Peru Amy Margolies,¹ Kamara Pather,² Jessica Huamán Vilca³ and Deanna Olney¹ Urban nutrition profile Key messages Peru has made significant strides in reducing the burden of stunting, but progress has stalled: 8 percent of urban children and 20 percent of rural children are stunted. Overweight and obesity in women have been highly prevalent for more than a decade, with no signs of improvement; they affected 66 percent of urban and 61 percent of rural women in 2023). The problem also affects school-age children, adolescents, and adult men. Peru has the third highest urban sugar intake among eight countries in the region, but saturated fat intake is comparatively lower than the regional average (6.5% of total energy compared to 9.7%). Among all adults, consumption of fruits and vegetables is low. The cost of a healthy diet increased from $3.28 to $4.00 per person per day from 2017 to 2022, and 34% of the total population is unable to afford a healthy diet. Urban food environment (FE) studies, which mostly focus on Lima, Peru’s capital, should be expanded to other urban areas (e.g., smaller urban areas and Amazonia) and to rural areas where FEs have also started to undergo rapid changes. Research is needed to better understand how level of urbanicity, region (Amazon/Andean), ethnicity, or settlement type intersect to affect nutrition and diets. Evidence regarding the success of urban nutrition interventions is inconsistent and there is limited guidance on how nutrition programs can be adapted to urban contexts. Double-duty actions to address poor diets and the multiple forms of malnutrition that are affecting both urban and rural areas are urgently needed. These should include a redesign of social protection programs to ensure that they focus on healthy foods and meals and address all forms of malnutrition, especially among school-age children and women. While Peru has nutrition policies that both cover urban dwellers and encourage consumer demand for healthier diets and improved access to food, these programs should be adapted to effectively do double duty in preventing all forms of malnutrition, particularly overweight. Policy implementation and enforcement must be strengthened to address obesogenic FEs. In addition, accompanying interventions that target children and adolescents and innovations that stimulate consumer demand for healthier and more sustainable diets are needed. Total population: 34 million Annual urban growth rate: 1.3% 38% of the urban population lives in Lima 45% of the urban population lives in informal settlements Poverty rate (2022): 24% urban, 41% rural ¹International Food Policy Research Institute; ² Consultant; ³ International Potato Center Shawn Harquail CC BY-NC 2.0 Urban https://pmc.ncbi.nlm.nih.gov/articles/PMC6682987/ https://pmc.ncbi.nlm.nih.gov/articles/PMC6682987/ https://www.fao.org/faostat/en/#data/CAHD?countries=170&elements=6120&items=7004&years=2017,2022&output_type=table&file_type=csv&submit=true https://www.fao.org/faostat/en/#data/CAHD?countries=170&elements=6120&items=7005&years=2017,2022&output_type=table&file_type=csv&submit=true https://data.worldbank.org/indicator/SP.POP.TOTL?locations=PE https://data.worldbank.org/indicator/SP.URB.GROW?locations=PE https://data.worldbank.org/indicator/SP.URB.TOTL.IN.ZS?locations=PE https://data.worldbank.org/indicator/SP.POP.TOTL?locations=PE https://ourworldindata.org/grapher/share-of-urban-population-living-in-slums?tab=table&showSelectionOnlyInTable=1&country=~PER https://cdn.www.gob.pe/uploads/document/file/4543362/Nota%20de%20Prensa.pdf?v=1683819917 https://data.worldbank.org/indicator/SP.URB.TOTL.IN.ZS?locations=PE Nutrition and diets Undernutrition 2 Summary Peru has made notable progress to reduce child stunting in past decades, but no further progress has been observed since 2017. Currently, stunting affects 20 percent of rural children and 8 percent of urban children. There is also an urgent need to focus on overweight in school-age children, adolescents, and adults and to counter the growing influence of obesogenic food environments, especially in urban areas. National policies aim to counter the influence of unhealthy food marketing and improve nutrition labeling, but the stringency and effectiveness of their application varies. Programs with social protection and nutrition components have lower coverage in urban areas than rural ones. There is a pressing need for interventions and programs that simultaneously address multiple forms of malnutrition—referred to as double-duty actions—and address these complex challenges in both rural and urban areas. While Peru has made great strides in battling undernutrition, child stunting still affects about one in five children in rural areas and has not improved in recent years. The country now struggles with multiple burdens of malnutrition, including overnutrition and diet-related noncommunicable diseases (NCDs), especially in urban areas and among adolescents and adults. natalia alterna CC BY-NC 2.0 Peru has received international attention for reducing malnutrition [1]. From 2007 to 2017, stunting levels nearly halved among children under five years of age (not shown in Figure 1) [2, 3]. This change occurred in both rural and urban areas (rural—from 45 percent to 25 percent, urban—16 percent to 8 percent urban), while wasting remained low (less than 1 percent in both urban and rural areas) (wasting not shown in Figure 1) [2, 3]. Drivers of this reduction in stunting included, increased maternal body mass index (BMI), improvements in healthcare, increased parental education and rural-to-urban migration [4]. After a decade of success, however, stunting levels stagnated since 2017 (Figure 1) [2, 5, 6, 7, 8, 9, 10]. Half of Peru’s population experiences moderate to severe food insecurity [11]. Figure 1: Child* nutrition status in Peru, 2017–2023 Source: ENDES [2, 5, 6, 7, 8, 9, 10]. Note: *Among children under the age of five. ENDES = Encuesta Demográfica y de Salud Familiar. There are also nutritional disparities in vulnerable groups, such as urban Amazonian children (31 percent stunting among children under five) [12], and Indigenous populations that are increasingly migrating from rural to urban areas [13, 14]. The stunting gap between groups speaking Spanish and Amazonian languages was 36 percent, and 22 percent Spanish and Quechua speakers [1]. Anna & Michal CC BY-NC 2.0 Overnutrition 3 As part of Latin America and the Caribbean (LAC)—the second most urbanized region globally—Peru is now grappling with the lifestyle and dietary changes that accompany urbanization, including the growing influence of obesogenic urban food environments (FEs) and challenges related to availability, affordability, and access to healthy and nutritious foods [15]. Urban children are increasingly experiencing overnutrition, which is on the rise in Peru, as is the double burden of malnutrition (DBM)—the coexistence of under- and overnutrition within individuals, households, and populations [16]. Between 2000 and 2020, Peru was one of six countries in LAC that reduced the national prevalence of overweight among children under five (from 12 to 10 percent) [11]. However, while overweight [ᶦ] in children under five has remained low in rural areas (3–4 percent), it has slowly increased in urban areas, from 9 percent to 12 percent, and is now higher than the regional prevalence of 8.6 percent (not shown) [2, 5, 6, 9, 17]. In older children and adults, however, overnutrition is a rapidly growing problem, especially in urban areas. Overweight and obesity affects 45 percent of urban children (6–13 years old) compared to 15 percent of rural children, and 31 percent of urban adolescents (12–17 years old) compared to 16 percent of rural adolescents [18]. In addition, during the COVID-19 pandemic (2019–2021), the largest increase in child overweight and obesity prevalence in the LAC region occurred in South America (+0.4 percentage points [pp]) [19]. During the pandemic, the prevalence of overweight and obesity among children under five increased from 7.5 to 9.4 percent in urban areas of Peru, a statistically significant rise which researchers hypothesized was due to more sedentary lifestyles and unhealthy eating patterns [20]. Studies of DBM pairs of undernourished children and overweight mothers show DBM prevalence (maternal overweight with child anemia) affected more than one- third of peri-urban [ᶦᶦ] dyads [21], while another found urban DBM prevalence was lower than in rural areas [22]. Likewise, overweight and obesity affect a large proportion of adult women in both urban and rural areas (66 and 61 percent, respectively) (Figure 2) [2, 5, 6, 7, 8]. However, urban adults are more overweight than their rural counterparts. Notably, Peru is the only country in LAC to experience an increase in women’s urban–rural BMI difference between 1985 and 2017, despite increases of approximately 3 kg/m2 in both urban and rural mean BMI. By 2017, Peru had the LAC region’s largest urban–rural difference in BMI for men, jumping from a difference of 1.8 kg/m2 in 1985 to 2.5 kg/m2 in 2017. While Peru’s urban men have a mean BMI of 28 kg/m2, this level still falls below the mean BMI for men in other countries in the LAC region. Figure 2: Adult women overweight and obesity* in Peru, 2017–2023 Source: ENDES [14, 15, 8, 19, 25]. Note: *Overweight = BMI of 25–29.9; obesity = BMI ≥ 30. From 2017, rates of overweight and obesity for women in both rural and urban areas have increased by approximately 5 percentage points—driven by increases in obesity rather than overweight. At the subnational level, the rural sierra (mountains) has the lowest prevalence of overnutrition. Overweight prevalence is highest in the urban sierra (40 percent) and lowest in the rural sierra (31 percent), while obesity is highest on the urban coast (28 percent) and lowest in the rural sierra (12 percent) [23]. Frank Kehren CC BY-NC 2.0 https://ncdrisc.org/bmi-mean-ranking-urban-rural-diff.html https://ncdrisc.org/bmi-mean-ranking-urban-rural-diff.html 4 Diets Results from nationally representative surveys (ENDES 2021–2023) show that a high percentage of urban and rural children are fed according to recommended infant and young child feeding (IYCF) practices. For example, more than 90 percent of children ages 6–23 months were fed three or more food groups in the previous day (in both urban and rural areas), and a high percentage consumed foods rich in vitamin A (98 percent urban, 94 percent rural) and iron (94 percent urban, 87 percent rural) (Figure 3) [7, 8, 10]. Compared to the rest of Andean Latin America [ᶦᶦᶦ], Peru has a lower age-standardized prevalence [ᶦᵛ] of iodine deficiency (75 vs. 77.5), but a higher prevalence of dietary iron deficiency and vitamin A deficiency [ᵛ] [24]. Figure 3. Infant and young child* feeding practices in Peru, 2019–2023 Source: ENDES [7, 8, 10]. Note: *Children between 6–23 months of age. For other age groups, dietary patterns are less than optimal in both urban and rural areas. Only a small percentage of rural (5 percent) and urban residents (11 percent) meet the recommended daily consumption of five servings of fruits and vegetables (F&V); the urban coast has the highest consumption