COMMUNITY GARDENS: FOOD SECURITY & CULTURAL PRESERVATION
A mixed-methods approach to food systems analysis in the New American population in Syracuse, New York
A Thesis Submitted in Partial Fulfillment of the Requirements of the Renée Crown University Honors Program at Syracuse University
April Hill
Candidate for Bachelor of Science and Renée Crown University Honors Spring 2020
Honors Thesis in Nutrition and Citizenship and Civic Engagement
Thesis Advisor: ______Dr. Anne Mosher, Chair of Citizenship and Civic Engagement
Thesis Reader: ______Matthew Potteiger, Professor of Landscape Architecture
Honors Director: ______Dr. Danielle Smith, Director
ABSTRACT
New Americans experience food insecurity at twice the rate of other communities due to barriers including limited resources, limited access to higher-paying jobs, and limited social networks. This study takes a mixed-methods approach to examine the impact of community gardens on food security and cultural preservation in New Americans. Study One evaluates the food environment on the North Side of Syracuse through food acquisition site (FAS) audits. There were 42 identified FAS. Ethnic markets (n=16) were more likely to sell fresh fruits (p≤0.001) and vegetables (p≤0.001), but less likely to sell milk products (p≤0.001). Mean fresh vegetable (7.64±5.99), bean/legume (11.5±6.24), and frozen vegetable (5.33±3.44) options were higher at ethnic markets (p≤0.05). Prices were difficult to obtained, which could inhibiting comparative shopping and lead to people purchasing more expensive products without their knowledge. Study Two assesses New Americans’ food experiences in their home country and in the United States through interviews and food frequency questionnaires (FFQ). Seven interviews of current community garden participants were conducted, focusing on food security, dietary acculturation, and community gardening. About half of participants were male (57.1%), primarily Hindu (71.4%), and all had lived in the United States at least 6 years. Participants reported low dietary acculturation, maintaining their traditional diets that are high in vegetables and rice, with occasional meat consumption. All participants exhibited food insecurity at least some time in the past year. Barriers to food security included limited resources and high prices at ethnic markets. Participation in the community garden improved access to adequate amounts of food and cultural foods. These findings demonstrate the importance of community gardens for New Americans and can be used to direct community garden initiatives to enhance impact.
Keywords: Food insecurity, community garden, New Americans
i
EXECUTIVE SUMMARY
This thesis is an exploration of the food environment and resources available to New
Americans that either promote or hinder their ability to achieve food security. Syracuse is home to a large New American population, which is a population at increased risk of food insecurity and hunger for a variety of reasons. Refugee is an internationally recognized legal status for someone who has fled their home country for fear of persecution, legally filed for refugee status, and underwent a rigorous vetting process (The UN Refugee Agency, n.d.). Although the term
“refugee” is correct, there has been a move use the term “New Americans” to denote belonging.
In CHAPTER 1:, I present an overview of the factors that contribute to the food environment in Syracuse and how it may impact the health of New Americans. There are two components of my study, and I outline each component. Part one looks to determine if food is available, culturally appropriate, healthy, and affordable in neighborhoods where New
Americans live. The second component of my study looks to answer the question: How do acculturation and food security impact dietary intake, and what role do community gardens play in mediating food security? involved interviews with New Americans and a visual food frequency questionnaire. A food frequency questionnaire (FFQ) is a list of foods, and the participant responds whether they eat a food or not and how frequently. Then, I combine both components and position my research in the greater body of nutrition research.
CHAPTER 2: is divided into three main sections: an overview of refugees in the United
States, a description of the socioeconomic determinants of health, and a review of current literature surrounding the impact of community gardens on New Americans. Throughout, I define the key terms I use when discussing food insecurity and dietary acculturation.
ii
Particularly, it is important to understand the various pillars of food security. According to Guptil et. al (2012), food security is typically understood as a four-pillar concept.
1.) Availability: adequate nutritious and preferential food is physically present.
2.) Accessibility: adequate access to said food items, whether via transportation,
economics, or other factors is possible.
3.) Utilization: adequacy of the diet for health, clean water, and proper sanitation.
4.) Stability: the food source is stable and consistent from day to day and there is no
worry that food will run out.
In nutrition literature, food security also encompasses access to nutritious and culturally acceptable food. People who are food secure are more likely to eat a healthier diet, which helps prevent disease. Food insecurity is associated with increased health expenses, increased prevalence of non-communicable chronic diseases (NCCDs), and worsened management of
NCCDs (Seligman, Laraia, & Kushel, 2010; Crews, et al., 2013). NCCDs are non-contagious diseases that persist over a long period of time, like diabetes (high blood sugar), hypertension
(high blood pressure), and dyslipidemia (low HDL “good cholesterol”, high LDL “bad cholesterol, or both). These diseases are linked to nutrition, so food insecurity has a large impact on disease prevention and management.
In CHAPTER 3:, I describe the methods I used to collect and analyze my data. I used mixed-methods, meaning I combined quantitative data with qualitative data. Primarily, my research relied on semi-structured in-person interviews, FFQ data, and environmental audit information.
CHAPTER 4: gives more detail about the process of conducting the environmental audits, such as tool development and the geographic area of study. I focus my analysis on the
iii differences between ethnic markets and traditional food acquisition sites, since preliminary data analysis suggested each type of store contributes differently to the food environment. Ethnic markets provide more fresh produce and important cultural ingredients than traditional food acquisition sites. I discuss the implications that ethnic markets have on the food environment, including making ethnic foods available and fostering social networks. However, since price information was limited, ethnic markets might be economically inaccessible, so I also address the potential complications that ethnic markets introduce into a community.
CHAPTER 5: covers findings from the seven in-person interviews and FFQs.
Thematically, I divided my data into several topics: diets prior to migration, dietary acculturation in the United States, food insecurity, and community garden participation. I defined dietary acculturation as similarity between a New American’s current diet and their diet in the home country. Dietary acculturation is low in this sample of New Americans, and food insecurity is prevalent. This chapter addresses the perceptions of New Americans regarding the food environment and the impact of community garden participation on their ability to access healthy and culturally appropriate foods. I also address limitations and future areas of research.
In CHAPTER 6:, I end by summarizing my findings and drawing conclusions based on information from both studies. This study promotes community gardens as a legitimate mediator of food security and cultural preservation for New Americans, particularly by increasing food access. Information from this study will hopefully lead to more exploration and action in areas like food security and health for New Americans here in Syracuse and throughout the United
States. Although there are many systemic contributors that should also be addressed, using community gardens to mediate food insecurity and access to ethnic and cultural heritage could provide necessary assistance and connection for New Americans.
iv
TABLE OF CONTENTS
ABSTRACT ...... i EXECUTIVE SUMMARY ...... ii LIST OF FIGURES ...... vii LIST OF TABLES ...... vii ACKNOWLEDGEMENTS ...... viii CHAPTER 1: INTRODUCTION ...... 1 Background ...... 1
Goals and Objectives ...... 4
Thesis Organization ...... 5
CHAPTER 2: REVIEW OF LITERATURE ...... 6 Background: ...... 6
Federal Aid Programs for New Americans ...... 8 Countries of Origin of New Americans in Syracuse ...... 10
Bhutan ...... 11 Burma...... 12 Iraq ...... 14 Somalia ...... 15 New Americans and Nutrition Status...... 17
New Americans and Undernutrition ...... 19 New Americans and Overnutrition ...... 21 New Americans and the Double Burden of Disease ...... 23 New American Health Beliefs and Nutrition Risk ...... 24 Food Security: ...... 25
Dietary Guidelines and Aid Programs: ...... 27 Food Security and Health: ...... 29 Food Literacy and Food Security: ...... 31 New Americans and Food Security: ...... 32 New Americans and Economic Opportunity:...... 33 Acculturation and Diet Quality: ...... 34
v
Community Gardens and Food Security ...... 36
New Americans and Community Gardens: ...... 37 Summary: ...... 38 CHAPTER 3: METHODOLOGY ...... 40 Research Design ...... 40
CHAPTER 4: FOOD ENVIRONMENT AND AVAILABILITY ON SYRACUSE’S NORTH SIDE NEIGHBORHOOD ...... 41 Area of Interest: ...... 41
Food Acquisition Site Audit Instrument ...... 42
Data Collection ...... 44
Results and Data Analysis ...... 45
Conclusions ...... 51
Limitations/Areas for Future Research ...... 52
CHAPTER 5: FOOD AND DIETARY HABITS OF NEW AMERICANS ...... 54 Methodology: ...... 54
Recruitment ...... 55
Results and Data Analysis ...... 56
Themes ...... 56 Conclusions ...... 62
Takeaway Points ...... 66 Limitations ...... 67
CHAPTER 6: CONCLUSIONS ...... 68 REFERENCES ...... 72 APPENDIX A: TABLES AND ILLUSTRATIONS ...... 81 APPENDIX B: INSTITUTIONAL REVIEW BOARD FORMS ...... 90 APPENDIX C: MEAN PRICE OF SELECTED ITEMS AT FAS ON THE NORTH SIDE ...... 91 APPENDIX D: FOOD FREQUENCY QUESTIONNAIRE ...... 92 APPENDIX E: INTERVIEW QUESTION ...... 97
vi
LIST OF FIGURES
Figure 2-1: Factors contributing to nutrition status in New Americans ...... 81 Figure 4-1: Map of Selected Area of 1.0 mile and 0.5 mile radii ...... 83 Figure 4-2: Plot of all stores within 1 mile of center point ...... 83
LIST OF TABLES
Table 2-1: Prevalence of malnutrition in children 0-5 from selected countries ...... 81 Table 2-2: Definitions of Food Security (Economic Research Service, 2018) ...... 82 Table 2-3 Dietary Recommendations According to MyPlate and the USDA ...... 82 Table 4-1 List of topics from environmental audit ...... 84 Table 4-2 Frequencies of fruits and vegetables sold in stores ...... 85 Table 4-3 Proportion of FAS that sell selected items ...... 85 Table 4-4 Comparison of items in ethnic markets vs other stores ...... 86 Table 4-5 Availability of pricing data for all audited FAS ...... 86 Table 5-1 Demographics of participants ...... 87 Table 5-2 FFQ results from New Americans ...... 87 Table 5-3 Crops and weights of harvested food items from SCHF ...... 89
vii
ACKNOWLEDGEMENTS
First, I would like to acknowledge Dr. Anne Mosher for her continued guidance and encouragement throughout the past three years. Thank you for helping me explore my interests and always encouraging me to look at everything from a different point of view, whether it was my thesis, my career trajectory, or my coursework. Thank you for always working with me to make my path through CCE possible. Thank you to Dr. Kay Bruening, who believed in me before I believed in myself. I could not have asked for a better advisor and support system throughout college. I would also like to extend my gratitude to the faculty and staff in the
Department of Nutrition and Food Studies who have contributed to my education over the past four years. My education at Syracuse University has been more than I ever could have imagined, and so much of that is because of you and your influence.
This research would also not be possible without the help of Matthew Potteiger and Salt
City Harvest Farm. Thank you also to my community coordinators who assisted with recruitment, interpretation, and project development. Thank you for assisting me and educating me on the many things I need to learn. While there is still so much growth I have to do, I am more aware and more equipped because of you. Thank you to the Renee Crown University
Honors Program for funding this research. Thank you, Laura and Naomi, for fielding my questions and for working with me to make this project a reality
Last, but not least, thank you to my family and my friends who dealt with my eccentricity during this thesis development time, read my work, and made sure I remembered to breathe sometimes.
viii
CHAPTER 1: INTRODUCTION
Background
Between 2007 and 2016, Syracuse welcomed approximately 10,000 refugees from various nations, with the most prevalent nations being Syria, Iraq, and Somalia (Baker, 2019).
With the refugee allowance reduced to 18,000, Syracuse has welcomed approximately 200 refugees since 2017 (Baker, 2019). According to Onondaga Citizens League, approximately
12,000 refugees and former refugees currently live in Syracuse as of 2013 (Onondaga Citizens
League, 2013). The number is believed to be higher as of 2019, but data directly describing the
New American population is lacking due to frequent interstate migration to follow social connections and opportunities. “Refugee” is an internationally protected legal status that denotes someone who fled their home country for fear of persecution, legally filed for refugee status, and went through a rigorous vetting process (The UN Refugee Agency, n.d.). The total population of
Syracuse, New York is 142,749, meaning New Americans comprise a significant portion of the population (United States Census Bureau, 2019). Of the New Americans living in Syracuse, there are approximately 50 individuals who identify as deaf or hearing-impaired.
New Americans, especially those who have lived in the United States for shorter periods of time, start at lower income levels and work primarily blue-collar jobs (New American
Economy, 2017). This is significant because income is strongly associated with food security.
Plus, factors such as limited social networks and lack of familiarity with foods sold in the United
States cause New Americans to be at an increased risk of food insecurity (Hadley, Patil, &
Nahayo, 2010). Individuals experiencing food insecurity often do not consume a diet that aligns with the 2015-2020 Dietary Guidelines for Americans, an evidence-based set of guidelines meant to promote health and reduce chronic disease risk (Mulik & Haynes-Maslow, 2017). Five
1 of the seven risk factors for non-communicable chronic diseases (NCCDs) are nutrition-related, so addressing these disparities at their source is an important step in poverty reduction and health promotion (World Health Organization, 2018). Food insecurity is strongly associated with altered dietary intake, including lower fruit and vegetable intake (Laraia, 2013). Food insecurity is also associated with increased prevalence of chronic diseases like cardiovascular disease, hypertension, type 2 diabetes mellitus (T2DM), and stroke (Seligman, Laraia, & Kushel, 2010), especially in women. Food insecurity also negatively impacts adherence to special diets for chronic disease, such as carbohydrate-controlled diets for diabetes (Laraia, 2013). New
Americans experience chronic disease prevalence greater than natural-born citizens in the United
States but may be less likely to receive adequate care (Amara & Aljunid, 2014; Yun, et al.,
2012). Thus, reduced access to foods and unfamiliarity with food systems in the United States contribute to decreased health in New Americans.
The food environment surrounding a person has a large impact on consumption habits. In areas where convenience stores are the primary FAS, consumption of fruits and vegetables is lower, nutrition risk increases, and prevalence of disease increases (Larson & Story, 2009).
Based on this knowledge, when food security or food insecurity is referenced in this thesis, it describes adequate access to healthy and culturally appropriate food. Many families have adequate access to calories, but the distribution of calories or nutrients contained within the foods may be insufficient to promote health and prevent disease (Darmon & Drewnowski, 2015;
Myers, et al., 2019).
There are a variety of food programs meant to alleviate food insecurity and promote health in the United States population. These programs include government programs like the
Supplemental Nutrition Assistance Program (SNAP) or The Special Supplemental Nutrition
2
Program for Women, Infants, and Children (WIC) (Food and Nutrition Service, 2020).
Typically, however, the allowance for these programs do not supply enough funds to support a diet in line with the 2015-2020 Dietary Guidelines for Americans (Mulik & Haynes-Maslow,
2017). Emergency food systems like food pantries or soup kitchens, where people can receive either food goods or hot meals, also help to promote food security. People who rely on food pantries still experience reduced diet quality and micronutrient deficiencies since they eat fewer servings of fruits, vegetables, and dairy products (Simmet, Depa, Tinnemann, & Stroebele-
Benschop, 2017).
Community gardens have emerged as alternate food systems to provide fresh produce and alleviate the burden of food insecurity. There are several models of community gardens, including community plots (Alaimo, Packnett, Miles, & Kruger, 2008) and donation-style, where harvests are donated to food pantries (Furness & Gallaher, 2018). Both methods have shown to increase availability of vegetables to participants (whether gardeners or food pantry participants).
There are also significant cost-savings involved in community garden participation (Algert,
Diekmann, Renvall, & Gray, 2016), so community garden participation can alleviate food insecurity during harvest months. For New Americans, the benefits are compounded by increasing access to difficult to find or expensive cultural foods (Hartwig & Mason, 2016;
Gichunge & Kidwaro, 2014).
Syracuse Grows is one of the main organizations working to develop community gardens in Syracuse. They provide funding, mentorship, and administrative organization for community gardens and community centers with gardens. This model is unique since individuals retain autonomy and independence in their food acquisition, instead of relying on charitable organizations. There are a growing number of gardens associated with Syracuse Grows,
3 including Salt City Harvest Farm. The community gardens follow various formats, including shared plots and individual plots. Since 2014, Salt City Harvest Farm (SCHF) has started incubator farming plots and developed a specific program for the Deaf New American population of Syracuse (Salt City Harvest Farm, 2018). They also have a “farmers market” program where New Americans grow crops to sell for income. SCHF work closely with organizations helping New Americans, like Refugee and Immigrant Self-Empowerment (RISE), to receive funding and develop programs for New Americans (Salt City Harvest Farm, 2018).
Many opportunities exist for further research surrounding the needs of New Americans after their initial resettlement in the United States. This study aims to fill current knowledge gaps regarding community gardens and their impact in the New American community, as well as the current food environment in a neighborhood where many resettled New Americans live. A mixed-methods design provides a comprehensive approach, combining the benefits of quantitative and qualitative data to assess the resources available to the population. Knowledge gained from this study can help to determine effective action steps to increase food security and to better address the dietary needs and improve the long-term health of a vulnerable population.
Goals and Objectives
Study 1: Environmental Audits of Food Acquisition Sites on Syracuse’s North Side
Objective: The aim of this study was to conduct a quantitative assessment to determine access to culturally appropriate and nutritious foods within the community in which many New Americans live. The long-term goals are to better understand available resources and gaps in access to appropriate and nutrition foods, so targeted intervention can directly address legitimate problems within the community. The following research questions are addressed:
1. What food acquisition sites exist on the North Side of Syracuse for New Americans?
4
2. What foods are available at these sites, and would these foods contribute positively or
negatively to a healthy and appropriate food environment for New Americans?
3. Are desirable foods accessible, both in location and in price?
Study 2: Community Gardens and their Impact on Food Security and Cultural Preservation
Objective: The aim of this study was to use qualitative interviews to explore dietary habits in
New Americans who participate in the community garden at Salt City Harvest Farm and how their dietary habits have evolved through migration to the United States. The other goal of this study was to document the impact of participation in a community garden on their food security and access to culturally appropriate foods. Long-term goals are to expand access and output of
Salt City Harvest Farm to better serve the unique needs of New Americans, thereby increasing food security and expanding their reach to serve more New Americans. The following questions were addressed:
1. How has migration impacted the dietary habits of New Americans in Syracuse?
2. What impact does participation in a community garden have on New Americans’
food security and access to cultural foods?
Thesis Organization
This thesis begins with a literature review examining food security in the United States, healthy dietary patterns and factors impacting disease risk, community gardens, New Americans in the United States, and New Americans’ cultural backgrounds. Following the review of literature, the methodology behind the two studies will be described and the results of the three components will be summarized. To conclude, discussion and analysis, references, and the appendices of supporting documents will be covered in this thesis.
5
CHAPTER 2: REVIEW OF LITERATURE
As the New American population continues to grow, emphasizing proper nutrition for the
New American population will be paramount. The key to proper nutrition in this group is addressing food security, particularly addressing issues of access. Adequate nutrition is a key factor in reducing the prevalence of chronic disease, which is a costly burden to both the individual and the United States healthcare system. This is especially important given the data that suggests high rates of developing diseases like cardiovascular disease and T2DM in New
Americans after their arrival in the United States. Promotion and utilization of community gardens may be an effective solution toward promoting cultural preservation and food security among New Americans. Further research is needed to identify how to leverage program reach and impact.
Background:
When individuals move from one country to another, they can be put into variety of categories depending on their circumstances. The terms refugee, asylum-seekers, and migrants describe distinct populations (The UN Refugee Agency). A refugee is a person who has fled their country because they are at a high risk of experiencing human rights violations and persecution if they remain (The UN Refugee Agency, n.d.). Refugees are a specifically defined and protected group since they are unable to go home to their country of origin (The UN Refugee Agency).
