Introdução: O consumo adequado de frutas, verduras e legumes (FVL) durante a gestação apresenta impacto positivo sobre a saúde da mulher e da criança. Os fatores ambientais associados ao comportamento alimentar vêm recebendo destaque no âmbito da saúde pública por afetar diretamente a saúde dos indivíduos. Entretanto, desconhecemos a existência de estudos que investigaram a relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes. Objetivo: Verificar a reprodutibilidade de um questionário sobre a percepção do ambiente alimentar e para o consumo de frutas e hortaliças em gestantes (manuscrito 1) e avaliar a relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes (manuscrito 2). Metodologia: O estudo de reprodutibilidade (manuscrito 1) foi conduzido em 2010 entre 48 gestantes usuárias do serviço público de saúde de Ribeirão Preto, SP. O questionário é composto por 12 questões de múltipla escolha que incluem a percepção do ambiente alimentar e para o consumo de frutas e hortaliças. Para verificação da reprodutibilidade, o questionário foi aplicado em duplicata, com intervalo entre 15 e 45 dias. A concordância entre as respostas foi avaliada por meio do teste de Kappa ponderado ou Kappa. A relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes (manuscrito 2) foi avaliada empregando-se os dados de um estudo transversal, conduzido em 2012, entre 282 gestantes adultas. O consumo de FVL foi avaliado por meio de um questionário de freqüência alimentar (QFA) , e dois recordatórios de 24 horas. O Multiple Source Method foi utilizado para estimar o consumo usual de FVL. A percepção do ambiente alimentar foi avaliada mediante a aplicação de questionário estruturado. Para a investigação da relação entre a as variáveis da percepção do ambiente alimentar e consumo adequado de FVL (400g/dia), modelos de regressão logística [OR (95% IC)] foram empregados ajustados por escolaridade, idade e classe econômica das gestantes. Resultados: No manuscrito 1, verificou-se a reprodutibilidade do questionário sobre a percepção do ambiente alimentar e para o consumo de frutas e hortaliças em gestantes. Concordância forte (Kappa entre 0,6 e 0,79) para: número de refeições ao dia, hábito de se alimentar no local de trabalho, distância entre a residência e local de aquisição de FVL e qualidade de FVL no local de aquisição. Concordância moderada (Kappa entre 0,4 e 0,59): hábito de se alimentar fora do domicílio, em restaurantes do tipo self-service ou por quilo, em lanchonetes, se adquire alimentos em mercearias, lojas de conveniência ou padaria, motivo da escolha do local para aquisição de FVL, variedade de FVL no local de aquisição e apoio familiar para ter uma alimentação saudável. Concordância fraca (Kappa entre 0,2-0,39): freqüência em que faz refeições na casa de amigos/ parentes, freqüência em que adquire alimentos em supermercados e varejão ou feira livre e percepção em relação ao preço de FVL. As questões que obtiveram concordância fraca foram reformuladas previamente a sua utilização. No manuscrito 2 observou-se que 35% das mulheres estudadas reportaram o Resumo consumo adequado de frutas e hortaliças durante a gestação, não encontrando uma associação direta entre a percepção do ambiente alimentar e o consumo adequado de frutas e hortaliças entre elas. Entretanto, as gestantes que relataram ter o hábito de fazer quatro ou mais refeições ao dia apresentaram maior chance de consumir a quantidade adequada de furtas e hortaliças quando comparadas àquelas que relataram menor número de refeições ao dia [OR 2.01 (95% IC 1.03, 3.91) p 0.04]. Da mesma forma, as mulheres que referiram o hábito de comprar FVL em varejão ou feira livre apresentaram maior chance de atingir a recomendação de frutas e hortaliças, independente de idade, escolaridade e classe socioeconômica [OR 1.68 (IC95% 1.01, 2.80) p 0.05]. Conclusão: O questionário