levels while the rural sierra has the lowest. Weekly mean F&V consumption (two and one serving[s] of each group, respectively) is the same in rural and urban areas [23]. The low consumption of F&V has changed little over time (2014–2022) [25]. Consumption of dark green leafy vegetables and Vitamin A–rich fruits is also low in both urban (30 percent, 28 percent) and rural populations (25 percent, 34 percent) [26]. However, nationally representative dietary data show that most women in urban (78 percent) and rural (72 percent) areas met the minimum diet diversity on the previous day. The cost of a healthy diet is $4.00 per person per day, and 34 percent of the population is unable to afford a healthy diet—higher than the regional average of 27 percent in LAC [11]. Among adults, national-level consumption of fish, dairy, and red meat is higher than EAT-Lancet targets for healthy and sustainable diets, while consumption of vegetables, legumes, nuts, and whole grains falls below recommended. Only fruit consumption targets are achieved. More than half of urban and rural residents consume dairy, and consumption of other animal-source foods (ASF) (eggs, meat, poultry, fish) is common and higher in urban areas (91 percent) than rural ones (83 percent) [26]. The high costs of ASF in rural areas can limit consumption [27]: surveys (2004, 2019) show a downward trend in meat, dairy, and egg consumption in rural areas, but a positive trend in starch consumption (cereals, bread) [28]. Juan Felipe Rubio CC BY-NC 2.0 https://www.dietquality.org/countries/per https://www.dietquality.org/countries/per https://www.fao.org/nutrition/assessment/tools/minimum-dietary-diversity-women/en/ https://www.fao.org/nutrition/assessment/tools/minimum-dietary-diversity-women/en/ https://globalnutritionreport.org/resources/nutrition-profiles/latin-america-and-caribbean/south-america/peru/#diet https://openaccess.city.ac.uk/id/eprint/21633/8/Food%20Planet%20Health.pdf 5 Ultra-processed foods (UPFs) are unhealthy, usually inexpensive, highly palatable, and convenient manufactured food products that may displace nutritious whole foods and are associated with increased risk of adverse health outcomes [29]. From 2009 to 2019, Peru experienced the largest increase in UPF retail sales in the LAC region, as it rose from having the region’s lowest level of per capita UPF sales. Foods—rather than beverages (such as sugar- sweetened beverages [SSBs])—drove this growth [30]. Currently, consumption of sweet foods (such as baked goods including cake, churros, or candies) is higher among urban than rural residents (48 percent vs. 40 percent) but consumption of highly processed foods such as salty packaged snacks and of salty and fried food is similar in both areas (22 percent and 35 percent, respectively) [26]. Urban residence is also significantly associated with an additional mean SSB consumption of 0.4 servings per day [31]. Peru had the third highest value of total urban sugar intake (106 g per capita per day, of which 70 grams are added sugar) among eight countries in LAC in 2015; urban sugar intake did not vary by socioeconomic status [32]. Convenience is a key driver of poor-quality diets in urban areas, especially in relation to the consumption of of ready-to-eat foods and meals for children of mothers working in the informal sector [29][ᵛᶦ]. Thirty-eight percent of rural households and 34 percent of urban households have a child under 18 with a caloric deficit [ᵛᶦᶦ], though the percentage is higher in Lima than in other urban areas (38 percent, the same as in rural areas) [35]. A higher percentage of rural households with children are beneficiaries of food distribution programs (78 percent) than urban households (51 percent) [35]. Diet-related noncommunicable diseases Twelve percent of total NCD deaths in Peru are attributable to dietary risks. Changes in dietary patterns in Peru —especially in urban areas—contribute to NCD burdens. Cardiovascular disease incidence is led by stroke (75 per 100,000 people annually) and ischemic heart disease (71 per 100,000 annually) [14]. Compared to traditional rural dietary patterns, the modern semi-urban diet, characterized by high UPF consumption and low vegetable consumption, was associated with a higher prevalence of hypertension (HT), high BMI, and type 2 diabetes mellitus (DM) [34]. HT and DM affected 23 percent and 6 percent of urban residents, and 18 percent and 2 percent of rural residents, respectively, in 2022 [25]. Among adults (18–59 years old), elevated triglycerides affected 40 percent of both urban and rural residents, while the prevalence of metabolic syndrome was higher among urban (36 percent) than rural adults (21 percent) (2018) [25]. Forty-one percent of urban residents and thirty-six percent of rural residents over 15 have at least one NCD or NCD risk factor (DM, HT, obesity [ᵛᶦᶦᶦ]) [23]. Scott Ableman CC BY-NC 2.0 http://ihmeuw.org/6q1t http://ihmeuw.org/6pvj 6 The Peruvian government’s (GoP) effort to reduce chronic malnutrition in young children has been documented as a success [35]. Beginning in 2005, the GoP’s national nutrition strategy was promoted through a newly formed civil society platform, the Child Malnutrition Initiative, a poverty reduction strategy targeting child malnutrition, Crecer (2007), and a focus on results-based budgeting for the nutrition funding mechanism [ᶦˣ]. The GoP also instituted mandatory fortification of salt (with iodine and fluoride), wheat flour (with folate, iron, niacin, riboflavin, and thiamin) and rice (with vitamins A, D, B6, B12, folate, iron, niacin, thiamin, and zinc) in 