Philippines Amy Margolies,¹ Kamara Pather,² Rebecca Namara,² Mrignyani Sehgal,² Carleneth San Valentin³ and Deanna Olney¹ Urban nutrition profile ¹ International Food Policy Research Institute; ² Consultant; ³ The World Food Programme Key messages Stunting remains a persistent problem among rural and urban children under the age of five. Since 2015, overweight has been increasing and now affects more than 15 percent of urban schoolchildren and adolescents. Overweight and obesity have also continued to affect more than a third of urban adults since that time. The prevalence of overweight and obesity is increasing, more than 15 percent of urban schoolchildren and adolescents are affected as well as more than one-third of urban adults. Similarly, in rural areas the prevalence of overweight and obesity is 29 percent among adults. The Philippines is among the top five countries with the highest percentage of total deaths from noncommunicable diseases (NCDs) attributed to poor diets in South and Southeast Asia. The cost of a healthy diet in the Philippines increased from $3.38 to $4.10 per person per day from 2017 to 2022, with 48 percent of the population unable to afford a healthy diet. National and local government-level investments in urban nutrition, particularly in urban agriculture—show political will for improving urban nutrition, diets, and food environments. There is a need to bring together different sectors—such as health, education, and social protection—to develop and test interventions and programs to improve the quality of diets and tackle the multiple burdens of malnutrition in children, adolescents, and adults. Incorporating actions to prevent overweight and obesity into the National Plan of Action for Nutrition and developing programs and policies that include double-duty actions to address all forms of malnutrition would be beneficial. Summary Total population: 115.6 million Annual urban growth rate: 2% 12% of the urban population lives in Manila (National Capital Region) 36% of the urban population lives in informal settlements Poverty rate (2022): 12% urban, 26% rural Urban Child stunting is a persistent problem in the Philippines. While stunting prevalence is higher in rural than in urban areas, it still affects one in four children under the age of five in urban areas and coexists with rising overweight in school-age children, adolescents, and adults. Some urban nutrition interventions have focused on reducing diet-related noncommunicable disease (NCD) risks, but they have not addressed the challenges of the double burden of malnutrition (DBM) (e.g., the coexistence of problems of undernutrition and overnutrition) in school-age children and adolescents. Likewise, the lack of evidence on interventions in the urban food environment (FE) signals a need for studies to better understand the role of FEs in driving unhealthy dietary changes and the DBM and to test approaches to shift consumption patterns toward healthier diets and lifestyles. NCDs are the leading cause of mortality in the Philippines, and NCD risks are higher in urban areas than rural ones. National policies support nutrition with multisectoral approaches, particularly through urban farming and gardening to promote healthy and affordable urban diets. Yet the urban-specific programs must be evaluated. Evaluations of urban agricultural initiatives are needed to document any impact on diets and nutrition and to assess the potential for scale up, especially given land scarcity in dense urban areas. Additionally, multisectoral double-duty actions must be developed to address all forms of malnutrition [1]. http://ihmeuw.org/6pie http://ihmeuw.org/6pie https://www.fao.org/faostat/en/#data/CAHD?countries=38&elements=6120&items=7004&years=2022&output_type=table&file_type=csv&submit=true https://www.fao.org/faostat/en/#data/CAHD?countries=171&elements=6120&items=7004&years=2017,2022&output_type=table&file_type=csv&submit=true https://www.fao.org/faostat/en/#data/CAHD?countries=171&elements=6120&items=7005&years=2017,2022&output_type=table&file_type=csv&submit=true https://ourworldindata.org/grapher/share-of-urban-population-living-in-slums?tab=table&time=2018..latest&showSelectionOnlyInTable=1&country=~PHL https://data.worldbank.org/indicator/SP.POP.TOTL?locations=PH https://psa.gov.ph/statistics/poverty/node/1684041626 https://data.worldbank.org/indicator/SP.URB.TOTL.IN.ZS?locations=PH Nutrition and diets Undernutrition 2 Stunting still affects one-quarter of urban children under five in the Philippines, with little change since 2013. This is higher than in the rest of East Asia and the Pacific region, where 14 percent of children under five are stunted [2]. Comparing with other countries in the region with recent DHS data for rural and urban areas, both Cambodia and Myanmar saw stunting decline. In Cambodia stunting fell from 32 percent to 22 percent between 2014 and 2022, both in urban and rural areas (from 24 percent to 17 percent in urban areas, and from 34 percent to 25 percent in rural areas) [3, 4]. Overweight among children under five is lower than the regional average of 8 percent [2]. Child overweight was relatively constant in the Philippines (from 3 percent to 2.7 percent in rural areas, and from 5 percent to 4.5 percent in urban areas from (2013–2019)) and in Myanmar (2.3 to 2.4 percent in urban areas, with a small decline from 1.7 to 1.3 percent in rural areas from 2008–2016), while it increased slightly in Cambodia (from 3 percent to 6 percent in urban areas, and from 1.4 percent to 3 percent in rural areas from 2015–2022) [3, 6, 7]. In 