Identifying priority double-duty actions to tackle the double burden of malnutrition in infants and young children in Peru: Assessment and prioritisation of government actions by national experts.

Multiple forms of malnutrition coexist in infants and young children (IYC) in Peru. The World Health Organization has proposed double-duty actions (DDAs) to simultaneously address undernutrition and overweight/obesity. We assessed current implementation of- and priority for- government-level actions to tackle multiple forms of malnutrition in IYC in Peru. Mapping of current policy activity was undertaken against 47 indicators of good practice for five DDAs (exclusive breastfeeding, complementary feeding, food marketing, maternal nutrition, preschool nutrition; assessed by 27 indicators) and for the enabling policy environment, i.e., 'infrastructure support' (health in all policies, platforms for interactions, financing, monitoring, governance, leadership; assessed by 20 indicators). Interviews with 16 national experts explored views on the level of and barriers to implementation of DDAs and infrastructure support, as well as their prioritisation based on likely impact and feasibility. The level of implementation of actions was categorised into two groups (agenda setting/formulation vs. implementation/evaluation). Mean scores were generated for prioritisation of DDAs and infrastructure support. Deductive qualitative analysis was undertaken to identify barriers that influence policy implementation. Only 5/27 DDA indicators were reported as fully implemented by all national experts (international code that regulates the marketing of breastmilk substitutes, iron supplementation for IYC, micronutrient powders in IYC, iron/folic acid supplementation in pregnant women, paid maternity leave). Only 1/20 infrastructure support indicator (access to nutrition information) was rated as fully implemented by all experts. Barriers to implementing DDAs and infrastructure support included: legal feasibility or lack of regulations, inadequate monitoring/evaluation to ensure enforcement, commercial influences on policymakers, insufficient resources, shifting public health priorities with the COVID-19 pandemic and political instability. The experts prioritised 12 indicators across all five DDAs and eight infrastructure support indicators. Experts highlighted the need to improve implementation of all DDAs and identified ways to strengthen the enabling policy environment.

Designing intervention prototypes to improve infant and young child nutrition in Peru: a participatory design study protocol.

INTRODUCTION: Nutrition during the complementary feeding period (6-23 months) is critical to ensure optimal growth and reduce the risk of diet-related disease across the life course. Strategies to reduce multiple forms of malnutrition (stunting, overweight/obesity and anaemia) in infants and young children (IYC) are a key priority in low-income and middle-income countries, including Peru. This study aims to co-design and develop prototypes for interventions to address the multiple forms of malnutrition in IYC in urban Peru, using a participatory design approach. METHODS AND ANALYSIS: The study will be based within peri-urban communities in two areas of Peru (Lima and Huánuco city). Following the identification of key nutritional challenges for IYC aged 6-23 months through formative research (phase I), we will conduct a series of workshops bringing together healthcare professionals from government health centres and caregivers of IYC aged 6-23 months. Workshops (on idea generation; creating future scenarios; storyboarding and early implementation and feedback) will take place in parallel in the two study areas. Through these workshops, we will engage with community participants to explore, experiment, co-design and iteratively validate new design ideas to address the challenges around IYC complementary feeding from phase I. Workshop outputs and transcripts will be analysed qualitatively using affinity diagramming and thematic analyses. The intervention prototypes will be evaluated qualitatively and piloted with the participating communities. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Ethical Review Committee of the Instituto de Investigación Nutricional (IIN) Peru (388-2019/CIEI-IIN), Loughborough University (C19-87) and confirmed by Cardiff University. Findings of the participatory design process will be disseminated through a deliberative workshop in Lima, Peru with national and regional government stakeholders, as well as participants and researchers involved in the design process. Further dissemination will take place through policy briefs, conferences and academic publications.

Exploring the magnitude and drivers of the double burden of malnutrition at maternal and dyad levels in peri-urban Peru: A cross-sectional study of low-income mothers, infants and young children.

Multiple forms of malnutrition coexist in Peru, especially in peri-urban areas and poor households. We investigated the magnitude of, and the contribution of, dietary and socio-demographic factors to the double burden of malnutrition (DBM) at maternal (i.e., maternal overweight/obesity with anaemia) and dyad (i.e., maternal overweight/obesity with child anaemia) levels. A cross-sectional survey was conducted among low-income mother-child (6-23 months) dyads (n = 244) from peri-urban communities in Peru. Dietary clusters and the minimum dietary diversity score (MDD) were generated for mothers and infants, respectively. A composite indicator using the maternal dietary clusters and the MDD was created to relate to dyad level DBM. Two dietary clusters were found: (i) the 'high variety (i.e., animal-source foods, fruit and vegetables), high sugary foods/beverages' (cluster 1) and (ii) the 'high potato, low fruit and vegetables, low red meat' (cluster 2). DBM prevalence among mothers and dyads was 19.9% and 36.3%, respectively. Logistic regression analyses revealed that the only socio-demographic factor positively associated with maternal DBM was maternal age (aOR/5 years: 1.35 [1.07, 1.71]). Mothers belonging to diet cluster 1 were less likely to experience the DBM (aOR = 0.52 [0.26, 1.03]), although CIs straddled the null. Socio-demographic factors positively associated with dyad level DBM included maternal age (aOR/5 years: 1.41 [1.15, 1.73]), and having ≥ two children under 5 years (aOR = 2.44 [1.23, 4.84]). Diet was not associated with dyad-level DBM. Double-duty actions that tackle the DBM are needed given that one-third of dyads and a fifth of mothers had concurrent overweight/obesity and anaemia.

Diet and food insecurity among mothers, infants, and young children in Peru before and during COVID-19: A panel survey.

The COVID-19 pandemic may impact diet and nutrition through increased household food insecurity, lack of access to health services, and poorer quality diets. The primary aim of this study is to assess the impact of the pandemic on dietary outcomes of mothers and their infants and young children (IYC) in low-income urban areas of Peru. We conducted a panel study, with one survey prepandemic (n = 244) and one survey 9 months after the onset of COVID-19 (n = 254). We assessed breastfeeding and complementary feeding indicators and maternal dietary diversity in both surveys. During COVID-19, we assessed household food insecurity experience and economic impacts of the pandemic on livelihoods; receipt of financial or food assistance, and uptake of health services. Almost all respondents (98.0%) reported adverse economic impacts due to the pandemic and 46.9% of households were at risk of moderate or severe household food insecurity. The proportion of households receiving government food assistance nearly doubled between the two surveys (36.5%-59.5%). Dietary indicators, however, did not worsen in mothers or IYC. Positive changes included an increase in exclusive breastfeeding <6 months (24.2%-39.0%, p < 0.008) and a decrease in sweet food consumption by IYC (33.1%-18.1%, p = 0.001) and mothers (34.0%-14.6%, p < 0.001). The prevalence of sugar-sweetened beverage consumption remained high in both mothers (97%) and IYC (78%). In sum, we found dietary indicators had not significantly worsened 9 months into the COVID-19 pandemic. However, several indicators remain suboptimal and should be targeted in future interventions.