying undernutrition and overnutrition. Criteria for obtaining high-quality data include using the right equipment to collect the data and employing standard measuring techniques.36 For example, children should be weighed in their underwear without shoes. Children under the age of 2 years should lie on a suitable board to have their length measured, and children over 2 should stand up to have their height determined.

To interpret the anthropometric measurements, the AAP and the ÐÇ¿ÕÓéÀÖ¹ÙÍø recommend use of the WHO growth standards charts for children from birth to 24 months of age and the ÐÇ¿ÕÓéÀÖ¹ÙÍø growth standards charts for children from 2 – 19 years of age. ÐÇ¿ÕÓéÀÖ¹ÙÍø recommends the use of body mass index (BMI) to interpret anthropometric measurements in adults (see Table 1 WHO/ÐÇ¿ÕÓéÀÖ¹ÙÍø growth charts).

Physical examination findings associated with malnutrition can include:

  • Dermatologic findings: associated with severe undernutrition: Changes in skin or hair color (depigmentation) or texture (dryness); associated with zinc and niacin deficiency: dermatitis (inflammation of the skin)
  • Skeletal system findings: associated with vitamin D deficiency: bone pain and tenderness, skeletal deformities (e.g., genu varum (bowlegs), genu valgum (knock knees), frontal bossing (prominent forehead), rachitic rosary (costochondral swelling), craniotabes (softening of the skull bones), enlargement of the wrist and bowing of the distal radius and ulna; associated with vitamin C deficiency: poor dentition (can interfere with chewing and exacerbate undernutrition)
  • Neurologic findings: associated with thiamine, niacin/tryptophan or B12 deficiency: Altered proprioception (ability to sense body movement and position) or vibratory sensation, ataxia (impaired balance or coordination), loss of deep reflexes, peripheral neuropathy
  • Cardiac findings: associated with moderate to severe anemia: low-grade cardiac flow-murmur; associated with thiamine deficiency: signs or symptoms of heart failure, such as third or fourth heart sounds, cardiomegaly (enlarged heart), shortness of breath, cough, or edema (fluid retention)

Laboratory Screening

Initial laboratory screening for nutritional status should include the following:

  • Complete blood count (CBC) with differential, including red blood cell indices (see "Laboratory Testing" section of the domestic guidelines).

Iron deficiency anemia and hereditary anemias (e.g., thalassemia and sickle cell disease) can be common in refugees. A CBC can serve as a screening test for anemia. Results may indicate the need for additional evaluation which can be completed in the primary care setting.

Age determination of refugee children

Accurate interpretation of the child's anthropometric measurements and nutritional status requires accurate determination of age. For many refugee children, an accurate age is not known. The age displayed on their legal documentation may be inaccurate (often showing a standardized birth date of January 1), raising concern that the year of birth may also be incorrect.37 This finding could be intentional, or because some cultures do not keep track of dates of birth or age in years. Although the child may appear bigger or smaller than their stated age, if the age is not correct, the weight-for-height should not be affected, since this measurement is not age-dependent.

If concern arises for a discrepancy between observed and recorded age, the provider may use narrative history along with developmental milestones, height and weight (plot on 50th percentile and find matching age), and sexual maturity (when culturally appropriate) to estimate the number of months' difference between the estimated age and official age.38 Narrative history may include the following:

  • Request for/review of records that may show child's age – immunization/health records/school transcripts
  • Location of the family at the time of birth (many refugees can estimate time according to their location)
  • Time of year at birth (winter, summer, wet season, dry season)
  • Age that child was able to walk independently (approximately 1 year, although may vary by culture)
  • Age of the child in relationship to the other children in the family

Dental evaluation may assist in determining approximate age. Traditionally bone radiography has been used in efforts to estimate age. Confounding factors such as past states of undernutrition, inadequate vitamin D and calcium intake, ethnic differences in bone maturation, and/or history of serious illness may all significantly impact the rate of bone ossification and maturation.39 Therefore, use of radiographs to estimate age is discouraged.

Treatment and Prevention

At the domestic medical examination, refugees are referred to primary care for continued preventive healthcare services and to specialists as needed for treatment of health conditions. Malnutrition should be considered, and additional diagnostic evaluation and treatment may be warranted in these healthcare settings. Refugees with clinical or laboratory evidence of poor nutrition may benefit from a multivitamin or individual vitamin supplementation according to published standards of practice.

Nutrition Counseling

Traditional eating habits vary between refugee groups and can change in response to many factors, including new living conditions, increased access to foods, availability of cooking facilities, and cultural adjustment. Adequate medical follow-up and continuity of care after initial screening are important for identifying nutritional and other health issues, monitoring growth and development, and providing preventive services and education. The domestic medical examination is an opportunity for clinicians to encourage healthy eating and continued preventive care and to educate refugees on nutritional resources, including the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and school lunch programs.

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National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
  1. In this guidance, the term refugee is used to refer to all humanitarian-based newcomers eligible for the screening program. Humanitarian-based immigration status applies to refugees (including unaccompanied refugee minors), asylees, Amerasians, Afghan and Iraqi Special Immigrant Visa (SIV) holders, and Cuban and Haitian parolees. Certified victims of human trafficking are also eligible for refugee benefits, including the domestic medical screening (see for additional information on benefits eligibility). Spouses and dependent children of adults with humanitarian-based immigration status are also eligible to receive a domestic medical screening. The provides humanitarian-based newcomers with important resources, benefits, and services to help them become integrated members of American society. These benefits include a comprehensive domestic medical screening.
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