{'fraction_non_alphanumeric': 0.03439761600681141, 'fraction_numerical': 0.01668795232013623, 'mean_word_length': 5.157536041939712, 'pattern_counts': {'":': 0, '<': 5, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Diet and food insecurity among mothers, infants, and young children in Peru before and during COVID‐19: A panel survey

Abstract The COVID‐19 pandemic may impact diet and nutrition through increased household food insecurity, lack of access to health services, and poorer quality diets. The primary aim of this study is to assess the impact of the pandemic on dietary outcomes of mothers and their infants and young children (IYC) in low‐income urban areas of Peru. We conducted a panel study, with one survey prepandemic (n = 244) and one survey 9 months after the onset of COVID‐19 (n = 254). We assessed breastfeeding and complementary feeding indicators and maternal dietary diversity in both surveys. During COVID‐19, we assessed household food insecurity experience and economic impacts of the pandemic on livelihoods; receipt of financial or food assistance, and uptake of health services. Almost all respondents (98.0%) reported adverse economic impacts due to the pandemic and 46.9% of households were at risk of moderate or severe household food insecurity. The proportion of households receiving government food assistance nearly doubled between the two surveys (36.5%–59.5%). Dietary indicators, however, did not worsen in mothers or IYC. Positive changes included an increase in exclusive breastfeeding <6 months (24.2%–39.0%, p < 0.008) and a decrease in sweet food consumption by IYC (33.1%–18.1%, p = 0.001) and mothers (34.0%–14.6%, p < 0.001). The prevalence of sugar‐sweetened beverage consumption remained high in both mothers (97%) and IYC (78%). In sum, we found dietary indicators had not significantly worsened 9 months into the COVID‐19 pandemic. However, several indicators remain suboptimal and should be targeted in future interventions.


| INTRODUCTION
Despite significant progress over the last decades, many low-and middle-income countries (LMICs) still encounter high levels of malnutrition, often including multiple burdens of underweight, stunting, micronutrient deficiencies, and overweight/obesity. The potential risks of the COVID-19 pandemic on maternal and infant nutrition have been highlighted, with all forms of malnutrition predicted to increase due to the pandemic (Headey et al., 2020).
The COVID-19 pandemic is expected to adversely affect infant and young child (IYC) nutrition in LMICs through a combination of increased household food insecurity, lack of access to nutrition-related health services, and poorer quality diets (Picchioni et al., 2021). Diet quality may be worsened by lower dietary diversity; changes in the types and quantities of foods consumed, or changes in the number of meals consumed. Reduced diet quality may in turn be driven by unemployment, worsening economic conditions, and reduced access to food Pérez-Escamilla et al., 2020;Picchioni et al., 2021). In such crises, IYC are at increased nutritional risk because of the high energy and nutrient requirements needed to support healthy growth and development and the potential for long-term adverse health consequences (Lutter et al., 2021).
A recent systematic review of the effects of the COVID-19 pandemic on diet quality, food security (FS), and nutritional status found major gaps in evidence on outcomes such as dietary diversity of women and young children (Picchioni et al., 2021). Furthermore, evidence indicates that the pandemic has increased the proportion of households with moderate or severe food insecurity in LMICs, mainly through loss of income. Household food insecurity can potentially lead to increases in different forms of malnutrition (Rocha et al., 2021), such as iron or other micronutrient deficiencies, as well as overweight and obesity or other nutrition-related noncommunicable diseases, which in turn increases the risk of COVID-19 morbidity and mortality (Gao et al., 2021).
The COVID-19 outbreak has also highlighted stark inadequacies in pandemic preparedness. Weaknesses in food and health systems across the globe have led to a lack of protection against hunger, food, nutrition, and health insecurity in the most vulnerable groups (Pérez-Escamilla et al., 2020) and reduced access to health services (Headey et al., 2020). Policy responses (e.g., financial support/social protection) have mitigated some of the adverse effects of the pandemic on malnutrition, but data on the efficiency of policy responses on nutritional outcomes are scarce (Picchioni et al., 2021).
Concerns have been raised regarding the adverse impacts of the pandemic on overall breastfeeding prevalence due to isolation of mothers, lack of breastfeeding counselling due to disrupted health services, and less access to enabling environments outcomes (Busch-Hallen et al., 2020;Picchioni et al., 2021). However, many aspects surrounding the impact of the pandemic on the diets of mothers and IYC remain poorly understood (Picchioni et al., 2021).
Peru went into a rapid lockdown and declared a state of emergency in response to the COVID-19 pandemic in March 2020. Despite rapid action, the country has experienced the highest mortality rates from COVID-19 globally (Dyer, 2021). Subsequently, the country went through varying periods of lockdown and easement, resulting in a drastic reduction in the availability of health services as well as exposing long-term healthcare inequalities (Gianella et al., 2021). IYC in Peru are offered routine "well child" (Crecimiento y Desarrollo [CRED]) health services which include growth and development monitoring, health and nutrition counselling, vaccination, haemoglobin measurement, and iron supplementation. In the initial months of the state of emergency, health services ceased to offer face-to-face CRED appointments, with some gradual resumption of face-to-face services from August 2020 alongside virtual/telephone consultations.
Studies on the impact of COVID-19 on diet and nutrition are often limited by the lack of directly comparable data immediately before the pandemic. Further, surveys during the pandemic have