1969, 1996, and 2021, respectively. National urban nutrition plans, policies, programs and guidelines The National Strategic Nutrition and Food Security Plan (2015–2021) aimed to reduce undernutrition through education and outreach to families, schools, and communities, but it did not include specific actions for urban areas, apart from developing productive capacities in food-insecure households in peri-urban areas. The Food and Nutritional Security Law (2021) created a legal framework for the right to food and for policies on nutrition and food security. The National Agenda for Children and Adolescents (2021–2026) highlights children living in marginalized, poor urban areas as a priority for promoting adequate nutrition. However, as city size increases, coverage of food- or nutrition-related social programs declines [28]. Urban street children have also been excluded from food programs for lacking national identity cards. The National Multisectoral Policy for Children and Adolescents through 2030 outlines improvements to housing and water and sanitation for poor urban families, but lacks nutrition-specific activities. Several national policies target overnutrition, which is particularly relevant for urban FEs, including through decrees to label processed food with high amounts of sugar and fats, a decree to incorporate healthy foods into school canteens, SSB taxes (25 percent for nonalcoholic beverages containing more than 6 grams of sugar per 100 milliliter [mL] and 17 percent for less than 6 gram per 100 mL) [36], and the Promotion of Healthy Eating for Children and Adolescents Act (2013) limiting unhealthy food advertising. After the approval of this law, however, industry influence led to modifications that made the regulations more flexible (such as removing prohibitions on cartoon advertising to children, minimum sizes for nutrition warning labels, etc.) and likely less effective [37]. A school food policy (2019) established guidelines for promoting healthy eating, nutrition education and improved sanitary conditions in public and private schools, such as restricting the sale of unhealthy foods and beverages (those with octagon warning labels for high sugar and/or fat content) in kiosks and cafeterias. The city of Lima’s food charter established the Lima Food System Council (CONSIAL) to promote food security through policies on the promotion of healthy FEs for children (ordinance 2366), food recovery efforts to reduce food waste such as through redistribution of fresh agricultural products to food- insecure urban populations (ordinance 2498), and exclusive breastfeeding (ordinance 2524). CONSIAL also created a food security working group that collaborated with ‘Ollas comunes’ to combat food insecurity, especially during the pandemic. Several large-scale national programs target nutrition, including the Programa Nacional de Alimentación Escolar Qali Warma (PNAEQW) and the Vaso de Leche (Glass of Milk) program [ᵛᶦᶦᶦ]. PNAEQW is a national school feeding program that provides school meals in both rural and urban areas, with the explicit aim of improving school-age children’s nutrition. Vaso de Leche covers 16 percent of urban households and 34 percent of rural households with at least one child aged 13 or younger [38]. School meals cover 4.2 million children, mostly in pre- and primary–school levels, reaching 71 percent of enrolled students [39]. Breakfasts in state schools cover 79 percent of rural students and 64 percent of urban students (ages 3–11), while lunch is provided to 42 percent of rural students but only 12 percent of urban students [38]. https://tinyurl.com/269q7ve7 https://leap.unep.org/en/countries/pe/national-legislation/decreto-supremo-n-008-2015-mimagri-plan-nacional-de-seguridad https://www.unicef.org/peru/media/9736/file/Agenda%20por%20la%20ninez%20y%20adolescencia%202021-2026.pdf https://faai.ch/sites/default/files/source/docs/peru-2022.pdf https://www.gob.pe/42698-politica-nacional-multisectorial-para-las-ninas-ninos-y-adolescentes-al-2030-pnmnna https://www.gob.pe/42698-politica-nacional-multisectorial-para-las-ninas-ninos-y-adolescentes-al-2030-pnmnna https://cdn.www.gob.pe/uploads/document/file/4717010/6-Promocion-del-acceso-a-viviendas-adecuadas-de-la-poblacion-en-ambitos-urbanos.pdf?v=1687443160 https://cdn.www.gob.pe/uploads/document/file/4717011/7-Servicio-de-saneamiento-ampliado-mejorado-y-rehabilitado-en-beneficio-de-la-poblacion-del-ambito-urbano-y-rural.pdf?v=1687443160 https://cdn.www.gob.pe/uploads/document/file/4717011/7-Servicio-de-saneamiento-ampliado-mejorado-y-rehabilitado-en-beneficio-de-la-poblacion-del-ambito-urbano-y-rural.pdf?v=1687443160 https://cdn.www.gob.pe/uploads/document/file/4717011/7-Servicio-de-saneamiento-ampliado-mejorado-y-rehabilitado-en-beneficio-de-la-poblacion-del-ambito-urbano-y-rural.pdf?v=1687443160 https://cdn.www.gob.pe/uploads/document/file/4717011/7-Servicio-de-saneamiento-ampliado-mejorado-y-rehabilitado-en-beneficio-de-la-poblacion-del-ambito-urbano-y-rural.pdf?v=1687443160 https://gifna.who.int/countries/PER/policies/43617 https://foodactioncities.org/case-studies/lima-food-charter/ https://www.gob.pe/institucion/munilima/normas-legales/2504273-ordenanza-municipal-n-2277-30-10-2020 https://library.fes.de/pdf-files/bueros/peru/17426.pdf From 2010 to 2022, 11 studies were published on urban nutrition-related interventions (Table 1). These studies concerned both problems of undernutrition (micronutrient deficiencies, IYCF practices) and overnutrition (NCD risks). Most of this research had limited impact on the outcomes studied. Only two studies used randomized controlled trials: one assessed the impact of maternal zinc supplementation during pregnancy on infants’ monthly growth velocity and found no impact [47]. The other study tested the impact of a HT-focused mHealth intervention in adults with systolic (SBP) and diastolic blood pressure (DBP) in the pre-HT range [48] after one year and five years of implementation. It found no impacts on SBP, DBP or physical activity, no increase in fruit and vegetable consumption or reduced sodium intake but small increases in high- fat and high-sugar foods occurred. 