Nadia Ali had never left Baghdad. But in 2005, as she watched the city skyline fade into the distance, she knew that she would never go back to Iraq. She left behind her childhood home, her books and photographs, her friends, her aging parents. Her husband, Mohammed, left behind his job as a professor and the nation he had fought for in the Iraq-Iran war. To protect their two young sons from the escalating danger of their native city, the couple fled to Cairo, Egypt.

Home videos give a glimpse of the Alis’ life in Cairo. One of Nadia’s sons haltingly recites a prayer from the Quran from memory in a spacious room with crown molding. A vase of fresh flowers sits nearby. Every day, Nadia would get out of the house to walk her sons somewhere or to meet a friend a couple blocks away. A market place bustled just down the street and, on weekends, Nadia would return to the apartment with her arms full with heavy paper bags of rice, meat, and produce.

One day, Hashim, Nadia’s elder son, came home from primary school with a bloody scalp. Crying, he told his mother that his teacher had thrown a book at him. An administrator subsequently told Nadia that physical discipline was permitted in Egypt.

Nadia pulled the boys out of school. The young family began seeking another future — one in the United States. Relocation, the Alis knew, would shelter their family from the violence of car bombs and corporal punishment. What they didn’t know was that their new home in the U.S. would also threaten their health—in a more subtle but serious way. By changing how they moved and ate, how they worked and relaxed, their new environment would dramatically change the Alis’ bodies and, in doing so, their lives.

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I first met Nadia in the summer of 2011, in a dingy apartment complex in East Haven, Conn. I had just joined the Yale Refugee Project, a Yale College group that works to ease the transitions of refugees newly arrived in New Haven. I was nervous about my first session teaching English. Knocking on the peeling screen door, I ran through my lesson plan.

In his cozy living room, Mohammed immediately peppered me with questions about my studies and about New Haven. The fluency of his English caught me by surprise. He had quickly honed his skills by working three jobs to support his family.  “If he is this advanced only a year after moving to the US,” I wondered, “what am I doing here?”

Suddenly, a clattering rang out from within the kitchen. Nadia emerged: her face was pale and round and mascara coated her long, dark eyelashes. Long swatches of beautiful cloth fell from her headscarf and draped her short, round frame. During the two-hour visit, Nadia said not one word. Mohammed explained that his wife was silent because she spoke English poorly, and  regardless, she didn’t have much to say. Because Mohammed works jobs at all hours, I never saw him again.

Nadia’s English, I realized in subsequent visits, was much better than her husband had said. For the first few months of our weekly visits, we both tried to stick to the English curriculum. But with increasing frequency, Nadia would answer the door looking exhausted, blank worksheets in hand.

While her husband worked and her kids attended school, Nadia spent her days in the tiny apartment. Isolated and depressed, her weight was ballooning beyond her control. By winter, everyday tasks like grocery shopping and climbing stairs exhausted her. She began wincing as she stood up from the couch. At the end of each day, she told me, excruciating pain shot through the joints of both knees.

By the end of her first year in the US, Nadia had added more than 30 lbs. to her already heavy frame. Our conversations gradually transitioned from clauses and prepositions to cholesterol and dieting. Nadia decided to start an exercise routine and stick to a basic nutrition plan.

A few months later, I knocked on the door of the Ali household and nobody answered. Lingering outside, I called Nadia on my cell phone. She explained in broken English that she was in the hospital. Short of breath, she had called an ambulance. Her tests came back normal, but my goal of helping Nadia get fit suddenly became more serious.

Nadia fully understood the detriments of her habits and possessed the information, resources, and free time to improve them. But she hadn’t. How could a woman in her mid-thirties who had kept her family together through violence and turbulent change, lack the willpower to lose weight? In the following months, Nadia did not maintain a single one of her exercise or diet goals. I couldn’t understand what was holding her back.

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As refugees integrate their diverse backgrounds and skills into communities, they alter the American body. But through its culture, America, too, alters the bodies of the vulnerable population it grants residence.

Over their first 15 years of residence in the U.S., refugee and immigrant populations experience a dramatic jump in the prevalence of obesity: from 8% to 20%. All refugee demographics show a significant increase in average body mass index in their first year in the US.

Refugee populations have traditionally suffered from a heavy burden of infectious disease relative to the rest of the American public. Presently, however, many resettled refugee populations display an ever higher prevalence of non-communicable diseases, such as heart disease, obesity, and hypertension.

