# **1 Introduction**

It is widely acknowledged that obesity is one of the most pressing public health issues in many emerging economies (Abdulai 2010; Alderman et al. 2006; Meng et al. 2009). In these contexts, recent obesity trends mostly derive from the nutrition transition that stems from changes in lifestyle. These are expressed in reduced physical activity and greater food consumption in supermarkets or restaurants, often resulting in unhealthy diets (Popkin et al. 2012). Because of these recent trends, emerging economies often face undernutrition and overnutrition simultaneously, leading to a _dual burden of disease_ (Popkin et al. 2012). Chronic diseases, such as type 2 diabetes, cardiovascular diseases, certain cancers and hypertension, are associated with poor diet and cause rising morbidity and mortality rates (Popkin 2006; Rosin 2008; Swinburn et al. 2011). The costs of this emerging obesity epidemic can be substantial and can exceed the costs associated with other chronic diseases putting formal or informal insurance schemes under financial pressure (Bhattacharya and Sood 2011, Strupat and Klohn 2018). Finkelstein et al. (2010) estimate the costs of overweight and obesity in the United States and find that the total annual cost attributable to obesity among full-time employees is $73.1 billion.

Peru is no exception, and its recent economic transition to an upper-middle-income economy has come hand in hand with a steeply upward obesity trend (World Bank 2017). Female obesity rates increased from 15 percent in 1997 to 24 percent in 2016 (Knoema 2017). According to the World Bank (2011), 64 percent of the Peruvian population ages more than 15 were overweight in 2009. The World Health Organization (WHO 2014) estimates that 66 percent of total deaths in 2012 in Peru can be attributed to non-communicable diseases such as cardiovascular diseases, cancers and diabetes. In response to these findings and their negative implications for the country’s economic development, the Peruvian government has implemented several interventions. Yet, these are mostly intended to eliminate undernutrition, whereas overnutrition receives less attention (Acosta and Haddad 2014). At the same time, 65 percent of all urban households in Lima that include at least one adult consume food away from home (FAFH) on a daily basis. According to data of the National Household Survey 2013 (Encuesta Nacional de Hogares, ENAHO) and Farfan et al. (2017), Peruvian households spend an average of 27 percent of their food expenditures on eating outside the home. Because the nutrition transition is a rather recent development in Peru and the consumption of FAFH is high across urban areas, gaining a better understanding of the determinants of overweight and obesity is highly relevant.

Even though some cases of obesity and overweight are linked to genetic and metabolic factors, the obesity epidemic itself is related to behavioral determinants and the social and physical environment (Sturm and An 2014; Cannuscio et al. 2014; Katare and Beatty 2018). There is growing agreement among experts that the food environment is a key driver of rising trends in excess body weight (Steeves et al. 2014).<sup>1</sup> Increased

> 1 This comprises the types of food sources that are accessible to an individual and to which consumers are exposed in those environments (the availability of healthy and unhealthy foods, food prices and so on).

2