sobre a percepção do ambiente alimentar e para o consumo de FVL apresentou boa precisão entre gestantes. Não houve associação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças entre as gestantes estudadas. / Introduction: The adequate intake of fruits and vegetables (FV) during pregnancy has a positive impact on the health of women and children. Environmental factors associated with eating behavior have received attention in the context of public health by directly affecting individuals health. However, unaware of the existence of studies that investigated the relationship between self perceived food environment and fruit and vegetable intake in pregnant women. Objective: To evaluate the reliability of a self perceived questionnaerie about the food environment and for the consumption of fruit and vegetable in pregnant women (manuscript 1). To evaluate the relationship between self perceived food environment and the adequate consumption of fruits and vegetables in pregnant women (manuscript 2). Methods: The study was conducted in 2010 among 48 pregnant women attended by the public health service of Ribeirão Preto, SP. The questionnaire consists of 12 multiple choice questions which include the perception of the food environment and consumption of FV. To investigate the reproducibility of the questionnaire, it was administered twice, between 15 and 45 days apart. The agreement between the responses was assessed using the Kappa or Kappa weighted (manuscript 1). A cross-sectional study was conducted in 2012 among 282 adult pregnant women. Fruit and vegetable intake during pregnancy was assessed by a food frequency questionnaire, and 2 dietary recalls. The Multiple Source Method approach was applied to estimate usual FV intake. Self perceived food environment was assessed by a structured questionnaire. For the present analysis, we examined the association of self perceived food environment and the adequate intake of fruit and vegetable (400g/daily) in logistic regression models [OR (95% CI)], adjusted by maternal age, socioeconomic class, and educational level (manuscript 2). Results: Manuscript 1 describes the reliability of a self perceived questionnaire about the food environment and for the consumption of fruits and vegetables in pregnant women. There was strong agreement (Kappa: 0,6 to 0,79) for: meals per day, habit of eating at work, distance between the residence and places to purchase fruit and vegetable, quality of fruit and vegetable at the purchase place. Moderate agreement (Kappa 0,4 to 0,59): habit of eating out of home, habit of eating in self service restaurant, habit of eating in fast food restaurant, purchase food at grocery stores, convenience stores or bakery, variety of fruits and vegetables available and family support for healthy eating. Weak agreement (Kappa 0,2 to 0,39): habit of eating in friends or family house, purchase food at supermarket or FV specialized food market and perception of FV price. All the questions that had weak agreement were reformulated prior to use it. The manuscript 2 showed that 35% of the women intervied reported adequate intake of FV during pregnancy, with no association between self perceived food environment and adequate FV intake. However, a higher meal frequency was associated with a better chance of daily adequate intake of fruit and vegetable [OR 2.01 (95% CI 1.03, 3.91) p 0.04]. Moreover, the habit of buying fruit and vegetable in Abstract specialized food market was associated with the daily intake of 400g of fruit and vegetable [OR 1.68 (IC95% 1.01, 2.80) p 0.05]. Conclusion: The questionnaire of the perceived food environment and for the consumption of fruits and vegetables showed good precision among pregnant women. No association between self-perceived food environment and the adequate intake of FV among pregnant women was found.