2022, half of urban Filipino children consumed diverse diets, compared to 60 percent of urban Cambodian children [3, 8]. However, overweight prevalence in the Philippines has steadily increased in both rural and urban school-age children and adolescents. Stunting affects one in three rural children and one in four urban children under the age of five in the Philippines, without much improvement since 2013 (Figure 1). Figure 1: Child* nutrition status in the Philippines, 2013–2019 Source: ENNS [6, 9, 7, 10]. Note: *Among children under the age of five. ENNS = Expanded National Nutrition Survey. The 2021 ENNS results available did not present under-five stunting by residence. The proportion of stunted children in the poorest urban quintile parallels the poorest rural quintile (42 percent urban, 45 percent rural) (not shown in Figure 1) [9]. Similarly, wasting prevalence has not meaningfully changed since 2013: it declined from 8 percent to 6 percent, with no significant differences in prevalence between urban and rural areas [9, 6]. Since 2015, underweight has declined in school-age children, falling from 36 percent to 22 percent in rural areas, and from 26 percent to 17 percent in urban areas [7]. However, there has been little improvement among children under five, for whom prevalence has held at 22 percent in rural areas and 17 percent in urban areas. Overnutrition The prevalence of overweight has increased nationwide. Overweight is slightly more prevalent in urban areas and among certain age groups. Overall, 30 percent of adults were overweight in 2021 (32 percent urban, 29 percent rural) [7]. Among urban women, 38 percent were overweight compared to 34 percent of rural women [7]. In Myanmar, stunting fell from 40 percent in 2000 to 29 percent in 2016 (43 to 32 percent in rural areas and 32 to 20 percent in urban areas) [2, 5]. Diets 3 Figure 2: Child and adolescent* overweight in the Philippines, 2015–2021 Source: ENNS [7, 9, 10]. Note: *Among children 5–10 years old and adolescents 10–19 years old. Childhood overweight is a concern among school-aged children (17 percent urban, 12 percent rural) and adolescents (16 percent urban, 12 percent rural) (Figure 2). Adolescents are insufficiently active in both urban (74 percent) and rural areas (68 percent) [7]. However, adolescent overweight is associated with urban living and with wealth [11]. In the elderly, overweight (29 percent urban, 23 percent rural) and inactivity (51 percent urban, 45 percent rural) are also prevailing issues [7]. Nationally representative data shows that infant and young child feeding (IYCF) practices are mostly similar among urban and rural children. Infants (0-5.9 months old) in rural areas were more likely to be exclusively breastfed than those in urban areas (60 percent vs. 52 percent) [9]. A slightly higher proportion of urban children were fed the recommended five or more nutritious food groups (49 percent urban vs. 45 percent rural) and received the minimum meal frequency requirement[ᶦ] (77 percent urban vs. 71 percent rural) [8]. However, consumption of commercially produced complementary foods (CPCF)—60 percent of which are ultra-processed foods (UPFs)—are increasing in older urban infants (<3 years old) and young children [12]. UPFs are unhealthy, inexpensive, highly palatable, and convenient manufactured food products that may displace nutritious whole foods and are associated with increased risk of adverse health outcomes [13]. Only 37 percent of CPCF sampled in the National Capital Region met nutrient composition thresholds and 59 percent had total sugar content meriting high sugar warnings [14]. Consumption of vitamin A (~80%) and iron–rich foods (~60%) in the past 24 hours was quite high and did not differ between urban and rural areas (Figure 3)[ᶦᶦ][8]. Vitamin A deficiency among children (6 months–5 years) is also similar between rural (17 percent) and urban areas (14 percent) [9]. Figure 3: Infant and young child* feeding practices in the Philippines, 2022 Source: DHS [8]. Note: *Among all children ages 6 months to 23 months of age. Data measure consumption over the last 24 hours. DHS = Demographic and Health Survey. Diet-related noncommunicable diseases 4 Unhealthy diets are becoming more common in the Philippines alongside increasing availability, affordability, and accessibility of unhealthy foods. Since 2007 there has been a dramatic 32 percent increase in per capita UPF sales [15]. This increase is spurred by the rapid expansion of modern convenience stores (+669 percent), hypermarkets (+913 percent), and supermarkets (+106 percent) and 62 percent of UPF sales occur in these modern outlets [15]. More than one-third of young urban and rural children were fed sugar- sweetened beverages (SSBs) [ᶦᶦᶦ] in the past day, 24 percent of urban children were not fed any fruits or vegetables (vs. 30 percent of rural children), and 47 percent were fed unhealthy foods [ᶦᵛ] (vs. 44 percent of rural children) [8]. Adolescents with pocket money frequent modern food retail outlets and are exposed to unhealthy UPFs [16], which they value for reasons such as media visibility, taste, convenience, low cost and popularity [17]. An online survey found mean SSB intake by urban adolescents (13–19 years) was 13 drinks weekly. Adolescents reported eating meals from street vendors twice weekly and from vending machines, fast food joints, or food stands more than twice weekly. Also, 44 percent of these teenagers ate vegetables less than twice in the past day (either did not eat vegetables or ate vegetables only once) [17]. Seventy percent of adolescents