Under the New York Declaration for Refugees and Migrants, the distinction between refugees and migrants was defined, giving special status to refugees under United States law (UN General
Assembly, 2016). An asylum-seeker is also someone who is experiencing persecution and human rights violations or the threat of these actions (Amnesty International). They may be an individual who has not yet been granted refugee status (Mossaad, 2019). There is no
6 internationally-accepted definition of a migrant, but Amnesty International recognizes them as people who stay outside of their country of origin who are not asylum-seekers or refugees. The term New American is given to refugees living in the United States, as it denotes belonging, both legally and socially. However, the term “refugee” is still considered correct terminology.
The United Nations High Commissioner for Refugees (UNHCR) is responsible for awarding legal refugee status (U.S. Committee for Refugees and Immigrants). Approximately
1% of all refugees are referred for resettlement in a third country (U.S. Committee for Refugees and Immigrants). Refugee status is difficult to gain, and once refugee status is granted, it can take a lot of time to move from a refugee camp to a resettlement country. Many refugees will spend almost two decades in a refugee camp before they are either resettled in a third country or repatriated to their country after the conflict ends (The UN Refugee Agency).
If a person is given refugee status and selected for resettlement, they do not get to choose where they are resettled (Onondaga Citizens League, 2013). In the United States, refugee resettlement agencies will disburse a funding allotment and assist with housing and initial education (Fact Sheet: U.S. Refugee Resettlement, 2019). However, this funding is small compared to the cost of starting a new life. Furthermore, economic opportunities are limited for
New Americans. According to the New American Economy Research Fund, many refugee families start with a median annual household income of approximately $21,800 during their first five years in the United States. The poverty guideline in 2020 is considered $26,200 for a family of four (U.S Department of Health & Human Services, 2020). Their income does grow significantly with time spent in the United States, but within 25 years it is typically equal to or greater than the U.S. population (New American Economy, 2017). While this trend is important
7 to note, there is still a significant length of time when New American families will experience poverty and food insecurity.
Prior to 2016, the United States led the world in refugee acceptance, although the numbers fluctuated each year due to global events (Krogstad, 2019). Since 2002, the most refugees have come to the United States from Burma, Iraq, and Somalia (Krogstad, 2019).
According to the United States Census Bureau, the percent of people identifying as white, non-
Hispanic is predicted to decrease from 65% of the population to 46% of the population by 2050
(United States Census Bureau, 2018). Refugees and their families will contribute to these figures.
Onondaga County, per capita, settled more refugees than any other county in New York state, and at the third highest rate in the nation during 2014 (Eisenstadt, 2019). Between 2007 and
2016, approximately 10,000 refugees were resettled in Syracuse, with the top three countries of origin being Syria, Iraq, and Somalia (Baker, 2019). In the early 2000s, Bhutan and Burma were top nations of origin for refugees in Syracuse (Onondaga Citizens League, 2013). In total, more than 12,000 refugees and former refugees are thought to live in Syracuse, although direct numbers are difficult to assess due to frequent secondary migration within the United States
(Onondaga Citizens League, 2013).
Federal Aid Programs for New Americans
Refugees, upon being settled in the United States, receive a stipend. The stipend is distributed through resettlement agencies and comes from the Department of Homeland
Security’s International Office of Migration (IOM) (Fact Sheet: U.S. Refugee Resettlement,
2019). There are 9 voluntary agencies handling resettlement funds nationally, and they work through local organizations (Fact Sheet: U.S. Refugee Resettlement, 2019). In Syracuse, two organizations resettle refugees: Catholic Charities and InterFaith Works (Eisenstadt, 2019). Each
8 refugee, including children, is entitled to a minimum $925 dollars in Syracuse. These funds are typically used by the organizations for rent, furnishings, clothing, and food items (Fact Sheet:
U.S. Refugee Resettlement, 2019). They also help with Social Security, enrolling children in school, and teaching newly resettled refugees how to navigate life in the United States (Fact
Sheet: U.S. Refugee Resettlement, 2019).
New Americans are also eligible for Temporary Assistance for Needy Families (TANF),
Supplemental Security Income (SSI), and Medicaid. Those not eligible for TANF, SSI, or
Medicaid are eligible for Refugee Cash Assistance and Refugee Medical Assistance for 8 months
(U.S. Department of Health and Human Services). Most New Americans are eligible for SNAP benefits (Food and Nutrition Service, 2013). New Americans are eligible for unemployment benefits but subject to the same basic requirements of other workers, including unemployment
“through no fault of their own,” having enough wages earned to establish a claim, and able to work and actively searching for work (National Employment Law Project, 2002).
Airfare from a refugee’s country of origin is paid through interest-free travel loans from the IOM (Robinet, 2019). New Americans must start making payments on these loans within 6 months after their arrival in the United States, and they must be repaid within 46 months
(Onondaga Citizens League, 2013). These loans average $1,100 per person, so for a family, the amount adds up and can strain an already tight budget once the repayment period begins
(Robinet, 2019). It is possible to get deferments or waivers depending on employment status and extenuating circumstances (Robinet, 2019) There are other government programs that provide funding for employment or social services.
9
Countries of Origin of New Americans in Syracuse
The New Americans residing in Syracuse come from diverse nations. Population estimates for 2018 from the United States Census Bureau suggest Syracuse’s foreign-born population comprises 13.3% of the population, which is significantly higher than Onondaga
County at 7.9%. This means approximately 19,000 individuals in Syracuse are foreign-born
(United States Census Bureau, 2019). From 2001 to 2012, 7,210 refugees were resettled in
Syracuse, according to the U.S. Department of State (Onondaga Citizens League, 2013).
Between 2007 and 2016, Syracuse resettled approximately 10,000 refugees (Baker, 2019). Since
2017, Syracuse has welcomed approximately 200 refugees due to a reduction in overall refugee resettlement throughout the United States (Baker, 2019). To add to these numbers, approximately 250 secondary migrants, or refugees who settled somewhere else and then relocate to be closer to friends or family, are estimated to come to Syracuse annually (Onondaga
Citizens League, 2013). There are also 50 New Americans of various ethnicities who identify as part of the deaf or hearing-impaired community (Salt City Harvest Farm, 2018).
The number of refugees and their countries of origin are strongly influenced by world events, although the number of refugees resettled in the United States has declined in recent years (Krogstad, 2019). In Syracuse, between 2001 and 2012, the largest number of refugees came from Burma, Bhutan, and Somalia (Onondaga Citizens League, 2013). In the United
States, between 2002 and 2019, the most refugees have been resettled from Burma, Iraq, and
Somalia (Krogstad, 2019). However, for fiscal year 2019, the actual breakdown for the United
States shows the largest number of refugees were from the Democratic Republic of Congo, followed by Ukraine, Eritrea, and Afghanistan (Krogstad, 2019).
10
There are many challenges to fulfilling the needs of these diverse, fluctuating populations. Each nation has unique foods and cultural practices surrounding consumption, as well as other circumstances that help or hinder their ability to be self-sufficient in the United
States. Some of these items include English fluency, education level, technical skills, age, and sex. The next section gives a brief overview of the most prevalent ethnic groups in Syracuse.
Bhutan
Bhutan is located near China, India, and Nepal among the Himalayan Mountains.
Bhutanese refugees are primarily Lhotshampas, one of three main ethnic groups in Bhutan. They are descendants of Nepali farmers who migrated to follow economic opportunity, and they settled primarily in Southern Bhutan (Dhungana, 2010). Because they lived in remote areas in
Bhutan, they were not exposed to modernization, and thus maintain more traditional Nepali culture (Hutt, Lhotshampa Culture, 2005).
Within the Lhotshampa group, there are many subgroups that follow different religions, speak different languages, and have different practices. They are primarily Hindu, although some ascribe to Kiranti (Summit County Health Department), Buddhism or Christianity (Dhungana,
2010). The refugees resettled in the United States are primarily young adults between 15-44
(60%), although 15% are 45-64 years old, and 20% are under the age of 15. Only 5% of the refugees resettled are 65 years or older (Division of Global Migration and Quarantine, 2014).
Some of the younger refugees may speak English if they received formal schooling or learned in the refugee camps in Nepal, but older Bhutanese refugees likely won’t speak English
(Division of Global Migration and Quarantine, 2014). Approximately 35% of Bhutanese refugees living in camps have a functional understanding of English. Literacy in their native language is approximately 65% (Division of Global Migration and Quarantine, 2014). It is
11 common for Bhutanese families to be multigeneration, so a family’s financial situation is shared among all members (Summit County Health Department)
Few Bhutanese refugees are vegetarians, but they consume meat infrequently (Division of Global Migration and Quarantine, 2014). Since many Bhutanese practice Hindu, they will not consume beef or pork (Hutt, Lhotshampa Culture, 2005). Diets are primarily rice, lentils, and vegetables, which they grow within their communities. Chilis are also central to Bhutanese cooking, and most dishes will be prepared with large amounts of hot peppers (Planet). Many
Bhutanese rely on agriculture for their living (Berthold, 2005). Vitamin B12 and megaloblastic anemia, which stems from Vitamin B12 deficiency, are health conditions of concern for the
Bhutanese refugee population (Division of Global Migration and Quarantine, 2014).
Burma
Myanmar, a country formerly known as Burma, is located near Bangladesh, China, Laos, and Thailand. The name changed from Burma to Myanmar occurred in 1989 after the military junta suppressed an uprising and killed thousands. The United States and the United Kingdom have yet to recognize the country’s official name change, despite the United Nations and other major economic partners recognizing the nation as Myanmar (Who, What, Why: Should it be
Burma or Myanmar?, 2011). For this reason, this thesis will also refer to the country as Burma.
Refugees from Burma come from a variety of ethnic backgrounds, most of which are represented in Syracuse, including Karen, Kachin, Burman, Chin, Mon, and Karenni (Onondaga
Citizens League, 2013), and they all speak a unique language. The Karen are one of the largest displaced people of Burma and one of the most numerous groups in refugee camps and in the
United States (Barron, et al., 2007). The various ethnic groups prefer to be identified by their
12 ethnic group rather than the general term “Burmese” as typically only the Burmans are called
Burmese (Bridging Refugees Youth & Children's Services).
Most of these groups rely heavily on agriculture for their livelihoods. The crops grown differ slightly depending on the ethnic groups, but most include corn, beans, and wheat (Barron, et al., 2007). The Karen also grow betel nut, ground nut, sesame, beans, fruits, sugar, and tea.
The Karen also hunt animals and fish, and they serve meat alongside vegetables for most meals.
Sour flavors and fish pastes are common flavors in Karen cooking while Burmans utilize nuts and beans heavily (Lonely Planet, 2013). The Burmans typically eat boiled rice, curry, and condiments. In rural areas, breakfast is similar to the other meals and constitutes rice, curry, boiled beans, dried fish, and vegetables (Barron, et al., 2007). Fermented green tea leaves may be eaten for dessert with sesame seeds, nuts, and fried, crunchy ingredients (Lonely Planet, 2013).
In urban areas, breakfast might include bread or naan (Barron, et al., 2007). For all ethnic groups, rice is a staple food, and it is usually eaten with two to three meals per day (Lonely Planet,
2013).
Most Karen who are resettled in the United States have minimal knowledge of English, although some older adults who attended schools before they were severely defunded will have medium English proficiency (Barron, et al., 2007). Overall, in the camps, 55% report receiving primary education, 7% report completing middle school, and 3.5% report finishing secondary school (Barron, et al., 2007). Less than 1% of refugees had completed vocational training or university as of a 2006 survey (Barron, et al., 2007).
Another refugee group from Burma are Rohingya Muslims. They practice Sunni Islam and are of Indian and Bengal descent rather than Sino-Tibetan roots like the rest of Burma.
Under the Burmese government, the Rohingya Muslims are severely repressed and face
13 significantly safety and human rights concerns, both in Burma and in refugee camp nations.
Between 2017 and 2019, over 742,000 Rohingya Muslims have fled to Bangladesh refugee camps (The UN Refugee Agency USA, 2019). However, there are many others who live unregistered in Bangladesh or in camps along the Burma-Thailand border (Rahman, 2015). The
Rohingyan Muslim observe Ramadan and consume more fish, seafood, and chili than other groups (Metro South Health, 2015).
Iraq
Iraq is located in the Middle East, bordering Iran, Saudi Arabia, Syria, and Jordan. The country is primarily Muslim, split mostly between Shiites, Sunnis, and Shi’as, with a small percentage of Christians, Mandeans, and Yazidis (Campo, 2016). Discourse between the various
Muslim sects has been a central reason for the Iraq refugee crisis. The United States has also played a large role in the Iraqi conflict leading to Iraq’s refugee crisis (Sánchez, 2010). Between
2003 and 2010, there have been approximately 2 million Iraqi refugees displaced to other nations
(Sánchez, 2010). Originally, many Iraqis who fled were professionals from the upper or middle class, but the financial security of the refugees gradually declined with time (Sánchez, 2010).
Unlike other countries, many Iraqis, generally those who had the means to flee and emigrate, immigrated to the United States before Iraqis started to come refugees (Division of Global
Migration and Quarantine, 2014). There are also special provisions for Iraqis who worked for the
United States government or specific U.S.-based organizations in Iraq (Sánchez, 2010).
Many refugees who come to the United States will migrate to join already established
Iraqi communities (Division of Global Migration and Quarantine, 2014). As of 2013, there were
322 refugees from Iraq (Onondaga Citizens League, 2013). It’s likely this number is greater in
2020, given the increase in Iraqi refugees starting in 2011. Because of the various shifts in
14 political power, Iraqi refugees come from several opposing religious or ethnic groups, as well as economic backgrounds, education levels, and professional skills (Sánchez, 2010). Approximately half of Iraqi refugees resettled in the United States speak English very well or speak only English
(Division of Global Migration and Quarantine, 2014). Within the Iraqi refugee population, chronic diseases such as diabetes mellitus, hypertension, and malnutrition are conditions of concern (Division of Global Migration and Quarantine, 2014).
Most Iraqi refugees are Muslim, and the dietary restrictions for Muslims are similar across the different sects. Many Muslims only consume halal foods, meaning all meats must be slaughtered according to Islamic law (Division of Global Migration and Quarantine, 2014). Pork is never consumed (IRFAD). Consumption of alcohol is forbidden, including in items such as vanilla extract (Division of Global Migration and Quarantine, 2014). Tea is the most common drink, and it is consumed several times per day (IRFAD). All other edible animals, including sheep, lamb, goat, and fish, are consumed regularly and in their entirety, including their organ meats (IRFAD). Beans, rice, wheat, bulgur, and dates are staple foods and are generally consumed with seasoned meats for meals (IRFAD). Like the rest of Mediterranean and
Mesopotamian culture, lemon, pomegranate, eggplant, nuts, and spices are complementary components (Harn, 2018).
Somalia
Somalia is in Eastern Africa, and it borders Ethiopia, Kenya, and Djibouti. A majority
(85%) of the country share a common Samaale ancestry, religion, language, and culture, with minority ethnic groups constituting the other 15%, including the Somali Bantu (Central
Intelligence Agency, 2020). Four primary clans make up the ethnic Somali majority, and each ethnic minority is its own, smaller clan (UN Office for the Coordination of Humanitarian Affairs,
15
2002). These clans face marginalization and discrimination in Somalia (UN Office for the
Coordination of Humanitarian Affairs, 2002). Political instability in the early 1990s resulted in a humanitarian crisis and territorial civil war that continues to divide the country between insurgent groups and rival militias (Division of Global Migration and Quarantine, 2018).
Although Somali refugees come from all ethnicities, the Somali Bantu are a prominent refugee group due to discrimination in Somalia prior to the civil war (Lin, Hopkins, & Chanoff, 2002).
Food security is a problem in the country due to arid conditions and abnormal rainfall, which makes farming difficult (The UN Refugee Agency, 2020).
Somali is the official language, although many will also speak Arabic (Central
Intelligence Agency, 2020). Italian and English are common, and many speak other indigenous languages such as Maay or Oromo (Division of Global Migration and Quarantine, 2018).
Literacy rates are estimated at approximately 50% for men and 26% for women in refugee camps
(Division of Global Migration and Quarantine, 2018). Primary school enrollment between 2000 and 2007 was estimated at 25%, with secondary school attendance at 6% (Brophy, 2014).
Separate gender roles are maintained, so women will typically oversee food acquisition and preparation (Evanson, 2019).
Sunni Muslim is the majority religion, with less than 1% of the population adhering to different Islamic sects or other religions (Division of Global Migration and Quarantine, 2018).
Since the majority are Muslim, most Somali refugees abstain from pork and alcohol. Meat must be slaughtered in accordance to Islamic law, and they fast during for Ramadan (Division of
Global Migration and Quarantine, 2018). Somali food culture centers around spiced meat, including camel, goat, and beef, with vegetables acting as side dishes (Davila, 2001). Notable vegetables are green peppers, spinach, and garlic while notable fruits are mango, guava, and
16 banana (Davila, 2001). They also eat a spongy flatbread called anjara (Davila, 2001). Black tea with milk and sugar and camel milk are two popular drinks (Davila, 2001). For the Somali
Bantu, maize is a staple food item, as are beans, sorghum, vegetables like sweet potatoes, and fruits like bananas (Van Lehman & Eno, 2003). Fish and wild game are also commonly consumed alongside vegetables with maize (Van Lehman & Eno, 2003). Due to outside influences, spaghetti and rice have become prominent in both the Somali (Davila, 2001) and
Somali Bantu diet (Van Lehman & Eno, 2003). Upon coming to the United States, these are familiar foods.
As of 2013, there were 972 Somali refugees living in Syracuse (Onondaga Citizens
League, 2013). The primary nutrition concerns in the Somali population include anemia, diabetes mellitus, and lead toxicity (due to the related nutrition implications) (Division of Global
Migration and Quarantine, 2018).
New Americans and Nutrition Status
Adequate nutrition is important in improving overall health outcomes and reducing health care costs. Malnutrition is any nutritional disorder, whether characteristic of excessive nutrition, inadequate nutrition, or imbalanced nutrition. The health of refugees is important to consider because it has implications for the healthcare systems of their new home country
(Grammatikopoulou, et al., 2018). The prevalence of malnutrition in refugees coming to the
United States is relatively unknown due to low rates of nutrition screening in refugee camps
(Grammatikopoulou, et al., 2018).
Although malnutrition is typically associated with undernourishment, malnutrition can be either undernutrition, overnutrition, or micronutrient-related malnutrition, which is a deficiency or excess of specific vitamins or minerals (World Health Organization, 2018). Undernutrition
17 can be either acute, chronic, or acute and chronic. Acute malnutrition shows through wasting, chronic malnutrition shows through height stunting, and acute and chronic malnutrition show through the presence of wasting and stunting, sometimes referred to as underweight (using weight-for-age metrics) (Waterlow, 1972). Overnutrition presents as conditions like obesity or overweight, as well as nutrition-related non-communicable (non-contagious) chronic diseases
(NCCD) like heart disease or diabetes (World Health Organization, 2018). An example of micronutrient-deficiency malnutrition is iron-deficiency anemia, which can cause fatigue, growth and development complications, and heart problems (National Heart, Lung, and Blood Institute,
2011).
New Americans in the United States are at higher risk of having or developing NCCDs
(Division of Global Migration and Quarantine, 2013). Some refugee groups are at heightened risk for certain diseases in camps, such as anemia in the Bhutanese (Division of Global
Migration and Quarantine, 2014) and Somali (Division of Global Migration and Quarantine,
2018) refugee groups, and undernutrition in Iraqi (Division of Global Migration and Quarantine,
2014) refugee groups. Malnutrition overall is very prevalent in refugees. Only 18% of Western
Sahara refugee families living in Algeria had neither undernutrition nor overnutrition in at least one individual (Grijalva-Eternod, et al., 2012), meaning 82% of the families living in Algeria had at least one individual with either undernutrition, overnutrition, or both within the same family.
