Abstract

The characteristics of the food environment can interfere with physical access to healthy foods and accentuate health inequalities. The presence of food swamps, i.e., the greater availability of ultra-processed food and commercial establishments compared to those that sell healthier options, are associated with the consumption of unhealthy foods. This study identified the spatial distribution of these establishments in Campinas, São Paulo. Fast-food restaurants, open-air organic/agroecological food markets and supermarkets were geocoded. Regional administrations (RAs) with greater social vulnerability according to the 2010 Census and with a greater availability of fast-food restaurants in relation to open-air food markets and supermarkets were considered food swamps. The less vulnerable neighborhoods had a higher concentration of all types of commercial food establishments compared to the most vulnerable regions. In Campinas, of eighteen RAs, five were considered food swamps. The findings reinforce the need for actions to improve exposure to healthy foods in more vulnerable neighborhoods.

Key words:
Inequalities; Food; Socioeconomic factors

Introduction

The physical, economic, political and sociocultural contexts that constitute the food environment have the ability to influence the population’s acquisition, preparation and consumption of food. They are inserted in contexts, such as race, income, education, and the location, number and type of commercial food establishments¹1 Food and Agriculture Organization of the United States (FAO). Nutrition and food systems. A report by the High Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security. HLPE Report 12 [Internet]. 2017 [cited 2019 ago 12]. Available from: http://www.fao.org/cfs/cfs-hlpe.
http://www.fao.org/cfs/cfs-hlpe... ^,22 Jallinoja P. The public health relevance of food consumption and food environments. Scand J Public Health 2019; 47(5):475-476..

The inequity in the location of commercial food establishments, combined with social, economic and residential segregation, contributes to health inequalities in several countries, including Brazil³3 Powell LM, Slater S, Mirtcheva D, Bao Y, Chaloupka FJ. Food store availability and neighborhood characteristics in the United States. Prev Med 2007; 44(3):189-195.

4 Lopes F. Para além da barreira dos números: desigualdades raciais e saúde. Cad Saude Publica 2005; 21:1595-1601.

5 Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR Jr. Associations of the local food environment with diet quality--a comparison of assessments based on surveys and geographic information systems: the multi-ethnic study of atherosclerosis. Am J Epidemiol 2008; 167(8):917-924.

6 Drewnowski A. Obesity, diets, and social inequalities. Nutr Rev 2009; 67(Supl. 1):36-39.^-77 Assari S. Unequal Gain of Equal Resources across Racial Groups. Int J Health Policy Manag 2018; 7(1):1-9.. The unequal availability of locations that sell fresh and minimally processed foods is potentially one of the mechanisms that explains the higher prevalence of obesity and type 2 diabetes in more vulnerable population groups⁸8 Alexei V, Cavalcanti AM, Pecoits Filho R, Précoma DB. Socioeconomic Status: The Missing Link Between Obesity and Diabetes Mellitus? Curr Diabetes Rev 2018; 14(4):321-326.

9 Freitas IC, Moraes SA. Social vulnerability effect over obesity anthropometric indexes: results from population-based epidemiological study. Rev Bras Epidemiol 2016; 19(2):433-450.^-1010 Diderichsen F. The Epidemiology of the Diabetes: Depression Comorbidity in Brazil - Inequality and Interaction. In: Faintuch J, Faintuch S, editors. Obesity and Diabetes. Berlin: Springer, Cham; 2020. p. 457-470..

Regions with difficult access to fresh foods and minimally processed foods at affordable prices are known as “food deserts”¹¹11 Cummins S, Macintyre S. "Food deserts"- evidence and assumption in health policy making. BMJ 2002; 325(7361):436-438., while socioeconomically vulnerable regions with a preponderance of establishments selling ultra-processed foods in relation to the number of establishments selling fresh and minimally processed foods can be considered “food swamps”¹²12 Daley B. How urban planning and housing policy helped create 'food apartheid' in US cities [Internet]. 2021 [cited 2019 set 16]. Available from: https://theconversation.com/how-urban-planning-and-housing-policy-helped-create-food-apartheid-in-us-cities-154433.
https://theconversation.com/how-urban-pl... ^,1313 Cooksey-Stowers K, Schwartz MB, Brownell KD. Food Swamps Predict Obesity Rates Better Than Food Deserts in the United States. Int J Environ Res Public Health 2017; 14(11):1366.. The presence of food swamps has been associated with higher rates of obesity than the so-called food deserts¹³13 Cooksey-Stowers K, Schwartz MB, Brownell KD. Food Swamps Predict Obesity Rates Better Than Food Deserts in the United States. Int J Environ Res Public Health 2017; 14(11):1366.. These concepts seek to quantify the access to fresh and minimally processed foods in urban centers and help in the planning and formulation of measures aimed at combating the inequalities of access to these foods¹⁴14 Campus Environmental Center. 'Food Apartheid' (not 'Desert') [Internet]. 2021 [cited 2021 abr 16]. Available from: https://utenvironment.org/projects/microfarm/food-justice/glossary/food-apartheid-not-desert.
https://utenvironment.org/projects/micro... .