had easy access to ready-to-eat street foods, SSBs, desserts, and fast foods inside or near schools in addition to delivery apps, on which fast foods are two-thirds of adolescent purchases [10]. National mean SSB intake [ᵛ] is high in both urban and rural youth (3–19 years) (6 servings/week), with little change from 1990–2018 [18]. There are unhealthy dietary patterns in women, particularly in urban areas, similarly influenced by the increasing availability of unhealthy foods [19]. Among urban women, 41 percent ate fried or salty foods in the past day (vs. 35 percent of rural women), and 55 percent drank sodas, malt drinks, sport drinks or energy drinks (vs. 48 percent of rural women) [8]. Yet a nationally representative survey found no differences in diet diversity between rural and urban women (80 percent achieved minimum dietary diversity [ᵛᶦ]). Urban residents also consume significantly more processed meats than rural residents (46 percent urban, 31 percent rural) [20]. Urbanicity, wealth, and proximity to a market were associated with UPF consumption in adolescents in Cebu [21]. In access to healthy foods, nationally, 34 percent of urban households have gardens, a third have fruit trees, and a third raise small livestock [9]. However, a study found that the diets of poor children in both urban and rural areas were nutritionally inadequate; for the former, preferences limited consumption of available healthy foods (e.g., dislike of vegetables), while for the latter, diets were negatively affected by poverty and geographic barriers to accessing healthy foods [22]. This highlights the need to address both supply and consumer demand for nutritious foods. There is a lack of regular national-level data collection on populations of informal settlements. A FAO-UNICEF-WFP survey of Asian informal settlements found only 16 percent of women in Quezon City achieved minimum dietary diversity [23], well below the average of 80 percent for all urban women [24]. It must be noted, however, that the former survey was conducted in 2020. Thus, women’s low dietary diversity could have been, at least to a some extent, related to the pandemic. The Philippines has among the highest percentage of total deaths from noncommunicable diseases (NCDs) attributed to poor diets in South and Southeast Asia. Diet-related NCD risk scores are significantly higher in urban (16 percentage points) than rural areas [20]. UPF consumption is now common [25][ᵛᶦᶦ], especially in urban areas [20], and is accompanied by sedentary lifestyles that contribute to NCD risks [7]. A cohort study found higher prevalence of overweight, obesity, hypertension, and prediabetes in urban areas than rural ones [26]. Hypertension is a risk factor for NCDs such as heart disease and contributes to mortality. Hypertension is slightly more prevalent in urban than rural adults [9]. Prevalence is high among older adults (≥60 years) and slightly more so in urban residents (73 percent) than rural ones (67 percent) [27]. Overall, adult diabetes prevalence decreased (10 percent to 7 percent) since 2011. Yet risk factors like high fasting blood glucose are slightly more common in urban than rural adults (17 percent, 12 percent), but are more similar among the elderly (8 percent urban, 6 percent rural) [9]. http://ihmeuw.org/6pie http://ihmeuw.org/6pie http://ihmeuw.org/6pie https://diabetesatlas.org/data/en/country/157/ph.html Urban nutrition interventions 5 Promoting nutrition is a priority under the Philippine Development Plan 2023–2028. As the key body responsible for nutrition policy, the National Nutrition Council develops programs and supports data collection. The Plan of Action for Nutrition (2023–2028) aims to improve food security and nutrition and highlights the urban poor. A strategic plan to address overweight and obesity is under development but is not yet publicly available. The National Objectives for Health (2023–2028) outline the importance of addressing determinants of health and improving healthy behaviors, including through sustainable and resilient food systems. The objectives also highlight low physical activity and undernutrition and obesity in urban and rural areas but do not have urban- specific actions. The government has national mandatory restrictions on marketing “red food” (defined by nutrient limits like saturated fats and sugar, and categorical restrictions for caffeine, etc.) and competitive food sales in canteens in primary and secondary schools. Regional and division monitors track compliance with these policies [28]. There should be a nutrition policy covering all forms of malnutrition, with joint approaches (programs and policies) addressing all forms of malnutrition and preventing harm (e.g., double-duty actions and policies). The government’s agricultural agencies support urban agriculture to improve household food security and resilience, such as Pagkain para sa Masa (Food for the People), wherein local governmental units (LGUs) promote urban community and school gardens. The Buhay sa Gulay (Joy of Farming) project is supported by the Department of Agrarian Reform in partnership with LGUs: in Quezon City (QC), urban lots are planted to diversify the diets of the urban poor and generate income. QC’s other food security initiatives include a law exempting landowners from idle land taxes if the land is used for urban agriculture. There is limited published evidence on nutrition-related interventions in urban areas of the Philippines from 2010 to 2022 (Table 1), and of these, most are limited in duration and/or have small sample sizes [29, 30, 