Erika Sarmiento Canales PHN Soiree February 27, 2018 Indigenous Populations and the Nutrition Transition in Peru: Efforts and Challenges in Promoting Healthy Diets in an Andean Town Good evening everyone, my name is Erika SC, and today I will talk about Indigenous Populations and the Nutrition Transition in Peru, for which I conducted a literature review, and the Efforts and challenges in promoting healthy diets in an Andean town, which I learned about by doing case study on a town called Pauza. I will share my motivation for this topic, my findings, and my future goals. Erika Sarmiento Canales PHN Soiree February 27, 2018

Teodolfo & Ricardina Late 1950s These are maternal grandparents, Teodolfo and Ricardina, who helped take care of me until I was four years old and moved the the United States. (I got to know them better as a young women when they moved to the US as well.) My grandpa was born in the Andes and his first language was Quechua. He grew up working the land and eating from it. Once married, he and grandma were were substantive farmers, and also traded and sold crops like potatoes, cabbage, onions, corn and others. Teodolfo & Ricardina Late 1950s

This is his and my mother’s hometown, Huancara, in the department of Ayacucho. Currently there are about 50 people are living here. When I visited for the first time in 1997, I was moved by the beauty of the land, and the feeling of being reconnected to a past people. I also welcomed the differences between this place and my environment and surrounding environments in SF, such as cooking with firewood, the cuys, or guniea pigs my grandma was raising in her kitchen, or the lack of electricity and sewage, to name a few. Well- it took me a while to get used to now sewage, but I loved being in Huancara. But I couldn’t help but think about the various long-term impacts of colonization and exploitation as well in regards to poverty and health status. Huancara, Ayacucho

Kiosk with packaged foods Over the years of visiting Peru, it was apparent that food landscape was changing. The presence of fast food chains, packaged foods, and sugar sweetened beverages grew. Through, this project I learned thatDr. Bary Popkin, a well-known professor at Univeristy of N.Carolina developed the theory of the nutrition transition which is all about this. Exploring this topic called to me in given my family’s background and intention to become involved in working to help resolve health issues in Peru. Kiosk with packaged foods

Stages of the Nutrition Transition Popkins identified five patterns to describe the NT which posits that increased consumption of highly processed ready-to- eat foods leads to high chronic disease prevalence. This is all thought to occur with other shifts that involve reproductive health and life expectancy, infectious and non-communicable diseases, economic growth, and changes in the food system and lifestyle associated with globalization and urbanization (3). So globally, as countries adopt the Western diet—characterized by nutrient-poor, energy-dense foods high in fat, sugar, and sodium, sugar-sweetened beverages, animal-source foods, and foods low in fiber—coupled with the shifts I mentioned, there’s a rapid shift into the fourth pattern of nutrition related non-communicable diseases, such as obesity,, that represents the major focus, generally, when the nutrition transition is discussed. (2,3) Unfortunately, there’s lack of data collection in many settings that limits the extent to which associations can be made between shifts in the food system, diet intake, obesity and other conditions. (2) But we are seeing that overall, women are becoming more obese than men in several countries, including Peru, and prevalence in urban settings is higher compared to rural residence although rural settings are also seeing an increase in obesity. (2, 6)

Stunting and obesity are two important nutritional statuses experienced in the shifts I’ve talked about. Stunting is when a child doesn’t grow well and is too short for his or her age, and this is associated with impaired brain development, lower IQ, weakened immune systems, and greater risk of serious diseases like diabetes and cancer later in life. Not really an issue in the US, unlike child overweight and obesity, which are associated with worse concurrent and adulthood health outcomes, and also have important implications for healthcare costs and human productivity. (4) Here’s a picture from a study that addressed stunting , and both of these are girls are six but pretty different in height. What we know is that proper nutrition is critical from during pregnancy to prevent stunting - there isn’t really anything that can be done to reverse it once a child is about two years old. Sidenote: (Chronic, starts in the womb when mother malnourished (estimated 20% of cases), feeding practices, repeated infections all which can’t support baby’s growth) Stunting: Measurement of height per age z-score (HAZ) < -2 standard deviations below WHO growth standards median. National strategy in 2007 via the Articulated Nutritional Program (PAN ) Stunting