Key Messages
• Almost all respondents (98.0%) reported negative economic impacts on their households from the pandemic.
• During the pandemic, almost half of households (46.9%) were at risk of moderate or severe household food insecurity.
• During the pandemic, 66.9% of households received cash transfers, and 59.4% received food assistance from the government.
• Nine months into the pandemic, positive changes included an increased prevalence of exclusive breastfeeding <6 months, a decreased proportion of mothers and infants and young children (IYC) consuming sweet foods, and stable dietary indicators for IYC and women.
• Consumption of sugar-sweetened beverages and unhealthy foods remained high across the two time periods for mothers and IYC and should be targeted in future interventions.
often relied on the voluntary completion of online questionnaires or telephone interviews, yielding results that are susceptible to selfselection bias and underrepresentation of disadvantaged communities who are most affected by pandemic economic shocks. The primary aim of this study is to assess whether the COVID-19 pandemic influenced dietary indicators of mothers and IYC living in two low-income urban areas of Peru by direct comparison pre-and during the pandemic via a panel survey. In the survey during COVID-19, we assessed household food insecurity experience; the perceived economic impacts of the pandemic on households' livelihoods, and receipt of financial or food assistance and uptake of health services to understand the broader contextual influences on mothers and IYC diets in these disadvantaged communities.

