Healthy eating is an important determinant of health [1
]. Chronic diseases, overweight and unhealthy eating habits, especially when combined with food insecurity, compromise the population’s health [2
]. The high prevalence of these conditions has been shown to generate significant individual, social, and health service costs [5
]. It is estimated that overweight and obesity alone generate 3 billion CAN$
in direct and indirect health care costs for the province of Quebec [7
]. Overweight and chronic diseases can be prevented by reducing energy intake and improving the quality of the food offer, particularly among vulnerable populations [9
The adoption of healthy eating habits depends on individual and collective determinants such as the characteristics of the physical, economic, political, and sociocultural environments [10
]. Improving the population’s diet, therefore, requires a portfolio of multi-targeted and multi-level strategies [13
] including those aimed at improving the local food environment.
1.1. Local Food Environment and Health
For several years now, Quebec, a province of Canada, has been investing to create healthy eating environments for the population as a whole [14
]. Previously, healthy eating was considered to be mainly dependent on individual factors alone. However, collective and environmental factors, including public policies, are now recognized as conditioning food choices by making them easier to make [10
The population’s diet is influenced by the food environment to which it is exposed [8
]. In particular, diet is associated with the community or local food environment, which refers to the characteristics of the places where food can be obtained, i.e., the type of outlet, its location, number of shops in a sector, and geographical accessibility [15
]. The local food environment includes businesses that offer food products for retail sale (convenience stores, grocery stores and supermarkets), restaurants (with table service or quick service) and alternative forms of food distribution (farmers’ markets, short food supply chain, online shopping, etc.) [15
Accessibility is a key concept when it comes to the local food environment. It encompasses commercial availability, geographic access, convenience, economic access, and social and cultural acceptability. This paper focuses exclusively on geographical accessibility and its influence on the location of food deserts and food swamps [16
Several studies have shown that the availability and accessibility of healthy food can vary according to the income and educational level of individuals living in an area [19
]. These disparities in access to food may in turn be related to eating habits and behaviours or obesity [17
]. Access to retailers offering healthy food in socioeconomically disadvantaged neighbourhoods is more difficult than elsewhere. This prompted the studies on food deserts. The term food desert refers to an area that is highly disadvantaged socioeconomically and provides poor or low access to food stores offering food of high nutritional value in urban, non-metropolitan and rural areas [22
]. It was originally used in studies from the United Kingdom [19
Other studies in the United States and Canada have also noted that socioeconomically disadvantaged neighbourhoods are characterized by a concentration of fast food restaurants and convenience stores. These neighbourhoods can be considered as food swamps [24
]. Food swamps are food environments where access to food of low nutritional value is so important that it “drowns” access to healthy food of high nutritional value [29
]. There is no single definition or indicator of food deserts or food swamps. This explains, for example, why some researchers consider food swamps to be located only in disadvantaged areas [27
], while others do not make this distinction [30
Research has shown an association between body weight and food swamps [20
]. The results of a recent study conducted in the United States in 3141 counties shows that even after statistically controlling for the effects of food deserts, food swamps still had a significant positive effect on the rate of obesity in adults [33
]. In this study, the regression analyses showed that the association of food deserts to obesity became statistically insignificant when the food swamp indicator was included [33
]. These researchers concluded by recommending that policy-makers address both food deserts and food swamps to improve the population’s eating habits and body weight [33
]. Furthermore, Canadian researchers have hypothesized that in Canada, where food deserts do not seem as widespread as in the USA, food swamps may be a more salient indicator of food environments [26
1.2. Study Objectives
This paper has two objectives. The first objective is to illustrate, using a method based on geographical information systems (GIS) and field validation, the development of indicators to identify sectors qualified as food deserts and food swamps for the region. Based on the results of this approach, the second is to present how the regional public health authority (RPHA) disseminated food deserts and food swamps mapping to partners and used this information to stimulate regional food environment actions.
The first objective of this study was to develop indicators of food deserts and food swamps to be used by the Gaspesie region. It also aims to present how regional public health authorities can use these indicators and food environment mapping to raise awareness, mobilize and support their partners to act on the characteristics of the region’s food environment to increase food access and reduce food insecurity.
Analysis of the Gaspesie food landscape revealed that 11 sectors, both urban and rural, are characterized by poor access to stores offering healthy food. This represents 5% of the region’s population. Also, eight sectors (4.5% of the region’s population) are qualified as food swamps meaning that in these sectors foods of low nutritional value are prominent. An important proportion of residents (88% (3/8)) that are exposed to food swamps live in disadvantaged areas. This means that about 10% of the region’s residents are exposed to a food environment that is not conducive to healthy eating.