31]. They address issues related to both undernutrition and overnutrition as well as NCD risks. An intervention targeting stunted and underweight schoolchildren showed that milk and milk substitutes had positive impacts on reducing underweight and on improving weight-for-age and height-for-age z-scores (HAZ) [32]. Two trials assessed health and nutrition education impacts. The first focused on hypertension and provided education on cardiovascular diseases, diet, and exercise. The study found positive impacts on several risk factors including systolic blood pressure, body mass index (BMI), waist circumference and cholesterol [29]. Another study showed that water, sanitation, and hygiene education of varying intensity had no impact on schoolchildren's mean BMI-for-age z-scores or HAZ scores, but the odds of stunting were reduced with low- intensity health education (LIHE), and overnutrition was reduced with LIHE and high-intensity health education [31]. Three evaluations had less rigorous designs: one showed suggestive evidence that health system interventions for diabetes management with nutrition education were associated with positive effects on program adherence and improved glycemic control [33]. Another targeted the elderly to increase body weight, finding that BMI increased with a common savory food flavor enhancer (monosodium glutamate as compared to iodized salt) [30]. Lastly, a study examined associations between nutritional status and participation in the national conditional cash transfer program called Pantawid Pamilyang Pilipino Program: the study showed that participating children in urban areas had higher odds of stunting and overweight than rural partipants [34]. National urban nutrition plans, policies, and programs The National Urban and Peri-Urban Agriculture Program promotes urban food production and supports LGUs through materials, inputs, training, and funding for projects such as community gardens. Halina’t Magtanim ng Prutas at Gulay, Kadiwa’y Yayaman (Plants for a Bountiful Barangay Movement) is an urban gardening program to support food sufficiency and address high food prices through fruit and vegetable production in backyards and vacant lots, and to increase food security and diversify diets through community gardens. Other efforts to improve the diets of the urban poor include a pilot food e-voucher program (Walang Gutom, “No Hunger”) to aid nutritionally vulnerable groups in buying nutritious food, which is to be scaled to 1 million people. Finally, the Kadiwa ng Pangulo program facilitates food purchases in urban areas through a direct farm-to-consumer supply chain to address high food costs and improve food access. https://pdp.neda.gov.ph/philippine-development-plan-2023-2028/ https://doh.gov.ph/uhc/national-objectives/ https://uclg-aspac.org/quezon-food-and-nutrition-security-initiatives/ https://car.dswd.gov.ph/programs-services/core-programs/pantawid-pamilyang-pilipino-program-4ps/ Randomized controlled trial Population Intervention Results Yes [32] Underweight and stunted schoolchildren (6–8 years)[ᵛᶦᶦᶦ] Testing milk substitutes to address child undernutrition through 200 mL milk given at school: (1) coconut skim milk (CocoM), (2) coco-dairy blend (CDMB), (3) cow milk (CM) (control) (3 months). CocoM, CDMB, and CM all significantly increased mean WAZ and HAZ; underweight prevalence dropped in all three groups; but stunting prevalence decreased only in CocoM group. Yes [29] Adult men and women (pre- hypertensive and Stage 1 hypertensive) Monthly lifestyle education: (1) Education on CVD, diet, and exercise; (2) control: non-CVD-focused lectures, nutritionadvice (6 months). Intervention significantly decreased BMI, systolic blood pressure, waist circumference, total cholesterol compared to control; no change in fasting glucose. Yes [31] Schoolchildren WASH health education in varying intensities: (1) Low (LIHE), (2) Medium (MIHE), (3) High (HIHE), compared to (4)control (CG); all groups received some nutrition education (9 months). No impacts on undernutrition prevalence, BAZ, or HAZ scores in treatment groups. Odds of stunting significantly lower in LIHE compared to CG; LIHE and HIHE reduced odds of overnutrition. No [33] Adults (>20 years) with diabetes Multicomponent health system intervention for diabetes management including nutrition education, compared to control. Treatment group had greater adherence to diabetes testing and nutrition consultation, lower mean blood sugar and improved glycemic control; no difference from control for other CVD risk factors. No [30] Elderly in nursing homes Provision of flavor enhancers: (1) 0.5 MSG or (2) iodized salt twice a day (2 months). BMI and body weight increased with MSG, not with salt. In both groups, increases in systolic blood pressure occurred. No [34] Children and adolescents (3–19 years) Pantawid Pamilyang Pilipino Program conditional cash transfer; conditions include health/nutrition visits. Beneficiaries had higher odds of stunting and overweight than non-participants, but no association with concurrent stunting/overweight; participants in rural areas had lower odds of stunting than those in urban areas; and urban children had a four times higher likelihood of overweight. Qualitative findings show challenges of obesogenic urban school environments. 