| Study design and sampling
This was an unbalanced panel study conducted amongst low-income urban households in Peru. We collected data via two surveys: one conducted from December 2019 to March 2020 before the COVID-19 pandemic (PERUSANO survey) and one conducted in December 2020 (STAMINA survey), 9 months after the onset of the pandemic. The PERUSANO survey was part of a wider interdisciplinary project to address multiple forms of malnutrition, particularly stunting, anaemia, and risk of overweight/obesity, in urban Peru while the STAMINA survey was designed to examine the nutritional risks of mothers and IYC in the same communities during COVID-19. The surveys took place in Manchay, Pachacamac District, Lima, and the city of Huánuco, Huánuco District in the Andean Highlands. In each study area, we purposively selected the principal health centre and one subsidiary health centre. Periurban (low-income urban) communities within the jurisdiction of these health centres were selected to participate.
In the PERUSANO survey, we recruited participants by systematic random sampling using quotas via house-to-house visits. Before recruitment, enumerators mapped each block of houses within each "sector" (local planning administrative unit for urban areas) of the community within the health centre catchment, and the block was used as the sampling unit. We chose a block at random as the starting point from the mapped sector, then proceeded to knock on the first house, and every third house thereafter until completing the sector. A random starting point was chosen for the next sector, and recruitment continued. The target sample size for PERUSANO was 360 mother-infant dyads based on the original aims before the emergence of COVID-19.
The sample size rationale was to capture the diversity of characteristics relevant to IYC diets, food patterns, and practices via quota sampling by age (6-11, 12-17, and 18-23 months), maternal employment (employed/nonemployed) and study area (Lima/Huánuco). Recruitment stopped in March 2020 because of the pandemic, at which point 244 mother-infant dyads had been recruited.
For the STAMINA survey, the sample size was set to match the pre-COVID sample (n = 250) with the same quota sampling by age and study site. Sampling took place through follow-up of the pre-COVID-19 survey participants (PERUSANO) for those still eligible (aged 6-23 months) (24% of the sample). We recruited the remaining participants using systematic random sampling from the local authority child registration records for the participating health centres. From the total number of eligible IYC records within an age group, we selected every nth record to attain the required number of participants. At least two attempts were made to contact participants via telephone before noting them as unavailable. If one participant declined or was unavailable, the next birth record after that case was selected.
In both surveys, a screening questionnaire was used to check the eligibility of mothers and IYC with the following inclusion criteria: i. singleton infants aged ≥6 months and <24 months on the day of interview; ii. no congenital malformations affecting nutrition or growth; and iii. primary residence of mother/primary caregiver in the study site for the previous 6 months. One supervisor from the original pre-COVID-19 team checked the completed questionnaires. Hence, the same team was used for both surveys and had close knowledge of the communities from which participants were selected.

| Data collection
For the PERUSANO survey, paper questionnaires were completed, and data were entered in Microsoft Access. Automated consistency checks were run and double data entry for a random sample of 10% of questionnaires was used to calculate the error rate. A predefined threshold was set to determine an acceptable level of variation in responses, with the error rate set at 1%. For the STAMINA survey, questionnaires were completed using tablets (Samsung Galaxy Tab-A) with an electronic data capture (CsPRO) PRADEILLES ET AL. | 3 of 12 during telephone interviews. Data quality was enhanced in CSPrO through programming of skips, controls, and other logic of the questionnaire.
Data collected in both surveys included: household sociodemographic characteristics; infant and young child feeding (IYCF) practices using standardised and validated questions (WHO, 2008;WHO and UNICEF, 2021), and child and maternal qualitative 24-h dietary recalls using the standardised open recall method (WHO, 2008). These questionnaire modules were the same in both surveys. New questions were added in the STAMINA questionnaire to assess the impact of COVID-19 on households including changes in employment status, adaptations to finance, sources of financial support, household food insecurity experience as well as access to, and uptake of, well-child clinics and vaccination health services. We developed questions through engagement with policy-makers, stakeholders, and expert discussion forums that highlighted gaps in knowledge and concerns surrounding the potential impacts of the pandemic in Peru. We also reviewed emerging literature on the consequences of COVID-19 on maternal and infant nutrition in LMICs. We measured the experience of household food insecurity using the validated food insecurity experience scale (FIES) survey module (Cafiero et al., 2018).

| Diet outcomes
For both surveys, we used the most recent guide to generate IYCF practices for infants aged 0-23 months (WHO and UNICEF, 2021).
Breastfeeding indicators (i.e., ever breastfed; early initiation of breastfeeding; exclusive breastfeeding under 6 months; continued breastfeeding 12-23 months) were generated using the retrospective recall of the mother/caregiver. Given that our sample of IYC only included those aged 6-23 months, we were not able to generate the exclusive breastfeeding indicator using 24-h recall as advised in the IYCF guide. Instead, we asked a series of questions to establish retrospectively whether mothers practised exclusive breastfeeding in the first 6 months or whether foods and beverages were introduced vegetable or fruit consumption) were generated using mother/caregiver reported intakes of foods and beverages during the past 24 h.
For the mother/caregiver, the reported food and beverage consumption during the past 24 h was used to calculate dietary diversity scores (FAO and FHI 360, 2016). Women who had consumed at least 5 out of the 10 predefined food groups were classified as meeting the adequate MDD for women. We also derived standardised maternal indicators of: egg and/or flesh food consumption, zero fruit and vegetable consumption, sweet beverage consumption, and unhealthy food consumption to match with the IYC indicators.