The risk for NCCDs are high prior to arrival in the United States, but risk also increases with time spent in the United States (Division of Global Migration and Quarantine, 2013). Not all NCCDs are nutrition-related, but reducing risk factor prevalence could eliminate 75% of cardiovascular disease, diabetes, and stroke, as well as 40% of all cancers (World Health
18
Organization, 2018). Risk factors include physical inactivity, alcohol use, tobacco use, excessive sodium intake, obesity, hyperglycemia, and hyperlipidemia (World Health Organization, 2018).
Poverty is closely linked with NCCDs, and the prevalence of NCCDs is predicted to impede poverty reduction initiatives due to the increased cost of health care (World Health
Organization, 2018). Political instability often contributes to poverty and insecurity, which promote development of disease and adult mortality (Ranabhat, Kim, Park, & Acharaya, 2017).
However, the risk of NCCDs is still high for New Americans resettled in the United states.
Although the political conflict, instability, and persecution does not physically follow them to the
United States, many of the risk factors still exist in the United States but in a different form, due to limited economic self-sufficiency (Capps, et al., 2015). These risk factors are poverty, poor access to health care, poor social cohesion, social stratification, substance abuse, and disease
(Figure 2-1) (Ranabhat, Kim, Park, & Acharaya, 2017).
New Americans and Undernutrition
Globally, nearly half of all deaths in children under five are related to malnutrition.
Approximately 21.3% of children under five exhibit stunting and 6.9% exhibit wasting, but this estimates includes “high income” countries like the United States that typically have lower rates of stunting and wasting than lower and middle income country (LMICs) (UNICEF, World
Health Organization, & World Bank, 2020). Stunting and wasting are both uncommon ailments in children under 5 in the United States, with stunting impacting only 3.5% of children and wasting impacting only 0.4% of children (UNICEF, World Health Organization, & World Bank,
2020). In refugee producing nations, rates of wasting, stunting, and underweight in children are above global averages (Table 2-1) (UNICEF, World Health Organization, & World Bank, 2020).
19
Undernutrition in children is likely systemic and intergenerational, as maternal undernutrition during pregnancy can predispose an infant to chronic undernutrition, particularly if the circumstances that facilitated maternal undernutrition remain unchanged (Hashmi, et al.,
2019). The Association of Medical Doctors of Asia and the United Nations High Commissioner for Refugees (UNHCR) conducted a nutritional survey of young children between 6 months to 5 years of age. Although only 4.2% of children experienced acute malnutrition, 26.9% of children were chronically malnourished and 43.3% had anemia (The United Nations Refugee Agency,
2019). In Ethiopia, prevalence of acute malnutrition in South Sudanese children aged 6-59 months ranged from 25.8% to 30.3%, and prevalence of severe acute malnutrition ranged from
5.7% to 10.0% (Andresen, et al., 2014). Female children are at increased risk of malnutrition compared to male children, potentially due to food robbing or cultural factors
(Grammatikopoulou, et al., 2018).
Non-governmental agencies may help to reduce undernutrition in refugees, as all registered refugees in camps receive food rations (Andresen, et al., 2014). The refugees who qualify for third-country resettlement in the United States had to be registered. Although they had access to food rations, undernutrition prevalence differs greatly between refugee camps for reasons not completely understood (Grammatikopoulou, et al., 2018). The impact of undernutrition will influence the healthcare needs refugees will have once they are resettled
(Andresen, et al., 2014).
Resettlement in the United States usually is not enough to correct nutrient deficiencies
(Lufty, Cookson, Leisel, & Rochat, 2013). A study of refugee children resettled in Washington
State (n=219) found nearly half of all Somali refugee children less than 10 years of age had stunting or wasting (Dawson-Hahn E. E., Pak-Gorstein, Hoopes, & Matheson, 2016). For most
20
New American groups, prevalence of undernutrition among children decreases below global averages after time in the United States (Lufty, Cookson, Leisel, & Rochat, 2013). If uncorrected, undernutrition can directly impair brain development, which leads to impaired school performance and decreased graduation rates (Adair, et al., 2008). In studies from Brazil,
China, and Central America, undernutrition was associated with decreased lifetime earnings
(Adair, et al., 2008).
New Americans and Overnutrition
Weight gain is a condition of concern for New Americans when they are resettled in the
United States (Rondinelli, et al., 2011). It may be caused by a prior lack of access to healthy foods, so they became accustomed to eating unhealthy foods (Rondinelli, et al., 2011). Since these foods are available in larger quantities in the United States, New Americans eat larger quantities of these foods and gain weight (Rondinelli, et al., 2011). In addition, lifestyle factors like long work hours, neighborhoods inconducive to physical activity, and unfamiliarity with foods available in the United States all contribute to consumption of unhealthy foods and subsequent weight gain in refugees regardless of age (Rondinelli, et al., 2011).
In a longitudinal study of New Americans resettled in Buffalo, New York, rates of obesity and overweight in children, men, and women rose significantly in all groups except
Middle Eastern and Eastern European refugees (Mulugeta, et al., 2018). Each additional year the
New American individual lived in the United States increased risk of overweight and obesity
(Mulugeta, et al., 2018). The increased risk of overweight and obesity in African and Asian refugees was corroborated in a study of refugee children from Rhode Island (Heney, Dimock,
Friedman, & Lewis, 2013) and in other studies across the country (Olson, Kurland, Rosenbaum,
21
& Hobart, 2017). Obesity rates came to surpass U.S.-born children, suggesting refugee children have other risk factor for overnutrition (Heney, Dimock, Friedman, & Lewis, 2013).
Although there is a clear link between resettlement and weight gain, there is also increasing weight status in refugees prior to resettlement. Body mass index (BMI) is increasing globally for children, women, and men, trending toward higher prevalence of obesity since 1975
(NCD Risk Factor Collaboration, 2016). In 2014, the World Health Organization estimated by
2020, NCCDs would encompass 80% of the global burden of disease and cause 7 out of every 10 deaths in developing countries (Islam, et al., 2014). Overweight and obesity rates are increasing in adults, and this reflects in refugees resettled in the United States.
In a cross-sectional study of all qualifying refugees, using data collected from the overseas medical exam required for resettlement, nearly 40% of all U.S.-bound refugees were overweight or obese (Davis, Phares, Salas, & Scherrer, 2020). Hyperlipidemia, overweight/obesity (24.6%), and hypertension (15.2%) were common in Iraqi refugees being resettled in San Diego, with prevalence increasing with age (Centers for Disease Control and
Prevention, 2010). Overnutrition is less prevalent than undernutrition, but it still impacts a significant number of refugee children prior to resettlement (Dawson-Hahn E. E., Pak-Gorstein,
Hoopes, & Matheson, 2016).
The prevalence of overweight and obesity in adults prior to the study was higher than non-refugees from their country of origin but lower than U.S.-born averages in Buffalo, NY
(Mulugeta, et al., 2018). This suggests there is an obesogenic aspect to refugee status, whether it is due to unhealthy diet or sedentary lifestyle (Mulugeta, et al., 2018). Psychological stress, both short-term and long-term, can increase inflammatory pathways and promote certain physiological pathways lead to increased storage of body fat, reduced insulin sensitivity, and
22 stimulate overconsumption (Sinha & Jastrebof, 2013). Over time, chronic psychological stress relating to forced migration and threat of persecution can increase susceptibility to NCCDs like hypertension and diabetes (Naja, et al., 2019). Increasing bodyweight creates feedback cycles that alter glucose metabolism, insulin sensitivity, and hormonal regulation, further leading to increased weight, increased intake, and reduced insulin sensitivity (Sinha & Jastrebof, 2013).
Resettlement in the United States carries different stressors, like economic stress, adaptation difficulties, and minimal social networks, continue to contribute to physiological changes (Figure
2-1).
NCCDs are also not the primary focus of health initiatives, as acute health needs are considered more pressing and consume health care resources (Naja, et al., 2019). However, without targeted and systemic shifts, weight gain and NCCDs can lead to future health complications, higher healthcare costs, and health disparities (Mulugeta, et al., 2018).
New Americans and the Double Burden of Disease
Although the pathophysiology and determinants of health causing undernutrition and overnutrition appear different, the prevalence of both within the same person or the same household is increasing. During the past 30 years, overweight and obesity rates have risen so there are now more people overweight in the world than clinically undernourished (Grijalva-
Eternod, et al., 2012). In many countries with high rates of stunting and underweight among children, there are also high rates of obesity among adults (Bose, 2013). There is maternal overnutrition and child undernutrition (MOCU) within the same household (Hauqe, Sakisaka, &
Rahman, 2019). This phenomenon is known as the double burden of disease. Since refugees are vulnerable to factors that facilitate malnutrition, obesity and undernutrition are highly prevalent in refugee households (Grijalva-Eternod, et al., 2012).
23
Malnutrition and infections during early childhood might increase the risk of NCCDs during adulthood (Abarca-Gómez, Abdeen, Zargar, Abu-Rmeileh, & Acosta-Cazares, 2017).
Both low birthweight and high birthweight in infants are associated with greater health risk once the infant grows up. Low birthweight in infants can result from undernutrition in the mother during pregnancy, while high birthweight can result from overnutrition in the mother (Kolĉic,
2012). Intrauterine growth restriction (IUGR) that may occur in undernutrition can permanently alter fetal metabolism, so when the infant is raised in a globalized, calorie-plenty environment, the infant is at greater risk of developing overnutrition (Kolĉic, 2012). Large studies have consistently demonstrated familial correlation in BMI that suggest obesity is impacted by several gene variants (Joffe & Houghton, 2016).
New American Health Beliefs and Nutrition Risk
Religious beliefs will influence dietary patters, as many religions prohibit specific foods or require specific considerations. Religious adherence should be respected, but nutrition education needs to be adapted to the cultural background of New Americans. New Americans from primarily Hindu or Buddhist backgrounds eat little to no meat and have a diet high in rice.
White rice, a common staple in many countries, can contribute to poor nutrition status. In the
United States, white rice is enriched to prevent micronutrient deficiencies like the B vitamins, but it is still considered a simple carb. Diets high in simple carbs can contribute to weight gain and diabetes. However, white rice is considered a status symbol (Carpenter, 2000), so many New
Americans from Asian countries might be resistant to choosing brown rice, despite the health benefits.
Some Muslims believe disease development is part of God’s plan, so they cannot influence disease progression (Wilson & Renzaho, 2014). This could lead to continuation of
24 undesirable food habits, worsening disease progression. Other refugees see a link between diet and disease development. Habits such as drinking large quantities of sugar-sweetened tea or cooking with large amounts of oil are cited culprits for weight gain and disease (Wilson &
Renzaho, 2014).
Some cultures hold tightly to food classifications that determine what foods they should eat during different life stages. Hot, cold, and neutral foods are an example of this. Generally, hot and cold foods should be balanced, but babies should only have neutral foods, but this excludes most fruits and vegetables (Freimer, Echenberg, & Kretchmer, 1983). Others will use non- traditional foods as a reward if they eat traditional foods (Wilson & Renzaho, 2014). This can inhibit a child’s ability to self-regulate or restrict themselves, which can increase risk of overweight or obesity in children (Wilson & Renzaho, 2014).
Other beliefs may be shared widely amongst refugee groups. Food scarcity meant eating everything available. Cambodian refugees resettled in Massachusetts responded with surprise that life-saving behaviors such as eating the excess fat from meat could lead to health problems
(Peterman, et al., 2010). Furthermore, years of near-starvation and food restriction will negatively impact the way New Americans respond to dietary advice to restrict foods (Peterman, et al., 2010). Other times, excess weight is a symbol of prosperity and is seen as desirable, so some refugees will promote weight gain as positive (Wilson & Renzaho, 2014).
Food Security:
Although often considered interchangeable, hunger and food insecurity describe two separate conditions. Hunger is a physiological condition, while food insecurity is an economic and social condition of having limited or unstable access to adequate food (Economic Research
Service, 2019). Someone who experiences high food security has no problems accessing enough
25 food. “Low food security” puts people “at-risk” of hunger and “very low food security status” means people are facing hunger (Economic Research Service, 2019). According to the USDA,
11.1% of houses were food insecure during 2018 (Economic Research Service, 2018). Of households with children, 13.9% were food insecure (Economic Research Service, 2018). Of the
13.9% households with children, children experienced food insecurity at incidences of 51%, which includes approximately six million children in the United States (Economic Research
Service, 2018). New Americans are at increased risk of food security and hunger.
The Food and Agriculture Organization of the United Nations (FAO) defines food security as “when all people, at all times, have physical and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life.” (Food and Agriculture Organization, 2006). The FAO makes an important distinction: access to adequate calories is not the equivalent of food security. Rather, access to enough healthy, affordable, culturally appropriate food that enable adherence to preferences, preparation abilities, and safety knowledge is food security. This definition is complex and takes a more expansive definition than the traditional model of food security, which is understood as a four- pillar concept: availability, access, utilization, and stability (Guptill, Copelton, & Lucal, 2012).
Availability describes having enough food of appropriate quality (Guptill, Copelton, & Lucal,
2012). Food access is defined as access to enough food resources for a nutritious diet (Guptill,
Copelton, & Lucal, 2012). Utilization describes adequacy of diet, clean water, and sanitation to meet all physiological needs (Guptill, Copelton, & Lucal, 2012). Stability describes having a consistent food source, without worry that food needs will not be met (Guptill, Copelton, &
Lucal, 2012). The FAO includes these four pillars as well as two important components: nutritious foods and cultural foods (Food and Agriculture Organization, 2006).
26
In applying the FAO definition of food security, someone may be able to afford a diet high in processed foods, but they are still considered food insecure since they are unable to purchase a nutrient-rich diet. Engel’s Law recognizes although the absolute amount of money spent on food increases as incomes increase, the proportion of money spent on food drops
(Darmon & Drewnowski, 2015). This means people with lower incomes spend a greater proportion of their income on food, even if they spend less money overall (Darmon &
Drewnowski, 2015).
Intake of nutrient rich foods like fruits and vegetables are positively correlated with food security. As food security decreases, consumption of nutrient-rich foods decreases and consumption of energy-dense foods increase (Morales & Berkowitz, 2016). Energy density and the cost of energy is inversely related. Foods high in energy but low in nutrients are less expensive than foods high in nutrients and low in calories, such as fruits and vegetables
(Drewnowski, 2010). Carbohydrates, sugar, and fat were the least expensive nutrients per 100 grams while protein, fiber, vitamins, and minerals were associated with higher prices per 100 g when adjusted for energy (Drewnowski, 2010). The relationship between nutrient density and price is one explanation for the link between obesity and food insecurity (Morales & Berkowitz,
2016).
Dietary Guidelines and Aid Programs:
Emergency food systems and government programs have evolved to help alleviate some of the burden on families and individuals. SNAP is a federal program that provides nutrition benefits to assist individuals and families in purchasing foods (Food and Nutrition Service,
2020). It is available to individuals who falls at or below 130% of the federal poverty level, which is $16,200 for an individual or $33,475 for a family of four (Food and Nutrition Service,
27
2020). Despite easing the burden of food acquisition for many participants, SNAP benefits only cover 43-60% of the cost for a diet consistent with federal dietary guidelines (Mulik & Haynes-
Maslow, 2017). The United States utilizes a healthy eating guide known as MyPlate (
Table 2-3). MyPlate operates under the USDA, and it includes food recommendations across various sexes and ages (United States Department of Agriculture, n.d.).
In 2011, the USDA calculated the cost of adhering to various food plans and determined a low-cost food plan would cost $147 per week for a family of four based on the 2005 Food
Pyramid guidelines (Mulik & Haynes-Maslow, 2017). With individual contributions to the monthly food budget and SNAP allowance, a family of four (one adult male, one adult female, one child aged 2-4 years, one child aged 5-7 years) would have a deficit of $475.87 each month
(Mulik & Haynes-Maslow, 2017). This number translates to a deficit of approximately 40-57 percent of what it costs to follow the federal dietary guidelines (Mulik & Haynes-Maslow, 2017).
This illustrates the disconnect between the cost of following a healthy diet and an individual’s means.
A study conducted by the Food and Nutrition Service of the USDA revealed 45% of
SNAP participants restrict food intake to make their food last the entire month (Food and
Nutrition Service, 2013). Another coping mechanism is changing the type of food consumed, with 46% of respondents choosing foods like potatoes, pasta, and other inexpensive food options toward the end of the month, when SNAP dollars run out (Food and Nutrition Service, 2013).
Diet quality, measured in average servings of fruits, vegetables, dairy products, and calcium, is reduced among food pantry participants (Simmet, Depa, Tinnemann, & Stroebele-Benschop,
2017). Large numbers of food pantry users did not meet recommendations for B vitamins, vitamins A, C, and D, iron, magnesium, and zinc (Simmet, Depa, Tinnemann, & Stroebele-
28
Benschop, 2017). Furthermore, Feeding America estimates 10 million individuals are food insecure but have incomes above the cutoff for nutrition assistance (Feeding America, 2018).
Food Security and Health:
Several studies describe a relationship between food insecurity and wasting, stunting, and underweight (Weigel, Armijos, Racines, & Cevallos, 2016). Low dietary quality and low dietary diversity occur with food insecurity, which contribute to malnutrition (Weigel, Armijos, Racines,
& Cevallos, 2016). In the United States, overnutrition is more common than undernutrition. The age-adjusted prevalence of obesity rate in the United States was 42.4% from 2017-2018 (Hales,
Carroll, Fryar, & Ogden, 2020).
Food insecurity resulting from disparities in neighborhood food environments is well- studied and suggests the environment is a major contributor to poor diet and obesity (Yan,
Bastian, & Griffin, 2015). Since many grocery stores move to the suburbs and create urban pockets without access to large grocery retailers (known as a food desert), there in an increased reliance on small grocers or convenience stores with limited food options (Yan, Bastian, &
Griffin, 2015). Lower grocery store accessibility is positively associated with obesity (Yan,
Bastian, & Griffin, 2015). People with better access to grocery stores have healthier diets (higher intake of fruits, vegetables, nuts, soy protein cereal fibers, and polyunsaturated fats) (Larson &
Story, 2009). Additionally, lower access to convenience stores reduces the risk of obesity
(Larson & Story, 2009). When grocery stores stock more healthful options, patrons tend to buy more healthful foods (Larson & Story, 2009; Dannefer, Williams, Baronberg, & Silver, 2012).
For many, health is not related to a lack of knowledge about healthy foods. Participants in several studies can identify healthy foods compared to unhealthy foods (Darmon & Drewnowski,
2015). Rather, barriers such as affordability prevent them from consuming healthier foods
29
(Darmon & Drewnowski, 2015). The affordability barrier also influences their willingness to try new foods, since they can’t afford food waste if they don’t like something (Darmon &
Drewnowski, 2015).
Due to the coping mechanisms, food insecurity is associated with higher risk of poor health (Nunnery & Dharod, 2017). Lower incomes have repeatedly been identified as a barrier to consuming healthier diets (Darmon & Drewnowski, 2015). Studies concluded there were many reasons for the association between obesity and poverty, including consumption of foods richer in energy, low cost of energy-dense foods, and high palatability of foods high in fat and sugar
(Darmon & Drewnowski, 2015). Another potential contributing factor is parents who experience food insecurity serve fruits and vegetables less frequently than parents who are food secure
(Martin, Wu, Wolff, Colantonio, & Grady, 2013). Households that experience food insecurity may experience frequent feast-famine cycles, causing overconsumption when resources are available (Nunnery & Dharod, 2017).
Food insecurity is positively associated with body mass index (BMI = height/weight2) and waist circumference (Myers, et al., 2019). In a national study of more than 5000 individuals, researchers found food-insecure households had higher prevalence of disease and poorer disease management (Seligman, Laraia, & Kushel, 2010). Food-insecure households were at greater risk of diabetes and hypertension than food-secure households (Seligman, Laraia, & Kushel, 2010).
