Understanding How the Food Retail Environment Influences Household Food Purchasing Practices: A Cross Sectional Survey

The aim was to assess retail food environments in an urban area neighbourhoud of a middle-income country, Tunisia, and assess associations with household food practices. A mixed methods approach was used: a comprehensive census survey of all food outlet types and all food products displayed for sale; a cross-sectional survey in a random sample of households to assess the main food shopping practices; an exhaustive census survey on food advertisements. The NOVA classification and the SAIN, LIM nutrient profiling system were used to classify food products and dishes for sale according to the extent of the processing and the nutritional value. The most common outlets were grocery stores, followed by fast-food catering, kiosks and supermarkets. Ultra-processed foods (UPFs) were the most frequently available for sale (68%). Only 12% of dishes offered by restaurants were considered healthy. Food advertisements were displayed in all food outlets including street vendors. Grocery stores and kiosks were the most used outlets by the lower socioeconomic households while supermarkets were most frequently used by the higher ones. Proximity was the top criteria reported by households for choosing their shopping outlets, followed by the freshness and diversity of foods. Residents in an urban city are excessively exposed to UPFs as compared to other foods that contribute more towards healthy diets. Grocery stores and kiosks are more frequent in poorer neighbourhoods and contribute the most to the availability of UPFs. Policies are needed to ensure equal access to healthy retail food environment in low and middle income countries.