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Immigrant and Refugee Health

Nutrition

Central American Refugee Health Profile

El Salvador, Guatemala, and Honduras have reported high rates of low birth weight in infants (birth weight <2,500g), as well as high rates of malnutrition among infants and children. However, there is an increasing prevalence of overweight and obesity among older children, teens, and adults. This paradox of poor nutrition in early childhood followed by obesity in older children and adults has been described as the “double burden” of malnutrition faced in many developing countries.

Malnutrition

Inequalities and extreme poverty directly affect food security and nutrition, particularly in rural areas of El Salvador. It is estimated that 16.3% of rural Salvadoran families are unable to cover the costs of basic food needs73. Additionally, 18.9% of all children under age 5 experience chronic undernutrition, with 25.6% of children living in rural regions experiencing chronic undernutrition73. Overall, approximately 21% of Salvadoran children are stunted, while 6% are underweight, and 2% are wasted54, 74. It is estimated that malnutrition contributes to more than 30% of all childhood deaths, as chronic undernutrition is known to increase severity of disease54. Micronutrient deficiencies, including vitamin A deficiency, are also common in young children54. 

Rural, indigenous populations in Guatemala are often the impacted by food and economic insecurities. Guatemala has the third-highest rate of stunting, or chronic malnutrition, worldwide55,75. Indigenous populations are disproportionately affected and suffer from malnutrition at twice the rate of non-indigenous children55, 74. Approximately 49.8% of all Guatemalan children are undernourished, while 69.5% of children in rural, indigenous areas are undernourished76. Micronutrient deficiencies are relatively common in Guatemala. A multiyear study revealed that 16% of preschool children are vitamin A deficient77. Iodine deficiency has also been observed, and it is reported that less than 50% of families use iodized salt55.

Poverty is widespread in Honduras, with 75% of the population living in extreme poverty and 12% of households being food-insecure78, 79. As in other Central American nations, stunting and malnutrition remain major concerns, particularly for children living in rural areas. Up to 50% of children in some regions are stunted, and children living in rural areas are 2.5 times more at risk for growth faltering than children who live in urban areas56. Additionally, children in the poorest households are eight times more likely to be stunted than children born to wealthy families56. Chronic malnutrition can be as high as 48.5% in some rural areas78. Micronutrient deficiencies, including vitamin A and iron deficiencies, are common in Honduras and are often observed in young children and pregnant women56

All children between 6 months and 59 months old should be prescribed multivitamins with iron. Older children who are malnourished should also take multivitamins for presumed micronutrient deficiency.

Overweight and Obesity

Although stunting and malnutrition affect large numbers of children in El Salvador, Guatemala, and Honduras, overweight and obesity are growing problems. In Latin America, it is estimated that between 42.5 and 51.8 million children aged 0-18 years are overweight or obese80. Studies indicate that 5% to 6.5%, 13%, and 7.1% of children under 5 years old are overweight or obese in El Salvador, Guatemala, and Honduras, respectively81. To date, few countries have implemented national programs or policies to combat the obesity epidemic in Latin America80.

Overweight and obesity are also increasing among adults, with up to 60% of adults in some Latin American countries classified as overweight or obese82. Furthermore, models predict increases in overweight and obesity in Latin American females and males by 205082. Recent studies indicate that 67% of Guatemalans over 15 years old are overweight, of which 29% of those overweight are obese55, 83. In Honduras, 46% of all people 15 years and over are either overweight or obese56, 83, while 49% of adults in El Salvador are either overweight or obese54, 84. Overweight and obesity, for both children and adults, are largely due to rapid urbanization, adoption of modern Western diets high in refined carbohydrates, saturated fats, and sugars, and increasingly sedentary lifestyles. Additionally, slow progress in improving community infrastructure and public health systems have contributed to overweight and obesity epidemics54, 55, 56, 85.

Children who are overweight (BMI 85th-95th percentile) or obese (BMI >95 percentile) should be followed closely. Overweight or obese children, as well as their family members, should be offered dietary counseling and support86. All children, regardless of nutrition status, should have blood pressure checked starting at 3 years old and followed annually87. Fact sheets and other health promotional materials for healthy eating and physical activity should be shared with all newly arrived patients and family members, regardless of nutritional status upon arrival.

See CDC nutrition-growth guidelines for further recommendations and guidelines regarding nutritional assessment and management among newly arrived refugee children.

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