Among adults with diabetes, those living in food-insecure households were more likely to have poor management of their diabetes (Seligman, Laraia, & Kushel, 2010), higher rates of chronic kidney disease (CKD) diagnosis in individuals with diabetes or hypertension (Crews, et al.,
2013). Adiposity is also significantly greater in food-insecure individuals when controlling for
30 health literacy level (Myers, et al., 2019). Among those with low health literacy, the prevalence of food insecurity and food security were not statistically significant (Myers, et al., 2019).
Variable food insecurity can also have an impact on health status, such as food security patterns characterized by adequate resources after benefits are received followed by diminished resources as the month ends. Maternal exposure to variable food accessibility during a child’s infancy resulted in children with greater weight gain, higher BMI, and indicators of insulin resistance, with the mothers exhibiting signs of increased insulin resistance and metabolic syndrome (Laraia, 2013). This suggests food insecurity during pregnancy or infancy can lead to lifelong health complications for both the mother and the child (Laraia, 2013).
Food insecurity is associated with greater healthcare expenditures over time (Berkowitz,
Basu, Meigs, & Seligman, 2018). Individuals spend more to manage their health conditions
(Berkowitz, Basu, Meigs, & Seligman, 2018). A diabetes diagnosis increases the chance of household food insecurity by 4% each year (i.e. 4% the first year, 8% the second year, 12% the third year, etc.) (Gucciardi, Vahabi, Norris, Del Monte, & Farnum, 2014). Health problems are also compounded by less access to healthcare, particularly preventative healthcare (Berkowitz,
Basu, Meigs, & Seligman, 2018). Furthermore, healthcare costs can impede poverty reduction in
LMICs, quickly draining resources, stifling development, and forcing people into poverty (World
Health Organization, 2018), so a similar pattern likely occurs in the United States.
Food Literacy and Food Security:
Food literacy is an evolving term in nutrition literature, with definitions falling into one of four domains (Perry, et al., 2017). Nutrition facts describes knowledge of a variety of foods, ingredients, and some knowledge of nutrients’ role in the body so the person can consume a healthful diet (Perry, et al., 2017). Food skills relate to the knowledge needed to prepare foods,
31 like purchasing, preparing, food safety, and storage (Perry, et al., 2017). Self-efficacy encompasses personal skills, although these skills are dependent upon cultural alignment and family variables (Perry, et al., 2017). The ecological view describes the socio-cultural influences of food, food systems, and infrastructural determinants (Perry, et al., 2017).
Some definitions incorporate all of these facets into food literacy, describing the ability to plan and manage food intake, select foods, prepare foods, and consume a healthy, balanced intake (Vidgen & Gallegos, 2014). Food literacy is also very contextual, and these traits will manifest differently depending on an individual’s circumstances (Vidgen & Gallegos, 2014).
Unfamiliarity with foods and the food environment in the host country has frequently been cited as problematic for resettled refugees in Europe, the United States, and Australia (McElrone, et al., 2019; Sanou, et al., 2014; Hadley, Zodhiates, & Sellen, 2007; Lawlis, Islam, & Upton, 2017).
New Americans and Food Security:
One of the primary risk factors for food insecurity is poverty (Nunnery & Dharod, 2017).
Most New Americans are eligible for SNAP benefits as long as their income is below the threshold, and women and children are eligible for WIC benefits (Food and Nutrition Service,
2013). Participation in food assistance programs can be a major facilitator of food security in
New Americans (McElrone, et al., 2019). Participation in federal programs like WIC can reduce or reverse the effects of wasting, stunting, and anemia in New Americans (Smock, et al., 2020).
However, it is difficult for New Americans to navigate the paperwork required for food assistance, which causes gaps in coverage or loss of benefits if they do not submit the right paperwork at the correct times (McElrone, et al., 2019).
Several studies have documented significantly higher food insecurity rates in New
Americans when compared to the general population. A qualitative study of three groups of
32 refugees in different parts of the United States, consisting of 69 participants in total, found 70% of the study participants experienced some level of food insecurity. On average, participants had been resettled for 8 years (Nunnery & Dharod, 2017). Another study from 2009 found only 23% of participants did not meet any of the food insecurity parameters (Hadley, Patil, & Nahayo,
2010). Among Somali mothers resettled in the United States, 72% were food insecure (Dharod,
Croom, Sady, & Morrell, 2011).
The unique challenges New Americans face include low availability to traditional foods, difficulty accessing traditional food outlets, limited knowledge of foods in their host country, and food instability due to low income and social supports (Lawlis, Islam, & Upton, 2017). Lack of resources is a primary driver of food insecurity in New Americas, as payments like rent, bills, and medical expenses take precedence over foods (Nunnery & Dharod, 2017). Unfamiliarity with American foods and cooking equipment complicates food security (McElrone, et al., 2019).
Social supports are frequently identified as important to food security, since these social supports help New Americans become accustomed to living in the United States (McElrone, et al., 2019).
Through these supports, they learn how to use cooking equipment, learn where to buy food items, and provide transportation (McElrone, et al., 2019). Lack off private transportation and have difficulty navigating public transportation are other identified barriers (McElrone, et al.,
2019).
New Americans and Economic Opportunity:
New Americans have lower incomes than other immigrants, although their incomes do rise with increased length of stay in the United States (Capps, et al., 2015). Low income status is more prevalent in refugees than the U.S.-born population, with 44% of refugees considered low income compared to 33% of U.S.-born individuals (Capps, et al., 2015). English language
33 proficiency is critical for New Americans to attain self-sufficiency, but a majority of New
Americans have limited English proficiency after 20 years of living in the United States (Capps, et al., 2015). Low literacy rates in the native language can complicate learning, as some countries have poor education systems or a lack of educational opportunity due to long-term instability
(Capps, et al., 2015). This further impairs their ability to get stable, high-paying jobs in the
United States.
Along with lower incomes, many refugees send money to relatives in their home country.
These remittances are important to their families abroad, so New Americans may reduce food spending to send more money home (Nunnery & Dharod, 2017). Already resettled New
Americans may also have to support newly resettled family members (Hadley, Zodhiates, &
Sellen, 2007).
Acculturation and Diet Quality:
Some studies measure acculturation via a proxy, such as how many years someone has lived in the United States (Smith & Coleman-Jensen, 2020), English proficiency, or both
(Dharod, Croom, Sady, & Morrell, 2011; Ward, Jilcott, & Bethel, 2011). Other studies factor in how well someone has acculturated to navigate the food environment here, including transportation and food availability (McElrone, et al., 2019). Other studies directly evaluate changes in dietary habits using food frequency questionnaires or 24-h recalls (Sanou, et al.,
2014; Gilbert & Khokhar, 2008).
Traditional and indigenous diets tend to contain more fruits and vegetables with less sugar and saturated fat (Gilbert & Khokhar, 2008; Lipski, 2010). Traditional diets also protect against cardiovascular disease, T2DM, cancer, hyperlipidemia, hypertension, and obesity
(Lipski, 2010). However, in some populations, maintenance of traditional eating habits and foods
34 can increase risk of certain conditions, particularly conditions associated with high sodium intake
(Sanou, et al., 2014) or high sugar intake from sweetened beverages (Haq, 2003). In a systematic review of dietary habits of selected ethnic groups in Europe compared to their host country, researchers found the majority of ethnic groups integrated unhealthy elements of the “Western
Diet” (the dietary patterns of the United States, Canada, Europe, and Australia), although the extent of change was moderated by ethnic identity, age at time of immigration, economic status, and availability of ethnic foods (Gilbert & Khokhar, 2008; Patil, Hadley, & Nahayo, 2009).
Dietary change is independently associated with overweight and obesity, even when controlling for other variables (Roshania, Venkat Narayan, & Oza-Frank, 2012).
Increased consumption of the Western diet, among other lifestyle factors like lack of exercise and stress, also increases risk of NCCDs, particularly among South Asian and African
Caribbean groups (Gilbert & Khokhar, 2008). Higher levels of dietary acculturation and integration lead to the migrant groups having similar or even higher prevalence of diseases and mortality when compared to the host nation (Gilbert & Khokhar, 2008). Using years lived in the host country as a proxy for acculturation led to a positive correlation with increased BMI, onset of chronic conditions like coronary heart disease, and frequency of healthcare usage (Sanou, et al., 2014; Smith & Coleman-Jensen, 2020).
Africans report the most dietary change and consumption of Western foods, which may contribute to increased unhealthy weight gain (Roshania, Venkat Narayan, & Oza-Frank, 2012).
However, acculturation may lead to positive benefits such as protection against nutritional deficiencies like calcium, vitamin D, and iron (Sanou, et al., 2014). Furthermore, other studies suggest acculturation can protect against some diseases (Sanou, et al., 2014), so acculturation is one factor in a multitude of factors that influence overall health in New Americans.
35
Community Gardens and Food Security
In some areas, community gardens and farms are tended by volunteers who donate the produce to food banks or food pantries in the area (Furness & Gallaher, 2018). Some community gardens are kept for use within the community and tended by community members, either with shared plots or individual plots. In other spaces, produce is sold.
In studies of the general population, community gardens reduce rates of food insecurity in communities (Morris, et al., 2017). Urban community gardens increased the likelihood a family would consume fruits or vegetables daily when compared to non-gardeners (Alaimo, Packnett,
Miles, & Kruger, 2008). Even if only one person in the family participates in gardening, the entire household increases fruit and vegetable intake (Alaimo, Packnett, Miles, & Kruger, 2008).
During harvest seasons, the frequency of concern over food running out before there was money to buy more dropped significantly (Carney, et al., 2012).
Community gardens may also alleviate other problems like preference, quality, selection, cost, and transportation (Alaimo, Packnett, Miles, & Kruger, 2008). They can provide significant cost-savings, with one California study reporting savings of $84 per month of harvest season (Algert, Diekmann, Renvall, & Gray, 2016). These cost savings can reduce food insecurity for families (Algert, Diekmann, Renvall, & Gray, 2016; Carney, et al., 2012).
However, the substantial costs for initiating a home garden and a community garden act as a barrier to participation, especially for low-income families (Algert, Diekmann, Renvall, & Gray,
2016).
The donation-model of community gardens makes significantly more produce available to food pantry participants (Furness & Gallaher, 2018). In particular, they are beneficial for making more fresh produce available, although participation in gardening is low among the food
36 pantry beneficiaries (Furness & Gallaher, 2018). In the donation model, participants were constrained by limited variety available on days they went to the food pantry (Furness &
Gallaher, 2018).
Community gardens have received some criticism for addressing symptoms rather than the structural problems relating to food security, such as systemic poverty, discriminatory zoning, and inaccessible food distribution systems (Heynen, Kurtz, & Trauger, 2012). These food movements can take resources away from larger, systemic change and shift focus from the bigger picture to immediate food provision (Furness & Gallaher, 2018).
New Americans and Community Gardens:
Recently, studies involving New Americans and community gardens have increased. The literature suggests gardening provides numerous health benefits for New Americans, including social support, mental wellness, exercise, and better access to produce (Hartwig & Mason, 2016;
Gichunge & Kidwaro, 2014). Besides providing fresh produce, community gardens can build relationships between New Americans, providing a social support network and emotional healing
(Hartwig & Mason, 2016). Furthermore, it can give New Americans a feeling of self-worth; they are self-sufficient and can provide for their families (Gichunge & Kidwaro, 2014). Working in the garden also provides exercise, which may protect against NCCDs and obesity (Gichunge &
Kidwaro, 2014).
Many New Americans were farmers or had gardens in their home countries, relying primarily on grown or gathered items for food (Nunnery & Dharod, 2017). This connection can compound the positive effects of gardening and mediate other stressors (Hartwig & Mason,
2016). New Americans desire the ability to grow their own foods, especially if it facilitates access to culturally appropriate foods (McElrone, et al., 2019). In gardens, New Americans can
37 grow specific cultural foods that are unavailable or inaccessible otherwise (Algert, Diekmann,
Renvall, & Gray, 2016; Gichunge & Kidwaro, 2014). Participation in a community garden can reduce the amount of money a family spends on food each month and provides a stable source of food during the harvest months (Hartwig & Mason, 2016).
Summary:
New Americans experience various challenges to proper nutrition and good health, many of which compound on each other. It is difficult to generalize about New Americans as a group, since there are different ethnic groups, pre-resettlement factors, and environmental circumstances influencing a New American’s experience in the United States. Many New Americans come to the United States with pre-existing health conditions, whether over- or undernutrition (Davis,
Phares, Salas, & Scherrer, 2020; Centers for Disease Control and Prevention, 2010; Dawson-
Hahn E. E., Pak-Gorstein, Hoopes, & Matheson, 2016). Genetic factors that provided an evolutionary benefit at one point could lead to problems in an energy-abundant environment.
This genetic factor in addition to physiological stress and overconsumption of inexpensive, energy-dense foods lead to increased health risk (Sinha & Jastrebof, 2013; Rondinelli, et al.,
2011).
With the rising costs of healthcare and NCCD management (Mulugeta, et al., 2018), as well as the link between food insecurity and poor health outcomes (Berkowitz, Basu, Meigs, &
Seligman, 2018), targeting factors that prevent or treat malnutrition in New Americans is vital to their integration into life in the United States. Literature suggests that maintenance of traditional dietary patterns is protective, since they contain more fruits and vegetables (Gilbert & Khokhar,
2008; Lipski, 2010), while dietary acculturation increases intake of processed foods (Gilbert &
Khokhar, 2008). Community gardens could mediate some of this health risk by increasing fruit
38 and vegetable intake, increasing access to traditional food items, and improving food security by reducing the total amount spent on food each month (Hartwig & Mason, 2016; Algert,
Diekmann, Renvall, & Gray, 2016), along with providing other emotional health benefits.
However, there are many individuals who lack access to the means to garden, so the feasibility of expanding community gardens for entire communities requires more research.
39
CHAPTER 3: METHODOLOGY
Research Design
A mixed-methods research design combining quantitative and qualitative methodology was used to assess the dietary habits of a population of New Americans living in the North Side neighborhood of Syracuse. Data was collected utilizing three different strategies. Quantitative research was used to assess availability and economic determinants of food security through grocery store audits and food frequency assessments. Qualitative research was gathered to analyze more detailed accounts of food security, such as personal access and cultural factors influencing intake. Other information pertaining to qualitative research was collected regarding personal accounts of community gardens on food acquisition and cultural norms surrounding dietary intake. For Study 2, protocol was reviewed by Syracuse University’s Institutional Review
Board for Human Subjects Research and was approved under expedited full-board review.
40
CHAPTER 4: FOOD ENVIRONMENT AND AVAILABILITY ON
SYRACUSE’S NORTH SIDE NEIGHBORHOOD
Area of Interest:
This study was conducted in the North Side neighborhood within the City of Syracuse, where there is a large community of resettled New Americans. The White Branch Library in the
North Side of Syracuse was identified as a common meeting area for New Americans participating in SCHF’s community garden; thus, it was chosen as the epicenter for data collection. Food acquisition sites (FAS) from within a one-mile radius of the library were compiled. The radius was later reduced to 0.5-miles from the library due to the large number of
FAS in the neighborhood. The neighborhood encompasses two zip codes in the Syracuse area:
13208 and 13203.
To identify the FAS on the North Side, Reference USA was used. Each address was plotted on a map to ensure it was located within a one-mile radius of the White Branch Library.
Reference USA is a database which contains detailed listings of businesses and establishments with the ability to search by type of establishment, location, business size, industry, and financial data, among other parameters. Reference USA keeps records of verified businesses and unverified businesses. Originally, only verified businesses were included in the search. However, after canvassing the neighborhood, it was revealed that several FAS were not listed as verified businesses. FAS were physically counted by driving through the area. This list was later cross- checked with data from Reference USA and Google Maps.
Figure 4- illustrates all plotted food acquisition site according to Reference USA. Based on the data from Reference USA, there are 46 FAS within a one-mile radius of the White Branch
Library. However, a thorough canvassing of the neighborhood prior to data collection revealed
41 there was no comprehensive and up to date listing of FAS within the neighborhood. Most stores were simply not listed, while other stores were listed under different names. Occasionally, there were stores listed that are no longer in business. Thus, prior to data collection, a list of all FAS on the North Sides was compiled. There were 66 FAS within the one-mile radius. Most of these sites had data points on Google Maps, however, there were some listed under different names.
There were five sites in total that are considered FAS and were not listed on Google Maps under their current or past names. There were three sites listed on Google Maps but are no longer open.
This suggests there is a large turnover of grocery stores and grocery store ownership.
FAS included grocery stores, gas station mini-marts, and convenience stores. Restaurants, both full-service and quick service, were excluded from analysis. Pop-up markets or farmers’ markets were also excluded since they are not available every day. Specialty stores such as meat markets or bakeries were not included in the possible pool for auditing due to their limited stock and specialized nature. They were included when describing the food environment because these stores can provide niche items and are an important facet of the food landscape.
Of the 42 FAS identified within the 0.5-mile radius, 36 accept SNAP benefits, although this information was not always clearly visible within the store and had to be identified using a
SNAP retailer locator (Food and Nutrition Service, 2019).
Food Acquisition Site Audit Instrument
The Culturally Appropriate Food Environment Audit (CAFE-A) was designed from several existing instruments (Izumi, et al., 2012; Horacek, et al., 2018; Economic Research
Service, 2002; Larson & Story, 2009) to assess both food availability and prices, as well as the cultural appropriateness and environmental features that impact food acquisition. This instrument contained 97 questions broken into ten categories: Outside the store, inside the store aesthetic,
42 produce (n=48), meat and meat substitutes (n=45), dairy products (n=30), grains (n=24), packaged snack items (n=17), beverages (n=16), and miscellaneous items (n=33). The list contained more and less healthy items (e.g. whole milk and nonfat milk) considered staples in the United States. The CAFE-A included culturally specific foods like lychee, bitter gourd, bok choy, adzuki beans, and camel milk. These foods were selected due to their prevalence in the diets of the major New American groups resettled in the United States. Price data was collected for select items.
All varieties of products were considered as separate entries, but the same variety of food from different brands was counted only once (e.g. creamed corn and whole kernel corn are separate, Del Monte and Great Value whole kernel corn were the same). Vegetarian marinara sauce and pizza sauce were counted as vegetables, since they are considered vegetables according to the USDA for school lunch purposes. Different varieties of marinara sauce were counted separately (e.g. classic marina vs. chunky vegetable marinara). Pickled fruits and vegetables were also counted as part of the total canned fruit or vegetable total, due to the prevalence and importance of pickled fruits and vegetables in many Asian cultures. Beans were counted as canned vegetables, including dry beans, and as legumes, since they are considered vegetables for non-vegetarians according to the dietary guidelines. Deli meats, hot dogs, and sausages counted as fresh meats.
On the outside of the store, types of advertisements, store size, and lighting were evaluated. The inside was evaluated for number of registers, lighting, cleanliness, cultural display symbols, presence of non-English signs of food items, and food items associated with an ethnic cuisine. The instrument was tested in a variety of settings prior to use in the intended neighborhood.
43
Data Collection
Data was collected over a two-month period of December 2019 to January 2020. The estimated time for completion of the audits was 2 hours. The audits took an average of one hour to complete, with completion times ranging from 28 minutes to 118 minutes. Stores were tracked based on Reference USA lists and physical drive through data to compare, but audits were only conducted for stores identified on the physical store list and located within the defined 0.5-mile radius. All data was collected on the premises.
Within the store, the study and its goals were briefly explained. All data from the stores has been aggregated and will remain anonymous, as clerks were assured the information would not be traced back to the individual stores. Only one store clerk refused to allow the audit. The interior of the store was analyzed based on cleanliness, presence of advertisements, availability of shopping accessories, and availability and prices of foods Prices were only listed if the data was available without purchasing or asking a store employee. For the items listed, the cheaper brand was used for price data, and sale prices were not taken into consideration. The usual price was the price recorded in order to better illustrate the usual food environment in the community.
During the audit, each store was catalogued based on its characteristics for later analysis.
• Convenience store: These stores sell snacks and beverages, may sell gas, have ≤2
cash registers, and a small selection of grocery items, mostly dried goods.
• Drug store: These stores sell mostly self-care items, may have a pharmacy, and
some grocery items.