Research on food swamps is in its infancy; however, some authors suggest that these environments have particularly pernicious effects by encouraging people to make poorer food choices since they are made quickly to experience immediate gratification [50
]. Bridle-Fitzpatrick (2015) [51
] notes that participants in her study who were continuously exposed to foods and beverages of low nutritional value reported that they now perceive these products as normal and that their desire to consume them was therefore increased. In their study, exposure to food swamps appeared to influence not only food choices, but also food preferences and norms. This author, therefore, considers that actions on food deserts are necessary, but insufficient to “clean up” food swamps, which requires more robust interventions than increasing access to healthy food for disadvantaged populations [51
It has been suggested that in urban areas in Canada, food swamps may be a more salient metaphor to characterize the food environment than food deserts [26
]. This study shows that in a rural setting, food deserts and food swamps co-exist. Still, more research needs to be done to elucidate the associations between the indicators of the food environment, eating behaviours, food insecurity, and indicators of health.
Public health agencies and researchers recognize the importance of developing and strengthening the local food environment to make it favourable to healthy eating and supportive of food security [52
]. Promising interventions to improve physical access to food can be divided into four categories: introducing new conventional sources of supply (e.g., supermarkets) [56
] or alternative sources of supply (e.g., solidarity grocery stores, public markets, and mobile markets) [59
], improving in-store food offering (e.g., fruits and vegetables in convenience stores) [62
], land use planning (e.g., zoning) [64
], and, increasing mobility (transportation infrastructure) [63
In 2014, the CDC published a guide outlining strategies to be carried out to improve physical access to more nutritious food [65
]. Before putting into place promising interventions such as those outlined above, they propose to initially evaluate the characteristics of the food environment. The methods illustrated in our research could facilitate this evaluation of the local food environment. For example, in the United States, interventions to increase healthy food access often take the form of tax exemption, financial incentives or zoning by-law amendments to encourage entrepreneurs to open a new grocery store or supermarket in communities designated as food deserts [66
]. Notably, in Philadelphia in recent years, the Pennsylvania Fresh Food Financing Initiative (public-private partnership) has funded the establishment of many food stores and cooperatives [67
]. Urban or community-supported agriculture could also improve the situation of people living within areas known as deserts and food swamps. This is the conclusion of the analyses of urban agriculture initiatives in New York and Detroit. Urban agriculture becoming the starting point of a food system by providing, for example, produce to local markets [68
The Gaspesie region has also put into place interventions to improve access and reduce food insecurity. Notably, they invested in increasing mobility to facilitate access to existing shops by providing buses that go to local stores. This type of intervention could also be beneficial in influencing food swamps since a recent study reported a greater association between food swamps and obesity in areas where the population had lower mobility [33
]. Improving population mobility reduces the impact of food deserts and food swamps on the population.
The food swamp map of Gaspesie could also be used to implement measures that would limit the introduction of new fast food or convenience stores in areas identified as being at risk because of the higher density of these types of businesses compared to supermarkets, grocery stores and fruit and vegetable stores [29
The food desert and food swamp data reported in this study should be interpreted with caution. Several limitations are associated with the methods used. First, there is no universal measure of deserts and food swamps, nor is there consensus on the thresholds to be used that are associated with consequences on food quality or population health. Second, the categorization of food stores based on MAPAQ’s registry is not optimal, as some stores categorization could not accurately reflect the products offered and new stores could have opened that would not be included in the registry. This limitation is often raised in the literature [70
]. We have addressed this limitation by using field validation with public health professionals to improve the validity of the MAPAQ registry.
Furthermore, the RPHA decided to add fishmongers to the healthy stores category as well as fruit and vegetable shops. These stores were not initially included in the indicator as it was deemed that they could not provide the wide range of foods that are necessary for healthy eating. In total the region added 41 food stores and deleted 10 convenience stores. These changes to the database in effect “decreased” the number of food deserts and of food swamps than would have been identified if using only the MAPAQ registry.
An additional limitation is the variable offering found in some food stores. For example, while supermarkets qualify as stores offering food of high nutritional value they also offer a wide range of foods of low nutritional value [72
Finally, physical accessibility is only one way of describing the food environment. Some argue that the concepts of deserts or food swamps place too much emphasis on spatial distribution to the detriment of other dimensions of accessibility such as income, household characteristics, transportation opportunities and the notion of (available) time, which are also factors that need to be addressed because they are closely related to eating behaviours [29