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Living in the Shadows: When a New Home Means a New Diet, Health Problems Can Arise for Refugees

A special series by the Reporting on Health Collaborative

About This Series

Many immigrants feel isolated in America – suffering that can turn toxic over time.

Six news outlets joined together as the Center for Health Journalism Collaborative to highlight the interplay between immigration status and health. The USC Annenberg project involves Mundo Hispánico (Atlanta), New America Media (California and New York), Radio Bilingüe (Fresno and Washington), WESA Pittsburgh, Univision Los Angeles and Univision Arizona.

Living in the Shadows: When a New Home Means a New Diet, Health Problems Can Arise for Refugees

January 14, 2014


On a typical weekday morning, 47-year-old Tek Nepal is moving about the Mount Oliver duplex he shares with his wife, sons, daughter-in-law and grandchild.

He works nights so the mornings are when he gets his family time in. And often, that time centers around eating. Those meals used to consist of lots of starches. But since a Type 2 diabetes diagnosis last year, they have changed.

Tek Nepal: I don’t eat rice at all I don’t eat potatoes. I try to eat a lot of green vegetables like lettuce, spinach…carrots and I don’t eat totally fried things. 

Tek Nepal is ethnically Nepalese. He was resettled in California as a refugee, moved to Tennessee; then Pittsburgh, which has a lower cost of living and boasts an increasingly growing Bhutanese-Nepalese population. Before coming to the US, he spent seventeen years in refugee camps in Bhutan.

Nepal: You have no health facilities, no hygiene if you are not careful you are losing your life there. It was really hard

Twenty five point eight million Americans have diabetes – and another 79 million are pre-diabetic. These numbers have risen sharply over the last few decades. Included among those statistics are newer Americans – people such as Tek Nepal who came here as refugees. According to a study published in Human Biology, an immigrant’s risk of obesity and hypertension – indicators of diabetes - grow with every year they are here.

At the Squirrel Hill Health Center, a federally qualified facility that provides the bulk of initial and follow-up care to refugees, Andrea Fox, the Center’s Chief Medical Officer is perpetually busy. She spots trends in her patient population. Rarely do the Bhutanese come to the US with a diabetes diagnosis but they’ve found a high prevalence of the disease in those they treat.

Andrea Fox: Sometimes they develop it once they are here, once they start gaining weight while they are here. And sometimes they come undernourished. So weight gain is a good thing but sometimes they get over nourished while they are here…like everyone else and that’s when they develop it.

The Centers for Disease Control and Prevention monitors refugee populations. Among their priority health conditions for the Bhutanese are anemia, B12 vitamin deficiency and mental health. They haven’t been tracking diabetes numbers. 

A study done earlier this year at a clinic in Atlanta looked at noninfectious diseases among Bhutanese refugees – high numbers were found for obesity, hypertension and diabetes.

Tek Nepal says as difficult as things were in the camps, there was more physical activity in day-to-day life.

Nepal: It was a very big transition for us because we came from a totally different world – a totally different – where everything was done manually.

While Saraswati Bhandari spends hours every day cleaning hotel rooms – work that is physically demanding, much of her life is easier. For example, she uses washing machines to wash her family’s laundry instead of washing by hand. When she was pregnant she developed gestational diabetes.  The 32-year-old refugee had to change her eating habits. 

Saraswati Bhandari: For my baby and for my health I control myself its not that difficult. I like to eat but I control you know. I ate salad and then brown rice and I controlled myself and I ate a lot of vegetables.

Now, with a healthy baby (sound of her feeding baby) she has kept some of those habits – her home is supplied with vegetables.

Bhandari lives in Prospect Park, a South Hills community full of refugees. There, at the Prospect Park Family Center, Elizabeth Heidenreich, a family development specialist does everything from accompanying refugees to doctor’s appointments to helping them read ingredients on packaged foods offered by food bank trucks who set up in the community. That’s become important.

Elizabeth Heidenreich: A lot of my clients say in their country nobody has diabetes but in this country, everybody has diabetes.

Back at the Squirrel Hill Health Center, Dr. Fox says once diagnosed, some people don’t want to change their eating habits. They may not have health literacy and doctors may have to explain the function of the pancreas for example. And they may have to tell patients to take their medicine even when they don’t actually feel sick.

Fox: The idea of having preventative follow-up visits and regular blood checks and how to refill medicines once your done with them for a month – they think, well I’m done with the medicine instead of going back and refilling the prescription month after month, all those concepts are kind of new that we have to teach them. 

And then there is the issue of health insurance. Tek Nepal had a job that provided him coverage. And as a pregnant woman Saraswati Bhandari qualified for Medicaid.

After a refugee’s initial medical benefits run out, if they don’t have a job that provides medical benefits or qualify for Medicaid, they may just end up uninsured. With a diabetes diagnosis, Fox says that can lead to all sorts of other problems.

Fox: Its very expensive, insulin costs about a hundred dollars a vial for inexpensive insulin. If you go into some of the more expensive ones like Lantis, which is easy to administer and you only have to take it once a day it goes much higher than that.

There’s also diet. Fox says its not as simplistic as refugees coming to America and subsisting on fast food and soda– there are some of the culinary traditions the refugees bring with them.

Fox: Carbohydrates are usually pretty inexpensive and the Bhutanese diet is usually pretty high on potatoes and rice and noodles and all of the things that are high in carbohydrates. So we explain to them that it isn’t that you cant eat those things, we’re not taking away those things, you just have to eat less of them.

Once they understand the risks it is easier to change their habits – particularly because in their recent history they have had to change so many other aspects of their lives.

Since his diagnosis, Tek Nepal has been promoted into a job that’s made him more active – he is delivering medication throughout Mercy Hospital.

Nepal: The whole hospital in my 8 hours there I walk like 7 hrs so that helps me a lot now.

He got his diagnosis after escalating symptoms – he was always thirsty and had to urinate often – and then there was the health scare that led to his diagnosis.

Nepal: When I was driving and I stopped suddenly because of my blurry vision I had to ask someone for help and they took me to St. Clair hospital.

He’s also cut back on foods he loved - items like potato stuffed deep fried samosas.

Nepal: People in our community eat a lot of fat in the food and they like it – fried, oily, spicy, cheesy, hot everything – so now – I’m out of that. I only like to have the green things more.

In the process, he’s lost thirty excess pounds. He’s gotten his wife and older relatives to eat like he does now. But he does have concerns about his sons and their appetite for French fries and pizza.

Nepal: I’m trying to not have my kids have diabetes, diabetics itself is not only one disease, it is related with the kidneys, heart, so I’m worried about my kids, I don’t want my kids to have this.

After all, he says, they’ve been through a lot and he wants his family to have a better life than the one they had in the refugee camps.

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