The use of the term “food apartheid” highlights inequalities in access to healthy foods as a symptom of the presence of social injustices such as poverty, racism and other forms of discrimination that lead to unequal allocation of resources¹⁵15 Brones A. Food apartheid: the root of the problem with America's groceries [Internet]. 2018 [cited 2021 abr 16]. Available from: https://www.theguardian.com/society/2018/may/15/food-apartheid-food-deserts-racism-inequality-america-karen-washington-interview.
https://www.theguardian.com/society/2018... . The lack of availability of fresh and minimally processed foods and greater exposure to ultra-processed foods affect individuals of all colors and races, but black and brown populations are disproportionately affected¹⁵15 Brones A. Food apartheid: the root of the problem with America's groceries [Internet]. 2018 [cited 2021 abr 16]. Available from: https://www.theguardian.com/society/2018/may/15/food-apartheid-food-deserts-racism-inequality-america-karen-washington-interview.
https://www.theguardian.com/society/2018... . Communities with predominantly white individuals are more likely to have greater availability of fresh and minimally processed foods with affordable prices compared to communities with predominantly black and brown populations¹²12 Daley B. How urban planning and housing policy helped create 'food apartheid' in US cities [Internet]. 2021 [cited 2019 set 16]. Available from: https://theconversation.com/how-urban-planning-and-housing-policy-helped-create-food-apartheid-in-us-cities-154433.
https://theconversation.com/how-urban-pl... .

In Brazil, where ethnic minorities have a lower average income than whites¹⁶16 Osorio RG. A desigualdade racial da pobreza no Brasil. Texto para Discussão. Rio de Janeiro: Ipea; 2019., supermarkets¹⁷17 Duran AC, Diez Roux AV, Latorre MdRDO, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23:39-47. and establishments that sell a greater amount of fresh and minimally processed foods¹⁸18 Lopes ACS, Menezes MCd, Araújo ML. Food environment and access to fruits and vegetables: "A metropolis into perspective". Saude Soc 2017; 26(3):764-773. are more frequently found in the richest regions. Residents living in regions with a higher concentration of establishments that sell fresh and minimally processed foods have a more frequent consumption of these foods compared to those who live farther away¹⁷17 Duran AC, Diez Roux AV, Latorre MdRDO, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23:39-47.^,1919 Vedovato GM, Trude ACB, Kharmats AY, Martins PA. Degree of food processing of household acquisition patterns in a Brazilian urban area is related to food buying preferences and perceived food environment. Appetite 2015; 87:296-302.^,2020 Leite FHM, Cremm EC, Abreu DSC, Oliveira MA, Budd N, Martins PA. Association of neighbourhood food availability with the consumption of processed and ultra-processed food products by children in a city of Brazil: a multilevel analysis. Public Health Nutr 2018; 21(1):189-200..

Healthy eating environments contribute to the maintenance of eating habits consistent with the recommendations of the Food Guide for the Brazilian Population²¹21 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. 2014 [acessado 2020 nov 1]. Disponível em: https://bvsms.saude.gov.br.
https://bvsms.saude.gov.br... . As the most recent data from the 2017/2018 Family Budget Survey show, there has been an increase in the consumption of food from outside the home in the poorest regions of the country, such as Northeast²²22 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2017-2018 - POF [Internet]. 2020 [acessado 2020 nov 1]. Disponível em: https://biblioteca.ibge.gov.br.
https://biblioteca.ibge.gov.br... , which may represent a greater demand for ready meals, and consequently, an increase in the number of eating establishments, such as fast-food restaurants²³23 Bezerra IN, Moreira TMV, Cavalcante JB, Souza AdM, Sichieri R. Food consumed outside the home in Brazil according to places of purchase. Rev Saude Publica 2017; 51(0):15..

The mapping of the distribution of commercial food establishments and the identification of regions of the city that can be considered food swamps allow us to better characterize the food environment, describe the presence of a potential food apartheid, and inform interventions and public policies that help to correct possible inequalities. The objective of the present study was to map the distribution of commercial food establishments and to determine if and where food swamps are located in the municipality of Campinas, São Paulo, Brazil.

Methods

An ecological study was conducted in the municipality of Campinas, São Paulo, Brazil, which is the headquarters of the metropolitan region of Campinas, one of the ten largest regions in the country with a population of 3.2 million inhabitants²⁴24 Instituto Brasileiro de Geografia e Estatística (IBGE). Estimativas de População [Internet]. 2018 [acessado 2020 nov 3]. Disponível em: https://www.ibge.gov.br.
https://www.ibge.gov.br... . The Gross Domestic Product of Campinas is the 3^rd largest in the state and the 14^th largest in the country, showing the economic importance of the region at the state and federal levels²⁵25 Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades [Internet]. 2021 [acessado 2020 nov 3]. Disponível em: https://cidades.ibge.gov.br.
https://cidades.ibge.gov.br... .