| Household food insecurity
The FIES is an eight-item experience-based scale of food insecurity severity. Respondents answered (yes/no) questions on household food-related behaviours and experiences of limited access to food due to lack of resources in the past 30 days. Statistical techniques borrowed from the toolkit of item response theory (Rasch models) allowed the generation of two prevalence rates comparable across countries: i. moderate or severe food insecurity and ii. severe food insecurity only (Cafiero et al., 2018). The internal reliability of the instrument was good as the modified Rasch reliability test was estimated at 0.80 (Agarwal et al., 2009).

| Sociodemographic factors
We created a common household wealth index for both surveys using factor analysis (i.e., multiple correspondence analysis) applied to proxy indicators of the household environment (ownership of consumer durables; source of drinking water and type of toilet facilities; the number of household members per room used for sleeping; type of materials used for the floors, roof, and walls; and livestock ownership). Analysis of proxy indicators of the household environment revealed no major differences between Lima and Huánuco; hence, we ran the factor analysis with the two settings combined. Variables with low variability (i.e., either less than 5% or more than 95% ownership) were not included in the factor analysis. We split the continuous score of the household wealth index into tertiles of socioeconomic status (SES), with the first tertile representing the relatively poorest households. The first component retained explained 85% of the overall variance.
We assessed internal validity by tabulating ownership of durable assets and other housing characteristics by SES tertile. We categorised mothers' self-report of completed educational level as less than secondary; secondary/technical, and university level. Other sociodemographic characteristics included maternal working status (yes/no); marital status (married/living together vs. not); child's age and sex; maternal age; and place of residence (Lima vs. Huánuco).

| COVID-19 pandemic related factors
From the survey during COVID-19, we collated responses to questions on financial impacts of the pandemic on households, adaptations to financial impacts, sources of financial support, as well as access to and uptake of nutrition-related health services reported by the caregiver. Questions regarding sources of food assistance were asked in both surveys.

| Statistical analyses
We generated descriptive statistics (mean, standard deviation or number [n], and percent) for sociodemographic and maternal and infant nutrition-related factors for each survey. For the STAMINA survey, we described the additional variables on the impact of the pandemic on households and livelihoods, that is, economic impact; coping mechanisms; household food insecurity; and access and uptake of nutritionrelated health services. To examine whether the pandemic influenced dietary outcomes, we performed univariate and multivariable logistic regressions for binary outcomes and linear regressions for continuous outcomes, with the survey type pre-COVID-19 (PERUSANO) versus during COVID-19 (STAMINA) as the main exposure variable. To account for repeated measures (24% of the sample) across the two surveys, we used a mixed-effects model with a random effect (intercept).
Models were adjusted for competing exposures (i.e., those not related to the exposure but the outcomes only) as adjusting for these increases precision in estimates of exposure-outcome associations. These competing exposures included maternal education; maternal working status; wealth index; and place of residence. Models for maternal and child outcomes controlled for maternal age or child age, respectively. We used Stata SE version 16 for statistical analyses. The type I error risk was set at 0.05.

