Abstract:

This study aims to explore potential barriers and facilitators for healthy eating in the consumer food environment, and to analyze the association with different types of food retailers, having as theoretical reference the Dietary Guidelines for the Brazilian Population. This is a cross-sectional study carried out in the municipality of Jundiaí, São Paulo State, Brazil, with audits of the consumer food environment carried out in 650 retail stores. We identified barriers and facilitators of healthy food choices in the internal environment of the retail. Factor analysis estimated factors that characterized the environment according to barriers and facilitators. Linear regression evaluated the association between the factors and the different categories of establishments. Most establishments had priority sales of ultra-processed products. Out of the total food retailers studied, 75.9% offered sugary drinks; 37% rice, beans and 30% fruits and vegetables. We characterized the first factor by the presence of both barriers and facilitators (mixed factor), the second factor by more facilitators and the third by greater presence of barriers in the consumer environment. Supermarkets were positively associated with the three factors (p-value < 0.001). The fruit and vegetable stores and the neighborhood markets had a positive association with the most facilitating factor (p-value < 0.001). Markets and bakeries were positively associated with the more barriers factor (p-value < 0.001). The patterns that characterize barriers and facilitators for healthy eating differ significantly according to types of food retailers.

Keywords:
Food Supply; Healthy Diet; Environmental Health

Introduction

The food environment refers to the physical, economic, political and sociocultural context in which consumers interact with the food system to acquire, prepare and consume food ¹1. High Level Panel of Experts on Food Security and Nutrition. Nutrition and food systems. A report by the High Level Panel of Experts on Food Security and Nutrition. Rome: High Level Panel of Experts on Food Security and Nutrition, Committee on World Food Security; 2017. (HPLE Report, 12).. The conditions and characteristics of this environment influence the choices and life habits of individuals, and this can be considered an obesogenic environment and favor the development of obesity ²2. Swinburn B, Egger G, Raza F. Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med 1999; 29:563-70.. There are several national ³3. Pessoa MC, Mendes LL, Gomes CS, Martins PA, Velasquez-Melendez G. Food environment and fruit and vegetable intake in a urban population: a multilevel analysis. BMC Public Health 2015; 15:1012.^,44. 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; 21:189-200.^,55. Duran AC, Almeida SL, Latorre MRDO, Jaime PC. The role of the local retail food environment in fruit, vegetable, and sugar-sweetened beverage consumption in Brazil. Public Health Nutr 2016; 19:1093-102.^,66. Jaime PC, Duran AC, Sarti FM, Lock K. Investigating environmental determinants of diet, physical activity, and overweight among adults in São Paulo, Brazil. J Urban Health 2011; 88:567-81. and international ⁷7. Caspi CE, Sorensen G, Subramanian SV, Kawachi I. The local food environment and diet: a systematic review. Health Place 2012; 18:1172-87.^,88. Glanz K, Johnson L, Yaroch AL, Phillips M, Ayala GX, Davis EL. Measures of retail food store environments and sales: review and implications for healthy eating initiatives. J Nutr Educ Behav 2016; 48:280-8.^,99. Glanz K, Sallis JF, Saelens BE, Frank LD. Healthy nutrition environments: concepts and measures. Am J Health Promot 2005; 19:330-3.^,1010. Sallis JF, Glanz K. Physical activity and food environments: solutions to the obesity epidemic. Milbank Q 2009; 87:123-54. studies that explore the complex relationship between the different environmental determinants and health-related outcomes, such as physical activity, food consumption and obesity.