7 Urban nutrition interventions During the pandemic, the government adapted the school meals program to provide take-home rations to nutritionally vulnerable children, and a legislative decree authorized temporary complementary feeding to other vulnerable persons [40]. PNAEQW had significant short-term positive effects on cognitive test performance for poor children who did not eat breakfast at home, yet the same study found that the meals did not meet program requirements for calories or nutrients [41]. From 2016 to 2023, food-based programs benefiting children and adolescents expanded coverage from 43 to 57 percent of households nationally, with higher coverage in rural areas compared to urban areas (78 percent vs. 51 percent) [33]. However, sufficient funding has not always accompanied increases in program coverage. A resolution from 2024 recognizes grassroots community kitchens (Ollas comunes) as part of the Programa de Complementación Alimentaria, a food supplement program, to regulate the kitchens and to guarantee their sustainability with government financing. The conditional cash transfer program Programa Juntos, launched in 2005 [1], signaled a departure from solely food distribution–based nutrition programs. Juntos has been shown to contribute to improvements in nutrition, such as child anthropometry [42] and reduced overweight in women [43]. However, impacts may be limited to those exposed to severe stunting in early childhood (under four years) [44, 45]. Also, vulnerable populations such as Indigenous children in both rural and urban areas have seen lower reductions in malnutrition than the rest of the population. Vulnerable communities would benefit from outreach and cultural adaptation is needed to target and tailor these programs to improve outcomes and help address disparities [46]. Eight studies with less rigorous designs targeted adults (n=4), caregivers and young children (n=2), adolescents (n=2), and school-age children (n=1) with a range of interventions, including health/nutrition education [49, 50], iron supplementation [51], anemia prevention [52], food assistance [53], household gardens [54], and HT screening and control [55, 56]. Interventions documenting nutrition impacts include a study that found lower odds of anemia in communities where national anemia legislation had been implemented [52]; a nutrition education program that reported a greater proportion of adolescents without any clinical signs of metabolic syndrome [49]; a nutrition education program that influenced some caregivers’ IYCF practices [51]; and two HT reduction interventions that showed mixed results [55, 56]. None of these studies used an experimental evaluation design or included a control group, preventing the attribution of changes to a given intervention or program. A study examining repeated nationally representative surveys between 2003 and 2010 found an association between participation in national food assistance programs (FAPs) and risk of overweight in a sample of urban and rural dwellers but not for poor women (≥ 2 poverty indicators) in Lima, other urban areas and rural areas [54]. This evidence is not causal, but it could suggest that FAP interventions—which, in Peru may include energy-dense foods—should be re-designed to provide healthier food and meal options and improve diet quality. https://www.gob.pe/11779-ministerio-de-desarrollo-e-inclusion-social-programa-de-complementacion-alimentaria-pca Randomized controlled trial Population Intervention Results Yes [47] Infants (0–12 months), peri- urban informal settlement Supplementation intervention: (1) IG maternal zinc supplementation (15mg zinc + 60mg iron + 250mg folic acid); (2) CG (iron/folic acid) during pregnancy. Prenatal supplementation during pregnancy did not lead to improvements in infant: (1) monthly growth velocity (length or weight) or incremental velocities (monthly/quarterly); (2) proportional changes (percent of total size at 1 year gained/month; or (3) individual velocity variability compared to CG. Yes [59] Men/women (30– 60 years), SBP/DBP in pre- HT range mHealth intervention: (1) Monthly nutritionist calls, weekly texts on healthy lifestyles and diets; (2) control (12 months) in Argentina, Guatemala, Peru. No differences in SBP or DBP between IG and control. Subgroup analyses for Peru show significant net reduction in body weight from baseline in IG compared to CG and significant difference in increased daily intake of FV. Yes [48] Men/women (30– 60 y), SBP/DBP in pre-HT range ˣ] mHealth intervention: (1) Monthly nutritionist calls + weekly texts on healthy lifestyle/diet; (2) control (12 months). 5-year follow-up of same intervention as above [59]: IG did not significantly reduce HT risk; no changes in SBP/DBP compared to CG; analyses of secondary outcomes found IG had lower body weight and BMI than CG, no impacts on physical activity, increase in fruit/vegetable or reduction in sodium intake; in fact, small increases in high-fat and high- sugar foods occurred. The study noted no changes in behavioral factors explained body weight or BMI reductions. No (4 pooled surveys pre- intervention [2014–2017), post-program survey [2018], PSM) [52] Children (2–11 years) in an urban informal settlement National anemia programs: screening, surveillance, treatment (children 6–36 m), nutrition promotion, deworming (2–17 years). 