Identification of commercial food establishments

To evaluate the geographic distribution of establishments that sell food in the municipality of Campinas, three types of establishments were identified according to the products mostly sold: i) fast-food restaurants, where the sale of ultra-processed foods predominates²⁶26 Liu J, Rehm CD, Micha R, Mozaffarian D. Quality of Meals Consumed by US Adults at Full-Service and Fast-Food Restaurants, 2003-2016: Persistent Low Quality and Widening Disparities. J Nutr 2020; 150(4):873-883., ii) open-air organic/agroecological food markets, characterized by the sale of fresh and minimally processed products²⁷27 Watanabe MA, Luiz AJB, Abreu LSd. Preços de hortifrutis convencionais e orgânicas em feiras livres e supermercado de Barão Geraldo, Campinas, SP, Brasil [Internet]. 2018 [acessado 2020 out 5]. Disponível em: https://www.embrapa.br/busca-de-publicacoes/-/publicacao/1105340/precos-de-hortifrutis-convencionais-e-organicas-em-feiras-livres-e-supermercado-de-barao-geraldo-campinas-sp-brasil.
https://www.embrapa.br/busca-de-publicac... ^,2828 Ueno VA, Fagundes GG, Habib M. Análise comparativa das feiras livres convencionais e orgânicas no município de Campinas (SP). Cad Agroecologia 2016; 10(3):1-5., and iii) supermarkets, considered mixed establishments because they offer both fresh and minimally processed and ultra-processed foods²⁹29 Câmara Interministerial de Segurança Alimentar e Nutricional. Mapeamento dos desertos alimentares no Brasil [Internet]. 2018 [acessado 2019 nov 12]. Disponível em: https://aplicacoes.mds.gov.br.
https://aplicacoes.mds.gov.br... .

The study included the largest fast-food restaurant chains classified by Entrepreneur³⁰30 Entrepreneur. The Top Food Franchises of 2019 [Internet]. [cited 2020 out 5]. Available from: https://www.entrepreneur.com/article/333376.
https://www.entrepreneur.com/article/333... magazine and Brazilian restaurant chains: McDonalds, Bob’s, Giraffas, Burger King, Pizza Hut, Subway, Habib’s, Domino’s, Taco Bell and KFC. Store addresses were found on the official website of each company. In addition to fast-food restaurants, stores from the four supermarket chains responsible for the highest sales volumes in the country were incorporated, according to information provided by the Euromonitor of 2017³¹31 Euromonitors International. Grocery Retailers in Brazil [Internet]. Vilnius, Lithuania; 2016 [cited 2020 out 5]. Available from: https://www.euromonitor.com., Grupo Cassino (including the Sugarloaf and Extra Stores), Carrefour, Walmart and Dia. The regional supermarket chains Dalben, Pay Less, Covabra and Paulistan were included. Data on the location of open-air organic/agroecological food markets existing in the municipality were collected through the Campinas municipality website³²32 Campinas. Serviços Técnicos Gerais. Feira livre [Internet]. 2019 [cited 2020 out 5]. Available from: https://setec.sp.gov.br/site/solo-feira.
https://setec.sp.gov.br/site/solo-feira... and through the platform “Map of Organic Fairs” of the Brazilian Institute of Consumer Protection (Instituto Brasileiro de Defense do Consumidor - IDEC)³³33 Instituto Brasileiro de Defesa do Consumidor. Mapa de feiras orgânicas [Internet]. 2018 [acessado 2020 out 5]. Disponível em: https://feirasorganicas.org.br/.
https://feirasorganicas.org.br... and confirmed by the General Technical Services of Campinas (Setec), the municipality responsible for the management of open markets and municipal markets in the city. These three types of commercial food establishments were selected due to the lack of consistent secondary data on neighborhood markets and other smaller food retailers.

After identification of the establishments, the programming interface of the Google geocoding application was used to establish the geographic coordinates of each establishment. Spatial validation, i.e., the process of confirming the accuracy of geographic codes, was performed to ensure data reliability. Points identified outside the geographical boundaries of the municipality of Campinas were removed from the analysis. The data were organized between March and June 2018 and updated in January 2019.