One of the conceptual models developed to support the understanding of the complexity of environmental determinants and their relationship with food consumption was built by Glanz et al. ⁹9. Glanz K, Sallis JF, Saelens BE, Frank LD. Healthy nutrition environments: concepts and measures. Am J Health Promot 2005; 19:330-3. and divides the food environment into four dimensions: community, consumer, organizational and information. All these dimensions are influenced by public policies and by the private sector, shaping the population’s eating patterns. A literature review also performed by Glanz et al. ⁸8. Glanz K, Johnson L, Yaroch AL, Phillips M, Ayala GX, Davis EL. Measures of retail food store environments and sales: review and implications for healthy eating initiatives. J Nutr Educ Behav 2016; 48:280-8. showed that most of the studies using the model cited are on the community food environment with a focus on the presence, density and type/category of commercial food establishments and their relationship with obesity and food consumption ⁷7. Caspi CE, Sorensen G, Subramanian SV, Kawachi I. The local food environment and diet: a systematic review. Health Place 2012; 18:1172-87.^,88. Glanz K, Johnson L, Yaroch AL, Phillips M, Ayala GX, Davis EL. Measures of retail food store environments and sales: review and implications for healthy eating initiatives. J Nutr Educ Behav 2016; 48:280-8.^,1111. McKinnon RA, Reedy J, Morrissette MA, Lytle LA, Yaroch AL. Measures of the food environment: a compilation of the literature, 1990-2007. Am J Prev Med 2009; 36 Suppl 4:S124-33.. A smaller number of studies explore the relationships between the consumer’s food environment with diet and obesity ⁷7. Caspi CE, Sorensen G, Subramanian SV, Kawachi I. The local food environment and diet: a systematic review. Health Place 2012; 18:1172-87.. The consumer environment is the space where people acquire food and at the same time are exposed to factors that can positively or negatively influence food choices ¹1. High Level Panel of Experts on Food Security and Nutrition. Nutrition and food systems. A report by the High Level Panel of Experts on Food Security and Nutrition. Rome: High Level Panel of Experts on Food Security and Nutrition, Committee on World Food Security; 2017. (HPLE Report, 12).^,88. Glanz K, Johnson L, Yaroch AL, Phillips M, Ayala GX, Davis EL. Measures of retail food store environments and sales: review and implications for healthy eating initiatives. J Nutr Educ Behav 2016; 48:280-8.^,1212. Black C, Ntani G, Inskip H, Cooper C, Cummins S, Moon G, et al. Measuring the healthfulness of food retail stores: variations by store type and neighbourhood deprivation. Int J Behav Nutr Phys Act 2014; 11:69.^,1313. Zenk SN, Lachance LL, Schulz AJ, Mentz G, Kannan S, Ridella W. Neighborhood retail food environment and fruit and vegetable intake in a multiethnic urban population. Am J Health Promot 2009; 23:255-64.^,1414. Cameron AJ, Waterlander WE, Svastisalee CM. The correlation between supermarket size and national obesity prevalence. BMC Obes 2014; 1:27.. Among these factors are the availability of food, variety, quality, price, sale, advertising, location of products on the shelves, organization of physical space and nutritional information ⁷7. Caspi CE, Sorensen G, Subramanian SV, Kawachi I. The local food environment and diet: a systematic review. Health Place 2012; 18:1172-87..

In the consumer food environment, the use of strategies such as increasing supply and variety of healthy foods at affordable prices ¹⁵15. Liberato SC, Bailie R, Brimblecombe J. Nutrition interventions at point-of-sale to encourage healthier food purchasing: a systematic review. BMC Public Health 2014; 14:919., making fruits and vegetables available at the store entrance and or at strategic positions ¹⁶16. Stanton RA. Food retailers and obesity. Curr Obes Rep 2015; 4:54-9., carrying out promotional pricing for healthy foods and reducing advertisements for unhealthy foods seem to act as facilitators for healthier food choices ⁸8. Glanz K, Johnson L, Yaroch AL, Phillips M, Ayala GX, Davis EL. Measures of retail food store environments and sales: review and implications for healthy eating initiatives. J Nutr Educ Behav 2016; 48:280-8.^,1212. Black C, Ntani G, Inskip H, Cooper C, Cummins S, Moon G, et al. Measuring the healthfulness of food retail stores: variations by store type and neighbourhood deprivation. Int J Behav Nutr Phys Act 2014; 11:69.^,1717. Adjoian T, Dannefer R, Willingham C, Brathwaite C, Franklin S. Healthy checkout lines: a study in urban supermarkets. J Nutr Educ Behav 2017; 49:615-22.^,1818. Jahns L, Payne CR, Whigham LD, et al. Foods advertised in US weekly supermarket sales circulars over one year: a content analysis. Nutr J 2014; 13:95.. On the other hand, the most common barriers found in literature that manipulate the purchase behavior and force the consumer to acquire unplanned foods ¹⁹19. Foster GD, Karpyn A, Wojtanowski AC, Davis E, Weiss S, Brensinger C, et al. Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: a randomized controlled trial. Am J Clin Nutr 2014; 99:1359-68. are: the presence of publicity and promotions with ultra-processed foods ²⁰20. 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; 81:168-73., the use of sophisticated marketing skills to influence the consumer (for example, ensuring the circulation throughout the store so that the consumer goes through all sections, including islands and displays with ultra-processed foods, making ultra-processed foods available in the cashier lines), offering tastings of foods ²¹21. Castro IA, Majmundar A, Williams CB, Baquero B. Customer purchase intentions and choice in food retail environments: a scoping review. Int J Environ Res Public Health 2018; 15:2493., allowing suppliers of ultra-processed foods to pay for privileged spaces inside the stores and increasing the space in the shelves for unhealthy foods or positioning them at eye-level ¹⁶16. Stanton RA. Food retailers and obesity. Curr Obes Rep 2015; 4:54-9..