| Household livelihoods and coping mechanisms
When asked to list up to three concerns about the effects of the pandemic, unemployment or loss of income was the most commonly reported concern (85.4%), followed by fear of infections/ illness or mortality from coronavirus for the respondent (73.6%) and the impact of quarantine (stay at home orders) on mental wellbeing (30.7%) (Figure 1a)

| Access to and use of health services
Most caregivers reported that their access to health services had been affected, either a lot (73.6%) or slightly (18.9%). Only 5.5% thought that health services had not been affected, and five respondents stated that they did not know (2.0%). Most respondents (75.6%) reported that they had taken their child to a health facility in the past month for routine Food consumption: Overall, the consumption of nutrient-rich foods amongst IYC was higher during COVID-19 in comparison to pre-COVID-19 ( Figure 2). Indeed, the proportion of IYC who consumed legumes, nuts, and seeds; eggs; dairy products; vitamin A-rich fruits and vegetables; and other fruits and vegetables was higher during COVID-19. Food groups for which consumption was lower during the pandemic included sweet foods and savoury/fried snacks.

| Impact of COVID-19 on maternal dietary outcomes
Maternal dietary indicators, including MDD, egg and/or flesh food consumption and zero vegetable or fruit consumption were favourable ( Table 2)  immediately before as well as during the pandemic, using the same interview teams and assessment instruments. While data collection methods differed (face-to-face interviews in the first survey vs. telephone interviews in the second), we used the same interviewers, all of whom had close knowledge of the communities studied. Telephone interviews could potentially have excluded households without mobile phone access, but since 95% of households nationally have access to a mobile phone (INEI, 2020b) this is unlikely to be a major source of selection bias.
Limitations of the study include the use of population-level nutrition indicators, such as MDD, MMF, and MAD, which provide a broad assessment of dietary quality but are not designed to detect quantitative changes in food intake. A quantitative dietary assessment, capturing data on portion sizes or weighed food intakes, would be required to identify any changes in quantities of food consumed or nutrient adequacy. This type of dietary assessment would be challenging to conduct via telephone interviews because of the length of interviews and the need to assess portion sizes via visual prompts. We had no a priori sample size calculation because the impact of COVID-19 on dietary indicators was unknown at the onset of the pandemic when we developed the STAMINA study. However, we hypothesised that a reduction of 10% points in the MDD prevalence from PERUSANO to the STAMINA survey would indicate a notable detriment to the diets of mothers and infants. Using a post hoc power calculation with power at 80%, α at 5%, and the sample size in each survey (n = 244 and n = 254) with the pre-COVID prevalence of meeting MDD, then we had the power to detect an 11% point reduction in maternal MDD (i.e., 77%-66%) and a 10% point reduction in infant MDD (89%-79%). For some indicators, such as the FIES, we did not collect data before the pandemic and therefore cannot directly compare this indicator pre-and during COVID-19 in these communities. However, knowledge of household food insecurity during the pandemic is an important benchmark for future comparisons of the impact of COVID-19 with changing economic and social conditions. This survey may not reflect the longer-term consequences of the pandemic on the diets of mothers and IYC since the date of the survey.

| CONCLUSION
Compared to prepandemic data, maternal and IYC dietary indicators had not significantly worsened 9 months into the COVID-19 pandemic. Despite this, almost half of households were at risk of moderate-severe household food insecurity. A high proportion of households received food assistance or government cash transfers during the pandemic which may have contributed to the stability of dietary indicators.
We identified maternal and IYC feeding indicators requiring improvement, such as reducing the consumption of sugarsweetened beverages, and the prevalence of unhealthy food consumption. These unhealthy dietary indicators could be targets for future policy.
The negative economic impact of the pandemic, and consequent reductions in household food expenditure, demonstrate the importance of providing foods of high dietary quality (i.e., nutrient-rich) and variety through social programmes as a future policy recommendation. Informal food support systems, such as the shared pot, may also contribute to resilient dietary outcomes and warrant further exploration.
Implementation of double-duty actions (i.e., actions that target multiple forms of malnutrition simultaneously) to improve the suboptimal nutritional indicators and address multiple forms of malnutrition in the population will be particularly important as populations recover from the COVID-19 pandemic.