Neighborhood socioeconomic variables

To analyze the distribution of commercial food establishments according to the socioeconomic characteristics of the neighborhoods, we used the average income of the head of the household and the proportion of black and brown minorities in the census tracts of Campinas provided by the 2010 National Demographic Census³⁴34 Instituto Brasileiro de Geografia e Estatística (IBGE). Operação censitária. Censo 2010 [Internet]. [acessado 2019 ago 3]. Disponível em: https://censo2010.ibge.gov.br/.
https://censo2010.ibge.gov.br... because the cost of food is a barrier to adequate and healthy eating³⁵35 Ricardo CZ, Claro RM. Custo da alimentação e densidade energética da dieta no Brasil, 2008-2009. Cad Saude Publica 2012; 28:2349-2361. and minorities face barriers that hinder their mobility³⁶36 Vargas JHC. Apartheid brasileiro: raça e segregação residencial no Rio de Janeiro. Rev Antropol 2005; 48:75-131.. The average income of the head of household (R$) was categorized into five groups according to the minimum wage of R$ 510 established on June 15^th, 2010³⁷37 Brasil. Lei nº 12.255, de 15 de junho de 2010. Dispões sobre o salário mínimo a partir de 1º de janeiro de 2010, estabelece diretrizes para a política de valorização do salário mínimo entre 2012 e 2023 e revoga a Lei nº 11.944, de 28 de maio de 2009. Diário Oficial da União; 2010.. The proportion of minorities was divided into quartiles.

Distribution of commercial food establishments and mapping of food swamps

The socioeconomic information of the neighborhoods and the geographic coordinates of the commercial food establishments were imported into ArcGis 10.6.1 software; using the digital mesh of the Regional Administration (RAs) of Campinas provided by Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística)³⁸38 Instituto Brasileiro de Geografia e Estatística (IBGE). Mapas. Malhas Digitais [Internet]. 2019 [acessado 2019 jun 7]. Disponível em: https://www.ibge.gov.br.
https://www.ibge.gov.br... , choropleth maps were developed to analyze the distribution of commercial food establishments according to the socioeconomic variables of the RAs. The RAs are submunicipalities divided according to the geographical position and the history of occupation of the regions to facilitate the administration of the municipality and divide the territory of Campinas into 18 regions: RA 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12 (or Ouro Verde), 13 (or Campo Grande), 14, Barão Geraldo, Joaquim Egidio, Nova Aparecida and Souzas³⁹39 Campinas. Coordenadoria das Administrações Regionais [Internet]. 2019 [acessado 2019 jun 5]. Disponível em: https://www.campinas.sp.gov.br/governo/infraestrutura/departamentos/coar.php.
https://www.campinas.sp.gov.br/governo/i... .

Densities of each type of commercial food establishment were identified and two indicators were developed. Indicator 1 refers to the density of fresh and minimally processed food establishments per 10,000 inhabitants in each RA. In this indicator, open-air organic/agroecological food markets and supermarkets were considered. The open-air food markets were included because they mostly sell fresh food²⁷27 Watanabe MA, Luiz AJB, Abreu LSd. Preços de hortifrutis convencionais e orgânicas em feiras livres e supermercado de Barão Geraldo, Campinas, SP, Brasil [Internet]. 2018 [acessado 2020 out 5]. Disponível em: https://www.embrapa.br/busca-de-publicacoes/-/publicacao/1105340/precos-de-hortifrutis-convencionais-e-organicas-em-feiras-livres-e-supermercado-de-barao-geraldo-campinas-sp-brasil.
https://www.embrapa.br/busca-de-publicac... ^,2828 Ueno VA, Fagundes GG, Habib M. Análise comparativa das feiras livres convencionais e orgânicas no município de Campinas (SP). Cad Agroecologia 2016; 10(3):1-5. and the supermarkets because they also offer fresh and minimally processed foods. Moreover, in the southeast of the country, the profile of food acquisition in supermarkets is mixed²⁹29 Câmara Interministerial de Segurança Alimentar e Nutricional. Mapeamento dos desertos alimentares no Brasil [Internet]. 2018 [acessado 2019 nov 12]. Disponível em: https://aplicacoes.mds.gov.br.
https://aplicacoes.mds.gov.br... . The index, also used by CAISAN to identify food deserts²⁹29 Câmara Interministerial de Segurança Alimentar e Nutricional. Mapeamento dos desertos alimentares no Brasil [Internet]. 2018 [acessado 2019 nov 12]. Disponível em: https://aplicacoes.mds.gov.br.
https://aplicacoes.mds.gov.br... , was calculated using the following formula:

Indicator 1:

Based on classifications used in Brazil and other countries that take into account the existence of regions with low physical access to establishments that sell fresh and minimally processed foods and the abundance of establishments that sell ultra-processed foods²⁹29 Câmara Interministerial de Segurança Alimentar e Nutricional. Mapeamento dos desertos alimentares no Brasil [Internet]. 2018 [acessado 2019 nov 12]. Disponível em: https://aplicacoes.mds.gov.br.
https://aplicacoes.mds.gov.br... ^,4040 Census Tract Level State Maps of the Modified Retail Food Environment Index (mRFEI) [Internet]. 2011 [acessado 2019 jun 1]. Disponível em: https://www.cdc.gov.
https://www.cdc.gov...

41 Luan H, Law J, Quick M. Identifying food deserts and swamps based on relative healthy food access: a spatio-temporal Bayesian approach. Int J Health Geogr 2015; 14(1):37.