The presence of facilitators and barriers to healthy food choices differ according to types of food retailers. In the United States, grocery stores or small retails (equivalent to neighborhood markets in Brazil), are associated with better availability of healthy foods than those named corner stores (equivalent to our convenience stores) ²²22. Gustafson A, Christian JW, Lewis S, Moore K, Jilcott S. Food venue choice, consumer food environment, but not food venue availability within daily travel patterns are associated with dietary intake among adults, Lexington Kentucky 2011. Nutr J 2013; 12:17.. In supermarkets the findings are divergent. In Australia, a study has identified that supermarkets can market healthy foods in variety, but their shelves and marketing strategies emphasize ultra-processed foods, which, despite being profitable for retailers, does not comply with food guidelines that recommend the consumption of in natura or minimally processed foods ¹⁶16. Stanton RA. Food retailers and obesity. Curr Obes Rep 2015; 4:54-9.. In the United States ²³23. Martin-Biggers J, Yorkin M, Aljallad C, Ciecierski C, Akhabue I, McKinley J, et al. What foods are US supermarkets promoting? A content analysis of supermarket sales circulars. Appetite 2013; 62:160-5., the Netherlands ²⁴24. Ravensbergen EAH, Waterlander WE, Kroeze W, Steenhuis IHM. Healthy or unhealthy on sale? A cross-sectional study on the proportion of healthy and unhealthy foods promoted through flyer advertising by supermarkets in the Netherlands. BMC Public Health 2015; 15:470. and Brazil ²⁵25. Camargo AM, Farias JP, Mazzonetto AC, Dean M, Fiates GMR. Content of Brazilian supermarket circulars do not reflect national dietary guidelines. Health Promot Int 2020; 35:1052-60., flyers available in supermarkets with food promotions and advertising are dominated by ultra-processed foods compared to in natura or minimally processed foods. In other regions of the world, the presence of fresh food in supermarkets is associated with a lower prevalence of obesity compared to areas served only by local markets with more restricted options available ²⁶26. Morland K, Diez Roux AV, Wing S. Supermarkets, other food stores, and obesity: the atherosclerosis risk in communities study. Am J Prev Med 2006; 30:333-9.^,2727. Rose D, Hutchinson PL, Bodor JN, Swalm CM, Farley TA, Cohen DA, et al. Neighborhood food environments and body mass index. Am J Prev Med 2009; 37:214-9..

In Brazil, although two important studies with representative samples of the population identify that the main place of food acquisition among Brazilians is the supermarket ²⁸28. 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; 116:381-8.^,2929. Costa JC, Claro RM, Martins APB, Levy RB. Food purchasing sites: repercussions for healthy eating. Appetite 2013; 70:99-103., we have in the national territory different types of shops where food sales occur, such as supermarkets, hypermarkets, wholesalers, markets, grocery stores, convenience stores, bakeries, butchers, fish shops, fruit and vegetable stores and greengrocer. These establishments differ in terms of the nature of the products marketed, size and physical structure ³⁰30. Instituto Brasileiro de Geografia e Estatítica. Comissão Nacional de Classificação: CNAE. https://cnae.ibge.gov.br/concla.html (acessado em 21/Set/2020).
https://cnae.ibge.gov.br/concla.html... . Brazilian studies suggest that food retailers are associated with the consumption of fruits and vegetables as well as sugary drinks and ultra-processed foods ⁵5. Duran AC, Almeida SL, Latorre MRDO, Jaime PC. The role of the local retail food environment in fruit, vegetable, and sugar-sweetened beverage consumption in Brazil. Public Health Nutr 2016; 19:1093-102.^,3131. Machado PP, Claro RM, Martins APB, Costa JC, Levy RB. Is food store type associated with the consumption of ultra-processed food and drink products in Brazil? Public Health Nutr 2018; 21:201-9., and among the environmental factors that lead to these findings are food availability, price and advertising.

On the national scenario, where the population has been increasingly purchasing and consuming ultra-processed foods ³²32. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares, 2017-2018: primeiros resultados. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019. and with a higher prevalence of obesity ³³33. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas. Brasília: Instituto Brasileiro de Geografia e Estatística; 2014., understanding the barriers and facilitators to healthy food choices present in the consumer environment may help identify the locations that increase the supply of healthy foods, to assist in understanding the environmental factors related to obesity and guide the population in their process of acquiring food ³⁴34. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2013.. Considering that, this study aims to explore potential barriers and facilitators for healthy eating in the consumer food environment and analyze the association with different types of food retailers, having as theoretical reference the Dietary Guidelines for the Brazilian Population³⁵35. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014..