6 Table 1: Nutrition interventions in the urban Philippines, 2010–2022 Note: BAZ = BMI-for-age z-score; BMI = body mass index; CDMB = coco-dairy blend; IG = intervention group; CG = control group; CM = cow’s milk; CocoM = coconut skim milk; CVD = cardiovascular disease; HAZ = height- for-age; HIHE = high-intensity health education; LIHE = low-intensity health education; MIHE = medium-intensity health education; mL = milliliters; MSG = monosodium glutamate; WAZ = weight-for-age. Considering the growing challenge of the double burden of malnutrition (DBM), or the coexistence of under- and overnutrition within individuals, households, and populations [35], evidence is needed on interventions addressing multiple forms of malnutrition simultaneously (e.g., double-duty interventions [ᶦˣ]). 7 Urban food environments Filipino urban food environments (FE) are characterized by the rapid growth of modern supermarkets, informal neighborhood retail stores (sari sari) [ˣ], traditional wet markets, and street vendors. Studies on urban FEs (n=18) are descriptive (n=11), observational/inferential (n=5), or modeled (n=2). Nine studies each explored formal and informal FEs, two investigated cultivated FE [ˣᶦ], and one examined institutional FEs (schools). Studies used primarily quantitative methods (n=13), followed by mixed-methods (n=3) and qualitative methods (n=2). Vendor/product properties was the most studied FE dimension, while desirability was the most studied individual factor related to the FE (Figure 4). Figure 4: Studies of urban food environments in the Philippines, 2000–2023 Source: Authors. Note: This figure summarizes the results of a systematic scoping review of the urban FE literature in the Philippines. Papers were categorized under multiple dimensions as appropriate. From these studies, three themes emerged: food safety in informal markets, obesogenic FE, and the promotion of diverse, sustainable diets. Several studies examined the challenges of informal urban markets, such as (1) informal vendor knowledge and practices, finding inconsistent vendor adherence to national food safety guidelines [36], and insufficient vendor knowledge and hygiene [37]; (2) safety issues in animal-source foods, including salmonella in meat [38], microplastics in fish [39], and banned antibiotics in chicken [40]; and (3) fresh produce contamination [41]. Studies on obesogenic FEs and unhealthy diets focused on the role of food preferences and the influences of marketing. Research documented a high density of unhealthy food advertising near schools (85 percent of advertisements), with soft drinks advertised the most [42]. Another study noted frequent consumption of fast food by young adults who had a limited understanding of its negative health impacts [43]. Consuming fast food, eating out, and using food delivery was also reported as becoming popular among the urban middle class [44]. Urban residents showed preferences for spicy and salty foods [45], with food quality, safety, and the dining atmosphere in fast food chains influencing customer preferences [46]. The evidence on urban FEs focuses on food safety, obesogenic and unhealthy FEs, and sustainable and diverse diets. Nutrition education and behavior change communication can support urban home and community gardening, improve diets, and encourage sustainable and healthy purchasing behaviors. Mothers can also encourage healthy dietary patterns for their children. Schools can also contribute by countering nutritional misinformation and fostering healthy eating habits. Regulating advertising near schools can also help reduce children’s exposure to unhealthy food marketing. Finally, ensuring that food is safe—in addition to healthy—is key. Food safety training for vendors, implementation of market-level hygiene practices, safety monitoring in informal markets, and greater regulation and screening could assist to this end. There were no evaluations found of urban FE interventions or evaluations of interventions reporting disaggregated results in urban areas. Further research is needed on ways to address diet and nutrition challenges, including tackling the DBM in urban areas, as well as research on how to strengthen food system resilience considering climate shocks. Research highlighted areas of concern such as food safety in informal FEs, but there is no published evidence on interventions to address these issues. The rollout of governmental urban nutrition and FE programs presents an opportunity for testing and evaluating innovations. Other papers investigated FE factors that influenced diverse, safe, and sustainable diets through (1) urban agriculture as a strategy to diversify diets and (2) the role of seafood as part of a diverse diet. Home gardening was associated with increased dietary diversity of preschool children and greater vegetable consumption [47]. COVID-19 lockdowns affected food preferences, with households using urban backyard gardening as a coping strategy [48]. One study itemized produce available in Manila [49], while another found a third of vegetable demand in the city could be met by farming in vacant lots [50]. Urban consumers were more interested in seafood sustainability than rural ones, but both rural and urban consumers valued safety [51]. Retail approaches to mix vegetables with fish (canned tuna with vegetables) was considered an acceptable approach to improve diets and decrease pressure on fisheries [52]. Child nutritional status was shown to be affected by child preferences (desirability of healthy foods) and parental control of food intake rather than by the availability of nutritious foods or household income, yet many children do not achieve country-specific recommended daily allowances for energy, protein, vitamins A and C [53]. Endnotes 9 ABOUT THE AUTHORS Amy Margolies is a Research Fellow at the International Food Policy Research