A prospective multicenter birth cohort study of iron adaptive homeostasis, growth and development in three Peruvian regions

Peru is a South American country which in the last two decades has experienced a continuous economic growth and has improved its population wealth. However, in Peru still a large proportion of children are suffering from anaemia due to insufficient iron levels in their blood. That situation generates a great hazard to the future of Peruvian children and their adult health. The roots of this problem are likely to be complex because numerous ecological, biological, social and political factors explain in part the persistence of anaemia. The majority of the government interventions are currently focussed on treatment and not to prevention. However, treating this disease might have side effects, as too much iron, interacting with other nutritional or environmental factors, can also negatively affect growth and development.

In this project, we will study the complexity of environmental and nutritional factors that alter the mechanisms of iron balance in a group of Peruvian babies, from birth to their first year of life. Children and their mothers will be studied in 3 cities in Peru located on the coast, the Andes and the Amazon. Various measurements and samples of water, blood, faeces will be made; baby size measurement, interviews, nutritional observation and focus groups with participating mothers will be collected. Some health policies and strategies implemented in the past will also be evaluated.

Background.
Despite economic growth and improvement of development indicators, Peru has a high prevalence of iron deficiency (ID) and iron deficiency anaemia (IDA), for reasons that are unclear. A complexity of eco-bio-social-political factors underlies anaemia and it will be posing increased pressure on the most marginalised people, if not addressed adequately, from an integrative sustainable perspective. Most government interventions are aimed at treatment and not prevention.

Aim: To understand the complexity of environmental, social, and nutritional factors altering mechanisms of adaptive iron homeostasis in infants during the Anthropocene.

Methods: This is a multicentre prospective cohort study with an eco-bio-social-political approach in 3 cities of Peru located in the Coast, Andes and Amazon.

Study period: April 2019 to March 2022 (36 months) Study population: healthy newborns at > 34 weeks of gestation, born in 2020. Follow-up: Prenatal (mothers), then at birth and at months 4, 6, 8 and 12 (mother-infant pairs).
Exposure: nutritional or environmental factors that modify iron homeostasis. Outcomes: Primary Outcome: Iron Deficiency; Secondary outcomes: IDA, delay in infant growth.

Measurements: Ecological/Environmental: Water samples, GIS-mapping. Biological: Mother and infant: Blood, stool samples; anthropometric assessment according to standard procedures. Social: nutritional household survey; 24 hours of nutritional observation, in-depth interviews and focus groups with participating mothers. Political/Economic: Policy and capacity analysis, focus groups with stakeholders.

Official Development Assistance
This research will contribute to the social and economic development of Peru by addressing the complexity of factors determining iron deficiency anaemia in distinct parts of Peru.

Ethics
An Institutional Research Ethics Committee will review the study protocol at the Instituto Nacional de Salud del Niño (Peru) and at QMUL (London, UK).

Peru is a country that is known for its biodiversity and cuisine but struggles with populations who do not have access to quality and varied nutrition or suffer from food insecurity. Four in every 10 children between 6- 36 months in Peru suffer from anaemia, with potentially detrimental effects on their development and future health.

This research is directly aimed at infants, the future of Peru: in particular, those infants whose mothers do not have access to quality food, sanitation and live in deteriorated ecosystems. To break the vicious cycle that has been embodied for so long by society and been described by Anibal Quijano as continued coloniality, this research will use a participatory approach to assess the complexity of factors that determine iron deficiency anaemia in Peru, in order to plan future interventions.

This research will use an integrative systemic approach. It is sustainable as it addresses the complexity of eco-bio-social-political factors by facilitating the process of collaboration. It directly involves all key stakeholders from the onset, starting with engaging community/ grassroots level actors and government stakeholders and integrating them into research design and policy development.