42 Hager ER, Cockerham A, O'Reilly N, Harrington D, Harding J, Hurley KM, Black MM. Food swamps and food deserts in Baltimore City, MD, USA: associations with dietary behaviours among urban adolescent girls. Public Health Nutr 2017; 20(14):2598-2607.^-4343 Mui Y, Jones-Smith JC, Thornton RLJ, Pollack Porter K, Gittelsohn J. Relationships between Vacant Homes and Food Swamps: A Longitudinal Study of an Urban Food Environment. Int J Environ Res Public Health 2017; 14(11):1426., indicator 2 was created and adapted to identify the RAs of Campinas considered food swamps.

Using the formula below, we created a dichotomous variable in which the SWs had greater availability of fast-food restaurants in relation to open-air organic/agroecological food markets and supermarkets (value of the ratio greater than the median, (p50=0.332) in addition to the average income of the head of the household below the median income distribution in the municipality of Campinas (p50=R$ 2,275) and/or the mean proportion of minorities above the median income distribution (p50=26.9%).

Indicator 2:

+ average income of the head of household <median of the municipality and/or % of minorities > median of the municipality

Choropleth maps with the results of indicators 1 and 2 were made using ArcGis 10.6.1 software.

Results

Among the commercial food establishments analyzed in Campinas, 30.3% (n=79) were fast-food, 31.4% (n=82) supermarkets, and 38.3% (n=100) open-air food markets. Of the latter, 85.0% were free fairs and 15.0% were organic/agroecological fairs. The free fairs and organic/agroecological fairs were not fixed but were held on specific days and times and at planned locations.

To evaluate the density of commercial food establishments in Campinas and map the regions of the municipality considered food swamps, municipal division of RAs were used. The RAs with the highest incomes were those with the lowest percentages of minorities (Table 1). In addition, all the establishments analyzed coexisted predominantly in the census tracts in which the head of household had a higher average income (>R$ 1,021) and a lower proportion of minorities (<27.4%).

The highest densities of free markets, organic/agroecological markets and supermarkets were found in the central region of the municipality of Campinas and in the Souzas RA (Figure 1, Table 2).

In addition, in nine RAs, the ratio between the absolute number of fast-food restaurants and the absolute number of open-air organic/agroecological food markets and supermarkets was higher than the median ratio in the municipality (Table 2). Among these RAs, five were classified as food swamps considering the average income of the head of the household less than R$ 2,275 and the proportion of minorities less than 26.9% (Table 2, Figure 2). The regions considered food swamps accounted for one third (32.0%) of open-air organic/agroecological food markets and 26.5% of supermarkets in the municipality.

Discussion

When evaluating the distribution of commercial food establishments in the municipality of Campinas, we found evidence of inequalities in this distribution, and regions with higher income and lower percentage of minorities showed a higher concentration of all types of commercial food establishments analyzed - restaurants of fast-food, free markets and organic/agroecological and supermarkets - compared to the most vulnerable regions.

Five of a total of eighteen RAs in the municipality were considered food swamps. These RAs, which are located in the central and southern regions of the municipality of Campinas, showed indicators of social vulnerability; the ratio between the absolute number of establishments selling unhealthy foods and the absolute number of establishments with healthy options was greater than the median of ratio of the municipality.

Our results were similar to those of municipalities such as São Paulo¹⁷17 Duran AC, Diez Roux AV, Latorre MdRDO, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23:39-47., Jundiaí⁴⁴44 Fortes MF, Borges CA, Miranda WCd, Jaime PC. Mapeando as desigualdades socioeconômicas na distribuição do comércio varejista local. SAN 2018; 25(3):45-58., Belo Horizonte¹⁸18 Lopes ACS, Menezes MCd, Araújo ML. Food environment and access to fruits and vegetables: "A metropolis into perspective". Saude Soc 2017; 26(3):764-773., and Juiz de Fora⁴⁵45 Leite MA, Assis MM, Carmo AS, Nogueira MC, Pereira Netto M, Mendes LL. Inequities in the urban food environment of a Brazilian city. Food Security 2021; 13(3):539-549., which showed that, in general, wealthier neighborhoods have a higher density of in natura and minimal commercial food establishments. We also found that less vulnerable regions have a higher proportion of all types of establishments⁴⁵45 Leite MA, Assis MM, Carmo AS, Nogueira MC, Pereira Netto M, Mendes LL. Inequities in the urban food environment of a Brazilian city. Food Security 2021; 13(3):539-549.

46 Honório OS, Horta PM, Mendes LL. Desertos e pântanos alimentares em uma metrópole brasileira [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais; 2020.^-4747 Jaime PC, Duran AC, Sarti FM, Lock K. Investigating environmental determinants of diet, physical activity, and overweight among adults in Sao Paulo, Brazil. J Urban Health 2011; 88(3):567-581..

