New strategies to reduce anaemia and risk of overweight and obesity through complementary feeding of infants and young children in Peru

Peru is experiencing rapid change with progressive economic development and increasing migration to cities. Dietary habits and health are also changing. Infants and children are getting taller but also getting heavier. In the last 10 years there have been significant increases in overweight and obesity among children, adolescents and adults. At the same time, however, the diets of infants and young children aged 6-23 months do not contain enough micronutrients (essential vitamins and minerals), particularly iron. Despite good provision of dietary supplements (micronutrient supplements including iron) to women and young children through national health services, there is still a high prevalence of anaemia (a deficiency of red cells or haemoglobin in blood) caused by iron and other micronutrient deficiencies.

New strategies are required to address these two dietary problems of anaemia and overweight/obesity. An underlying driver of these two nutritional challenges is the consumption of foods that are high in energy and low in nutrients.

Infant feeding is a critical time for health because the nutrition and growth of infants has a significant effect on health in childhood, adolescence and adulthood. A lack of research and poor understanding of the multiple factors influencing infant and young child feeding is a barrier to improving nutrition and health. This project will take a holistic approach to identifying the factors that drive food consumption in infants and young children in Peru, particularly the role of caregivers and families, communities and local neighbourhoods (health facilities and daycare facilities). There is a need for stronger evidence that accounts for the environments that people live in to inform strategies to promote healthier feeding of infants and young children.

Our project will use novel methods and adopt a holistic approach to examine infant and young child feeding in two peri-urban centres reflecting different ecologies of coastal Lima and highland Huánuco. As well as understanding infant feeding patterns and practices, we will organise community-based participatory workshops to identify solutions to the identified challenges of healthy complementary feeding. The workshops will lead to prototypes for solutions (interventions) to improve infant and young child nutrition which will be piloted in the local community.

Compliance with Official Development Assistance
This project addresses SDG2: reduce hunger and malnutrition and ensure children have access to sufficient and nutritious food; and SDG3: ensure healthy lives and wellbeing. Optimal infant and child feeding is critical for healthy growth and development and to prevent lifelong disparities in health.

In Peru, peri-urban households with lower socio-economic status are at significant risk of nutrient-poor diets that are also high in energy. This increases the risk of overweight and diet-related non-communicable disease over the lifecourse.

The Peruvian Ministry of Health has invested in national programmes to reduce anaemia and to promote healthy complementary feeding practices, however, this has not yet achieved substantial reductions in anaemia and novel, more holistic, strategies are needed. This study will therefore work with the peri-urban populations in Lima and Huánuco to develop tailored strategies to improve infant and young child feeding. The work will benefit children, families, local communities, health services, regional and national health authorities whilst informing local and national policies.

There are three main components (work packages) to the research.
Work package 1 will conduct formative research on the drivers of infant and young child feeding patterns and practices in relation to caregiver behaviours and household, community and socio-cultural environments. Qualitative and quantitative methods include i) quantitative dietary intakes of infants assessed through 24hr recall ii) 28-day food frequency questionnaires of mothers/caregivers iii) household observations (feeding style, mealtimes, snacking, food environment) and iv) in-depth interviews with maternal and non-maternal caregivers. We will then examine infant and young child feeding (IYCF) practices in the context of health services and daycare facilities to further understand feeding styles and food consumption patterns and practices. A policy mapping component will critically review policy developments and implementation on IYCF in relation to the Double Duty Actions on over- and under-nutrition. Findings from the formative research will be synthesised to identify the key challenges in adopting healthy complementary feeding practices in the two ecological settings (coastal Lima and highland Huanuco).
Work package 2 is a community based participatory design process. Through a series of six sequential workshops with stakeholders and end users (caregivers and families, health professionals, local government) we will formulate the key challenges, then use idea generation and 'futures' workshops to develop prototypes for solutions and interventions to address the dual challenge of micronutrient deficiency and obesity prevention in infants and young children.
Work package 3 will pilot the prototype interventions in households, communities or government health facilities. We will conduct qualitative evaluations of the pilot including acceptability, usability and relevance and bring the body of evidence to a reflective workshop involving the investigators, stakeholders and government.

The impact of this UK-Peru interdisciplinary collaboration will be to mobilise an interdisciplinary research and policy agenda to promote healthy complementary feeding practices (6-23 months) in rapidly urbanising environments in Peru. We will achieve impact by identifying Double Duty actions to reduce malnutrition in infants and young children that can be translated into the revision of government guidelines on infant feeding currently underway. Our longer term impact goal is to reduce malnutrition (under- and over-nutrition) during early life in Peru. Nutrition in the first two years of life is a critical point in the life-course and healthy complementary feeding is important to reduce the risk of diet-related non-communicable diseases later in life.

The communities involved in the project will benefit directly from the research due to our strategy for engagement and participatory methods. Their experiences and preferences will directly feed into the intervention prototype. Wider beneficiaries of the research include the Ministry of Health and the Department for Development and Social Inclusion and regional organisations of the Fund to Stimulate Development (FED) Committee. FED is a joint initiative of the Ministry of Development and Social Inclusion (MIDIS) and the Ministry of Economics and Finance and will be represented on our stakeholder panel.

Engagement activities
Within three months of inception of the project, we will form stakeholder panels and host a meeting in each region of the study (peri-urban Lima and Huanuco). We will consult the local stakeholder panels at regular intervals throughout the lifetime of the project. The stakeholder panel, along with the research findings and idea generation with the communities, will stimulate debate on the barriers and facilitators for healthy complementary feeding of infants and young children. Participatory design workshops will include mothers, caregivers, community members and government health facilities staff who will continue to be engaged while we pilot the designed intervention prototypes. Engagement of researchers with stakeholders will continue beyond the project through active contribution to advisory groups and committees in nutrition.

Anticipated benefits
The benefit of this project is that the research need has been identified by the Peruvian Ministry of Health in their plans to revise current infant and young child feeding recommendations (0-2 years). It also benefits international agencies who aim to develop an obesity prevention model for children in Peru. Embedding our research within the health services and government facilities of peri-urban areas will bring benefits of tailoring prototypes for intervention to the local socio-cultural contexts and sustainability through existing services. This timely research will offer knowledge translation outside academia and continued engagement with the key stakeholders throughout the project will ensure we continue to align with their requirements.