This work is the first version of a tool that measures the Chilean food environment. It was adapted from NEMS-S to Chilean context to assess food availability. The country’s cultural and eating context was also considered.
NEMS–S is an environmental auditor tool. It is based on observation. The reliability of evaluators determines the consistency of the tool. NEMS–S reached high reliability in all versions, original and modified (Brazil. China. Spain. Canada). This confirms that the measurement protocol as well as training methods are sufficient to prepare interviewers for data collection with high precision. The kappa coefficient among evaluators for original NEMSS varied between 0.83 and 1.00 [12]For the Brazilian version, the kappa coefficient varied between 0.69 and 1.00, and the ICC between 0.75 and 1.00 [14]. Current NEMS S-CHILE version had results similar to NEMS CHINA [15]The acceptable kappa index (and ICC) varied from moderately high to high (0.42 to 1.00 for kappa coefficient, 0.65 to 1..00 for ICC).
Practically all categories were evaluated and the reliability of inter-evaluators’ measures for availability was high. However, the Group 3 of processed foods showed moderate concordance in mature dairy products and nuts (0.42-0.43). Similar results were also observed for other instruments in which product packaging, nutritional labels and health descriptors were not legible. [15, 17, 36].
To assess the quality of food by analyzing its organoleptic characteristics, only trained personnel in fruits and vegetables are needed to determine the sensory parameters that will be used for qualitative evaluation. Chile is a country where fresh fruits and vegetables are mainly bought at the street markets. The sale conditions are both outdoors and at the room. This could lead to differences in the quality or freshness of the food. The majority of fruits and vegetables were able to reach high levels of agreement with the pollsters in this study. The avocado is an exception (68.2%), as it is a food with subjective quality and high variability. This is due to the damage mechanics, frictions, punctures, and punctures that can affect quality, vascular darkness, consumption maturity and basal rot. These factors are not always reflected in its external appearance. [37, 38]. Concerning groups 2, 3, and 4, the availability is greater in supermarkets than street markets because of the higher level of processing.
In recent years, increased attention has been paid in recent years to the price differences between healthy and regular options. [39,40,41]. The availability and cost of healthy options may depend on the type of store, the size, and the rurality. It is possible for the healthier version to be more expensive that the regular or less healthy version.
This study uses a differentiating approach to distinguish foods according to their degree of processing. This allows for relevance in the scoring of foods that are in their natural or minimally-processed state. This is a modification to the original version. [12]And another version adapted [15,16,17]. In this instance, the focus is on healthier options. It prioritizes the low intake calories and fats, in some cases with high levels of industrial processing. Latin America has seen a dramatic shift in eating habits, particularly in recent years. This is due to the opening of foreign investment and lack of market regulation. [25]. Chile’s urbanization has led to a greater penetration of supermarket chains and a decrease in street market purchases. [21]. This is accompanied in large communication and food promotion campaigns that promote processed food high in critical nutrients (sugars fats and salt). This is why Chile and Mexico are the first to consume ultra-processed foods in the Latin American region. Their consumption is twice that of Brazil, where an adaptation of the original NEMS was already validated. Therefore, it would be necessary to validate the specific products, including the processing level and classification.
This has resulted in a shift in eating habits in low- and middle-income countries. Instead of consuming ready meals made from unprocessed or minimally-processed foods, these products are high in unhealthy fats and salt and have high caloric density. As previous research has shown, there is ample evidence to support the risk of eating ultra-processed food in causing weight gain and the appearance of cardiovascular disease. [23, 27, 42].
Determining the availability of these foods can help to determine the relationship between accessibility, availability, and epidemiological trends. It also helps to promote the development of improvement initiatives for food environments in the community.
The 2012 and 2015 laws 20.606 and 20.869, respectively, were established to regulate the nutritional content of food and its publicity. [44, 45]. It ensures that proper labeling is done, as required by the Chilean Food Health Regulations. It must provide clear information so that the population can understand the contents of energy, sugar and salt. It defines the form of the warning labeling as per the law. It does this by using an octagonal symbol on a background with black borders and text HIGH. Foods without warning labels are still considered ultra-processed. They are made with less sugar, salt, or fat, but retain their original formulas. This is because they contain by-products of other ingredients like starches, protein concentrates and flavorings. These ingredients would also be part of the NOVA classification.
Although warning labeling was initially thought to be a strategy to increase selection, it is not the answer to the obesity epidemic. Changes in eating habits must be accompanied with education about food and a revaluation traditional food. Strategies must be developed to facilitate local production and access to fresh food at reasonable prices.
One limitation of the labeling law is that the industry has modified ingredients to avoid logos. Ultra-processed food products still have health effects, but they also have a high level satiety.
Finally, we have highlighted regional differences in food availability and pricing. [43]. Similar to previous papers on NEMS adaptations in countries other than the United States [14, 15, 20]The selected geographical area corresponds to a specific metropolitan sector. The city of Concepcin represents both the Chilean agri-food reality and the retail trade. The high reliability of the instrument’s application allows it to be used in different territorial realities and thus to establish differences in the food environment of consumers based on their geographical location. However, the current study was limited to the Bio-Bio region. It is recommended that further studies be done to analyze differences between Chilean regions.
Strengths and weaknesses
The strengths of the study were that the interviewers were closely related to the identification and determination of food varieties and quality. This facilitates the use of the instrument. The training required to use the instrument could be obtained without the need for professional certification. The instrument could be used in supermarkets and on the streets twice in one day, without any limitations. The kappa statistic analysis to determine availability of a product and the ICC for determining the agreement between the qualifications, allowed the inclusion of quality, variety, price, and food in the score. The methodology produced more comprehensive results that could be used in food stores.
However, the study has some limitations. First, the instrument was validated only in the Province Concepcin metro area. Second, there could be differences in socioeconomic status and population density that could affect the availability and cost of food depending on where you live. A convenience sample was taken from supermarkets and street stalls to assess the reliability and adaptation of NEMS-SCHILE at this stage.
Second, the food list based on the level of processing may differ depending on the country’s geographical distribution. This means that not all foods are available in every part of the country. This work has a limitation in that it cannot be applied to convenience stores and food store environments. However, this work provides a foundation for future field work. The current study was limited to a specific region of Chile. It did not include extreme regions. This meant that the variability in food prices and availability among regions was not assessed. This limitation will be addressed in future studies.
The high percentage of acceptable quality, and in some cases the low availability in stores made it impossible to calculate kappa. This result could be affected by the availability of food at different places every day. The NEMS-S-CHILE was conducted according to the Family Budget Survey and the National Survey of Food Consumption 2011.