5-year follow-up of same intervention as above [60]: IG did not significantly reduce HT risk; no changes in SBP and DBP compared to CG; analyses of secondary outcomes found IG had lower body weight and BMI than CG, no impacts on physical activity, increase in fruit and vegetable consumption or reduction in sodium intake; in fact, small increases in high-fat and high-sugar foods occurred. The study noted no changes in behavioral factors explained body weight or BMI reductions. No (cohort, pre- post) [49] Adolescents (12– 16 years) Nutrition and health education (biweekly for 9 weeks). An increase in the proportion of adolescents lacking any metabolic syndrome components from baseline was 12%; significant reductions in proportions of adolescents with hypertriglyceridemia (22%) and arterial HT (3%), but not other metabolic components. No (mixed methods) [50] Caregivers and young children (<36 months) Nutrition education (age– appropriate feeding and/or breastfeeding with and without diarrhea) for exclusively breastfed IYC > 6 months of age (3 months). At baseline, 72% of caregivers would stop normal feeding or give less food when child had diarrhea, but at follow-up, none of the caregivers reported restricting feeding. 8 Table 1: Nutrition interventions in urban Peru, 2010–2022 FAPs in Peru's urban settings could also be better adapted or retrofitted as double-duty actions that not only provide nutritious foods and meals, but also promote healthy lifestyles, while continuing to educate parents about optimal IYCF practices, including avoidance of unhealthy snacks and SSBs among young children, to address all forms of malnutrition [57, 58]. No (cohort) [51] Caregivers and children (2–5 years) Iron supplementation (1 month) to examine the relationship between immune activation and lack of response to anemia treatment High CRP is associated with lack of response to supplementation with iron for anemia, body fat moderates this relationship. Greater difference in the probability of responding to supplementation between low and high immune activation with BMI z-scores below the mean. No significant difference when BMI z-score is >1, between children with low or high CRP. No (repeated cross-sections) [53] Adult women National food assistance programs: Vaso de Leche, Community Kitchens, Feeding & Nutrition Program for Tuberculosis Patients and Families, Wawa Wasi [ˣᶦ] (2003–2004, 2006, 2008–2010) FAP participation associated with 30–50% increased risk of overweight in non-poor women the whole sample (including both rural and urban areas). However, for poorer women (≥ 2 poverty indicators) in Lima, other urban areas and rural areas; participation was not associated with overweight risk. No (cohort) [54] Adults in informal settlements Individual household gardens (four 2- to 3-hour workshops on garden design, construction, and cultivation; one-time US$150 transfer for garden construction) There was no significant change in BMI, WC, or BP at either follow-up (6 or 12 months). At 6 months, there was a significant increase in mean fasting blood glucose, but at 12 months, the change in mean fasting blood glucose was not significant. No (pre-post cohort) [55] Adults Health center–based HT screening, education, prevention, control, and treatment (6 months) Change in BP pre-post showed increase in number of participants with normal BP, average participant SBP, DBP, BMI significantly reduced but increases in BP among prehypertensive group (≥ 60 years). No (cohort) [56] Adults (Low– income, HT, pre-HT) Individual phone consultations, texts, and group health education and meetings to reduce HT (2 years) No changes in physical activity, but decreased salt and UPF consumption, increased FV consumption, reductions in stress, lower alcohol/smoking, small decrease in mean BMI and WC, and statistically significant reductions in SBP and DBP. 9 Source: Authors. Note: BMI = body mass index; CG = control group; CRP = C-reactive protein; DBP = diastolic blood pressure; FV = fruits and vegetables; HT = hypertension; IG = intervention group; IYC = infants and young children; PSM = propensity score matching; SBP = systolic blood pressure; UPF = ultra-processed foods; WC = waist circumference. Urban food environments Urban FE studies (n=22) mostly took place in Lima (73 percent), with observational/inferential (n=8), descriptive (n=7), or modeling (n=6) designs. The populations covered were consumers (n=14) and vendors (n=9) in formal (n=10), informal (n=6), and institutional (school) (n=5) settings. The topics most covered by urban FE studies were vendor and product properties (n=10) and marketing and regulation (n=9) (Figure 4). Renzo Vallejo CC BY-NC 2.0 10 Figure 4: Studies of urban food environments in Peru, 2000–2023 Source: Authors. Note: This figure summarizes the results of a systematic scoping review of the urban FE literature in Peru. Papers were categorized under multiple dimensions of the food environment as appropriate. Obesogenic FEs present a great challenge for Peru’s urban population, given the high burden of overnutrition, especially among groups such as school-age adolescent children and women. Several studies examined the influence of unhealthy food marketing and school FEs in Peru, showing that many schools advertise UPFs [60]. SSBs are also