Methods

Study design and sample

This is a cross-sectional study conducted in the municipality of Jundiaí, São Paulo State, Brazil. An audit of the consumer food environment was conducted between the months of December 2017 to April 2018 in virtually the entire urban territory of the municipality. To get a general overview of this environment, first, all 624 urban census sectors of Jundiaí were identified and mapped. Of these, 92% (n = 573) were covered by the researchers and only 8% (n = 51) were not, due to difficulty of access or issues of urban violence. Among the census sectors covered, 650 food retailers were identified, and the internal audit of the establishment was carried out in all of them. All retail businesses that participated in the study received information and signed the Informed Consent Form. The study was approved by the Research Ethics Committee of the School of Public Health, University of São Paulo (CAAE: 69045917.5.0000.5421).

Audit of the consumer food environment and classification of retail trades

The audit was carried out by six researchers trained according to a previously published field manual ³⁶36. Borges CA, Scaciota LL, Gomes ATS, Serafim P, Jaime PC. Manual de aplicação de instrumento de auditoria do ambiente alimentar baseado na nova classificação de alimentos do guia alimentar (NOVA). São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2018.. The training lasted 6 hours, allowing the presentation of the healthy eating guidelines proposed in the Dietary Guidelines for the Brazilian Population³⁵35. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014.. The instrument used in the data collection was AUDITNOVA (https://nutritotal.com.br/pro/material/audit-nova/), a checklist-type instrument that allows collecting information on availability, variety and price (normal or in sales) of 66 foods and beverages, as well as advertising strategies, information and positioning of in natura or minimally processed foods, culinary ingredients, processed foods and ultra-processed foods according to the new food classification ³⁷37. Monteiro CA, Cannon G, Levy RB, Moubarac J-C, Louzada MLC, Rauber F, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutr 2019; 22:936-41.. Details on the process of validation and reliability assessment of this instrument are in a previous publication ³⁸38. Borges CA, Jaime PC. Desenvolvimento e avaliação de instrumento de auditoria do ambiente alimentar: AUDITNOVA. Rev Saúde Pública 2019; 53:91.

The 650 food retailers identified in the audit were grouped into 6 categories adapted from Machado et al. ³¹31. Machado PP, Claro RM, Martins APB, Costa JC, Levy RB. Is food store type associated with the consumption of ultra-processed food and drink products in Brazil? Public Health Nutr 2018; 21:201-9. and Castro Junior ³⁹39. Castro Junior PCP. Ambiente alimentar comunitário medido e percebido: descrição e associação com índice de massa corporal de adultos brasileiros [Tese de Doutorado]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2018.: (1) butcher/fish shop/slaughterhouses, (2) public and private fruit and vegetable stores, (3) neighborhood markets, (4) supermarkets, (5) bakeries, (6) trade with priority sale of ultra-processed products (consisting of corner stores, sweets and treats stores, pharmacies, food supplement stores and trade in beverages).

Construction of the variables barriers and facilitators

From the information present in the AUDITNOVA instrument, it was possible to create variables that were classified as barriers and facilitators for healthy eating in the consumer food environment, which were in dialogue with literature review studies on the subject ⁸8. Glanz K, Johnson L, Yaroch AL, Phillips M, Ayala GX, Davis EL. Measures of retail food store environments and sales: review and implications for healthy eating initiatives. J Nutr Educ Behav 2016; 48:280-8.^,4040. Pérez-Ferrer C, Auchincloss AH, Menezes MC, Kroker-Lobos MF, Cardoso LO, Barrientos-Gutierrez T. The food environment in Latin America: a systematic review with a focus on environments relevant to obesity and related chronic diseases. Public Health Nutr 2019; 22:3447-64.^,4141. Cobb LK, Appel LJ, Franco M, Jones-Smith JC, Nur A, Anderson CAM. The relationship of the local food environment with obesity: A systematic review of methods, study quality, and results. Obesity (Silver Spring) 2015; 23:1331-44. and also with the obstacles to achieve adequate and healthy eating present in the Dietary Guidelines for the Brazilian Population³⁵35. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014., in particular cost, information and advertising. Therefore, after this process, the dimensions considered for both barriers and facilitators were: advertising, information, physical modifications in the layout of the establishment, promotional pricing and availability. Table 1 shows in detail all the items included in the construction of each variable, as well as the dimensions analyzed.

In AUDITNOVA, the items that contemplate these dimensions are all dichotomous (with yes =1 and no = 0 answers). To create quantitative variables, the items were then added together for each of the barriers and facilitators studied.

The facilitators were built in the following quantitative variables: the advertising of in natura or minimally-processed foods, culinary ingredients; Information about in natura or minimally processed foods; Physical changes promoting in natura or minimally-processed foods; Promotional pricing of in natura or minimally-processed foods, culinary ingredients and processed foods; Availability of in natura or minimally-processed foods, culinary ingredients and processed foods. The construction of these indicators was guided by the Dietary Guidelines for the Brazilian Population³⁵35. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014., which recommends that the basis of food be composed of in natura or minimally processed foods and their culinary preparations, supplemented with small amounts of processed foods.