The food swamps identified in Campinas, consisting of regions of low socioeconomic status that have higher availability of ultra-processed food establishments compared to establishments selling fresh and minimally processed foods, indicate high exposure to unhealthy foods. The concept of food swamp complements the concept of food desert in that it highlights the deleterious role of competition established by the presence of establishments that sell a higher proportion of ultra-processed foods compared to mixed establishments and that sell primarily fresh and minimally processed foods⁴⁸48 Ghosh-Dastidar B, Cohen D, Hunter G, Zenk SN, Huang C, Beckman R, Dubowitz T. Distance to store, food prices, and obesity in urban food deserts. Am J Prev Med 2014; 47(5):587-595.. Evidence suggests that food swamps may play an even more relevant role than food deserts in contributing to the prevalence of obesity, diabetes and health inequities¹³13 Cooksey-Stowers K, Schwartz MB, Brownell KD. Food Swamps Predict Obesity Rates Better Than Food Deserts in the United States. Int J Environ Res Public Health 2017; 14(11):1366.^,4242 Hager ER, Cockerham A, O'Reilly N, Harrington D, Harding J, Hurley KM, Black MM. Food swamps and food deserts in Baltimore City, MD, USA: associations with dietary behaviours among urban adolescent girls. Public Health Nutr 2017; 20(14):2598-2607.^,4949 Phillips AZ, Rodriguez HP. U.S. county "food swamp" severity and hospitalization rates among adults with diabetes: A nonlinear relationship. Soc Sci Med 2020; 249:112858..

Individuals living in regions with limited access to fresh and minimally processed foods, such as food swamps, also have worse access to health services, transportation, parks and leisure facilities⁵⁰50 United States Department of Agriculture. Characteristics and Influential Factors of Food Deserts [Internet]. 2012 [cited 2019 nov 2]. Available from: https://www.ers.usda.gov.
https://www.ers.usda.gov... and higher rates of food and nutritional insecurity⁵¹51 Brito AP, Lima VN, Silva EGCM, Rêgo AS, Dias LPP, Silva JS, Carvalho WRC, Barbosa JMA. Fatores associados à Insegurança Alimentar e Nutricional em comunidade carente. Rev Bras Promo Saude 2020; 33:10415.. In Brazil, in households with low income, food and nutritional insecurity is even more aggravated among households headed by women and with black residents⁵²52 Marin-Leon L, Francisco PMSB, Segall-Corrêa AM, Panigassi G. Bens de consumo e insegurança alimentar: diferenças de gênero, cor de pele autorreferida e condição socioeconômica. Rev Bras Epidemiol 2011; 14:398-410..

Despite the classification of supermarkets as establishments that offer fresh and minimally processed foods²⁹29 Câmara Interministerial de Segurança Alimentar e Nutricional. Mapeamento dos desertos alimentares no Brasil [Internet]. 2018 [acessado 2019 nov 12]. Disponível em: https://aplicacoes.mds.gov.br.
https://aplicacoes.mds.gov.br... , it is important to note that currently, most of these establishments are not restricted to selling only one type of product, i.e., ultra-processed foods occupy the largest portion of supermarket offerings⁵³53 Borges CA, Cabral-Miranda W, Constante Jaime P. Urban Food Sources and the Challenges of Food Availability According to the Brazilian Dietary Guidelines Recommendations. Sustainability 2018; 10(12):4643.. Advertising strategies and high exposure to ultra-processed foods can influence the choice of these foods at the time of purchase⁵⁴54 Charlton EL, Kähkönen LA, Sacks G, Cameron AJ. Supermarkets and unhealthy food marketing: An international comparison of the content of supermarket catalogues/circulars. Prev Med 2015; 81:168-173.

55 Camargo AM, Farias JP, Mazzonetto AC, Dean M, Fiates GMR. Content of Brazilian supermarket circulars do not reflect national dietary guidelines. Health Promot Int 2019; 35(5):1052-1060.^-5656 Machado PP, Claro RM, Canella DS, Sarti FM, Levy RB. Price and convenience: The influence of supermarkets on consumption of ultra-processed foods and beverages in Brazil. Appetite 2017; 116:381-388.. Due to convenience and affordable prices, in addition to structural changes in food supply chains, supermarkets supply an increasing share of fresh and minimally processed foods purchased in Brazil and other Latin American countries⁵⁶56 Machado PP, Claro RM, Canella DS, Sarti FM, Levy RB. Price and convenience: The influence of supermarkets on consumption of ultra-processed foods and beverages in Brazil. Appetite 2017; 116:381-388.^,5757 Popkin BM, Reardon T. Obesity and the food system transformation in Latin America. Obesity Rev 2018; 19(8):1028-1064..