Majority of Peru is Experiencing the Double Burden of Malnutrition 2005 to 2015, national stunting rates reduced by half to 14% 2005 - Juntos, anti-poverty conditional cash transfer program 2013 - Healthy feeding of Children & Adolescents, and National Monitoring Center 2017 - National Pact Against Anemia and Stunting In Peru, the vast majority of the population is experiencing the double burden of malnutrition. (1) It’s hard to read the words on this map, but I’d like you to focus on the colors. One study mapped the nutrition transition and categorized it into three stages. The first is in green, where stunting is a larger issue than obesity, the second is in yellow, where there are high rates of both stunting and obesity, AKA as the double burden of malnutrition, and the third is in red, where Obesity is a larger issue. Peru is generally divided into three natural regions, the coast, the sierra, referring to the Andean mountain range, and the Jungle, inland – it’s fascinating is that even in remote areas, we see these changes. Between 2005 and 2015, national stunting rates reduced by half to 14%, credited in large part to government policies that focused on child health and nutrition - particularly through Juntos, an antipoverty conditional cash transfer program that I’ll talk more about later. (4,1) Government has also shifted some of its focus to the issue of rising obesity rates through the implementation of legislation on healthy feeding of children and adolescents ( in 2013), the creation a national monitoring center for nutrition and for the study of overweight and obesity. (5), and most recently, the signing of the National Pact Against Anemia and Stunting. ( 2010 and 2016) The sierra has had the most reduction of stunting (8.4% reduction vs 4% reduction in the jungle area, and 2.7% reduction in the coastal area). (9) But, still, the three departments with the highest prevalence of stunting are in that region. (including Ayacucho). (and Cajamarca and Huanuco) (9) In regards to obesity, over 35% of people 15 years and older, are overweight, and almost 18% are obese, with twice as much obesity in urban areas compared to rural, but overall, it is is growing in rural areas too. Sidenote: (Based on national demographic and health survey data (ENDES 2010)) Chaparro study in 2012 (Overlall, the prevalence of stunted children and overweight mothers reached 14% among the poorest families, the highest rate when compared to Ethiopia, India and Vietnam. (19) Sidenote: (There are 24 DEPTS in Peru. Study categorized DBMN as having stunting rates greater than 15%, and overweight and obesity rates greater than 30%.) The Andean department of Huancavelica, the poorest department in the cournty, had the highest prevalence of stunting at 54.6%.

Ethnic Diversity Indigenous peoples constitute close to one fourth of the total population Over 55 indigenous communities that speak 47 different languages So, there have been improvements, but indigenous groups, continue to experience disparities. Indigenous people are considered people who descend from habitants of the land during the conquest and colonial period and who presently conserve cultural, social, economic or political institutions. (6) They constitute close to one fourth of the total Peruvian population (7)generally, they have been identified as those who speak a language other than Spanish or a foreign language. (8) But Just this year the Census incorporated the option to self-report ethnicity (7) which we hope will help better meet the needs of this diverse population. This map created by the Ministry of Culture identifies over 55 indigenous communities that speak 47 different languages. Sorry you can’t see the legend, but with the color spread I wanted to give an idea of the ethnic diversity. (51 from the Amazon, and four from the Andes.) (http://bdpi.cultura.gob.pe/node/105#main-content) The largest indigenous populations, the Quechua and the Aymara, reside in the sierra region, and there are close to 50 indigenous populations in the jungle region (13)

Indigenous people experience 70% higher poverty rates Despite reductions in poverty in indigenous and non-indigenous groups, it’s thought the disparity has actually widened, and according to the World Bank, indigenous people experienced 70% higher poverty rates than their non-indigenous counterparts just a couple years ago.(7), and also, belonging to an indigenous group is associated with have lower levels of education and access to sewerage. (7) There’s also something to be said about urban and rural disparities. (Migration to urban areas took off in the 1950s and resulted in higher populated urban settings, particularly the capital Lima, which grew 10-fold within five decades. (7)) People in rural areas are more likely to experience extreme poverty, and children are about twice as likely to be malnourished or die compared to their counterparts in urban settings. (7) However, Even in urban areas, indigenous people face greater barriers, such as accessing services. (than their non-indigenous counterparts (7)) I didn’t find many studies about dietary changes, unfortunately, in indigenous communities, but want to highlight one study that reports that In the Andean region, consumption of vegetables, starchy roots, and fruit, which are considered traditional foods that come from what people grew in the land, has decreased, while store-bought items, such as sodas, have increased. (15) And also that climate and other environmental changes are factor in food security, which also ties into the need for food programs to be more culturally sensitive. This is in regards to the need for providing foods that are considered acceptable and thus trusted by indigenous communities, particularly those who consume fresh bush meat but are given canned foods, for example. On a similar note, program staff who can understand the geographic, linguistic and other needs of indigenous groups is important. Indigenous people experience 70% higher poverty rates Picture: Ministry of Culture