As barriers, the following continuous variables were created: advertising of ultra-processed foods; information in general; physical modifications promoting ultra-processed foods; promotional pricing of ultra-processed foods; availability of ultra-processed foods.

To create the variables on information, the main formats in which advertising messages and information on foods are available in the food retailers were considered (such as: posters, banners, flags, tabloids, flyers with recipes and magazines); for the advertising variable, the main consumer appeals were considered (example: health and well-being claim, practicality, practice of physical activity, among others); for the variable physical modifications, the main changes in the layout were considered to promote the sale of food (example: presence of food in the cash register, fruits and vegetables at the entrance of the store, displays and islands in the aisles of shops); and to create the variable promotional pricing, we considered if the food studied had a promotional price at the time of the audit (Table 1).

Statistical analysis

Analyses with descriptive statistics were used to characterize and explore the food retailers analyzed in the study. The means and the respective 95% confidence intervals (95%CI) were calculated for each variable considered facilitator and barrier to healthy choices, according to different categories of commercial establishment. To evaluate the differences in the variables barriers and facilitators according to the establishment category, an analysis of variance (ANOVA) was performed at a 95% confidence level.

Exploratory factor analysis was used to identify groups within the evaluated data that allowed to characterize the occurrence of barriers and facilitators of healthy eating in the consumer’s food environment. Factor analysis is especially interesting to identify latent variables from the studied data set ⁴²42. Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis. London: Prentice Hall; 2010.. The exploratory approach was chosen in the absence of an a priori understanding of what would be the possible combinations between facilitators and expected barriers in different categories of food retail trades. The analytical model included all 5 variables defined as barriers and 5 defined as facilitators in the form of continuous quantitative variables.

The Kaiser-Meyer-Olkin index (KMO) above 0.60 and the Bartlett’s test of sphericity (BTS) with a p-value below 0.05 were used to evaluate the adequacy of the sample and verify the applicability of the data for factor analysis ⁴²42. Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis. London: Prentice Hall; 2010.. After these procedures, exploratory factor analysis was performed (following the principal component factor extraction method) with orthogonal rotation of the varimax type. Each factor generated in the factor analysis represented a linear combination of the variables that entered the model. Variables with factor loads > 0.30 were considered important constituents of this factor ⁴²42. Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis. London: Prentice Hall; 2010.. Positive factor loads (> 0.30) indicate positive correlations between the variables and the factors obtained, while negative factor loads (> -0.30) indicate negative correlations.

To decide the number of factors to be retained by factor analysis, the following criteria were used: eigenvalues > 1, graphic interpretation of the Cattel or scree plot graphic test (observing the maximum point of inflection of the line) and interpretation of factor loads. After extraction of the main factors, standardized scores of each of them were calculated for each commercial establishment of the study.

Univariate linear regression analysis was used to evaluate the association between each of the factors (outcome) and the categories of food retailers studied (exposure). Positive associations show greater adherence of trade to certain set of barriers and facilitators, while negative associations show less adherence. All analyses were conducted in the statistical package Stata version 15 (https://www.stata.com). Values of p < 0.05 were considered significant.

Results

Of the 650 food retailers audited in the municipality of Jundiaí, 43.9% had a priority sale of ultra-processed products, 25.2% as neighborhood markets, 14.5% as bakeries, 5.9% butchers/fish shops/slaughterhouses and 5.9% as public and private fruit and vegetable stores (Table 2). In general, establishments offer a variety of in natura or minimally processed foods, culinary ingredients, processed foods and ultra-processed foods. Among the ultra-processed foods available, there was a high prevalence of establishments with the presence of sugary drinks (75.9%), candies, chocolates and sandwich cookies (74.8%), corn chips (59.1%) and ice cream (53.2%). On the other hand, there was also a high availability of culinary ingredients (55.5%), rice and beans (approximately 37.0% each), fruits, vegetables, roots and tubers (approximately 30% each) and water (79.7%) (Table 2).

Regarding the facilitators for healthy food choices, the supermarkets had, on average, more advertising of in natura or minimally-processed foods and culinary ingredients; more information on in natura or minimally-processed foods and promotional pricing of in natura or minimally-processed foods, culinary ingredients and processed foods, and more availability of in natura or minimally-processed foods, culinary ingredients and processed foods (p-value < 0.05). Public and private fruit and vegetable stores showed on average more physical modifications that promote the sale of food in natura or minimally processed (p-value < 0.001). However, it was also possible to observe that fruit and vegetable stores and neighborhood markets, along with supermarkets, were the three categories of establishment with the highest availability of in natura or minimally processed foods, culinary ingredients and processed foods (Table 3).