Considering the differences in the food environment between countries⁵⁷57 Popkin BM, Reardon T. Obesity and the food system transformation in Latin America. Obesity Rev 2018; 19(8):1028-1064.^,5858 Duran AC, Mialon M, Crosbie E, Jensen ML, Harris JL, Batis C, Corvalán C, Taillie LS. Food environment solutions for childhood obesity in Latin America and among Latinos living in the United States. Obes Rev 2021; 22(Supl. 3):e13237., it is possible to observe similarities and differences when comparing the food environment of large Brazilian metropolises and other countries. In the United States, for example, fewer supermarkets and more fast-food restaurants and convenience stores are located in neighborhoods with higher proportions of low-income residents compared to wealthier neighborhoods⁵⁹59 Morland K, Wing S, Diez Roux A, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med 2002; 22(1):23-29.. In addition, in the regions with the highest proportion of blacks, the availability of supermarkets corresponds to half of that found in the regions with the highest proportion of whites^3.60. On the other hand, in New Zealand and Canada, there is a higher density of different types of establishments, such as supermarkets and fast-food restaurants, in more vulnerable regions than in less vulnerable regions⁶¹61 Smoyer-Tomic KE, Spence JC, Raine KD, Amrhein C, Cameron N, Yasenovskiy V, Cutumisu N, Hemphill E, Healy J. The association between neighborhood socioeconomic status and exposure to supermarkets and fast food outlets. Health Place 2008; 14(4):740-754.

62 Black J, Carpiano R, Fleming S, Lauster N. Exploring the distribution of food stores in British Columbia: Associations with neighbourhood socio-demographic factors and urban form. Health Place 2011; 17:961-970.

63 Polsky JY, Moineddin R, Glazier RH, Dunn JR, Booth GL. Foodscapes of southern Ontario: neighbourhood deprivation and access to healthy and unhealthy food retail. Can J Public Health 2014; 105(5):e369-e375.

64 Sushil Z, Vandevijvere S, Exeter DJ, Swinburn B. Food swamps by area socioeconomic deprivation in New Zealand: a national study. Int J Public Health 2017; 62(8):869-877.^-6565 Yang M, Wang H, Qiu F. Neighbourhood food environments revisited: When food deserts meet food swamps. Can Geogr 2020; 64(1):135-154.. The term “food apartheid” therefore arises to reinforce that food environments are the result of social and racial policies and injustices¹⁴14 Campus Environmental Center. 'Food Apartheid' (not 'Desert') [Internet]. 2021 [cited 2021 abr 16]. Available from: https://utenvironment.org/projects/microfarm/food-justice/glossary/food-apartheid-not-desert.
https://utenvironment.org/projects/micro... , highlighting the discriminatory political structures of the past and present that affect food access¹⁴14 Campus Environmental Center. 'Food Apartheid' (not 'Desert') [Internet]. 2021 [cited 2021 abr 16]. Available from: https://utenvironment.org/projects/microfarm/food-justice/glossary/food-apartheid-not-desert.
https://utenvironment.org/projects/micro... .

Many factors influence the location of commercial establishments, including the income of residents, proximity to potential consumers, traffic and access facilities, location of competitors, and characteristics of the property⁶⁶66 Sfredo JM, Pereira LN, Moraes PRP, Dalmau M. Análise de fatores relevantes quanto à localização de empresas: comparativo entre uma indústria e uma prestadora de serviços com base nos pressupostos teóricos [Internet]. 2006 [acessado 2021 mar 12]. Disponível em: http://www.abepro.org.br/biblioteca/ENEGEP2006_TR530355_8296.pdf.
http://www.abepro.org.br/biblioteca/ENEG... . Urban planning tools can assist in food equity¹²12 Daley B. How urban planning and housing policy helped create 'food apartheid' in US cities [Internet]. 2021 [cited 2019 set 16]. Available from: https://theconversation.com/how-urban-planning-and-housing-policy-helped-create-food-apartheid-in-us-cities-154433.
https://theconversation.com/how-urban-pl... .

Promoting healthy eating habits, therefore, requires a combination of multilevel strategies⁶⁷67 World Cancer Research Fund International. Our Policy Framework to Promote Healthy Diets & Reduce Obesity [Internet]. 2020 [cited 2021 mar 12]. Available from: https://www.wcrf.org/policy/policy-databases/nourishing-framework/.
https://www.wcrf.org/policy/policy-datab... , including improving the local food environment, which can be achieved by restricting establishments that essentially sell ultraprocessed foods in areas close to schools⁶⁸68 Henriques P, Alvarenga CRT, Ferreira DM, Dias PC, Soares DDSB, Barbosa RMS, Burlandy L. Food environment surrounding public and private schools: an opportunity or challenge for healthy eating? Cien Saude Colet 2021; 26(8):3135-3145.^,6969 Peres C, Costa BVL, Pessoa MC, Honório OS, Carmo ASD, Silva TPRD, Gardone DS, Meireles AL, Mendes LL. Community food environment and presence of food swamps around schools in a Brazilian metropolis. Cad Saude Publica 2021; 37(5):e00205120., increasing the number of open-air food markets, and extending their opening hours to meet residents’ needs and providing incentive programs and/or subsidies to encourage the purchase of food in these locations⁷⁰70 Atoloye AT, Savoie-Roskos MR, Durward CM. Higher Fruit and Vegetable Intake Is Associated with Participation in the Double Up Food Bucks (DUFB) Program. Nutrients 2021; 13(8):2607.^,7171 Rummo PE, Lyerly R, Rose J, Malyuta Y, Cohen ED, Nunn A. The impact of financial incentives on SNAP transactions at mobile produce markets. Int J Behav Nutr Phys Act 2021; 18(1):26.. Our results may contribute to the design of local policies by identifying priority regions.

