Addressing the double burden of malnutrition in Peru: using a community-based system dynamics approach to improve food systems

The Peruvian people suffer from what has been described as a "double burden" of malnutrition. This means that they simultaneously experience undernutrition and over-nutrition. Undernutrition includes inadequate intake of vitamins, low height for age, or low weight for height. Over-nutrition is the result of high consumption of unhealthy and processed foods, which are high in fat, sugar and salt, and includes overweight and obesity and other diet-related diseases such as diabetes and heart disease.

The way that food is produced, sold and consumed in the country ("the food system") is a major driver of this problem. While Peru has undertaken some bold actions to address malnutrition over the past two decades most policies have a one-sided focus, targeting either under or over-nutrition and fail to address both aspects. The process of identifying and evaluating policies to address this problem needs to take into account the complex economic, social, and cultural factors that influence food systems.

We will use innovative research methods to identify drivers of the double burden of malnutrition in Peru and potential policy solutions which take these complex factors into account. The specific objectives of this project are: 1. Map the drivers of the food system that contribute to the double burden of malnutrition in three diverse regions in Peru; 2. Identify policies and interventions that would address the double burden of malnutrition through changes in the food system; 3. Quantify the impacts of identified policies and interventions on the double burden of malnutrition; 4. Prioritise identified policies and interventions and actively disseminate recommendations

Our research project is characterised by the active involvement of members of the community throughout all its stages. The projects starts with workshops in three regions of Peru (Lima, Tumbes and Huancavelica) during which our research team will guide small groups of community stakeholders to conceptualise and map the drivers of the food system that contribute to the double burden of malnutrition. Community stakeholders will include lay members of the community, policymakers at local and national government authorities, and academics, with a deep understanding of the community issues and experiences, either as residents or organisers, leaders, and service providers. At the next stages of the project, stakeholders will guide the research team to identify relevant policy options that are appropriate at national and regional level. They will also be consulted throughout the quantitative evaluation of these policies to ensure that it accurately represents stakeholder views as expressed during the workshops. Finally, they will have an active role in prioritising and recommending appropriate policy options, disseminating the results of the project to other members of the community, and acting towards policy change.

Our research project is a collaboration between universities in Peru, the United Kingdom and Brazil. The research team have expertise in policy evaluation, food systems and public heath nutrition, modelling and health economics. The project will strengthen academic collaboration between these institutions and build research capacity in Peru. It will also strengthen collaboration between Peruvian institutions and members of the local community by establishing long-term working relationships between parties.

Project beneficiary 1: Policy makers and the public
Achievement of policy and societal impacts is fundamental to this research project as evidenced through our methodological approaches. All phases of the research will have a strong policy maker and public stakeholder component, principally through our Community-Based System Dynamics (CBSD) approach. An important characteristic of CBSD is that it invests in building capacity within a community, hence the strong regional focus of the project. We will engage with workshop participants throughout the project including in a policy prioritisation exercise during the final six months. This will ensure that policy makers and the public will play an integral role in the process of identifying, quantifying and disseminating drivers and policy options to address the double burden of malnutrition in Peru. This approach substantially enhances the likelihood of research translation through informing the development of a set of policies which are feasible and will produce beneficial improvements in the health of the public.

Project beneficiary 2: Academic community
The project will build important capacity within Peruvian research institutions as it responds to their expressed need to strengthen in the areas of community-based system dynamics and food systems research. Learning within and between research partners will be facilitated by regular site visits by the UK based academics who will participate in the three regional meetings. The project will additionally build substantial research capacity within participating UK institutions, especially among early career researchers who will work with their Peruvian colleagues across all Work Packages. Insights gleaned from the project by the UK research teams will help strengthen methodological approaches to guide the evidence-based policies needed to address similar health challenges in the UK and other high-income countries.

Project beneficiary 3: Health and social welfare systems in Peru
The World Bank has estimated that Peru loses US $637 million in GDP annually due to vitamin and mineral deficiencies. Previous reports from the CRONICAS group have demonstrated that obesity may be responsible for at least a third of cases of hypertension and type-2 diabetes and is a major risk factor for cardiovascular morbidity and mortality. The health system and societal costs associated with these conditions are substantial and growing at an unsustainable rate (US$ 477.33 billion dollars projected for 2015-2030). Understanding drivers of the high double burden of malnutrition and policy options to address this is essential.