commonly advertised in school-adjacent corner stores in Lima, with a third of advertisements having cartoon characters that appeal to children [61]. A qualitative study of periurban adolescents explored the effect of social and environmental factors on dietary choices, such as the influence of school FEs, which offer low-nutrient, energy-dense foods [62]. University students in Lima lacked knowledge of the detrimental effects of UPFs, despite frequently consuming them [63]. Another study linked restaurant menus and nutritional quality of meals served with women’s anthropometry, finding that household proximity to restaurants offering less healthy foods and meals was significantly associated with higher rates of overweight and obesity [64]. Studies of institutional FEs suggest a need for school- and university-based interventions focused on nutrition education for children, adolescents, and young adults [60, 62, 63]; application of existing regulations to restrict unhealthy foods in educational institutions [60]; and mass media promotion and marketing of healthier foods to counter UPF and SSB marketing [60, 63]. David Berkowitz CC BY-NC 2.0 David Stanley CC BY-NC 2.0 Luis Cordova CC BY-NC 2.0 11 Studies explored urban consumer preferences for healthy, safe, and nutritious foods. More educated consumers showed preferences for quinoa [65], a traditional and nutritious pseudocereal [66]. A study examining fish consumption found that wealthier consumers who consumed fast food were more likely to spend more on beef than fish, and factors influencing fish expenditure included knowledge of the health benefits of fish [67]. A willingness-to-pay study found that urban diets could be improved through strengthening supply chains for locally produced tree fruits; the study also found that younger, more educated consumers and families with young children would be willing to pay more for fruit [68]. Other studies mapped the wide availability of UPFs: a study of three Lima supermarket chains characterized how the Promotion of Healthy Eating for Children and Adolescents Act would label unhealthy foods, revealing that many foods targeted to children would have the greatest number of front-of-package warning labels (bakery products, candies) and thus showing the potential impacts of legislation to combat overnutrition. Yet a potential limitation of the law is that many products do not include nutrition composition, as displaying nutritional information on products is voluntary in Peru [72]. An industry-oriented study found that better local institutional quality, such as improved urban physical infrastructure, contributed to a greater presence and density of fast-food outlets [73]. Finally, a peri-urban study of mothers at community kitchens found that nearly two-thirds had good knowledge of food hygiene; no relationship was found between household sociodemographic characteristics and good maternal knowledge of food hygiene [74]. Another study found that poor urban consumers would be willing to pay slightly more for a healthier meal with salad or fruit in government-run communal kitchens [69]. In terms of the availability of healthy foods, a study examining the availability of salads in Lima shopping centers found that salads were less affordable than other dishes and were not available in two-thirds of surveyed franchises [70]. A study of poor Lima neighborhoods found little difference in physical access to fresh food between food-secure and -insecure households despite less perceived access, quality, and selection by the food-insecure group [71]. Consumer choices were also examined in relation to environmental sustainability. A modeling study showed that preferences for purchasing organic foods were influenced by consumer access to organic foods, higher education, and higher health awareness [75]. Another study modeled optimized consumer food choices to improve the sustainability of urban diets, showing that decreasing chicken, milk, egg, and beef consumption and increasing cereal and cheese consumption had the potential to reduce Lima’s annual per capita carbon footprint by a third. The carbon footprint of the average Peruvian diet could be reduced by a quarter through increased consumption of fruits, vegetables, cereals, and dairy; this reduction would also require decreases in meat consumption and, more drastically, in foods high in added sugar, such as a 50 percent reduction in soda consumption [76]. Frank Delventhal CC BY-NC 2.0 Jeffrey Riman CC BY-NC 2.0 12 Challenges to the sustainability of consumer choices include seafood fraud and mislabeling, which was common in urban retail/markets, including the use of threatened species [77]. A multi-country study of Brazil, Colombia, and Peru explored linkages between Amazonian bushmeat supply chains and urban areas. Bushmeat trade and consumption is banned, except for subsistence purposes in Indigenous communities. However, definitions of subsistence (defined under the international treaty as being local to the area of the hunted bushmeat) need to be expanded to protect the cultural dietary traditions of mobile urban Indigenous populations, who mostly obtain bushmeat through social networks rather than markets. Bushmeat markets primarily supply non-Indigenous customers and restaurants; traders are key actors who should be targeted to curb illegal and unsustainable bushmeat practices [78]. One evaluation of an urban FE intervention examined a policy to support urban food markets facing pandemic regulations, including social distancing, food safety, and other approaches to maintain market function. This