Institute. Kamara Pather, Mrignyani Sehgal and Rebecca Namara were independent consultants at the time this work was conducted. Carleneth San Valentin was a Nutrition Programme Policy Officer at the World Food Programme at the time this work was conducted. Deanna Olney is the Unit Director, Nutrition, Diets and Health, at the International Food Policy Research Institute. [ᶦ]Minimum meal frequency is the minimum recommended number of feedings daily for age and breastfeeding status. [ᶦᶦ] Examples of vitamin A–rich foods commonly consumed in the Philippines include squash, orange camote, mango, moringa leaves, and water spinach. Iron-rich foods include meat (especially pork), eggs, and fish and seafood. [ᶦᶦᶦ] Sweet beverages include sweet/flavored milk/yogurt drinks, fruit juice, sweetened condensed milk, bubble tea, sodas, sago at gulaman, sports drinks, and sweetened tea/coffee, among others. [7]. [ᶦᵛ] Unhealthy foods include sentinel food types high in sugar, salt, and unhealthy fats commonly consumed by infants and young children such as sweet foods (cookies, sweet breads, ensaymada, kakanin, candy, and halo-halo, among others) and fried/salty foods (chips, chichacorn, cornick, fish balls, kropek, and instant noodles, among others) [7]. [ᵛ] Mean intakes in 248 gram servings a week of SSBs, which are defined as any beverage with added sugars and 50 kilocalories per 237 gram serving, such as commercial and homemade beverages, soft drinks, energy drinks, fruit drinks, punch, lemonade, and aguas frescas, but exclude 100 percent fruit and vegetable juice, non-caloric artificially sweetened beverages, and sweetened milk [18]. [ᵛᶦ] Minimum dietary diversity for women (MDD-W) is an indicator created as a proxy for dietary micronutrient adequacy in women of reproductive age (15–49 years) that determines if they have consumed a minimum of five out of ten predefined food groups in the past day (24 hours). [ᵛᶦᶦ] A recent cohort study found the daily average consumption of UPFs in the Philippines to be 2.3 servings, mainly dominated by sweets [55]. [ᵛᶦᶦᶦ] Baseline prevalence of underweight: (1) CocoM (68 percent), (2) CDMB (70 percent), and (3) CM 79 percent; baseline stunting prevalence: (1) 83 percent, (2) 78 percent, and (3) 76 percent. [ᶦˣ] Double-duty actions are interventions, programs, or policies that simultaneously prevent or reduce the risk of both nutritional deficiencies leading to underweight, wasting, stunting, and micronutrient deficiencies and problems of overweight, obesity, and diet-related NCDs. [ˣ] Sari sari stores are small neighborhood shops (sundry or convenience stores) that provide basic items such as coffee, soda, canned goods, instant noodles, candy, chips, and beer and allow for items to be purchased in small quantities or units. “Sari sari” is a Tagalog word meaning “variety” or “sundry.” [ˣᶦ] The cultivated FE includes natural FEs where consumers procure foods from home gardens, agricultural systems, orchards, fields, and pastures [54]. Map (page 1): Urban Settlement Points: Philippines. 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. 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). REFERENCES 10 [1] C. Hawkes, M. Ruel, L. Salm, B. Sinclair and F. Branca, "Double-duty actions: seizing program and policy opportunities to address malnutrition in all its forms," Lancet, vol. 395, no. 10218, pp. 142-155, 2019. [2] UNICEF, WHO, World Bank Group, "Joint Child Malnutrition Estimates: key findings from the 2023 edition," UNICEF, New York, New York, 2023. [3] National Institute of Statistics, Ministry of Health and ICF, "Cambodia Demographic and Health Survey 2021–22," MOH and ICF, Phnom Penh, Cambodia, and Rockville, MD, 2023. [4] National Institute of Statistics, "Cambodia Demographic and Health Survey 2014," National Institute of Statistics, Directorate General for Health, and ICF International, Phnom Penh, Cambodia, and Rockville, Maryland, 2015. [5] Ministry of Health and Sports (MoHS) and ICF, "Myanmar Demographic and Health Survey 2015-16," Ministry of Health and Sports and ICF, Nay Pyi Taw, Myanmar, and Rockville, Maryland, 2017. [6] FNRI-DOST, "Expanded national nutrition survey (ENNS)," Food and Nutrition Research Institute of the Department of Science and Technology, Taguig City, Philippines, 2013. [7] FNRI-DOST, "Expanded national nutrition survey (ENNS) 2021," Food and Nutrition Research Institute of the Department of Science and Technology, Makati City, Philippines, 2022. [8] Philippine Statistics Authority; ICF International, "2022 Philippine national demographic and health survey," PSA and ICF, Quezon City, Philippines and Rockville, MD, 2023. [9] FNRI-DOST, "Expanded national nutrition survey (ENNS) 2018-19," Food and Nutrition Research Institute of the Department of Science and Technology, Taguig City, Philippines, 2022. [10] FNRI-DOST, "Expanded national nutrition survey (ENNS): nutrition facts and figures 2015," Food and Nutrition Research Institute of the Department of Science and Technology, Manila, Philippines, 2016. [11] J. Platon-Desnacido, M. Dasco, A. Ducay, C. Duante and I. Angeles-Agdeppa, "Determinants of overweight/obesity among Filipino adolescents: 2018 expanded national nutrition survey," Philippine Journal of Science, vol. 151, no. 4, pp. 1463-1476, 2022. [12] A. Pries, E. Bassetti, J. Badham, P. Baker, J. Blankenship, E. Dunford and R. Kupka, "Ultraprocessing and presence of additives in commercially produced complementary foods in seven Southeast Asian countries: a cross-sectional study," The American Journal of Clinical Nutrition, vol. 120, no. 2, pp. 310-319, 