Drivers of stunting reduction in Peru: a country case study Luis Huicho,1,2,3 Elisa Vidal-Cárdenas,1,2 Nadia Akseer,4,5 Samanpreet Brar,4 Kaitlin Conway,4 Muhammad Islam,4 Elisa Juarez,6 Aviva Rappaport,4 Hana Tasic,4 Tyler Vaivada,4 Jannah Wigle,4,5 and Zulfiqar A Bhutta4,5,7 Downloaded from https://academic.oup.com/ajcn/article/112/Supplement_2/816S/5898918 by guest on 08 October 2020 1Research Center for Integral and Sustainable Development, Cayetano Heredia University, Lima, Peru; 2Maternal and Child Health Research Center, Cayetano Heredia University, Lima, Peru; 3School of Medicine, Cayetano Heredia University, Lima, Peru; 4Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada; 5Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; 6Center for the Promotion and Defense of Sexual and Reproductive Rights (PROMSEX), Lima, Peru; and 7Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan ABSTRACT Keywords: stunting, linear growth, children, nutrition, exemplar, Background: Peru reduced its under-5 child stunting prevalence Peru, Latin America, mixed methods notably from 31.3% in 2000 to 13.1% in 2016. Objectives: We aimed to study factors and key enablers of child stunting reduction in Peru from 2000–2016. Methods: Demographic and Health Surveys were used to conduct Introduction descriptive analyses [height-for-age z scores (HAZ) means and Many countries made commitments toward achieving the distributions, equity analysis, predicted child growth curves through Millennium Development Goals, and prominent among them polynomial regressions] and advanced regression analyses. An were those aimed at reducing maternal and child mortality and ecological (at department level) multilevel regression analysis was malnutrition (1). Low- and middle-income countries in diverse conducted to identify the major predictors of stunting decline from regions of the world have achieved significant reductions in 2000 to 2016, and Oaxaca–Blinder decomposition was conducted to their under-5 stunting prevalence, and Peru (Figure 1A) (2) identify the relative contribution of each factor to child HAZ change. has been one of these exemplary countries. Child stunting is A systematic literature review, policy and program analysis, and defined as a height-for-age z score (HAZ) that is more than interviews with relevant stakeholders were conducted to understand 2 SDs below the global median and is used as a marker of key drivers of stunting decline in Peru. chronic childhood undernutrition. In the early 1990s, Peru had Results: The distribution of HAZ scores showed a slight rightward a high prevalence of stunting, >35%, which remained generally shift from 2000 to 2007/2008, and a greater shift from 2007/2008 to stagnant for over a decade. However, between 2008 and 2016, 2016. Stunting reduction was higher in the lowest wealth quintile, the stunting prevalence fell to 15% (Figure 1B). Peru not only in rural areas, and among children with the least educated mothers. outperformed its South American counterparts (Figure 1B) but Decomposing predicted changes showed that the most important also the global average decline from 32.5% in 2000 to 21.9% in factors were increased maternal BMI and maternal height, improved 2018 (3, 4). maternal and newborn health care, increased parental education, Peru is an upper middle-income country that had a population migration to urban areas, and reduced fertility. Key drivers included of 31.8 million in 2016, with 21% living in rural areas the advocacy role of civil society and political leadership around (5). Indigenous groups comprise more than one-third of the poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy population (5). Since the 2000s, Peru has gained political stability since the early 2000s, and the acknowledgement that stunting and democracy, after the end of a period of social unrest from reduction needs much more than food supplementation. the 1980s to the early 1990s (6, 7). High rates of migration from Conclusions: Peru reduced child stunting owing to improved rural to urban areas during the instability and conflict period socioeconomic determinants, sustained implementation of out-of- resulted in a reduction of the rural population to only 28% by health-sector and within-health-sector changes, and implementation 2010 (8). Peru has made substantial economic gains in recent of health interventions. These efforts were driven through a years, reduced inequalities, and improved adult and adolescent multisectoral approach, strong civil society advocacy, and keen fertility rates. Concurrently, it increased women’s literacy and political leadership. Peru’s experience offers useful lessons on access to improved water and sanitation facilities, yet urban– how to tackle the problem of stunting under differing scenarios, rural disparities have persisted. Trends in these various contextual with the participation of multiple sectors. Am J Clin Nutr characteristics of Peru between 2000 and 2016 are presented in 2020;112(Suppl):816S–829S. Supplemental Appendix 1. 