In a system of perverse incentives, unhealthy food is often cheaper, more convenient, less time-intensive, and non-perishable, said Marlene Schwartz, PhD, Director of the Rudd Center for Food Policy & Obesity. Much of the center’s research investigates “obesogenic” environments, settings that structurally promote weight gain.

Current health interventions, however, focus largely on health education. “We see someone with a bad diet and bad health outcomes and we think ‘Oh we need to teach them how to eat,’” said Schwartz. “But education is just not powerful enough to overcome these structural factors. It’s really about changing an entire society, particularly about changing environments that offer food to children from low-income families.”

As Health and Wellness Programming Coordinator for Integrated Refugee and Immigrant Services (IRIS) of New Haven—the Alis’ sponsoring resettlement agency — Leslie Koons helps incoming refugees navigate America’s complex medical care system. But low levels of funding and human resource support, Koons explained, limit IRIS’s capacity for health outreach. While Koons’ work addresses refugees’ acute medical needs, topics like nutrition and fitness are relegated to informational handouts, available in multiple languages at IRIS headquarters.

Recognizing the lack of nutrition and physical activity outreach, IRIS and the Yale Refugee Project (YRP) have attempted various education-based interventions to reduce the prevalence of refugee obesity. The YRP offered yoga and dance classes, but the money, time, and transportation necessary to commute to Yale’s campus slashed turnout, and the initiative was canceled in 2010. More recently, weekly walking groups started meeting at IRIS. Last summer, IRIS cancelled the groups because of low rates of attendance. The majority of participants had been similar to Nadia—young mothers from Bagdhad. Koons explained that participation dropped because many women had to leave IRIS at midday to prepare lunch for their families. Most recently, a graduate student led a series of cooking classes intended to introduce new, healthy ingredients to refugees. Top enrollment, according to Koons, hovered around five attendees.

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Returning to New Haven in August 2012 after the summer break, I found that Nadia, who stands no taller than 5’2”, now weighed over 260 lbs.

After spending three months wearing a headscarf and long sleeves in a muggy, cramped apartment, Nadia was tired of feeling sweaty and sluggish. She wanted the weight gone and wanted me to help.

For one year, I tried to find a way for Nadia to exercise. The easiest and most inexpensive option, I thought, was to run outside. Nadia quickly rejected the idea. Speaking little English and living in a homogenously white area, Nadia already drew glances. At Wal-Mart around Halloween one year, a little boy had pointed up at Nadia’s cream hijab headscarf. “Mom, mom!” he had said, “It’s a ghost!” More recently, in a parking lot, a man had pointed at her and shouted angrily. Only one word rang out to her clearly: “Terrorist!”

Finding a way to work out inside proved equally difficult. Nooreen Reza, a former health liaison for YRP and current volunteer, has also tried to facilitate physical activity in her family of Afghani refugees, “If a woman wants to exercise and is more conservative,” Reza said, “it is hard for her to do that in a mixed gender space.” The number of single-sex, bargain-priced gyms within walking distance of Nadia’s apartment complex? Zero.

In Iraq and Egypt, exercise did not require planning. Walking was an everyday necessity. “Here in America, I do not walk,” Nadia said bluntly. Living off of a four-lane highway, Nadia needed the family’s vehicle — and her husband’s help — to go anywhere in America.

“I haven’t come across any women who had exercise regimens back home,” said Koons, the IRIS Health Coordinator. “Back in their home countries,” Reza said, “if a woman wanted to go running outside, maybe she couldn’t—because she culturally wasn’t able to or because it wasn’t actually safe to be outside.” Lacking these habits had made it hard for woman like Nadia to exercise in an already unfamiliar environment.

I noticed other ways that Nadia’s gender affected her health. Women in refugee families often remain in the home and miss out on the social connections and cultural integration their husbands enjoy on the job. Nadia’s isolation left her listless and depressed. With little to do other than surf the internet or watch TV, Nadia used snacks and mealtimes to lift her spirits and break up the long daytime hours.

The 24-inch flatscreen TV, turned on with the sound at high volume, is a permanent fixture in the Alis’ apartment. Walking through the front door for a visit, I would see Nadia and her sons snuggling on the couch, their faces basking in the TV’s glow.

After failing to cultivate the potential jock in Nadia, I took careful inventory of the Alis’ kitchen pantry. First, breakfast: 2 boxes Count Chocula, 1 off-brand Cookie Crisp, and 1 alarmingly orange box of puffed cereal.