Regarding barriers, supermarkets and neighborhood markets have, on average, more advertising of ultra-processed foods, physical modifications in the environment that promote ultra-processed foods, promotional pricing of ultra-processed foods and greater availability of ultra-processed foods, compared to other categories of establishments. It is noteworthy that fruit and vegetable stores showed the lowest averages for barriers such as advertising, information, physical modifications and promotional pricing of ultra-processed foods (p-value < 0.05) (Table 3).

Regarding the characterization of the consumer’s food environment through factor analysis with the barriers and facilitators of food choices, we were able to verify three main factors, which explained 71.9% of the total variance of the data. We characterized the first factor by the presence of both barriers and facilitators (hereinafter called the mixed factor), the second factor by the greater presence of facilitators (more facilitators) and the third factor had a greater presence of barriers in the consumer environment (more barriers) (Table 4).

Table 5 shows the β-coefficients (95%CI) between the categories of food retailers and the mean score of the factors found. Supermarkets had a positive association with the mixed factor and neighborhood markets and bakeries had a negative association. Public and private fruit and vegetable stores, neighborhood markets and supermarkets had a positive association with the factor more facilitators, while bakeries and businesses with priority sale of ultra-processed foods had a negative association (p-value < 0.001). Finally, supermarkets, bakeries and neighborhood markets showed a positive association (p-value < 0.001) with the factor more barriers, and butchers/fish shops/refrigerators (p-value < 0.01) and fruit and vegetable stores a negative association (p-value < 0.001).

Discussion

The study advanced in the identification of facilitators and barriers to food choices in the consumer environment, which differ significantly between the categories of establishments studied. We also identified that the availability of food in the municipality is varied, although the presence of ultra-processed products prevails. Approximately 70% of businesses sell sugary drinks and treats, against approximately 35% that sell rice, beans, fruits and vegetables, foods recommended for a healthy diet in Brazil ³⁵35. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014.. The exploration of factors that characterize the consumer environment in relation to the presence of barriers and facilitators for healthy food choices revealed three distinct patterns: (1) factor that shows advertising, information and promotional pricing for both healthy and unhealthy foods; (2) factor that shows advertising, information, physical modifications, promotional pricing and availability aimed at promoting healthy foods; and (3) factor that shows advertising, information, physical modifications, promotional pricing and availability aimed at promoting unhealthy foods. Among the categories of establishments studied, we positively associated public and private fruit and vegetable stores, neighborhood markets and supermarkets with the factor more facilitators, however, we also verified positive associations of supermarkets and neighborhood markets to the pattern more barriers, showing that within the same category of establishments we can have different forms of advertising, availability, information, physical modifications and promotional pricing.

In this study we explored characteristics of the consumer’s food environment that can act as barriers and facilitators of healthy food choices. The availability of food was one of the aspects studied. There was high availability of ultra-processed foods and beverages, with high energy density, and poor in nutrients ⁴³43. Louzada MLC, Martins APB, Canella DS, Baraldi LG, Levy RB, Claro RM, et al. Impact of ultra-processed foods on micronutrient content in the Brazilian diet. Rev Saúde Pública 2015; 49:45.. Exploring the relation between the availability and consumption of food and beverages represents an important future theme for consumer food environment research in Brazil and Latin America ⁴4. 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; 21:189-200.^,4040. Pérez-Ferrer C, Auchincloss AH, Menezes MC, Kroker-Lobos MF, Cardoso LO, Barrientos-Gutierrez T. The food environment in Latin America: a systematic review with a focus on environments relevant to obesity and related chronic diseases. Public Health Nutr 2019; 22:3447-64.^,4444. Ni Mhurchu C, Vandevijvere S, Waterlander W, Thornton LE, Kelly B, Cameron AJ, et al. Monitoring the availability of healthy and unhealthy foods and non-alcoholic beverages in community and consumer retail food environments globally. Obes Rev 2013; 14 Suppl 1:108-19.. Our data suggest that focusing on improving access to healthy food and beverages only through the physical availability of these foods in retail stores may not be effective, since other factors such as price, advertising, information, and physical modifications interact in the consumer environment.