2024. [13] G. Pagliai, M. Dinu, M. Madarena, M. Bonaccio, L. Iacoviello and F. Sofi, "Consumption of ultra-processed foods and health status: a systematic review and meta-analysis," British Journal of Nutrition, vol. 125, no. 3, pp. 308-318, 2021. [14] E. Bassetti, E. Zehner , S. Mayhew, N. Nasser, A. Mulder, J. Badham, L. Sweet, R. Crossley and A. Pries, "Nutrient profiles of commercially produced complementary foods available in Cambodia, Indonesia and the Philippines," Public Health Nutrition, vol. 25, no. 10, pp. 2720-2730, 2022. [15] Deakin University and UNICEF, "Mapping analysis of the food retail market in the Philippines," Deakin University and UNICEF, Manila, 2023. [16] UNICEF and Deakin University, "Healthier food retail environments for children: food retail trends in the Philippines, options for actions," UNICEF Philippines, Manila, Philippines, 2023. [17] Deakin University and UNICEF, "Investigating adolescent's food-related behaviors - survey findings from three countries in East Asia, 2022," Deakin University and UNICEF, Bangkok, Thailand, 2023. [18] L. Lara-Castor, R. Micha, F. Cudhea, et al., "Intake of sugar sweetened beverages among children and adolescents in 185 countries between 1990 and 2018: population based study," British Medical Journal, vol. 386, p. e079234, 2024. [19] N. Lipoeto, K. Lin and I. Angeles-Agdeppa, "Food consumption patterns and nutrition transition in South-East Asia," Public Health Nutrition, vol. 16, no. 9, pp. 1637-1643, 2013. [20] T. Beal, A. Herforth, G. Kennedy, et al., "Measuring what the world eats: insights from a new approach," Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland and Boston, MA, 2022. [21] K. Busse, N. Mayol, A. Ammerman, C. Avery, S. Martin and L. Adair, "Ultra-processed food intake during the transition to adulthood varies according to sociodemographic characteristics and maternal intake in Cebu, Philippines," The Journal of Nutrition, vol. 154, no. 7, pp. 2273-2283, 2024. [22] V. S. Van, Z. Sales, N. Gordoncillo, et al., "Multilevel pathways of rural and urban poverty as determinants of childhood undernutrition in the Philippines," Journal of Poverty, vol. 28, no. 1, pp. 1-21, 2024. [23] C. Auma, R. Pradeilles, H. Ohly, et al., "Urban nutrition situation in the slums of three cities in Asia during the COVID- 19 pandemic," Maternal and Child Nutrition, p. e13543, 2023. 11 [24] Global Diet Quality Project, "Diet Quality Questionnaire for the Philippines," Harvard and GAIN, Boston, MA, 2021. [25] M. Lane, E. Gamage, S. Du, D. Ashtree and A. McGuinness, "Ultra-processed food exposure and adverse health outcomes: umbrella review of epidemiological meta-analyses," British Medical Journal, vol. 384, p. e077310, 2024. [26] F. Punzalan, R. Sy, O. Sison and N. Castillo-Carandang, "Prevalence of cardiovascular risk factors in relation to socio-demographic profile of the life course study in cardiovascular disease epidemiology study (LIFECARE) Philippine cohort," Acta Medica Philippina, vol. 48, no. 2, pp. 62-69, 2014. [27] G. Cruz, C. Cruz and Y. Saito, "Longitudinal study of aging and health in the Philippines, baseline data," Economic Research Institute for ASEAN and East Asia and Demographic Research and Development Foundation, Jakarta, Indonesia and Manila, Philippines, 2019. [28] M. Perry, K. Mardin, G. Chamberlin, E. Busey, L. Taillie, F. Carpentier and B. Popkin, "National policies to limit food marketing and competitive food sales in schools: a global scoping review," Advances in Nutrition, vol. 15, no. 8, p. 100254, 2024. [29] J. Gabiola, D. Morales, O. Quizon, R. Cadiz and K. Feliciano, "The effectiveness of lifestyle with diet and physical activity education program among prehypertensives and stage 1 hypertensives in an urban community setting (ENLIGHTEN) study," Journal of Community Health, vol. 45, no. 2020, pp. 478-487, 2019. [30] E. Bautista, C. Tanchoco, M. Tajan and E. Magtibay, "Effect of flavor enhancers on the nutritional status of older persons," The Journal of Nutrition, Health and Aging, vol. 17, pp. 390-392, 2013. [31] S. Sangalang, A. Lemence, Z. Ottong, J. Valencia and M. Olaguera, "School water, sanitation, and hygiene (WASH) intervention to improve malnutrition, dehydration, health literacy and handwashing: a cluster-randomized controlled trial in Metro Manila, Philippines," BMC Public Health, vol. 22, no. 1, p. 2034, 2022. [32] I. Agdeppa and J. Zamora, "The effects of coconut skim milk and coco-dairy milk blend on the nutritional status of children," Journal of Nutrition and Metabolism, vol. 1, p. 6793866, 2022. [33] S. Pilleron, E. Pasquier, I. Boyoze-Nolasco, J. Villafuerte, D. Olchini and A. Fontbonne, "Participative decentralization of diabetes care in Davao City (Philippines) according to the Chronic Care Model: a program evaluation," Diabetes Research and Clinical Practice, vol. 104, no. 1, pp. 189-195, 2014. [34] D. Herrera, M. Herrera, D. Amora, S. Bas, C. Miranda and G. Van Hal, "Mixed-method study on the association between inclusion to conditional cash transfer program and the multiple faces of malnutrition in children and adolescents aged 3 to 19 years: a school-based evidence from Caraga Region, the Philippines," BMC Pediatrics, vol. 23, no. 1, p. 630, 2023. [35] B. Popkin, C. Corvalan and L. Grummer-Strawn, "Dynamics of the double burden of malnutrition and the changing nutrition reality," Lancet, vol. 395, no. 10217, pp. 65-74, 2020. [36] C. Castillo, "Compliance to food safety standards of ambulant vendors in two cities of Nueva Ecija, Philippines," Asia- Pacific Journal of Innovation in Hospitality and