• Dollar store: These stores sell a wide variety of discounted personal care,
household, and food items.
44
• Ethnic market: These stores primarily sell foods associated with a particular
cuisine or ethnic group but may sell other home goods or prepared foods.
• Specialty store: This store caters to a specific item or need, like a bakery, but
carry limited other grocery items. These stores were not included in the
population for auditing, but they were included in observational analysis.
• Supermarket: This store sells primarily grocery items and has >3 registers. They
may also sell a large variety of fresh and frozen meats, fruits, or vegetables.
All the stores were cross-referenced against an online SNAP retailer portal to determine an accurate picture of retail locations that accept SNAP benefits.
Results and Data Analysis
Within the 1.0-mile radius of the White Branch Library, there were 66 FAS including specialty stores. Three of the results were gas station mini markets. Within the 0.5-mile radius of the White Branch Library, there were 46 FAS. There were specialty stores (n=4; three bakeries, one halal meat shop) excluded from analysis. Of the remaining 42 FAS, there were ethnic stores
(38%, n=16), pharmacies (2%, n=1), dollar stores (7%, n=3), and supermarkets (2%, n=1). The remaining stores were classified as convenience stores (50%, n=21). 36 of the FAS accepted
SNAP benefits (85.7%), including all the ethnic markets, pharmacies, dollar stores, and supermarkets, and 15 of the convenience stores (71.4%).
In total, there were 42 FAS on the North Side within the parameters for review. This list was accurate as of January 2020, but high turnover rates and ownership changes may impact the accuracy of the list. There were 37 audits completed in total to reach statistical significance. A list of these FAS was randomly generated, and the first 37 stores were audited. If a store was selected and visited three times without successfully completing the audit, whether due to store
45 hours or refusal of the store clerk, the next store on the list was included for analysis. Store visits occurred on a variety of days, with both weekdays and weekends included.
The final sample of 37 grocery stores included a drug store (3%, n=1); a supermarket
(3%, n=1), ethnic stores (38%, n=14); dollar stores (8%, n=3) and convenience stores (49%, n=18). Statistical analyses were conducted using IBM Statistical Package for the Social Sciences
(SPSS), version 26.0.
The best proxy to measure if a store should be classified as an ethnic market were number of food items specific to a particular cuisine and name of store and whether it specified a location, ethnic group, or was written in another language. Based on these two data points, 14 ethnic markets were identified from various ethnic backgrounds including African, Asian,
Hispanic, and Middle Eastern. These stores all offered >40 items associated with a particular cuisine. These characteristics are later used as variables for grouping analysis.
All stores had at least one form of canned fruit and vegetable. Prevalence of fresh fruits and vegetables was approximately half for both, with slightly more stores selling fresh vegetables (n=19) than fresh fruit (n=17). Very few stores had freezer sections, so frozen fruits and vegetables were the least common. There was a wide variance of fresh fruit and vegetable selection among stores that sold fresh fruits (7.5 ± 7.1) and vegetables (22.5 ± 20.1). Ten stores sold ≤5 varieties of fruit, with the most common fruits being apples, oranges, lemons, and limes.
Seven stores sold 5 or fewer types of fresh vegetables. Ten sold >20 varieties of fresh vegetables.
Of the stores with less than ≤5 varieties of vegetables, the most common vegetables were onion, garlic, and potatoes (
Table 4-).
46
Based on observational data, it appeared there were more fresh produce options at ethnic markets than non-ethnic FAS, but also less milk and dairy sold. To better analyze this for significance, stores were grouped into two categories: ethnic stores and non-ethnic stores.
Independent samples t-test of proportions were used to compare frequency of selected items found in ethnic stores compared to non-ethnic stores (
Table 4-).
Based on this analysis, ethnic stores are more likely to carry fresh fruits (p≤0.01), fresh vegetables (p≤0.01), frozen fish (p≤0.01), and soy products (p≤0.01). Non-ethnic stores are more likely to sell milk (p≤0.01), 100% juice (any kind) (p≤0.01), white bread (p≤0.01), and butter or margarine (p≤0.01). These findings are not surprising when considering cultural differences in dietary patterns. Native dietary patterns tend to be higher in fruits and vegetables (Gilbert &
Khokhar, 2008; Patil, Hadley, & Nahayo, 2009), so it is likely the store offerings reflect this pattern. The higher prevalence of milk also represents the value of milk in the diet the United
States, whereas it is less commonly consumed in Asian and African nations (Statista Research
Department, 2020). This supports the suggestion that acculturation could lead to increased calcium and vitamin D intake (Sanou, et al., 2014), as milk is an excellent source of both nutrients. However, few stores sold non-fat or low-fat milk (0% or 1% milkfat) (n=3), so this also contributes excess caloric intake if it is simply added into the diet. Ethnic stores sold fruit drinks more frequently than fruit juice.
Ethnic stores also carried difficult to find specialty items. Examples of these items were camel milk, fresh turmeric, roti, curry spice mix, lychee, daikon radish, bitter melon, saltfish, ackee, callaloo, herbs, paneer, bamboo shoots, specific types of legumes like adzuki beans, and grain flours like buckwheat flour. These items make up important components of New
47
Americans’ diets in their home country. Camel milk is considered the best of all milks in Somali culture (Haq, 2003). Inability to find cultural foods in traditional supermarkets presents a significant barrier to resettled refugees (Lawlis, Islam, & Upton, 2017; Nunnery & Dharod,
2017; Gichunge & Kidwaro, 2014; Hadley, Patil, & Nahayo, 2010).
From observational data, ethnic markets and convenience stores were both located directly within the neighborhood, so these were compared separately in some statistical calculations (as denoted in bold).The supermarket was also excluded from Table 4- analysis in due to high offerings of all items, which skewed results. It is important to note there is a supermarket within the defined radius, as access to a supermarket is considered protective against NCCDs and negative health effects (Yan, Bastian, & Griffin, 2015).
I wanted to determine if the variety of certain foods was larger at ethnic or non-ethic stores (Table 4-). Ethnic markets sold healthier food options than other stores (n=23). They sold more varieties of fresh fruits (mean = 9.2 vs 3.4; p≤0.05) and fresh vegetables (mean = 31.1 vs
3.8; p≤0.05). They also sold more frozen meat (mean = 6.6 vs 3.1; p≤0.05), while most convenience stores did not offer frozen food sections (n=1). The effect size was 0.8 or greater for beans/legumes (g=0.80), and over 1.0 for fresh vegetables (Δ =1.39) and frozen meats (g = 1.56).
This suggests the mean beans/legumes, fresh vegetables, and frozen meats available at the grocery store are significantly greater than those found at other stores (by between 0.80-1.56
SD).
The supermarket sold reduced price fruits and vegetables and cart strollers for transporting groceries between the store and home if the person walked to the store, increasing accessibility for those living within the community and walking to FAS. Price data was readily collected from the supermarket, but other convenience stores and ethnic markets had less price
48 data available. The collected data is summarized in Appendix D. The sample sizes were not large enough to be statistically significant, but descriptive analysis was conducted on the available data.
Items found in the ethnic markets and convenience stores were more expensive for 23 of the 31 selected items. Staple items like white bread (230%), white flour (156%), white pasta
(185%), white sugar (176%), white rice (173%), and canned tuna (174%) cost at least 150% more on average at stores other than the supermarket. Some items were similar in price (±5%) including chili powder, dried black beans, and dried lentils. Ethnic markets were as likely or more likely to offer a specific spice with the exception of oregano, vanilla, lemon juice, and baking powder. Spices, on average, were less expensive at non-supermarket FAS, with chicken bouillon, cinnamon, and paprika costing at least 15% less on average at stores other than the grocery store. 97% of all FAS sold spices (n=36) but there was great variation in spice variety offered. The most common spices were black pepper (n=33), salt (n=32), chili powder (n=29), garlic powder (n=26) and soy sauce (n=23). Asian ethnic markets were more likely to sell cardamom (71%, n=10 vs 0%, n=0), dried turmeric (100%, n=14), and coriander (79%, n=11) than other stores.
A one-way ANOVA was calculated for pricing data to determine if there is a relationship between the five categories (strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, strongly disagree) and presence of cultural food items (0-10 cultural items,
11-40 cultural items, 41+ cultural items). A Tukey HSD post hoc test was subsequently used to determine the specific group differences. There was a statistically significant difference between the availability of pricing data in ethnic stores than stores with 0-10 items belonging to a particular cuisine, with the stores with 0-10 items having pricing data strongly visible (p≤0.016).
49
There was no statistical difference between the groups comprising 11-40 food items with a particular cuisine and price data availability.
The lack of price data is concerning when considering the struggles of New Americans with achieving food security in relation to limited financial resources. With limited resources, lack of price data would make it difficult to compare prices between grocery stores. Low literacy and difficulty navigating the food environment immediately after resettlement means New
Americans may not check the prices of food before they buy. Rather, they remember how much they are able to buy and buy the same amount each time (Nunnery & Dharod, 2017). Using trial and error and input from their social connections, they may determine the foods they can buy and the best places to purchase items. Learning to use money in the United States also presents a challenge, so the individual may simply hand the money to the store clerk without understanding the cost of their purchases (McElrone, et al., 2019). Lack of comparison shopping, purchasing more expensive fruits, vegetables, and traditional items, and lack of coupon use and budgeting increase food insecurity even if income remains the same (Hadley, Patil, & Nahayo, 2010). This exacerbates problems of insecurity, food access, and dietary intake.
One unforeseen impact of ethnic markets is community-building. Shopping at specific ethnic markets provide a direct link to other New Americans from similar backgrounds, increasing social networks. From entering and auditing FAS, there were some stores where customers and store employees would stand and talk for large amounts of time, watch soccer games together, or ask each other questions. From direct observation, it is impossible to conclude whether these interactions came as a result of shopping at an ethnic market or the impact they have on the New American community overall. However, it appears the community provided by ethnic stores enhances social networks, social supports, and overall well-being.
50
Conclusions
The high number of FAS is consistent with Moore and Diez Roux (2006) who reported an association between the local food envionrment and neighborhood demographic factors.
Predominately minority neighborhoods and low-income neighborhoods had greater density of grocery stores but lower density of supermarkets than predominantly White neighborhoods and high-income neighborhoods (Moore & Diez Roux, 2006). There were 21 convenience stores within the specified goegraphic area, giving an approximate density of 42 convenience stores per square mile. High accessibility of convenience stores is positively associated with obesity
(Larson & Story, 2009). The presence of a grocery store with high walkability and structures to enhance access helps to promote food security, particularly for those who have unreliable access to private transportation. Lack of private transportation is consistently reported as a barrier to food security (Moore & Diez Roux, 2006), particularly in studies involving New Americans
(McElrone, et al., 2019).
Another unique aspect of this community is the role of ethnic markets. Within the 0.5- mile radius, there were 16 ethnic markets, belonging to various ethnic groups including African,
Asian, and Middle Eastern. This analysis suggests ethnic stores play an important role in increasing availability of foods from a specific culture, improving access to native foods and, by extension, food security (Lawlis, Islam, & Upton, 2017; McElrone, et al., 2019). It also suggests availability is not a primary barrier to food security in Syracuse, consistent with other findings in literature (Patil, Hadley, & Nahayo, 2009) but contrary to some findings (McElrone, et al.,
2019). This variation is likely due to difference in geographic region and store availability differs across cities.
51
The lack of pricing data, particulartly at ethnic markets, makes it difficult to speak to the true impact of ethnic stores on food security in New Americans, as price accessibility is another factor that impacts their food security (Hadley, Zodhiates, & Sellen, 2007; McElrone, et al.,
2019; Lawlis, Islam, & Upton, 2017). However, the lack of pricing data has some potential implications, including lack of budgeting, price comparison, purchase of more expensive products, all of which negatively impact food security (Hadley, Patil, & Nahayo, 2010). With limited resources, high prices found at ethnic markets would act as a barrier to New Americans, even if the items are available in the neighorhood (Nunnery & Dharod, 2017). However, observational data suggests ethnic markets contribute more to the food environment than edible items. The social connection and community centered around ethnic markets could enhance a
New American’s health, food security and adjustment to life in the United States (Lawlis, Islam,
& Upton, 2017; McElrone, et al., 2019; Ranabhat, Kim, Park, & Acharaya, 2017).
Limitations/Areas for Future Research
Although the initial sample size was chosen to reach statistical significance, there were several data points where 37 stores did not reach statistical significance due to missing values or unavailable data. One major limitation of this study was the lack of pricing data available.
Although the results show there is a variety of healthier items available throughout the neighborhood, price data would have provided more information about the accessibility of these foods items to New Americans. A follow-up study that gathers price data with store clerk assistance could provide more information about the true impact of ethnic stores on the food environment.
The instruments used in this study are not validated models, so the accuracy of the data cannot be guaranteed. The small sample size, although large enough for statistical significance
52 within the defined geographic area, is small compared to the neighborhood and typical distances people travel to the grocery store. This suggests the data presented here is only part of the food environment and does not accurately describe the possible factors at play. A larger, more inclusive study would need to be done to elucidate any causal relationships. Furthermore, the various sociopolitical influences on various cities in conjunction with the small sample size means the data is not generalizable. However, this study highlights the value of ethnic markets in the food environment, both for tangible and intangible products, that can be explored for their impact on New Americans, health, and food security.
53
CHAPTER 5: FOOD AND DIETARY HABITS OF NEW
AMERICANS
Methodology:
Part two was designed as a mixed-methods study to determine dietary intake in the individuals. It consisted of a visual food frequency questionnaire (FFQ) that tracked frequency of food consumed. This FFQ was based loosely on the NHANES Food Questionnaire developed by the National Cancer Institute for national use (Division of Cancer Control and Population
Sciences, 2020). It was adapted to be more appropriate for use with New Americans according to literacy and time constraints. This primarily included simplifying foods, combining categories of foods (i.e. “strawberries” was not divided into “when in season” and “during the rest of the year”) and including visual components. The number of food items associated with a specific cuisine also increased, such as tropical fruits like persimmons, different varieties of rice, vegetable varieties, and dumplings. It did not track quantity of food consumed, as these measurements were difficult to communicate with the target population. The visual FFQ can be found in Appendix E. Participants were requested to circle the foods they consume currently and mark their frequency of consumption with an “X” in the correct box. This activity was completed with interpretation assistance when required.
The FFQ was used in conjunction with in-person interviews, which took place during
February and March 2020. Food security was assessed during these interviews using a short- form food security assessment module based off a USDA-validated tool. The original 18-item interview tool is considered the gold-standard of assessment tools. A modified, 6-item assessment has also shown excellent sensitivity and good specificity (Blumberg, Bialostosky,
Hamilton, & Briefel, 1999). A study by Hager et al. (2010) reported two questions correctly
54 identified 97% sensitivity of food insecurity and 83% specificity to properly rule out food-secure households (Hager, et al., 2010). These two questions were incorporated into the interview questions and participants answered using a Likert scale (often true, sometimes true, never true) and gave room for open-ended explanation following.
“Within the past 12 months we worried whether our food would run out before we
got money to buy more”
“Within the past 12 months the food we bought just didn't last and we didn't have
money to get more.
Other topics treated their dietary habits in their country of origin, during their time spent in the UNHCR refugee camps, since resettlement in the United States, and the impact of the community garden on themselves and their families. Interpreters facilitated these interviews when necessary.
Recruitment
New Americans currently participating in the community garden at Salt City Harvest farm were recruited to participate. A sample size of 10-15 was needed to obtain adequate feedback for analysis and identification of themes. Due to safety concerns of COVID19 and New
Americans’ high-risk status due to low access to healthcare and limited resources to afford health services, only seven individuals were able to participate. Participants were recruited at community garden meetings and through snowball recruitment from within the community. Any
New Americans at least 18 years of age that participated in the community garden the previous year were eligible to participate. The community garden also serves the Deaf New American population in Syracuse, and these individuals were included in recruitment.
55
Results and Data Analysis
Sociodemographic characteristics were analyzed using descriptive statistics (IBM SPSS, version 26.0). Interviews were facilitated with appropriate interpretation specific to the New
American’s literacies, including Nepali Sign Language and American Sign Language. Interviews were audio-recorded and transcribed verbatim for analysis.
Seven interviews were conducted. Participants included men (57%) and women (43%), with all having origins in South Asia. Participants were all over 18, and most have lived in the
United States for 6-8 years, but one participant had lived in the United States for more than 10 years. All participants identified as Deaf or with hearing loss and all lived with family members.
All participants spent time in UNHCR camps prior to resettlement in the United States, although time spent in the camps varied between individuals. Anthropometric data and economic data were not collected as part of this study.
Themes
Foods consumed and acquisition methods: Rice was the core food item for all participants, with all participants reporting rice consumption for at least two meals per day.
Vegetables were frequently cited as complementary foods and were always eaten with rice.
Important vegetables in their diets were beans, cabbage, cauliflower, chili peppers, corn, garlic, mushrooms, onions, and pumpkin. Frequent consumption of hot peppers and a love of spicy foods were shared amongst the participants. Another vegetable frequently mentioned was saag, a spicy, leafy vegetable. All participants responded to drinking tea or tea with milk multiple times per day.
All participants participated in farming or gardening practices prior to living in a refugee camp. They shared or traded amongst their neighbors if there was something they wanted but did
56 not grow themselves. One participant, when asked about where he got his food, responded,
“Vegetables, I would all grow myself. Spices, I would go and get from the market.” Other individuals used crops they grew and plants they foraged to make their own spice mixes. They called these spice mixes “masala” and would season all their meals with them. Other items typically foraged were herbs, mushrooms, leafy greens, roots, flowers, and seeds. Taro root and fiddlehead fern (called niguro), were two items named by respondents.
Many participants also raised livestock like chickens, goats, and cows. From the goats and the cows, they made butter, yogurt, and a product called moi. Moi is a yogurt dish made with water and the remains of milk after it has been used to make butter. They also used chickens and goats for meat when they wanted meat. One woman recalled, “We had chickens on our farm too, so I we wanted chicken, we could always grab one, and then they gave us eggs.” Those who identified as Hindu raised cows for milk and labor, but not for meat since cows are considered sacred. Overall, foraging behaviors, livestock raising, and agricultural practices were central to the New Americans’ dietary habits prior to their resettlement in the United States.
Meal patterns in country of origin: Vegetables and meat were cooked together in oil.
The oil was heated in a pot first, then onion, garlic, and aromatics like hot chilis and masala were added. Following this, they added the vegetables and meat. During this time, rice was cooking.
Participants described this as the major preparation method for all their meals. Meat was sometimes dried for preservation over the fire or in the oven, depending on what was available.
Most participants reported cooking over a fire.
Meal size grew progressively through the course of the day. The morning meal usually consisted of tea, and some people also consumed rice, corn, pumpkin, and beans. The midday meal typically consisted of vegetables, beans, and rice. The even meal structure was similar, with
57 rice, spicy vegetables, and meat if it was available. Snacking was rare, with one participant (n=1) consuming fruit for snacks, while others (n=3) describe drinking water as a snack.
Respondents report to eating meat, on average, once per week. Typically, they would slaughter one of their animals and consume the meat until it was gone, then resume eating vegetables for a few weeks. Since meat consumption is rare, it is considered a special food. Goat is central to the Hindu celebration of Dasara, where it is traditional to consume goat, rice, and vegetables. The goat will first be sacrificed, then cooked, and eaten. During these celebrations, fish and chicken are also consumed. Other celebratory foods include edible flowers stuffed with meats, spices, and vegetables.
Dietary acculturation: Based on food frequency data and personal interviews, dietary acculturation is low for the New Americans included in this study. One participant reported, “I still eat with all of my friends and family, and I don’t eat American foods.” The reason for this may be related to preference, or it might be related to difficulty in learning how to prepare
American foods, as one participant reported, “When I got to America, I would watch Americans and how they ate, and how they would buy food, and I tried to figure it out. But I just eat the way
I’ve always eaten. I like American food, but I still eat the same.” American foods are more frequently consumed as a treat, such as going to a restaurant for food instead of cooking at home.