Higher exposure to ultra-processed foods and beverages, especially soft drinks or sugar-sweetened beverages, in items sold and advertised was more frequent in supermarkets and neighborhood markets. These products have been associated with the appearance of several chronic non-communicable diseases such as obesity, diabetes and coronary heart disease ⁴⁵45. Monteiro CA, Levy RB, Claro RM, de Castro IRR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr 2011; 14:5-13.^,4646. Popkin B. Ultra-processed foods' impacts on health, 2030. Food, agriculture and rural development in Latin America and the Caribbean. Santiago de Chile: Organización de las Naciones Unidas para la Alimentación y Agricultura; 2020.. Duran et al. ⁵5. Duran AC, Almeida SL, Latorre MRDO, Jaime PC. The role of the local retail food environment in fruit, vegetable, and sugar-sweetened beverage consumption in Brazil. Public Health Nutr 2016; 19:1093-102. identified an association between a greater variety of sugary drinks sold in retail stores and a 15% increase in the prevalence of their regular consumption (≥ 5 times/week). In addition, the high prevalence of businesses selling these products also reflects considerable effort by large multinational corporations to increase sales of ultra-processed foods in Latin American countries through infrastructure investments, including advertising and physical modifications of the consumer environment ⁴⁷47. Monteiro CA, Moubarac J-C, Cannon G, Ng SW, Popkin B. Ultra-processed products are becoming dominant in the global food system. Obes Rev 2013; 14 Suppl 2:21-8.^,4848. Vandevijvere S, Jaacks LM, Monteiro CA, Moubarac J-C, Girling-Butcher M, Lee AC, et al. Global trends in ultraprocessed food and drink product sales and their association with adult body mass index trajectories. Obes Rev 2019; 20 Suppl 2:10-9..

The identification and analysis of three possible combinations between barriers and facilitators in different categories of retail trade may bring new elements to underpin future public policies aimed at regulating the food retail sector and promoting healthier food spaces ¹⁶16. Stanton RA. Food retailers and obesity. Curr Obes Rep 2015; 4:54-9.. In addition, including the extent and purpose of food processing among the facilitators and barriers studied helps to bring the consumer food environment closer to the agenda of discussions on public food and nutrition policies in Brazil, since the current epidemiological and nutritional scenario points to an increase in the consumption of ultra-processed foods instead of traditional diet foods ³²32. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares, 2017-2018: primeiros resultados. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019..

What we currently have in Latin America on consumer food environment are studies that focus especially on assessing food availability and advertising (in general those aimed at children), leaving gaps in the exploration of other factors such as price reduction, physical modifications and information about food ³⁵35. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014.. In this sense, this study advances the understanding of three main factors that characterize the consumer’s food environment and that can put at risk or protect healthy food choices.

Supermarkets were the only establishment category that showed positive association with all three combinations of barriers and facilitators studied (mixed factor, more facilitators and more barriers). This information is particularly important, since in Brazil 49% of food purchases are made in supermarkets/hypermarkets ²⁹29. Costa JC, Claro RM, Martins APB, Levy RB. Food purchasing sites: repercussions for healthy eating. Appetite 2013; 70:99-103.. According to a study conducted by Machado et al. ²⁸28. 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; 116:381-8. with data from the 2008/2009 Brazilian Household Budget Survey, the share of ultra-processed foods and beverages in purchases made in supermarkets was 25% higher than in other types of food marketing establishments.

In Brazil, studies on the role of supermarkets in promoting healthy eating are divergent. Under consumer perception, a study showed that the wide variety of fresh products available in supermarkets was significantly related to the lower chance of ultra-processed food purchases ⁴⁹49. 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.. Another study, which also investigated the role of food retailers in the acquisition of healthy foods, showed that the prevalence in the regular consumption of produce was lower among low-income individuals and residents of neighborhoods with lower density of supermarkets and markets specialized in the sale of these foods ⁵5. Duran AC, Almeida SL, Latorre MRDO, Jaime PC. The role of the local retail food environment in fruit, vegetable, and sugar-sweetened beverage consumption in Brazil. Public Health Nutr 2016; 19:1093-102..

Public and private fruit and vegetable stores and neighborhood markets showed positive associations with factor 2, which refers to a greater number of facilitators for healthy food choices. In this case, they are places with the presence of advertising, information, physical modifications (ex.: fruit and vegetable section at the entrance to the store), promotional pricing and availability of food recommended by the Dietary Guidelines. Fruit and vegetable stores are equipment already specialized in the sale of healthy foods, and a national study showed that buying in these places increases by 89% the chance of acquiring food in natura or minimally processed ⁴⁹49. 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..

The creation of the variables defined as barriers and facilitators for this study allowed to include a good part of the characteristics that influence food purchases in the consumer environment. The use of the AUDITNOVA instrument ³⁸38. Borges CA, Jaime PC. Desenvolvimento e avaliação de instrumento de auditoria do ambiente alimentar: AUDITNOVA. Rev Saúde Pública 2019; 53:91 in the audit process of retail trades facilitated the union of these characteristics into factors. Other instruments validated in Brazil ⁵⁰50. Duran AC, Lock K, Latorre MRDO, Jaime PC. Evaluating the use of in-store measures in retail food stores and restaurants in Brazil. Rev Saúde Pública 2015; 49:80.^,5151. Martins PA, Cremm EC, Leite FHM, Maron LR, Scagliusi FB, Oliveira MA. Validation of an adapted version of the Nutrition Environment Measurement Tool for Stores (NEMS-S) in an urban area of Brazil. J Nutr Educ Behav 2013; 45:785-92. include aspects related to the availability, variety and price of food, but do not make it possible to classify them according to the NOVA classification groups ⁴⁰40. Pérez-Ferrer C, Auchincloss AH, Menezes MC, Kroker-Lobos MF, Cardoso LO, Barrientos-Gutierrez T. The food environment in Latin America: a systematic review with a focus on environments relevant to obesity and related chronic diseases. Public Health Nutr 2019; 22:3447-64.. In addition, AUDITNOVA made it possible to explore the presence of advertising and physical modifications from the perspective of facilitators, when promoting in natura or minimally processed foods and culinary ingredients, and from the perspective of barriers, when promoting ultra-processed foods. These aspects may contribute to future analyses that aim to monitor the implementation of public policies aimed at regulating the advertising and marketing of ultra-processed foods in the consumer environment.