Pauza, Provincia del Paucar del Sara Sara This is Pauza. Sidenote: (currently about an 18 hour bus ride from the capital, used to be longer.) This is the town’s 33 yrd as the capital of the province, home to governmental offices and greater educational and medical services. There are close to 11,000 people living in the province (13), and about 3,300 living in here, (14) Over 40% (42%) of population lives below poverty line. Sidenote: (The income per capita in the province is about $110 a month, 360 soles a month in 2013) (ranking 89th in Human Development Index among the country’s 195 provinces) (13) Currently, several infrastructure projects are underway here, including paving the streets, expanding sewerage, and improving access to potable water (15), as well as expanding irrigation for the production of crops. (16) In children under five years old, Stunting rate 9% in Pausa, and 20% in the province, and overweight is 3% in Pauza and double in the province, and obestity is 2% in the province (107 children) (Feb2018) And an interesting thing is happening here regarding the foods landscape, there’s a growing presence of fattier foods like pollo a la brasa, as well as stores that sell processed foods like instant soups, chips, and candy. (move which was common, so that the family could access school and medical services.) (with a greater percentage living in urban than in rural areas) largely indigenous Quechua community. In Pauza, about 16% of women are illiterate. (14) Pauza, Provincia del Paucar del Sara Sara Plaza de Armas

Perhaps the biggest driving force for changes is the economic growth resulting from working in the local mine, Luicho. Since 2006, hundreds of residents from Pauza in search of economic opportunity have left the town to work in the nearest mine, where monthly earnings can be on average 50,000 soles, a tremendous difference from the average monthly income in Pauza (19). Some residents have returned to town and set up their own businesses including stores and restaurants, so in regards to farming, many people have stopped, changing what’s produced locally and what’s bought. Sidenote: (19) Urbanization can both increase access to foods, but also negatively affect diet quality due to the types of foods that become more and more available. (20) Sidenote: At the max, 2,300 workers, and mine restricted to ppl from the province only. ) Mina Luicho Initially only open to residents from the Province Paucar del Sara Sara

National Food Programs Offered in Pauza National food and nutrition programs are carried out in Pauza. Juntos, the national conditional cash transfer program that provides about $60 every two months to the poorest households with the aim of improving children’s and pregnant women’s nutritional statuses, and increasing healthcare utilization (21), began in Pauza in 2013 and serves close to 150 households. (14) Parents receive cash transfers on the condition that they take their children to a number of health checkups and the children attend school. (21) Outcomes of the program, on a national level , have included linear growth in boys and a reduction of BMI-for-age z scores in girls, as well as participant-reported spending a mean of 72% of cash transfer on food. (21) Qali Warma is the national school food program that serves children older than three years old who attend public schools. (22) Program delivery is based on poverty levels, providing some schools with only breakfast only, and poorer schools with breakfast and lunch, presently serving close to 109,500 people in Ayacucho. Recently, in Pauza, cooking workshops were provided to the committees that operate the program.     Comedores populares, communal kitchens - Provincia de Paucar del Sara Sara tiene 891 beneficiarios, con 35 comedores populares en total. Vaso de leche con 376 personas beneficiadas a diciembre pasado. MOTHERS PARTICIPATING IN THE PROGRAM(S) SAY THAT… prefieren leche condensada, and change in what is brought from local agriculturers Vaso de leche Comedores Populares

Given what we know about the nutrition transition, Pauza, and the greater province of Paucar del Sara Sara, present a good opportunity to prevent overweight and obesity from further developing, while at the same time continuing to reduce stunting, an approach also recommended by researchers studying the regional differences of malnutrition in the country. (1) Issue and strategy: community-based assessment Lack of data These programs provide an opportunity to further integrate basic nutrition education, and promote the use of traditional foods, such as quinoa and vegetables. With the current irrigation project, an educational campaign should accompany the project and focus on the nutritional benefits that traditional foods have. To begin this process, a foods assessment of Pauza is encouraged to be done in partnership with community members. This can help document community knowledge about traditionally consumed foods, and if possible, nutritional analysis should be conducted. This has been done in other indigenous communities, and there are guides to help the process. (26) Pachamanca