Food preparation methods are similar as they were prior to resettlement in the United
States: combining oil, aromatics, and hot peppers in a pan before adding the other vegetables and meat, if it is being used. Meat is consumed weekly to twice monthly, which is similar to dietary patterns in their home country. Vegetable consumption is high, particularly for the foods commonly cited as popular prior to resettlement, such as onions, garlic, cauliflower, hot peppers, and potatoes. Rice remains the bulk of the diet. Milk is primarily used in tea or for making
58 yogurt, as some participants responded to making yogurt themselves. Spices are equally important, although not all spices and herbs are available here. Although stir-frying or sautéing is the primary cooking method, some will make soups like chatpata (a spicy, well-spiced soup).
Everything is cooked on the stove top, and most do not know how to bake foods in the oven.
One important variable with the food frequency questionnaire is that all participants were instructed to consider the past 12 months when they were answering, meaning the FFQ encompasses both harvest season and non-harvest season. In the interviews, some participants expanded upon their FFQ answers. One participant eats corn frequently during harvest season when she can get it fresh from the garden, but she does not eat corn outside of that period. There are also some foods that are consumed more frequently or in larger quantities during the harvest season, like cabbage, tomatoes, and hot peppers. Some responded that they do not add other foods to replace these foods, although they may subconsciously compensate by consuming more of their usual foods. These variations in dietary intake are important to consider, as it suggests lower vegetable consumption, food access, and dietary quality than during non-harvest season.
Consumption of fried foods (e.g. French fries, fried chicken, fish, or shrimp), baked beans, seafood (e.g. shrimp, crab), hamburgers, hot dogs, bacon, sausage, breakfast cereals (e.g. granola, shredded wheat, sugar-sweetened cereals), sweets (cakes, donuts, pie, chocolate, fruit candies, ice cream, popsicles), snack foods (pretzels, popcorn), and sweetened beverages (fruit punch, soda) remains low. Alcohol consumption is unchanged since resettlement. FFQ and interview data support the conclusion that dietary patterns have not changed dramatically since coming to the United States. However, there is some dietary change, as evident by increased consumption of pizza, chips, cookies, and bagels/muffins.
59
FFQ analysis does not support a link between years lived in the United States and frequency of consumption of foods associated with a Western dietary pattern. There might be a link between reliance on ethnic food markets and dietary acculturation, with individuals who shop at major supermarkets changing their diet more than those who shop primarily at ethnic markets. However, due to the small sample size, statistical significance and Pearson’s correlation cannot be determined with accuracy.
Food insecurity: Food insecurity impacted all New Americans who participated in this study. Each person who participated in this study mentioned difficulty in accessing enough food or worry that there would not be enough food for their families. Although some (n=3) mention primarily using ethnic grocery stores for their products, other individuals reference using the ethnic grocery stores only for items they cannot find at other major supermarkets. There are some items they cannot find here in the United States, particularly herbs and herb roots, but instead of searching for the ingredients, they omit the items from their diet.
All participants mentioned high prices at ethnic markets acting as barrier to food acquisition. To alleviate the problem, one participant states “I try to go to the American store and buy [foods] cheaper, if I can find the specific food.” Another participant added, “I can find the foods [I want], but its more expensive, especially if I want it fresh.” For some, availability of ethnic foods is less important as access to enough food. One person reported, “It’s not so much the specificity of it. It’s just having the food. I’m fine with anything.” Overall, participants report shopping at multiple locations to maximize their savings and have access to the foods they want to eat.
Community garden participation: Community garden participation is positively associated with mental wellness, cost-savings, and food security. They store bulk items like
60 potatoes, tomatoes, and onions for a long time, and they will use these throughout the year. The farm also offers the option to purchase bulk vegetables outside of harvest season, so they utilize this food channel to get some vegetables in large quantities for a lower price. Participants report making sporadic trips to the farm during the off-season to stock up on durable vegetables.
There are also cost saving benefits since New Americans do not have to purchase the food items from the store; rather, they harvest from the garden. This leads to significant cost benefits (Table 5-34). During harvest season, the New Americans make fewer trips to the grocery store, saving money. When asked about the community garden, one person stated,
“Everything at the farm is delicious. I don’t need anything in the store whenever I go [to the farm].” Participants report going to the store more frequently now (during non-harvest season) than they did during harvest season. At the community garden, the participants make use of all the edible parts available, including plants commonly considered weeds in the United States.
These include nettle leaves and purslane. Since they are accustomed to using all the edible parts of the plans, it was an adjustment to leave some leaves in the garden as compost, rather than harvesting them for food.
There are some items the New Americans wish were available at the garden, like saag, cauliflower, pumpkins, and beans, as well as a leafy green vegetable called “bethu.” These are foods they commonly ate in their home countries. Furthermore, with the importance of spicy food in their culture, they felt there were not enough spicy vegetables grown in the garden.
Cherry bomb peppers are not native to their countries, and they didn’t like them. They wanted long, hot peppers instead. Along with other plant varieties, the New Americans expressed desire for an animal farm where they could raise goats or chickens for food, preferably having access to
61 enough land so the animals could graze on grass for food. They would like to raise the animals to share amongst their farm community and their families.
The interviewees pointed to economic impact and food security facilitated by the community garden, but they also referenced improved mental health. All participants farmed or gardened in their home country, so having access to garden is associated with positive memories from home. One participant responded, “It makes me feel like I did when I was [home] and I had my own garden. I get to have the same vegetables that I had then. And I like it a lot.” Thus, community gardens could facilitate improved health outcomes on multiple fronts.
Conclusions
Prior to resettlement in the United States, the New Americans in this study relied heavily upon rice as their staple food item, with starchy vegetables, non-starchy vegetables, beans, and legumes acting as complementary foods. Participants reported vegetable consumption with two or three meals per day, no consumption of processed and packaged foods, and occasional consumption of meat. Spices, liquid oil, butter, and yogurt were secondary meal components.
This is conclusive with the literature that suggests native dietary patterns are higher in phytonutrients, fruits and vegetables than Western dietary patterns (Gilbert & Khokhar, 2008;
Lipski, 2010).
Participants identified some issues of availability for certain vegetables, roots, and herbs they used in their home country. Rather than substitute these items, they simply omit them from their diet. Overall, however, this sample of New Americans did not identify a lack of availability of specific cultural items as a barrier to their preferred dietary pattern, consistent with findings from Patil et al. (2009). They point to various ethnic FAS that carry the food items they want as part of their diet. This is contrary to previous studies, where many New Americans report lack of
62 local availability of specific foods and traveling large distances to get cultural items (McElrone, et al., 2019; Lawlis, Islam, & Upton, 2017).
Limited resources were the main determinant of food insecurity in this study sample, affecting all the participants. Higher prevalence of food insecurity in New Americans is well- documented in literature (Nunnery & Dharod, 2017; Hadley, Patil, & Nahayo, 2010; Dharod,
Croom, Sady, & Morrell, 2011). Prices at the ethnic markets are higher than American supermarkets, making cultural foods inaccessible even though they are available. To alleviate the disparity, participants report such as shopping at American supermarkets for most ingredients and ethnic markets for those they cannot find other places. Hadley et al. (2007) reported similar behavior, who found New Americans shopped at different food stores, bought less or other food items, or reduced consumption to alleviate financial difficulty.
The increased prevalence of inexpensive American foods at supermarkets could explain the link between dietary intake and FAS, since participants who shopped at American supermarkets tended to have higher consumption of Western foods than those who shopped predominantly at ethnic markets. Similar to European findings by Gilbert and Khokhar (2008), the core food behaviors have remained similar, with changes affecting accessory food items like snacks and sweets. Overall, however, acculturation in the New American participants of this study was low, with most maintaining native dietary habits (fruits, vegetables, rice) and low consumption of food items from the Western dietary pattern (cookies, chips, sweets). This could help prevent against overweight, obesity, and NCCDs, as dietary change is associated with increased risk of disease (Gilbert & Khokhar, 2008; Roshania, Venkat Narayan, & Oza-Frank,
2012). However, more research into anthropometric and health data is necessary to make stronger conclusions in this area.
63
The lack of dietary acculturation has a few potential roots. First, difficulty navigating
American grocery stores or understanding how to cook American foods could cause New
Americans to rely on foods and cooking methods they already know, which was a theme throughout the interviews and also identified in McElrone et al. (2019). Prior to resettlement, most participants used an open fire to cook. While everyone reported understanding how to use the stovetop, knowledge of baking and other preparation methods was low. Second, age of resettlement, economic status, and availability of ethnic foods mediate dietary acculturation
(Patil, Hadley, & Nahayo, 2009; Gilbert & Khokhar, 2008), so factors in Syracuse may be protective toward cultural preservation.
Access to the community garden could also mediate cultural preservation and food security in this population. Many New Americans have agricultural backgrounds, whether they relied on subsistence farming or tended a small garden, and they enjoy tending the community garden. Participants of this study and others (Algert, Diekmann, Renvall, & Gray, 2016; Carney, et al., 2012) cited fewer trips to the grocery store and decreased money spent on food during harvest season, thus improving food security. Furthermore, many of the vegetables grown in the garden are vegetables central to this study’s participants’ dietary habits in their home countries, like corn, potatoes, onions, hot peppers, cabbage, and edible weeds. Having access to this produce from the garden to supplement or replace their grocery store purchases could allow them to maintain their dietary habits here in the United States by making these food items accessible
(Gichunge & Kidwaro, 2014).
The primary role of the community garden in cultural preservation in this study is via mediation of food security. Since they don’t have to purchase the vegetables from the garden, it provides extra resources for the New Americans to purchase other supplies from the ethnic
64 markets or supermarkets or allow them to save resources for use during the off-season (Gichunge
& Kidwaro, 2014). The farm also promotes food security for New Americans by allowing them to purchase staple crops like potatoes and onions in bulk from the farm during the off-season.
This is beneficial since, during the off-season, they must go to the grocery store more frequently and have less access to fresh produce from the garden. The off-season is when New Americans in this sample struggle the most with getting enough food, and the alternating seasons may contribute to a feast-famine cycle that promotes overconsumption and weight gain (Nunnery &
Dharod, 2017).
The farm plays an important role in the New American’s food system, and there are some ways to expand its impact. One method is by increasing the variety of vegetables to encompass other complementary items, like cauliflower, pumpkin, and leafy greens (including spinach and mustard greens, among other cultural green leafy vegetables). Increasing plantings of hardy vegetables and easy to preserve vegetables would increase food security throughout the year and reduce fluctuations between harvest and off-season food security. Potential crops that are not already grown and would do well in New York State are dry beans, pumpkin (which can be canned for preservation), and mushrooms (dried). These could be preserved using limited resources and do not require refrigerator or freezer preservation. However, other inputs like ensuring proper food safety and canning supplies may be necessary, which could present barriers to implementation.
Other suggestions or requests from the interviewees are less easily implemented. There are items that would be difficult to grow or find seeds for here in the United States, like specific herbs and roots that grow wildly in their home countries. Raising livestock would require large amounts of land and structural inputs, which would be expensive, as well as the cost of animals
65 which varies depending on type. This is in addition to permits and cost of pasture maintenance or feed. However, if the structural components could be obtained, the New Americans are skilled at raising livestock, and the impact could be widespread, including milk, eggs, and occasionally meat. While the outcome is desirable, the initial feasibility, cost of start-up, and inputs required may overpower the potential long-term impact. Further research in this area could expand on the feasibility of raising livestock when considering costs, benefits, and policies.
Takeaway Points
• New Americans’ native food habits relied heavily on fruits, vegetables, and meat that
they produced themselves via subsistence agriculture and foraging. While their food
acquisition methods have changed significantly from their home country, their diets show
minimal dietary acculturation, suggesting they rely upon similar foods and preparations.
• Accessibility, not availability, is a perceived barrier to cultural food items, as ethnic
markets are accessible and carry food items they want, but the prices are too expensive.
• Community garden participation increases food access and may mediate cultural
preservation by reducing cost barriers to desirable and culturally preferred foods,
allowing more resources to be put toward cultural foods at ethnic stores and reducing
reliance on inexpensive, calorie-dense food choices associated with Western dietary
patterns.
• Exploring additional measures to alleviate the burden of food insecurity in New
Americans during the non-harvest season, such as increasing production of easily
preserved food items like dry beans, and other vegetables that were central to pre-
resettlement dietary patters, like cauliflower, is the next step.
66
Limitations
Due to time limitations and safety precautions of COVID19, many interviews were not able to take place. This sample is not a representative sample of the New American population in the United States and does not fully encompass the original scope of the study. The small sample size means it is difficult to generalize these results to other New American groups. Furthermore, all the participants have South Asian origins, so the results are not generalizable across New
Americans in Syracuse. However, the results are representative of the population of Deaf New
American farmers that work with SCHF, so it can speak to the impact of farming on this group.
Since anthropometric data was not collected, it is impossible to speak to the health impacts of food insecurity from this study. Furthermore, economic and employment status was not collected, so it is difficult to draw conclusions about available resources and how this contributes to food security. More detailed studies that focus on health and the impact of economic constraints on New Americans would better describe the role of community gardens in promoting food security.
My position as a Syracuse University student working with Salt City Harvest Farm also provides some room for bias, as participants may have been less honest for fear it would impact their participation in the garden. To help mitigate this dynamic, I emphasized honesty for the purpose of improving the community garden and their experience. I also spent time prior to recruitment to volunteer with the community garden, so all community garden participants could get to know me before the study.
67
CHAPTER 6: CONCLUSIONS
The variables that lead to food insecurity are multifaceted, including poverty, lack of access to nutritious foods, and high consumption of energy-dense foods (Morales & Berkowitz,
2016; Drewnowski, 2010; Darmon & Drewnowski, 2015; Nunnery & Dharod, 2017). Food insecurity is associated with greater healthcare expenditures (Seligman, Laraia, & Kushel, 2010), complicating poverty reduction efforts. New Americans experience higher risk of food insecurity than their U.S.-born counterparts for a variety of reasons, including limited access to higher- paying jobs, limited social networks, difficulty navigating the food environment in the United
States, and lack of access to culturally acceptable food items (Hadley, Patil, & Nahayo, 2010;
Hadley, Zodhiates, & Sellen, 2007; McElrone, et al., 2019; Lawlis, Islam, & Upton, 2017). This pattern was seen in the interviews with the New Americans in this study, as 100% experienced food insecurity at some point in the past year. However, based on data from the environmental audits and New American interviews, unavailability of cultural foods was not a major contributor to food insecurity.
Data from the environmental audits shows a high density of FAS within the North Side neighborhood of Syracuse, NY, where there is a large population of resettled New Americans.
There is access to a supermarket within the 0.5-mile radius, and the supermarket has equipment to facilitate access for those who lack private transportation. Furthermore, of 42 FAS in the community, 16 are classified as ethnic markets (African, Asian, European, Hispanic, and Middle
Eastern), providing food items central to certain cultures and dietary patterns. Ethnic markets, on average, sell more fresh vegetables, canned vegetables, beans and legumes, and frozen vegetables than convenience stores. When FAS stock healthier options, patrons tend to make
68 healthier purchases (Larson & Story, 2009), thus ethnic markets contribute positively to the food environment.
The prevalence of ethnic markets likely plays a role both in facilitating food security and food insecurity. There are many food items available in the ethnic markets that are not easy to find in traditional supermarkets, like pickled bamboo shoots, camel milk, and dried pumpkin leaves. The availability of these food items may facilitate maintenance of traditional diets, which tend to be healthier than Westernized diets (Gilbert & Khokhar, 2008). Furthermore, all the ethnic markets accept SNAP benefits, meaning people can use nutrition assistance funds toward these cultural food items. However, the availability of these items does not mean they are accessible (Nunnery & Dharod, 2017), even with SNAP benefits. Although price data was unavailable for many FAS, including ethnic markets, study participants report that high prices at ethnic markets impede their ability to purchase the cultural items they want. Many people only buy items at the ethnic store that are not available at American supermarkets since the supermarket is less expensive.
Shopping at an American supermarket may promote the slight dietary changes seen in
FFQ data amongst the New Americans in this study. Some reported increased consumption of accessory food items like snacks and sweets, despite core dietary habits remaining the same
(Gilbert & Khokhar, 2008). However, as a whole, dietary acculturation is low in the New
Americans who participated in the study. They report similar consumption of rice, vegetables, and meat in the United States as in their home country, as well as similar preparation.
The high density of ethnic stores within the neighborhood where the New Americans live may contribute to cultural preservation. Since ethnic markets are located in the neighborhoods, they are as accessible as convenience stores and more accessible than the supermarket by foot.
69
New Americans in the study did not frequent convenience stores, but regularly purchased items from ethnic markets. This likely reduces their exposure to Western food items and could explain the low levels of dietary acculturation evident in their FFQs, despite all participants living in the
United States for at least 6 years. However, since these markets are so accessible, people who want to maintain cultural dietary habits but lack transportation to shop at multiple locations may purchase all their food items at these ethnic markets, spending more money and negatively impacting food security (Hadley, Patil, & Nahayo, 2010). There is also less of a language barrier, both with store personnel and food names, which might encourage people to shop there even if it is not as advantageous financially.
Community gardens are an alternative to traditional food acquisition channels that not only promote food security among New Americans but enhance social networks and improve mental health. Since all the New Americans in this study have agricultural backgrounds, it offers them the opportunity to connect with their past lives, a feeling echoed in studies by Hartwig and
Mason (2016) and Gichunge and Kidwaro (2014). During the harvest season, New Americans report fewer trips to the grocery store and cost savings similar to those reported by Algert et al.
(2016). SCHF reports a 2019 harvest with a market value more than $5,000, which is a significant sum, even once divided among the 10-15 farmers who participated each week. This frees up money that they can save or use to purchase cultural foods at the ethnic markets. The farm also grows various vegetables that were central to their diet prior to resettlement, thus contributing to cultural preservation on two fronts.
The New Americans would like to expand the variety of vegetables to encompass other types they typically eat, including cauliflower, pumpkin, long hot peppers, and dry beans. The farm offers New Americans the opportunity to purchase inexpensive, bulk vegetables like onions
70 and potatoes throughout the year. The New Americans save or preserve as much as they can from harvest, too. However, planting more vegetables that could be preserved easily could help alleviate the cyclical food insecurity of the harvest/off-season. These vegetables include dry beans, pumpkin, and mushrooms.
Further understanding of the environmental and structural influences on the dietary choices of New Americans is central to designing programming and policy that promotes equity and opportunity. As the New American population continues to grow and evolve, it is important to recognize the risk factors that set them apart from the U.S.-born population, and how these factors will impact food security and health. This study hopes to explore some of the factors and elucidate future areas of research concentration. Future research in the areas of health and anthropometric analysis, feasibility of livestock raising, and price analysis of FAS within the environment will be important components of understanding New Americans and promoting
71
REFERENCES
Adair, L., Fall, C., Hallal, P. C., Martorell, R., Richter, L., & Sachdev, H. S. (2008). Maternal and child undernutrition 2: Maternal and child undernutrition: Consequences for adult health and human capital. The Lancet, 371(9609), 340-57. Alaimo, K., Packnett, E., Miles, R. A., & Kruger, D. J. (2008, March). Fruit and Vegetable Intake among Urban Community Gardeners. Nutrition Education and Behavior, 40(2), 94-101. doi:https://doi.org/10.1016/j.jneb.2006.12.003 Amara, A., & Aljunid, S. (2014). Noncommunicable diseases among urban refugees and asylum- seekers in developing countries: A neglected health care need. Globalization and health, 10(24). doi:10.1186/1744-8603-10-24 Amnesty International. (n.d.). Refugees, Asylum-Seekers and Migrants. Retrieved from Amnesty International: https://www.amnesty.org/en/what-we-do/refugees-asylum-seekers-and- migrants/ Andresen, E., Bilukha, O. O., Menkir, Z., Gayford, M., Kavosa, M., Wtsadik, M., . . . Shahpar, I. (2014). Malnutrition and elevated mortality among refugees from South Sudan--Ethiopia, June-July 2014. Morbidity and Mortality Weekly Report, 63(32). Baker, C. (2019, January 4). Refugees in Syracuse: Benefit or burden? Here's what the numbers say. The Post Standard. Retrieved from https://www.syracuse.com/poverty/2016/03/refugees_in_syracuse_benefit_burden.html# graphic4 Barron, S., Okell, J., Yin, S., Vanbik, K., Swain, A., Larkin, E., . . . Ewers, K. (2007). Refugees from Burma Their Backgrounds and Refugee Experiences. Washington, DC: Center for Applied Linguistics. Berthold, J. (2005). Bhutan: Land of the Thunder Dragon. Somerville, MA: Wisdom Publications, Inc. . Block, K., Gibbs, L., Staiger, P., Gold, L., Johnson, B., Macfarlane, S., . . . Mardie, T. (2011, December 13). The Impact of the stephanie Alexander kitchen Garden Program on the Social Learning Environment in Primary Schools. Health and Education Behavior, 39(4), 419-432. doi:https://doi.org/10.1177/1090198111422937 Bose, K. (2013). Human Malnutrition : Twin Burdens of Undernutrition & Overnutrition. Hauppauge, N.Y: Nova Science Publishers, Inc. Bridging Refugees Youth & Children's Services. (n.d.). Refugee Families from Burma. Washington, DC: Office of Head Start National Center on Cultural and Linguistic Responsiveness. Brophy, M. (2014). Somali Distance Education and Literacy, Somalia. London: UNESCO Institute for Lifelong Learning.