Tourism, vol. 8, no. 2, pp. 1-24, 2019. [37] V. Obsioma, K. Guiral, K. Matullano, A. Lorilla, J. L. Tagubase, K. Calumba, J. Sarmiento and P. Alviola, "Linking socio-demographics of meat vendor-processors to residual nitrate in skinless native sausage sold in a typical market in the Philippines," Philippine Journal of Science, vol. 149, no. 4, pp. 1141-1149, 2020. [38] P. Santos, K. Widmer and W. Rivera, "PCR-based detection and serovar identification of salmonella in retail meat collected from wet markets in metro Manila, Philippines," PLoS One, vol. 15, no. 9, p. e0239457, 2020. [39] B. Abinon, B. Camporedondo, E. Mercadal, K. Olegario, E. Palapar, C. Ypil, A. Tambuli, C. Lomboy and J. Garces, "Abundance and characteristics of microplastics in commercially sold fishes from Cebu Island, Philippines," International Journal of Aquatic Biology, vol. 8, no. 6, pp. 424-433, 2020. [40] K. Develos, "Chloramphenicol residues in retailed chicken in Davao City public markets," Advances in Animal Veterinary Science, vol. 7, no. 2, pp. 88-91, 2019. [41] K. Vizon, Z. Battad and D. Castillo, "Contamination of food-borne parasites from green-leafy vegetables sold in public markets of San Jose City, Nueva Ecija, Philippines," Journal of Parasitic Diseases, vol. 43, no. 2019, pp. 651-657, 2019. [42] B. Kelly, L. King, B. Jamiyan, N. Chimedtseren, B. Bold, V. Medina, S. De los Reyes, N. Marquez, A. Rome, A. Cabanes and J. Go, "Density of outdoor food and beverage advertising around schools in Ulaanbaatar (Mongolia) and Manila (The Philippines) and implications for policy," Critical Public Health, vol. 25, no. 3, pp. 280-290, 2015. [43] T. Matejowsky, "Gender, fast food, and nutritional perspectives in contemporary Philippines," Asia-Pacific Social Science Review, vol. 10, no. 1, p. 1, 2010. [44] M. Sahakian, C. Saloma and S. Ganguly, "Exploring the role of taste in middle-class household practices: implications for sustainable food consumption in metro Manila and Bangalore," Asian Journal of Social Science, vol. 46, no. 3, pp. 304- 329, 2018. 12 INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE A world free of hunger and malnutrition IFPRI is a CGIAR Research Center 1201 Eye Street, NW, Washington, DC 20005 USA | T. +1-202-862-5600 | F. +1-202-862-5606 | Email: ifpri@cgiar.org | www.ifpri.org | www.ifpri.info © 2024 International Food Policy Research Institute (IFPRI). This publication is licensed for use under a Creative Commons Attribution 4.0 International License (CC BY 4.0). To view this license, visit https://creativecommons.org/licenses/by/4.0. This is publication has not been peer reviewed. Any opinions stated herein are those of the author(s) and not necessarily representative of or endorsed by CGIAR or IFPRI. This work is part of the CGIAR Research Initiative on Resilient Cities. We would like to thank all funders who supported this research through their contributions to the CGIAR Trust Fund: https://www.cgiar.org/funders/. [45] N. Castillo-Carandang, O. Sison, F. Velandria, R. Sy, E. Llanes and P. Reganit, "You are what you eat: self-reported preferences for food taste and cooking methods of adult Filipinos (20-50 years old)," Acta Medica Philippina, vol. 48, no. 2, pp. 56-61, 2014. [46] K. Alada and M. Castano, "The effects of restaurant attributes on customers' emotions and loyalty," African Journal of Hospitality, Tourism and Leisure, pp. 1-10. [47] A. Cabalda, P. Rayco-Solon, J. Solon and F. Solon, "Home gardening is associated with Filipino preschool children's dietary diversity," Journal of the American Dietetic Association, vol. 111, no. 5, pp. 711-715, 2011. [48] J. Villanueva, J. Austria, K. Faronilo, A. Sunga-Lim, E. Replan, J. Sevilla-Nastor, R. Abuyan and N. Peyraube, "Effect of lockdown on food security during the COVID-19 Pandemic in the Philippines: two months after implementation," Philippine Journal of Science, vol. 151, no. 4, pp. 1419-1430, 2022. [49] I. Madaleno, "Food and medicinal plants consumed in Manila, the Philippines," WIT Transactions on the Built Environment, vol. 170, pp. 203-210, 2017. [50] Y. Hara, A. Murakami, K. Tsuchiya, A. Palijon and M. Yokohari, "A quantitative assessment of vegetable farming on vacant lots in an urban fringe area of Metro Manila: can it sustain long-term local vegetable demand?," Applied Geography, vol. 41, pp. 195-206, 2013. [51] M. Castro, I. Pabuayon , S. Catelo and J. Camacho Jr, "Analyzing consumer preferences for credence attributes of fish and fishery products in Davao City, Philippines," Asian Journal of Agriculture and Development, vol. 18, no. 1, pp. 84- 103, 2021. [52] M. Castro, J. Sarmiento and L. Digal, "Demand elasticities of canned tuna at point of sale of a large retail chain in Southern Philipines: implications for sustainability policy," Philippine Journal of Science, vol. 150, no. 4, pp. 657-668, 2021. [53] N. Blijham, L. De Kan and A. Niehof, "Determinants and adequacy of food consumption of children in La Trinidad, the Philippines," International Journal of Consumer Studies, vol. 31, no. 3, pp. 195-203, 2007. [54] S. Downs, S. Ahmed, J. Fanzo and A. Herforth, "Food environment typology: advancing a expanded definition, framework, and methdoological approach for improved characterization of wild, cultivated and built food environments toward sustainable diets," Foods, vol. 9, no. 4, p. 532, 2020. [55] T. Puoane, A. Mente and M. Dehghan, "Ultra-processed foods and mortality: analysis from the prospective urban and rural epidemiology study," The American Journal of Clinical Nutrition, vol. 117, no. 1, pp. 55-63, 2022. https://www.cgiar.org/funders/