816S Am J Clin Nutr 2020;112(Suppl):816S–829S. Printed in USA. Copyright © The Author(s) on behalf of the American Society for Nutrition 2020. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Drivers of stunting reduction in Peru 817S AB Downloaded from https://academic.oup.com/ajcn/article/112/Supplement_2/816S/5898918 by guest on 08 October 2020 FIGURE 1 Map of Peru and regional under-5 stunting prevalence. (A) Map of Peru. (B) The prevalence of under-5 stunting in selected South American countries, 1990–2018. Source: Joint Malnutrition Estimates (4). Various studies have explored the determinants of stunting include poverty alleviation and economic growth (8, 10, 15– reduction in Peru, but most of them involved only national-level 17), health spending (10, 18–22), population literacy (8, 23), analyses. Moreover, they used either qualitative or quantitative decreasing fertility rates (6, 24–26), utilization of maternal care approaches, but not both combined (8–14). Only 1 of them has services (27–29), and access to improved water (30) and hygienic been done at a subnational level (14). Some of the strongest conditions (8), among other factors, hinting at a multifactorial drivers of stunting reduction identified through the literature stunting success story (14). Results of the full systematic review and confirmed through quantitative subnational analyses literature review are presented in Panel 1 and Supplemental Appendix 2 (8–12, 14–20, 31–97). Supported by a Gates Ventures grant to the Centre for Global Child Health (to ZAB) and through a subcontract to Fundación Cayetano Heredia in Peru. The funder had no role in the design, implementation, analysis, or Panel 1 interpretation of the data. Supplemental Appendices 1–7 are available from the “Supplementary data” Systematic literature review of stunting determinants link in the online posting of the article and from the same link in the online Our literature review found that among basic causes of child table of contents at https://academic.oup.com/ajcn/. stunting reduction in Peru, various factors were found to be Data described in the article, code book, and analytic code will be made strongly related including the rapid economic growth (8–10, available upon request pending application and approval. 18, 93, 97), social welfare programs (8, 10, 15–17, 19, 31), Authors SB to JW organized alphabetically. rurality of residence (32–42), altitude (39–42), strong polit- Published in a supplement to The American Journal of Clinical Nutrition. ical commitment (8, 10–12, 43), Integrated Management of The Guest Editor for this supplement was Mark Manary, and reports no conflicts of interest. The Supplement Coordinator for the supplement Childhood Illness (IMCI), and vaccine coverage (22). Peru’s publication was Nadia Akseer, Gates Ventures/Hospital for Sick Children, economy grew rapidly between 2002 and 2010 (8, 18), and Toronto, Canada. Supplement Coordinator disclosure: no conflicts of interest. economic growth was estimated to account for upwards The Stunting Exemplars research Principal Investigator was Zulfiqar A of half of national stunting reduction (9). Stunting decline Bhutta, Hospital for Sick Children, Toronto, Canada. Principal Investigator and economic growth may not be directly related, because disclosure: no conflicts of interest. Publication costs for this supplement were there exists a gap in time between growth in the economy defrayed in part by the payment of page charges by Gates Ventures. The and stunting reduction (8), although there is an indirect opinions expressed in this publication are those of the authors and are not relation through social welfare programs (15). Although attributable to the sponsors or the publisher, Editor, or Editorial Board of The American Journal of Clinical Nutrition. many studies found that the poverty-reduction programs Address correspondence to LH (e-mail: [email protected]). Juntos and CRECER had a positive association with stunting Abbreviations used: ARI, acute respiratory infection; CAGR, compound reduction (8, 10, 16, 17, 19, 31), some found no association annual