In Brazil, although the supermarket is the most frequent place of food acquisition among Brazilians ³¹31. Machado PP, Claro RM, Martins APB, Costa JC, Levy RB. Is food store type associated with the consumption of ultra-processed food and drink products in Brazil? Public Health Nutr 2018; 21:201-9., other types of establishments should be encouraged, such as the case of public and private fruit and vegetable stores and also butchers, which were associated negatively to factor 3 (greater presence of barriers to healthy choices). Our study analyzed six categories of retail trade in the municipality of Jundiaí, and the most prevalent category was that of trades with priority sale of ultra-processed foods (43.9%), which was associated negatively with the factor more facilitators.

The comparison of the patterns (factors) that characterized the establishments according to barriers and facilitators with other national and international studies is still impractical because, to date, there are no studies that have used this same methodology. However, studies show that the consumer’s food environment may contain different barriers that interfere with consumers’ food choices and consequently may impact on energy intake ²⁸28. 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; 116:381-8., the quality of food purchased ³¹31. Machado PP, Claro RM, Martins APB, Costa JC, Levy RB. Is food store type associated with the consumption of ultra-processed food and drink products in Brazil? Public Health Nutr 2018; 21:201-9. and the nutritional status of individuals ¹⁶16. Stanton RA. Food retailers and obesity. Curr Obes Rep 2015; 4:54-9..

Recently, a panel of experts organized by Food and Agriculture Organization of the United Nations (FAO) on the role of food environments in food and nutritional security of populations pointed out that restricting the advertising of ultra-processed foods in supermarkets and markets, providing incentives to businesses to make a greater variety of food in natura or minimally processed available are key points to improve the food environment, contributing to achieve modern and sustainable food systems ¹1. High Level Panel of Experts on Food Security and Nutrition. Nutrition and food systems. A report by the High Level Panel of Experts on Food Security and Nutrition. Rome: High Level Panel of Experts on Food Security and Nutrition, Committee on World Food Security; 2017. (HPLE Report, 12)..

Some strengths of this study are noteworthy. This is an in-depth analysis of the internal environment of food retail stores that were audited face-to-face in a medium-sized municipality in Brazil. The mapping of the establishments present in practically all the urban census sectors allowed to carry out an extensive portrait of the food environment in the territory. Exploratory factor analysis allowed to explore possible combinations of barriers and facilitators (price, availability, information, advertising and physical modifications) ⁴²42. Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis. London: Prentice Hall; 2010.. The use of the AUDITNOVA instrument allowed us to identify in the consumer environment the barriers and obstacles to the achievement of healthy eating present in the Dietary Guidelines for the Brazilian Population³⁵35. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014., advancing in relation to studies that evaluate only the availability of food. However, the study also has some limitations, such as not including other food retailers such as restaurants and bars in the audit performed. Every year, the Brazilian population consumes more food outside their home ³²32. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares, 2017-2018: primeiros resultados. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019., and it is necessary to also investigate the barriers and facilitators present in these environments. The stores of Jundiaí do not represent the sample universe of Brazilian food retailers, so new studies are still needed to improve the variables defined as barriers and facilitators in different geographical and social contexts.

This study showed a more detailed exploration of the consumer’s food environment with regard to the presence of barriers and facilitators for healthy eating. The results showed that advertising, information and promotional pricing can, at the same time, form a mixed pattern that on the one hand promotes but on the other hinders healthy food choices, especially among supermarket categories. The internal environment of establishments that market food is still little explored from the point of view of studies on the food environment in Brazil and from the point of view of food and nutrition policies. The aspects explored in this study suggest that, in addition to the availability of food, other factors are important for the population to be able to access healthier foods. These findings may be useful in future research aimed at measuring the relation between aspects of the consumer’s food environment and its relation with diet quality and obesity, as well as evaluating the effects of interventions with multiple components in this environment.

Acknowledgments

To the São Paulo State Research Foundation (FAPESP), which funded the Post-doc grant of the research project that gave rise to this scientific article (process n. 2016/12766-6).

References

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