Yunza Issue and strategy : Education Breast feeding and complementary feeding, nutrition education school age children, Use of radio, GREAT WITH CURRENT OR FUTURE IRRIGATION CAMPAIGN Also, use of front of packaging labels, which are being used in other countries with the aim to improve healthy food choices (25), should be implemented in stores in Pauza and can complement a healthy eating campaign well .   En el 2013 se aprobó la Ley 30021, más conocida como la ley contra la comida chatarra. (https://elcomercio.pe/economia/peru/ley-alimentacion-saludable-reglamento-publicara-semana-434191) I think the town would work together given more resources and guidance, so many particpate in traditional festivities, like this one, there’s love and pride for cultural legacy. Yunza

Protein and culturally acceptable foods, other promotion of, particularly Kiwicha (or amanranth), rich in protein and iron *local government attention to the issue being better informed, coordination between sectors, issue of data for purposes of evaluation and new program or intervention design. Alternative to fast food that chicken is being consumed, because of the way raised and prepared government should consider a new project to increase the availability of healthy animal protein and iron to combat high rates of anemia (23) by providing cuys, guinea pigs, for households to use as food but also as an income generating strategy. Cuys are culturally acceptable foods for people in Pauza, are becoming more known in the culinary field, and are thought to have good potential for food security. (24) A program that provides information about proper care of cuys, as well as sanitation, may be a valuable option for households that cannot afford to raise larger animals. Cuy

RECENTLY, I’VE BEEN IN COMMUNICATION WITH THE MAYOR OF PAUZA AND HE IS INTERESTED IN CARRYING OUT FORMATIVE RESEARCH ON THE TOPIC OF FOOD SYSTEMS AND PROMOTION OF TRADITIONAL FOODS IN THE TOWN WITH THE AIM OF IMPROVING NUTRITION AND HEALTH STATUS IN THE LONG TERM. Child development, and really along the life-course, so we also have a healthier aging population. Next steps, with mayor and staff from social programs in the process of learning about the nutritional situation here, possibly into a formal project to evaluate or design an evaluation Interest in the roles of women and impact on women’s health in the mining sector. THIS PROJECT HELP FURTHER DIRECTION FOR MY FUTURE GOALS. PARTICULARLY WITH RESPECT TO PARTICIPATORY RESEARCH and child development AND WOMEN’S HEALTH IN THE AREA OF MINING. A couple in Pauza

Sources An overview on the nutrition transition and its health implications: the Bellagio meeting. 2002. Public Health Nutrition: 5(1A), 93–103 Emma Tsakoumis and Linda S. Adair. Childhood dual burden of under- and overnutrition in low- and middle-income countries: a critical review. Food and Nutrition Bulletin The Nevin Scrimshaw International Nutrition Foundation. 2014; vol. 35, no. 2 Fernald, L. Participation in the Juntos Conditional Cash Transfer Program in Peru Is Associated with Changes in Child Anthropometric Status but Not Language Development or School Achievement. Chaparro, MP and Estrada, L. Mapping the Nutrition Transition in Peru: Evidence for Decentralized Nutrition Policies. Rev. Panam Salud Publica. 2012;32(3):241-244. Peru: Systematic Country Report. World Bank Group. 2017. Report #112694-PE Ethnic map: http://bdpi.cultura.gob.pe/node/105#main-content Zavaleta et al. Indigenous Shawi communities and national food security support: Right direction, but not enough. Food Policy. 2017; 73:75-87 “Census 2017 to permit ethnic self-identification”, Peruvian Government website: https://www.inei.gob.pe/prensa/noticias/censos-nacionales-2017-seran-los-primeros-en-permitir-la-autoidentificacion-etnica-de-la-poblacion-9545/ Accessed 12/11/17 Office of the President’s website: http://www.presidencia.gob.pe/noticias/5463 “Peruvian population 15 years and older is obese”, Peruvian Government website: https://www.inei.gob.pe/prensa/noticias/el-355-de-la-poblacion- peruana-de-15-y-mas-anos-de-edad-padece-de-sobrepeso-9161/ Accessed 12/11/17 Abel Montes, resident of Pauza Tomas Sucari, Office of Social Programs and Planning, Municipality of Pauza