The present study is not without limitations. The geographical division of municipalities, widely used in the literature¹⁷17 Duran AC, Diez Roux AV, Latorre MdRDO, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23:39-47.^,7272 Gould AC, Apparicio P, Cloutier MS. Classifying neighbourhoods by level of access to stores selling fresh fruit and vegetables and groceries: identifying problematic areas in the city of Gatineau, Quebec. Can J Public Health 2012; 103(6):e433-e437., is important for the characterization of the food environment but does not necessarily reflect the eating experiences of individuals⁴⁵45 Leite MA, Assis MM, Carmo AS, Nogueira MC, Pereira Netto M, Mendes LL. Inequities in the urban food environment of a Brazilian city. Food Security 2021; 13(3):539-549.. In addition, we used a restricted spectrum of types of commercial food establishments due to the lack of reliable secondary data on the location of bars, small cafeterias, grocery stores, neighborhood markets, and candy stores. However, the identification of potential priority areas for the implementation of public policies allows assisting the government and civil society in directing local actions. We did not collect data on the supply and price of food sold in each of the establishments individually to better characterize them. However, the growing literature in the area allows us to classify the commercial food establishments studied as more or less healthy according to the proportion of ultra-processed foods vs. natural and minimally processed foods they offered their consumers¹⁷17 Duran AC, Diez Roux AV, Latorre MdRDO, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23:39-47.^,2929 Câmara Interministerial de Segurança Alimentar e Nutricional. Mapeamento dos desertos alimentares no Brasil [Internet]. 2018 [acessado 2019 nov 12]. Disponível em: https://aplicacoes.mds.gov.br.
https://aplicacoes.mds.gov.br... ^,7373 Borges CA, Gabe KT, Jaime PC. Consumer Food Environment Healthiness Score: Development, Validation, and Testing between Different Types of Food Retailers. Int J Environ Res Public Health 2021; 18(7):3690..

In addition, the cross-sectional design of the study does not allow us to infer the causes of the inequalities found, but it corroborates the findings of several other studies in the country¹⁷17 Duran AC, Diez Roux AV, Latorre MdRDO, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23:39-47.^,1818 Lopes ACS, Menezes MCd, Araújo ML. Food environment and access to fruits and vegetables: "A metropolis into perspective". Saude Soc 2017; 26(3):764-773.. Studies with experimental and quasi-experimental designs, which allow conclusions about the effects of the local retail environment on food purchasing and consumption behaviors, have found that the opening of a new supermarket in an area previously considered a food desert was associated with an improvement in food and nutritional security and decreased consumption of sugary foods among beneficiaries of a food aid program in the United States⁷⁴74 Cantor J, Beckman R, Collins RL, Dastidar MG, Richardson AS, Dubowitz T. SNAP Participants Improved Food Security And Diet After A Full-Service Supermarket Opened In An Urban Food Desert. Health Aff 2020; 39(8):1386-1394. and a lower prevalence of diabetes when compared to a counterfactual⁷⁵75 Richardson AS, Ghosh-Dastidar M, Beckman R, Flórez KR, DeSantis A, Collins RL, Dubowitz T. Can the introduction of a full-service supermarket in a food desert improve residents' economic status and health? Ann Epidemiol 2017; 27(12):771-776..

These findings demonstrate the potential effect of changes in the food environment and diet of populations living in more vulnerable areas and with less access to fresh and minimally processed foods among beneficiaries of income transfer programs. The combination of measures that affect both the supply and demand for fresh and minimally processed foods should therefore be stimulated to enhance their effectiveness. Finally, evaluations of food marshes, especially in low- and middle-income countries, should be refined to support new studies on the association between the distribution of commercial food establishments, food consumption, and health outcomes⁷⁶76 Honório OS, Pessoa MC, Gratão LHA, Rocha LL, de Castro IRR, Canella DS, Horta PM, Mendes LL. Social inequalities in the surrounding areas of food deserts and food swamps in a Brazilian metropolis. Int J Equity Health 2021; 20(1):168..

In Campinas, the most vulnerable regions had a lower concentration of all types of commercial food establishments compared to the less vulnerable regions. Approximately one-third of the RAs of Campinas were considered food swamps and should be prioritized in public policies and local interventions aimed at promoting the equitable distribution of fresh and minimally processed foods.

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