72
Bureau of East Asian and Pacific Affairs. (2020). U.S.-Burma Relations. Washington, DC: U.S. Department of State. Campo, J. E. (2016). Islam in Iraq. In J. E. Campo, Encyclopedia of world religions: Encyclopedia of Islam. Capps, R., Newland, K., Fratzke, S., Groves, S., Auclair, G., Fix, M., & McHugh, M. (2015). Integrating refugees in the United States: The successes and challenges of resettlement in a Global Context. Statistical Journal of the IAOS, 341-367. doi:10.3233/SJI-150918 Central Intelligence Agency. (2020, March 10). Somalia. Retrieved from The World Factbookk: https://www.cia.gov/library/publications/resources/the-world-factbook/geos/so.html Davila, F. (2001). Food and Fasting in Somali Culture. EthnoMED. Dawood, M., & Elkholy, O. (Directors). (2016). Somalia: The Forgotten Story [Motion Picture]. Dawson-Hahn, E. E., Pak-Gorstein, S., Hoopes, A. J., & Matheson, J. (2016). Comparison of the Nutritional Status of Overseas Refugee Children with Low Income Children in Washington State. PloS one, 11(1). doi:10.1371/journal.pone.0147854 Dawson-Hahn, E. E., Pak-Gorstein, S., Hoopes, A. J., & Matheson, J. (2016). Comparison of the Nutritional Status of Overseas Refugee Children with Low Income Children in Washington State. PLoS ONE, 11(1). doi:10.1371/journal.pone.0147854 Dhungana, S. K. (2010, June). Third Country Resettlement and the Bhutanese Refugee Crisis: A Critican Reflection. Refugee Watch, 35, 14-36. Division of Global Migration and Quarantine. (2013). Guidelines for Evaluation of the Nutritional Status and Growth in Refugee Children During the Domestic Medical Screening Examination. National Center for Emerging and Zoonotic Infectious Diseases , U.S. Department of Health and Human Services. Washington, DC: Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/immigrantrefugeehealth/pdf/Nutrition-and-Growth-Guidelines.pdf Division of Global Migration and Quarantine. (2014). Bhutanese Refugee Health Profile. National Center for Emerging and Zoonotic Infectious Diseases, U.S. Department of Health and Human Services. Washington, D.C.: Centers for Diseases Control and Prevention. Retrieved from Center for Disease Control and Prevention: https://www.cdc.gov/immigrantrefugeehealth/pdf/bhutanese-health-profile.pdf Division of Global Migration and Quarantine. (2014). Iraqi Refugee Health Profile. National Center for Emering and Zoonotic Infection Diseases, U.S. Department of Health and Human Services. Washington, DC: Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/immigrantrefugeehealth/profiles/iraqi/background/index.html Division of Global Migration and Quarantine. (2018). Somali Refugee Health Profile. National Center for Emerging and Zoonotic Infectious Diseases, US Department of Health and
73
Human Services. Washington, DC: Centers for Diseases Control and Prevention. Retrieved from https://www.cdc.gov/immigrantrefugeehealth/pdf/Somali-Refugee- Health-Profile.pdf Division, U. N. (2003). Population and Vital Statistics Report. New York: United Nations. Drewnowski, A. (2010, November). The cost of US foods as related to their nutritive value. The American Journal of Clinical Nutrition, 92(5), 1181–1188. doi:10.3945/ajcn.2010.29300 Economic Research Service. (2018). Food Security Status of U.S Households in 2018. Bethesda, MD: United States Department of Agriculture. Retrieved from https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key- statistics-graphics.aspx Eisenstadt, M. (2019, January 29). Trump policies stop the flow of refugees to Syracuse, once a resettlement magnet. The Post Standard. Retrieved from https://www.syracuse.com/news/2018/08/trump_policies_stop_the_flow_of_refugees_to_ syracuse_once_a_resettlement_magnet.html Evanson, N. (2019). Somali Culture. The Cultural Atlas. Retrieved from https://culturalatlas.sbs.com.au/somali-culture/somali-culture-references#somali-culture- references Fact Sheet: U.S. Refugee Resettlement. (2019, January 25). Retrieved from National Immigration Forum: https://immigrationforum.org/article/fact-sheet-u-s-refugee-resettlement/ Food and Agriculture Organization. (2006). Food Security. Rome: The United Nations. Food and Nutrition Service. (2013). SNAP Food Security In-Depth Interview Study Final Report. United States Department of Agriculture. Bethesda: Office of Research and Analysis. Food and Nutrition Service. (2013, September 4). SNAP Policy on Non-Citizen Eligibility. Retrieved from U.S. Department of Agriculture Food and Nutrition Service: https://www.fns.usda.gov/snap/eligibility/citizen/non-citizen-policy Galbraith, P. W. (2003). Refugees from War in Iraq: What Happened in 1991 and What May Happen in 2003. Washington, DC: Migration Policy Institute. Gichunge, C., & Kidwaro, F. (2014, September). Utamu wa Afrika (the sweet taste of Africa): The vegetable garden as part of resettled African refugee's food environment. Journal of the Dietitians Association of Australia, 71(4), 270-275. doi:https://doi.org/10.1111/1747- 0080.12143 Grammatikopoulou, M. G., Theodoridis, X., Poulimeneas, D., Maraki, M. I., Gkiouras, K., Tirodimos, I., . . . Chourdakis, M. (2018). Malnutrition surveillance among refugee children living in reception centres in Greece: a pilot study. International Health, 11(1), 30-35. doi:10.1093/inthealth/ihy053
74
Grijalva-Eternod, C. S., Wells, J. C., Cortina-Borja, M., Salse-Ubach, N., Tondeur, M. C., & Dolan, C. (2012). The double burden of obesity and malnutrition in a protracted emergency setting: a cross-sectional study of Western Sahara refugees. PLoS Medicine, 9(10). Guptill, A. E., Copelton, D. A., & Lucal, B. (2012). Food and Society: Principles and Paradoxes. Cambridge: Policy Press. Hadley, C., Patil, C., & Nahayo, D. (2010). Difficulty in the Food Environment and the Experience of Food Insecurity among Refugees Resettled in the USA. Ecology of Food and Nutrition, 49(5), 390-407. doi:10.1080/03670244.2010.507440 Hadley, C., Patil, C., & Nahayo, D. (2010). Difficulty in the Food Environment and the Experience of Food Insecurity among Refugees Resettled in the USA. Ecology of Food and Nutrition, 390-407. doi:10.1080/03670244.2010.507440. Harn, J. (2018, March 12). 10 Traditional Iraqi Dishes You Need to Try. Retrieved from The Culture Trip: https://theculturetrip.com/middle-east/iraq/articles/10-traditional-iraqi- dishes-you-need-to-try/ Hashmi, A. H., Nyein, P. B., Pilaseng, K., Paw, M. K., Darakamon, M. C., Min, A. M., . . . Carrara, V. I. (2019). Feeding practices and risk factors for chronic infant undernutrition among refugees and migrants along the Thailand-Myanmar border: a mixed-methods study. BMC Public Health, 19. doi:10.1186/s12889-019-7825-7 Hauqe, S. E., Sakisaka, K., & Rahman, M. (2019). Examining the relationship between socioeconomic status and the double burden of maternal over and child under-nutrition in Bangladesh. European Journal of Clinical Nutrition, 73(4). doi:10.1038/s41430-018- 0162-6 Heney, J. H., Dimock, C. C., Friedman, J. F., & Lewis, C. (2013). Pediatric Refugees in Rhode Island: Increases in BMI Percentile, Overweight, and Obesity Following Resettlement. Rhode Island Medical Journal, 98(1), 43-47. Human Rights Watch. (2006). Burma. New York: Human Rights Watch. Human Rights Watch. (2007). Burma. New York: Human Rights Watch. Hutt, M. (1996). Ethnic Nationalism, Refugees, and Bhutan. Journal of Refugee Studies, 9(4), 397-420. doi:10.1093/jrs/9.4.397 Hutt, M. (2005). Lhotshampa Culture. In M. Hutt, Unbecoming Citizens: Culture, Nationhood, and the Flight of Refugees from Bhutan. Oxford India Paperbacks. IRFAD. (n.d.). Iraq Food. Retrieved March 20, 2020, from IRFAD: http://www.irfad.org/iraq- food/
75
Islam, S. M., Purnat, T. D., Phuong, N., Mwingira, U., Schacht, K., & Fröschl , G. (2014). Non‐ Communicable Diseases (NCDs) in developing countries: a symposium report. Globalization and Health, 10(81). doi:10.1186/s12992-014-0081-9 Kranti, M., & Haynes-Maslow, L. (2017, September). The Affordability of MyPlate: An Analysis of SNAP Benefits and the Actual Cost of Eating According to the Dietary Guidelines. Nutrition Education and Behavior, 49(8), 623-631. doi:doi.org/10.1016/j.jneb.2017.06.005 Krogstad, J. M. (2019, October 7). Key facts about refugees to the U.S. Retrieved from Pew Research Center: https://www.pewresearch.org/fact-tank/2019/10/07/key-facts-about- refugees-to-the-u-s/ Laraia, B. A. (2013). Food Insecurity and Chronic Disease. Advances in Nutrition, 4(2), 203-212. doi:10.3945/an.112.003277 Lin, L., Hopkins, A., & Chanoff, S. (2002). America Here We Come. (R. Wilkinson, Ed.) Refugees, 3(128). Lonely Planet. (2013, January 10). Eating in Myanmar (Burma): an intro to Burmese food. Retrieved from Lonely Planet: https://www.lonelyplanet.com/articles/eating-in-myanmar- burma Lufty, C., Cookson, S. T., Leisel, T., & Rochat, R. (2013). Malnourished Children in Refugee Camps and Lack of Connection with Services After US Resettlement. Journal of Immigrant and Minority Health, 16(5). doi:10.1007/s10903-013-9796-6 MacKinnon, H. (2014). Education in emergencies: the case o the Dadaab refugee camps. Waterloo, ON, Canada: Centre for International Governance. McElrone, M., Colby, S. E., Moret, L., Kavanagh, K., Spence, M., Flouts, H. N., . . . Payne, M. (2019). Barriers and Facilitators to Food Security Among Adult Burundian ang Congolese Refugee Females Resettled in the US. Ecology of Food and Nutrition, 58(3), 247-264. doi:doi:10.1080/03670244.2019.1598981 Metro South Health. (2015). Food and cultural practices of Burmese communities in Australia – a community resource . Brisbane: State of Queensland Government. Morris, A., Campbell, K., Britton, R., Shabel, A., Pacumbaba, R., Taylor, D., & Wood, S. (2017, July). Urban Supplemental Nutrition Assistance Program - Education (USNAP-Ed) Community Garden Project. Journal of Nutrition Education and Behavior, 49(7), S130. doi:https://doi.org/10.1016/j.jneb.2017.05.064 Mossaad, N. (2019). Refugees and Asylees: 2018. Office of Immigration Statistics, United States Department of Homeland Security. Washington, DC: OFFICE OF STRATEGY, POLICY, AND PLANS. Retrieved from https://www.dhs.gov/sites/default/files/publications/immigration- statistics/yearbook/2018/refugees_asylees_2018.pdf
76
Mulik, K., & Haynes-Maslow, L. (2017, September). THe Afforability of MyPlate: An Analysis of SNAP Benefits and the Actual Cost of Eating According to the Dietary Guidelines. Journal of Nutrition Education adn Behavior, 49(8), 623-631. doi:https://doi.org/10.1016/j.jneb.2017.06.005 Mulugeta, W., Glick, M., Min, J., Xue, H., Noe, M. F., & Want, Y. (2018). Longitudinal Changes and High-Risk Subgroups for Obesity and Overweight/Obesity Among Refugees in Buffalo, NY, 2004–2014. Journal of Racial and Ethnic Health Disparities, 5, 187-194. doi:0.1007/s40615-017-0356-y Naja, F., Shatila, H., El Koussa, M., Meho, L., Ghandour, L., & Saleh, S. (2019). Burden of non- communicable diseases among Syrian refugees: a scoping review. BMC Public Health, 19. doi:10.1186/s12889-019-6977-9 Nath, L. (2016). Global Refugee Crisis and South Asia’s Geopolitics: The Case of the Bhutanese Refugees. Himalayan Policy Research Conference. Madison, WI: University of New Mexico. National Employment Law Project. (2002). Immigrants’ Eligibility for Unemployment Compensation. New York: National Employment Law Project. National Heart, Lung, and Blood Institute. (2011). Your Guide to Anemia. Bethesda, MD: National Institutes of Health. Retrieved from National Institutes of Health. New American Economy. (2017). From Struggle to Resilience: The Economic Impact of Refugees in America. Nunnery, D. L., & Dharod, J. M. (2017). Potential determinants of food security among refugees in the U.S.: an examination of pre- and post- resettlement factors. Food Security, 9, https://doi.org/10.1007/s12571-016-0637-z. doi:https://doi.org/10.1007/s12571-016- 0637-z Olson, B. G., Kurland, Y., Rosenbaum, P. F., & Hobart, T. R. (2017). Rapid Weight Gain in Pediatric Refugees After US Immigration. Journal of Immigrant and Minority Health, 19(2), 263-266. doi:10.1007/s10903-016-0461-8 Onondaga Citizens League. (2013). The World at Our Doorstep. Syracuse. Planet, L. (n.d.). Bhutan in Detail - Eating. Retrieved 3 19, 2020, from Lonely Planet: https://www.lonelyplanet.com/bhutan/in-location/eating/a/nar/273b1078-d3a6-4982- 8f2d-c567920a46d8/355819 Rahman, K. M. (2015). Ethno-Political Conflict: The Rohingya Vulnerability in Myanmar. International Journal of Humanities & Social Science Studies, 288-295. Ramos, M., Orozovich, P., Moser, K., Phares, C., Stauffer, W., & Mitchell, T. (2010). Health of Resettled Iraqi Refugees --- San Diego County, California, October 2007--September 2009. Washington, DC: Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a2.htm
77
Ranabhat, C. L., Kim, C.-B., Park, M.-B., & Acharaya, S. (2017). Multiple disparities in adult mortality in relation to social and health care perspective: results from different data sources. Globalization and Health, 13(57). doi:10.1186/s12992-017-0283-z Robinet, F. (2019, March 15). Welcome, Refugees. Now Pay Back Your Travel Loans. New York Times. Retrieved from https://www.nytimes.com/2019/03/15/nyregion/refugees- travel-loans.html Rondinelli, A. J., Morris, M. D., Rodwell, T. C., Moser, K. S., Paida, P., Popper, S. T., & Brouwer, K. C. (2011). Under- and Over-Nutrition Among Refugees in San Diego County, California. Journal of Immigrant and Minority Health, 13, 161-168. doi:10.1007/s10903-010-9353-5 Roshania, R., Venkat Narayan, K., & Oza-Frank, R. (2012). Age at Arrival and Risk of Obesity Among US Immigrants. Obeity, 16(12). doi:10.1038/oby.2008.425 Salt City Harvest Farm. (2018). History. Retrieved February 24, 2020, from Salt City Harvest Farm: https://www.saltcityharvest.farm/blog Sánchez, A. (2010). Iraqi Refugees : A Humanitarian Crisis? New York: Nova Science Publishers, Inc. . Seligman, K. H., Laraia, B. A., & Kushel, M. B. (2010). Food insecurity is associated with chronic disease among low-income NHANES participants. The Journal of Nutrition, 140(2), 304-310. Sinha, R., & Jastrebof, A. M. (2013). Stress as a Common Risk Factor for Obesity and Addiction. Biological Psychiatry, 73(9), 827-835. doi:10.1016/j.biopsych.2013.01.032 Smock, L., Martelon, M., Metallinos-Katsaras, E., Nguyen, T., Cochran, J., & Geltman, P. L. (2020). Recovery From Malnutrition Among Refugee Children Following Participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) Program in Massachusetts, 1998-2010. Journal of Public Health Management and Practice, 26(1), 71-79. doi:10.1097/PHH.0000000000000995 Summit County Health Department. (n.d.). Health Needs Assessment Report of Bhutanese Refugees of Summit County. Akron: Summit County Health Department. Retrieved from https://www.scph.org/sites/default/files/editor/Needs_Assessment_Bhutanese.pdf The UN Refugee Agency. (2018, May 14). Iraq Emergency. Retrieved from UNHCR: https://www.unhcr.org/en-us/iraq-emergency.html The UN Refugee Agency. (2020, January 7). Somalia Refugee Crisis Explained. Retrieved from UNHCR: https://www.unrefugees.org/news/somalia-refugee-crisis-explained/ The UN Refugee Agency. (n.d.). Asylum and Migration. Retrieved from UNHCR: https://www.unhcr.org/en-us/asylum-and-migration.html
78
The UN Refugee Agency. (n.d.). Refugee Camps. Retrieved from USA for UNHCR: https://www.unrefugees.org/refugee-facts/camps/ The UN Refugee Agency USA. (2019, July 31). Rohingya Emergency. Retrieved from UNHCR: https://www.unhcr.org/en-us/rohingya-emergency.html The UN Refugee Agency. (n.d.). What is a refugee? Retrieved from UNHCR: https://www.unhcr.org/en-us/what-is-a-refugee.html The United Nations Refugee Agency. (2019). Global Trends Forced Displacement in 2018. Geneva: United Nations High Commissioner for Refugees. Thronson, D. B. (1993). Cultural Cleansing: A Distinct National Identity and the Refugees from Southern Bhutan. Kathmandu: International Institute for Human Rights Environment and Development. U.S Department of Health & Human Services. (2020, 1 21). 2020 Poverty Guidelines. Retrieved from ASPE: https://aspe.hhs.gov/2020-poverty-guidelines U.S. Committee for Refugees and Immigrants. (n.d.). Frequently Asked Questions (FAQ). Retrieved March 14, 2020, from U.S. Committee for Refugees and Immigrants: https://refugees.org/serving-the-uprooted/faq/ U.S. Department of Health and Human Services. (n.d.). Refugee and Entrant Assistance - State Administered Programs. Retrieved March 15, 2020, from Benefits: https://www.benefits.gov/benefit/620 UN General Assembly. (2016). New York Declaration for Refugees and Migrants: Resolution / adopted by the General Assembly. New York: UN General Assembly. Retrieved March 14, 2020, from https://www.refworld.org/docid/57ceb74a4.html UN Office for the Coordination of Humanitarian Affairs. (2002). A study on minorities in Somalia. ReliefWeb. UNICEF, World Health Organization, & World Bank. (2020). UNICEF/WHO/World Bank joint child malnutrition estimates (country level). New York: UNICEF. United Nations Statistical Division. (2019). Population and Vital Statistics Report. New York: United Nations. United States Census Bureau. (2018). Methodology, Assumptions, and Inputs for the 2017 National Population Projections. Washington, DC: United States Department of Commerce. United States Census Bureau. (2019). QuickFacts Syracuse City, New York. Washington, DC: U.S Department of Commerce. Van Lehman, D., & Eno, O. (2003). The Somali Bantu Their History and Culture. Washington, DC: Center for Applied Linguistics.