policy gave funds to local officials to ensure compliance. The key findings of the study were that the governance structure of markets affected their compliance with rules, in that municipal markets followed safety measures better than privately owned markets, and that financing improvements to stalls was a challenge for vendors [79]. There is a need for educational interventions and marketing, particularly to low-income urban consumers, to promote demand and shape preferences toward healthy options, as well as to support local supply chains to improve the availability and affordability of nutritious—and sustainable—foods. In addition, the lack of studies aiming to understand the impacts of Peru’s stringent national regulations—or to simply track the application of these regulations—on SSBs, particularly in schools, represents a missed opportunity [81]. Eric Hunt CC BY-NC 2.0 In summary, ensuring access to nutritious diets in urban Peru requires a better understanding of urban food systems, FEs, and consumer demand. Geographically, few studies focused on urban settings other than Lima. Understanding the dynamics of secondary cities and the differences between Andean and Amazonian urban FEs is critical due to significant differences in food availability, dietary patterns, and preferences, among other factors. In addition, few urban FE studies examined vulnerable subgroups such as immigrants [80] or Indigenous populations. enoldent CC BY-NC 2.0 Frank_em_Main CC BY-NC 2.0 Endnotes 13 ABOUT THE AUTHORS Amy Margolies is a Research Fellow at the International Food Policy Research Institute. Kamara Pather was an independent consultant at the time this work was conducted. Jessica Huaman Vilca is a Nutritionist at the International Potato Center. Deanna Olney is the Unit Director, Nutrition, Diets and Health, at the International Food Policy Research Institute. [ᶦ] Overweight is defined as percentage of children under five years of age falling more than two standard deviations (moderate and severe) from the median weight-for-height of the reference population [82]. [ᶦᶦ] There is no global consensus on the definition of ‘peri-urban’ —much as there is a lack of a unifying definition for urban areas; some definitions focus on territorial characteristics, others on functional aspects or others [83]. [ᶦᶦᶦ] In this case, the definition of Andean Latin America includes the countries of Bolivia, Ecuador and Peru. [ᶦᵛ] Age-standardized prevalence rates utilize a method to compare disease (in this case, micronutrient deficiency) rates between populations while taking differences in age into account, as age is a risk factor for many conditions. Age standardization allows for these deficiencies to be compared between populations [84]. [ᵛ] Dietary iron deficiency and Vitamin A deficiency prevalence are reported as 10511 vs. 10368, and 6088 vs. 5905 per 100,000 respectively (2019). [ᵛᶦ] According to the Encuesta Permanente de Empleo Nacional (2023–2024), 66 percent of the urban Peruvian population works in the informal sector, including 82 percent of youth ages 14–24 [38]. [ᵛᶦᶦ] Caloric deficit (low energy intake) is determined by comparing the consumption of calories acquired through purchase, self-consumption, payment in kind, and transfer from public and private institutions with the caloric requirements of each individual person according to sex, age, and level of physical activity and at the household level. [ᵛᶦᶦᶦ] As a form of malnutrition, obesity is a risk factor for noncommunicable diseases. [ᶦˣ] Results-based budgeting focuses on delivery of services, rather than just on inputs, and can encourage coordination between service providers, technocrats, and government planners. In this case, it helped to secure and protect nutrition funding and make that spending more transparent to the public [35]. [ˣ] The prehypertension range is defined as being between 120- and 139-mm Hg (millimetres of mercury) for SBP and between 80- and 89-mm Hg for DBP, respectively. [ˣᶦ] Vaso de leche provides nutritional support that prioritizes children under six years of age and pregnant/lactating women, particularly vulnerable individuals with malnutrition and/or tuberculosis; Feeding & Nutrition Program for Tuberculosis Patients and Families provides nutritional counseling and monthly food baskets to tuberculosis patients, Wawa Wasi, which translates to “children’s home” in Quechua, was a program to provide early childhood development and care (ECD) for children under four, and was later incorporated into the larger-scale ECD program called Cuna Mas (established in 2012). Map (page 1): Urban Settlement Points: Peru. Center for International Earth Science Information Network (CIESIN), Columbia University, CUNY Institute for Demographic Research (CIDR), International Food Policy Research Institute (IFPRI), The World Bank, and Centro Internacional de Agricultura Tropical (CIAT). 2017. Global Rural-Urban Mapping Project, Version 1 (GRUMPv1): Settlement Points, Revision 01. Palisades, NY: NASA Socioeconomic Data and Applications Center (SEDAC). Accessed 2023. Luis Cordova CC BY-NC 2.0 We would like to acknowledge several rounds of thoughtful and detailed reviews from Marie Ruel (Senior Research Fellow, Nutrition, Diets and Health, IFPRI) and the excellent editing support of Claire Davis (Senior Editor, Communications and Public Affairs, IFPRI). https://cdn.www.gob.pe/uploads/document/file/5428875/4851203-presentacion-yauyos-4-programa-del-vaso-de-leche.pdf?v=1700146539#page=2.00 REFERENCES 14 [1] A. Marini, C. Rokx and P. 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