On to lunch and dinner. I opened the fridge. The hinges creaked under the weight of three bottles of cola lining the door. A leaning tower of single wrapped American cheese slices teetered onto a jumble of Saran-wrapped Hamburger Helper. In the back, in quiet homage to diets of another time and place, sat a platter slathered with thick waves of Nadia’s homemade hummus.

While Nadia had entered the US already slightly overweight, Hashim (12) and Hassan (11) were almost gangly when they first arrived in the US, blank slates for American culture’s marking.

Hassan put on weight quickly. Aware of his body’s changes, he poked fun at his own body, as well as those of his mother and brother. “I am in shape!” Hassan proclaimed to me during my last visit to their home. “See!” he shouted, dramatically tracing his finger around the periphery of his body “I’m in a shape!”

By the spring of my second year working with the Alis, Hashim was 5’1’’ and 147 lbs. and classified as morbidly obese. Because he had mastered English and Arabic, Hashim coordinated his family’s everyday business with the outside world. His bilingualism and quiet acceptance of its accompanying familial responsibilities gave Hashim the sense of a wise, old man trapped inside of a huge twelve-year-old’s body.

“I eat when I’m bored,” Hashim told me. “I eat to make the time pass,” he said.

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On a sunny day in September 2013, I pulled into the Xpect Discounts parking lot in East Haven to meet Nadia. The past few months had been eventful for the Ali family. Pinched for money, the family was searching for a smaller apartment and Nadia had just gotten a job stocking shelves in the night shift at Wal-Mart.

I found Nadia in frozen foods. Giving her a hug, I peered over her shoulder at the contents of her cart.

2 Betty Crocker chocolate chip muffin mixes
2 packages of Jumbo franks
1 carton of eggs
cool whip
hot cocoa

Save for the chickpeas, I couldn’t imagine this selection had much in common with what she used to bring home in Iraq.

After filling the cart, we moved into checkout line. Nearly at the register, Nadia noticed a bakery display. She darted from her spot and grabbed two four-packs of chocolate chip muffins.

“Why so many muffins?” I asked, pointing from the mixes to the tins.

“These are cooked,” Nadia said. Then, gesturing towards the foil pouches, “These take work.”

“But Nadia,” I said, “Why do you need chocolate chip muffins and chocolate chip muffin mix?”

“Oh, Amelia, please,” she stared at me reproachfully, “I like to eat them with my coffee!”

The cashier chimed in, “It’s ok, hon,” she said to Nadia. “You deserve it!”

Standing on an elevated platform, the cashier—who was herself overweight—threw me a nasty glance from behind her barricade of cigarettes, lottery tickets, and king-sized candy bars.

Raw heat blossomed across my cheeks. As my own voice echoed back to me, I could hear how patronizing I sounded.

“This just in!” my words seemed to say. “Baked goods make you gain weight!”

Nadia was a resilient wrangler of two rambunctious boys, a former next-door neighbor to war itself, a plucky champion for her family willing to abandon the known for a faint glimmer of a better unknown.
And I had been trying to teach her Muffins 101.

Nadia knew what food was healthy and what food was not. She understood that exercise would improve her life. I thought about the pains — physical and emotional — that had characterized Nadia’s life as a refugee since her arrival in the US. Aching knees, powerlessness, crippling lack of self-esteem. “You deserve it, hon,” the cashier had said.

“No,” I thought, “Nadia did not ‘deserve it.’” She deserved better, but no simple formula was going to make that happen.

Nutrition education is becoming less relevant as a strategy to reduce obesity. The idea that instruction alone can solve the obesity epidemic reflects an ugly and ill-conceived correlation: overweight = undereducated.
Self-control is a finite resource. While some people use willpower to resist that second cookie or run that extra mile, others expend their daily allotment by forcing themselves to work the graveyard shift and still get dinner on the table.

Though perhaps their marks are more visible on America’s newest and most vulnerable, the accepted structures that comprise the space in which Americans live, travel, eat, and sleep modify our behaviors and, consequently, our bodies.

I recently visited the Alis’ new home. Just a couple minutes off of the highway, their one-floor apartment was still full of moving boxes. I learned that Hassan was registered to play recreational basketball in the spring and that Nadia had made some new friends at work.

In the center of the table sat a wooden bowl teeming with fruit. A full bunch of bananas crested the top of the pile, appearing posed, as if for a still life painting. I heard an oven timer ding. Briefly disappearing into the kitchen, Nadia came back through the doorway with a wide smile and a plate of muffins, still steaming from the oven.