79
Waterlow, J. C. (1972). Classification and Definition of Protein-Calorie Malnutrition. British Medical Journal, 566-569. Weigel, M., Armijos, R. X., Racines, M., & Cevallos, W. (2016). Food Insecurity Is Associated with Undernutrition but Not Overnutrition in Ecuadorian Women from Low-Income Urban Neighborhoods. Journal of Environmental and Public Health. doi:10.1155/2016/8149459 Who, What, Why: Should it be Burma or Myanmar? (2011, December 2). BBC News. World Health Organization. (2018, February 16). Malnutrition. Retrieved from World Health Organization: https://www.who.int/news-room/fact-sheets/detail/malnutrition World Health Organization. (2018, June). Noncommunicable diseases. Retrieved from World Health Organization: https://www.who.int/news-room/fact- sheets/detail/noncommunicable-diseases Yun, K., Hebrank, K., Graber, L., Sullivan, M.-C., Chen, I., & Gupta, J. (2012). High Prevalence of Chronic Non-Communicable Conditions Among Adults Refugees: Implications for Practice and Policy. Journal of Community Health, 37(5), 1110-1118. doi:10.1007/s10900-012-9552-1
80
APPENDIX A: TABLES AND ILLUSTRATIONS
Economic Factors: Poverty, Social factors: poor social cohesion, minimal economic self-sufficiency, lack of social networks, social poor access to health care, stratification, psychological impacts difficulty accessing jobs or or post-traumatic stress disorder
promotions (PTSD)
Poor Nutrition Status
Figure 2-1: Factors contributing to nutrition status in New Americans
Table 2-1:
Prevalence of malnutrition in children 0-5 from selected countries
Country Refugee Status Wasting(%) Stunting(%) Underweight(%) Overweight(%)
Bhutan Country of Origin 5.9 33.5 12.7 7.6
Burma Country of Origin 6.6 29.4 18.5 1.5
Malaysia Host 11.5 20.7 13.7 6.0
Nepal Host 9.6 36.0 27.2 1.2
Somalia Country of Origin 14.3 25.3 22.5 3.0
Syria Country of Origin 11.5 27.9 10.4 17.9
Turkey Host 1.7 6.0 1.5 8.1
U.S. Host 0.4 3.5 Not available 9.4
81
Table 2-2:
Definitions of Food Security (Economic Research Service, 2018)
USDA Food Security Terminology Significance
High food security Households had no problems or concerns about consistently accessing enough food. Marginal food security Households had problems or concerns about accessing enough food at times, but quality, variety, and quantity was not changed. Low food security Households changed the quality, variety, and/or desirability of their diets but quantity of food and eating patterns were not disrupted. Very low food security Eating patterns of one or more household members displayed disrupted eating and reduced food intake due to lack of resources to acquire food.
Table 2-3
Dietary Recommendations According to MyPlate and the USDA
Fruits Vegetables Protein Foods Grains Dairy
Children 2-3 yrs 1 cup 1 cup 2 oz equivalent 3 oz equivalent 2 cups
4-8 yrs 1-1½ cups 1½ cups 4 oz equivalent 5 oz equivalent 2½ cups
Girls 9-13 yrs 1½ cups 2 cups 5 oz equivalent 5 oz equivalent 3 cups
14-18 yrs 1½ cups 2½ cups 5 oz equivalent 6 oz equivalent 3 cups
Boys 9-13 yrs 1½ cups 2½ cups 5 oz equivalent 6 oz equivalent 3 cups
14-18 yrs 2 cups 3 cups 6½ oz equivalent 8 oz equivalent 3 cups
Women 19-30 yrs 2 cups 2½ cups 5½ oz equivalent 6 oz equivalent 3 cups
31-50 yrs 1½ cups 2½ cups 5 oz equivalent 6 oz equivalent 3 cups
51+ yrs 1½ cups 2 cups 5 oz equivalent 5 oz equivalent 3 cups
Men 19-30 yrs 2 cups 3 cups 6 ½ oz equivalent 8 oz equivalent 3 cups
82
31-50 yrs 2 cups 3 cups 6 oz equivalent 7 oz equivalent 3 cups
51+ yrs 2 cups 2½ cups 5½ oz equivalent 6 oz equivalent 3 cups
Figure 4-1: Map of Selected Area of 1.0 mile and 0.5 mile radii
Figure 4-2: Plot of all stores within 1 mile of center point
83
Table 4-1
List of topics from environmental audit
CATEGORY SUBCATEGORY EXAMPLES OF ITEMS FRUITS Fresh Apple, orange, pineapple, lychee, pear, papaya, mango, banana, grapes, melon Frozen Strawberries, mango Canned Fruit packed in 100% fruit juice VEGETABLES Fresh Onion, green pepper, bok choy, tomato, chili peppers, cauliflower, cabbage, corn, spinach Frozen Broccoli, green beans, mixed vegetables, peppers, sweet peas Canned Specific varieties not recorded 100% JUICE Fruit, vegetable, Mixed fruit and vegetable PLANT PROTEIN Beans and Legumes Dry black beans, baked beans, canned garbanzo beans, canned chili beans, dried mung beans Soy Tofu, tempeh, soybeans, edamame MEAT Fresh Ground beef, pork chops, goat Frozen Frozen ground beef, meatballs, Canned POULTRY Fresh Chicken thighs, chicken breast, deli turkey slices, ground turkey Frozen Specific types not recorded Canned Boneless chicken FISH Fresh Specific types not recorded Frozen Whitefish, salmon Canned Tuna DAIRY Animal milk products Cow’s milk, goat cheese, cheddar cheese, cream cheese, camel milk Plant-based dairy Soymilk, rice milk, coconut milk, soy cheese GRAINS Bread Whole wheat, white, hamburger buns, cornbread Flour Whole wheat flour, rice flour, corn flour, enriched white flour, buckwheat flour Pasta Buckwheat, whole wheat, rice, white Grains Millet, quinoa, white rice, red rice, rolled oats PROCESSED FOODS Candy Fruit gummy candy, hard candies, Chocolate Candy bars without nuts, candy bars with nuts Packaged snacks Chocolate chip cookies, wafer cookies Frozen desserts Ice cream, popsicles, fruit pops, fudgsicles BEVERAGES Sweetened beverages Lemonade, energy drinks, tea, soda, diet soda Alcohol Beer, cider, wine, liquor, cocktails STORE FEATURES Exterior Presence of advertisements, hours listed, exterior lighting, available parking Interior Lighting, EBT/SNAP, food advertisements Overall Visible pricing, presence of cultural symbols, foreign language foods, cultural items 84
Table 4-2
Frequencies of fruits and vegetables sold in stores Does the store sell… Yes % No % Average Average Standard (all) (yes only) Deviation (SD) Fresh fruit? 17 45.9 20 54.1 3.4 7.5 7.1 Fresh vegetables? 19 51.4 18 48.6 11.6 22.5 20.1 Frozen fruit? 7 18.9 30 81.1 0.6 3.14 1.1 Frozen vegetables? 13 35.1 24 64.9 2.0 5.77 5.0 Canned fruit? 37 100 0 0 7.6 7.6 7.8 Canned vegetables? 37 100 0 0 25.5 25.5 35.1 100% juice? (any kind) 28 75.7 9 24.3 3.9 5.1 6.7 Non-fat milk 3 8.1 34 91.1 n/a n/a n/a 2% milk 13 35.1 24 64.9 n/a n/a n/a Whole milk 29 78.4 8 21.6 n/a n/a n/a
Table 4-3
Proportion of FAS that sell selected items Item Yes - No - Yes - non- No - non- T value p-value Ethic Ethnic ethnic ethnic Fresh fruits 11 3 6 17 -3.51 0.001* Fresh vegetables 12 2 7 16 -3.76 0.001* Frozen fruits 5 9 2 21 -1.96 0.58 Frozen vegetables 6 8 6 17 -1.00 0.32 100% fruit juice 5 9 23 0 6.60 0.000* Bread (any kind) 9 5 22 1 3.02 0.005* Butter or margarine 4 10 18 5 3.81 0.001* Milk or dairy (any 8 6 23 0 4.04 0.000* kind) Frozen fish 9 5 2 21 -4.19 0.000* Soy products 11 3 0 23 -8.93 0.000* *Denotes significance p≤0.05
85
Table 4-4
Comparison of items in ethnic markets vs other stores Item # Ethnic Ethnic # Other Other store t-test p- Effect market market mean store mean value value size variety variety Fresh 11 7.64±5.99 5 3.4±1.95 1.52 0.15 0.71a fruit Fresh 12 29.58±18.5 6 3.8±2.64 3.34 0.004* 1.39a vegetable Frozen 6 5.33±3.44 6 3.83±1.47 0.98 0.35 0.44a vegetable Canned 14 8.93±8.6 23 6.09±6.65 1.11 .27 0.38b fruit Canned 14 28.9±50.37 22 19.82±14.50 0.80 .42* 0.18a vegetable Frozen 5 5.25±1.71 7 3.14±1.07 2.55 0.031* 1.56b meats Beans / 14 11.5±6.24 22 7.45±4.30 2.68 .027* 0.80b legumes * Denotes significance p≤0.05; a Glass’s Δ; b Hedge’s g Bold = denotes significance only for ethnic store vs convenience store
Table 4-5
Availability of pricing data for all audited FAS
Pricing information was clearly visible
Value Frequency
Strongly agree 12
Somewhat agree 10
Neither agree nor disagree 2
Somewhat disagree 4
Strongly disagree 9
86
Table 5-1
Demographics of participants Characteristic Frequency Percent Sex Male 4 (57.1%) 57.1 Female 3 (42,9%) 42.9 Religion Hindu 5 (71.4%) 71.4 Christianity 1 (14.3%) 14.3 Did not answer/unspecified 1 (14.3%) 14.3 Time spent in the United States 0-5 years 0 (0%) 0 6-10 years 6 (85.7%) 85.7 11+ years 1 (14.3%) 14.3 Food Security Classification Food insecure 7 100 Food secure 0 0
Table 5-2
FFQ results from New Americans Food item a Average frequency* Apple 2.29 Avocado 3.3 Fruit juice 2.7 Grapefruit 3.3 Grapes 3 Papaya 3 Fresh Tomato 1.7 Canned tomato 3.3 Beans/lentils 2.7 Bitter melon 2 Bok choy 2.7 Broccoli 2.3 Brussel Sprouts 2.3 Cabbage 2.7 Carrot 2.1 Cauliflower 1.6 Celery 3 Chili sauce/paste 2.3
87
Corn 2.3 Cucumber 1.6 Eggplant 1.6 Garlic/Shallots 1.4 Hot peppers 1 Kale/collard greens 3 Lettuce 2 Mushrooms 2 Onion 1 Potato 1.1 Scallion 1.9 Spinach 2.3 Sweet peppers 1.6 Sweet Potato 2.7 Turnips 2.6 Chicken leg, wings, and thighs 2.7 Eggs 2.3 Fish 2.9 Lamb/goat 3.4 Nut spreads 3.2 Nuts 3.1 Soybeans 3 Tofu 3.1 Yogurt 2.7 Cottage cheese 3.1 Cheese 3.1 Dumplings 3 Rice (red, brown, wild, white) 1 Bagel, muffin 3.1 Chips 3.1 Cookie 3.4 Crackers 3.1 Flatbread 2.9 Pizza 3.1 Butter 3.1 Liquid oil 1 Margarine 3.1 Milk 1.4 Coffee 3.1 Tea 2 *1=daily, 2=weekly, 3=monthly, 4=never; a Foods not listed here had a mean frequency of 3.5 or higher, suggesting they are rarely consumed
88
Table 5-34
Crops and weights of harvested food items from SCHF Crop Weight (lb) Market value ($)* Broccoli 9 13.50 Cabbage 439 346.81 Cherry bomb pepper 137 957.63a Chilis 84 335.16 Corn 305 152.50 Edible weeds 140 n/a Green pepper 18 35.82 Habanero pepper 138 964.62 Onion 22 16.50 Pumpkin tips 59 n/a Red tomato (big) 671 1670.79 Red tomato (small) 327 650.73 Wild mustard 5 n/a Total 2254 5,144.06 *As of April 2020, in Syracuse, NY; a using aggregate pepper price data, as cherry peppers aren’t easily found in stores year-round; b
89
APPENDIX B: INSTITUTIONAL REVIEW BOARD FORMS
90
APPENDIX C: MEAN PRICE OF SELECTED ITEMS AT FAS ON THE NORTH SIDE
Item N=* Mean Price Supermarket Mean price as % of supermarket price Baked beansf 7 3.07±0.93 2.59 119 Black peppern 13 0.71±0.09 0.68 104 Canned tunac 18 1.55±0.35 0.89 174 Cayenne peppern 10* 0.49±0.16 0.57 86 Chicken bouillonn 6* 0.52±0.13 0.61 85 Chili powdern 8 0.42±0.14 0.44 95 Chocolate chip 20 2.99±1.11 2.21 135 cookiesk Chocolate chipsl 18 1.65±1.60 1.32 125 Cinnamonn 7 0.51±0.08 0.66 77 Cow’s butterd 9 4.03±0.29 3.59 112 Cuminn 7* 0.56±0.17 0.44 127 Dried black beansd 6* 1.41±0.36 1.49 95 Dried lentilsd 8* 1.46±0.39 1.49 98 Eggsb 11 2.17±0.42 1.79 121 Enriched wheat 18* 0.61±0.23 0.39 156 flourd Garbanzo beanse 17* 1.29±0.30 1.09 118 Garlic powdern 9 0.46±0.13 0.36 127 Margarined 12 1.54±0.33 1.09 141 Onion powdern 7 0.41±0.13 0.46 89 Oreganon 7 1.43±0.45 1.32 108 Packaged wafer 15 2.31±0.88 1.65 140 cookiesj Paprikan 9 0.42±0.10 0.57 74 Regular fat coconut 8* 2.53±0.79 2.36 107 milkg Saltn 14* 0.03±0.01 0.02 150 Sugarm 17 0.88±0.30 0.50 176 Vanillan 6 0.47±0.67 0.12 392 Vegetable oilh 17* 0.91±0.40 0.67 136 White breadi 7 2.30±0.79 1.00 230 White Pastad 20 1.83±0.37 0.99 185 White riced 17* 1.14±0.47 0.66 173 Whole milka 8 3.77±0.59 3.49 108 *ethnic store data was included aper gallon bper 1 dozen cper 5 oz dper 1lb eper 15.5 oz can fper 28 oz can gper 13.66 oz can hper 16 oz i20 oz load jper 11 oz kper 13 oz package lper 12 oz mper 17.5 oz nper 1 oz
91
APPENDIX D: FOOD FREQUENCY QUESTIONNAIRE Foods (circle what you eat) How often? 2x or more daily Daily Weekly Monthly Never
EXAMPLE: Apple Banana Peach
Apple Banana Peach Pear
Watermelon Honeydew Cantaloupe
Persimmon Orange Grapefruit Pomelo
Berries Cherries Apricot Grapes
Mango Papaya Durian Rambutan
Coconut Avocado Guava
Juice Applesauce
Tomato (whole, canned, juice, sauce)
Spinach Romaine, leaf, or iceberg lettuce
Kale Collard Greens Celery Bitter melon
92
Foods (circle what you eat) How often? 2x or more daily Daily Weekly Monthly Never
Bok choy Cabbage Turnip/greens
Broccoli Cauliflower Brussel Sprouts
Hot peppers (Habanero, cherry, chili, etc.)
Sweet peppers Eggplant Carrot Cucumber
Mushrooms (any variety)
Shallot, Garlic, Onion, Green onion/Scallion
Corn Potato Sweet Potato
French fries Fried potatoes
Beans, lentils Baked beans
Fish Filets Canned
Seafood Shrimp, crab, all seafood
Fish/Seafood Fried shrimp, fish, etc.
93
Foods (circle what you eat) How often? 2x or more daily Daily Weekly Monthly Never
Chicken/turkey Breast Legs, wings, thighs
Chicken Fried Chicken
Pork Loins Ground Ham
Lamb / goat Loins Ground
Hot dog Hamburger/Cheeseburger
Bacon Sausage Pizza
Eggs Tofu Soybeans/Edamame
Nuts, nut spreads
White bagel muffin crackers
Flour tortilla, white bread, naan, pasta
Whole wheat / buckwheat breads or pasta
Rice: white red brown wild
94
Foods (circle what you eat) How often? 2x or more daily Daily Weekly Monthly Never
Bran cereal Shredded wheat Granola
Other cereals
Donut Cookie Pie
Baklava Cakes
Chocolate Candy
Ice cream Popsicle Faluda
Yogurt Cottage cheese
Cheese (various types), cheese spreads
Dumplings (with various fillers)
Lentil/bean stew, curry, meat stews
95
Foods (circle what you eat) How often? 2x or more daily Daily Weekly Monthly Never
Stir-fry Mohinga / noodle soup
Chili sauce/paste
Chips, pretzels, popcorn
Butter Liquid oils Margarine
Wine
Beer
Liquor
96
APPENDIX E: INTERVIEW QUESTION
What is your country of origin?
How long have you lived in the United States? How many years in Syracuse?
Who does most of the cooking in your household?
Dietary habits before coming to the U.S
Tell me about the most common foods you would eat in ______.
How many meals did you eat each day? (Morning meal, afternoon meal, evening meal, etc) What are typical dishes for each meal / eating event? Are all dishes served at once? What components do meals have?
How often did you snack? What foods did you eat for a snack?
What cooking methods did you use?
Can you describe a commonly consumed dish? What are the ingredients?
What are some major holidays that you celebrated? Are there any special foods associated with these holidays?
Can you describe a special/festival dish that you would use to celebrate? What are the ingredients?
Where did you frequently get food items? (e.g outdoor market, supermarket, home garden)
If outdoor market/garden, how did consumption change throughout the year?
Dietary habits in the U.S
Do you follow a similar meal pattern? (morning meal…etc.)
Describe commonly eaten food items?
What foods do you eat for a snack?
What is a common serving size of ______(using hand measures)
What cooking methods did you use?
Can you find traditional foods or ingredients in the United States?
97
Where do you get these? / Can you buy these where you buy the rest of your food?
What ingredients do you use in place of items you could find in ______(country of origin)
What are some major holidays that you celebrate here? Are there any special foods associated with these holidays?
Are there any foods that you eat now that you did not eat before coming to the U.S? Which? What do you use them for?
Are there any foods that you do not eat now that you ate before coming to the U.S? Which ones?
What do you use them for?
Where do you purchase food items in the United States?
How do you travel there? / Is it difficult for you to get there?
Do you ever find it difficult to purchase enough food to feed yourself / family?
Do you ever worry about whether you will be able to buy enough food for you and your family?
What changes have you noticed? What has stayed the same? What challenges do you face with buying or preparing the foods you want to eat?
How long have you participated in the community garden? (Years, weeks, etc.)
Had you done any farming prior to participating in the community garden?
How did what you ate in the fall (harvest) differ from what you eat now?
Were you familiar with/know how to use all the vegetables grown on the farm?
What ones were new/unfamiliar?
What are some recipes you make with items from the community garden?
Do you typically cook your vegetables or consume them raw?
Is your harvest from the community farm typically consumed only by your household or is it shared amongst others?
During the harvest, do you still purchase other foods for consumption? If yes, what do you purchase?
What items do you wish were grown at the farm?
98