Introdução: Estudos realizados em outros contextos mostram que o acesso a alimentos saudáveis e o consumo alimentar variam conforme o local de residência, podendo contribuir com desigualdades em saúde já existentes em áreas urbanas. Objetivos: O estudo apresenta três objetivos: (1) propor e avaliar a confiabilidade de instrumentos de avaliação do microambiente alimentar urbano adaptado ao contexto do Município de São Paulo, (2) investigar se o acesso a alimentos varia de acordo com o nível socioeconômico da vizinhança, após ajustes para o tipo de estabelecimento, e (3) estudar a associação entre o ambiente alimentar local e o consumo de frutas, hortaliças e bebidas açucaradas dentre amostra da população adulta do município de São Paulo. Métodos: Estudo transversal conduzido em 2010-2011 em 52 setores censitários do Município de São Paulo selecionados de acordo com o nível socioeconômico e densidade de equipamentos de comercialização de alimentos. Dois instrumentos de avaliação do microambiente alimentar foram desenvolvidos e tiveram suas confiabilidades inter- e intra-avaliador testadas: (1) ESAO-s instrumento de avaliação de estabelecimentos de comercialização de alimentos para consumo no domicílio; e (2) ESAO-r instrumento de avaliação de estabelecimentos de comercialização de alimentos para consumo imediato. O acesso a alimentos saudáveis foi medido a partir de índices que resumiram as medidas coletadas acerca da disponibilidade, variedade e promoção de alimentos. Associações entre o nível de educação da vizinhança e o acesso a alimentos foram testadas com modelos de regressão multinível. Dados coletados em amostra de 1842 adultos residentes nos mesmos setores censitários acerca do consumo regular ( 5 vezes/semana) de frutas, hortaliças e bebidas açucaradas foram utilizados em modelos multinível de regressão logística com o intuito de estudar as associações entre características do micro- e macro-ambiente alimentar e o consumo de tais alimentos. Para cada participante, disponibilidade, variedade, qualidade, preço e promoção/propaganda de frutas, hortaliças e bebidas açucaradas foram medidos em todos os estabelecimentos de comercialização de alimentos no setor censitário de residência e em todos os estabelecimentos de comercialização de alimentos em um raio de 1,6 km da residência. Resultados: Os instrumentos foram considerados confiáveis, com coeficientes de kappa para as medidas intra e inter-avaliadores variando de 0,55 a 0,95. Eles também foram capazes de discriminar diferentes tipos de estabelecimentos. Supermercados e feiras-livres, mercados municipais e sacolões apresentaram maior disponibilidade de alimentos saudáveis do que pequenos mercados de bairro. Estabelecimentos de comercialização de alimentos localizados em bairros de maior nível socioeconômico apresentaram um maior número de opções saudáveis, quando comparados a estabelecimentos similares, mas localizados em áreas de menor nível de educação. Após ajustes para medidas individuais de sexo, idade, educação e renda, preços altos de bebidas açucaradas em regiões mais pobres da cidade foram associados a uma menor chance de consumi-las (OR=0,58;IC95%=0,34;0,97); enquanto a associação foi inversa nos bairros mais ricos da cidade (OR=2,33;IC95%=1,12;4,84). Associações significativas entre a disponibilidade e consumo de frutas foram mostradas para três diferentes medidas disponibilidade de frutas próximo à residência; presença de pelo menos um estabelecimento que comercializasse frutas, mesmo que com baixa variedade; e residir em uma área no último quartil do índice de acesso a alimentos saudáveis HFSI. Associações entre medidas de acesso e consumo de hortaliças foram menos consistentes. Conclusão: Encontramos diferenças no acesso a alimentos saudáveis em São Paulo, favorecendo as regiões da cidade de níveis socioeconômicos médio e alto. Aspectos do ambiente alimentar foram associados ao consumo de frutas, hortaliças e bebidas açucaradas. Políticas públicas e intervenções com o objetivo de diminuir as desigualdades de acesso da população a alimentos saudáveis devem considerar o impacto de aspectos do ambiente alimentar disponibilidade, preço, variedade e qualidade de alimentos saudáveis e não saudáveis / Introduction: Previous studies carried out in different settings have shown that access to healthy foods and diet patterns vary across neighborhoods, contributing to already present health disparities within urban settings. Objectives: This study comprises three objectives: (1) to develop and examine the reliability of two observational tools to measure the availability, variety, quality, pricing, and signage/promotion of healthy and unhealthy foods in retail food stores, specialized fruits and vegetables (FV) markets/stores, open-air food markets, and restaurants; (2) to examine whether food access varies across neighborhoods of different socioeconomic statuses, adjusted by store types; and (3) to examine the relationships between the neighborhood food environment and the consumption of fruits, vegetables, and sugar-sweetened beverages (SSB) among an adult sample from the city of Sao Paulo, Brazil. Methods: Cross-sectional study conducted in 2010-2011 across 52 census tracts in Sao Paulo city. We selected tracts according to socioeconomic characteristics and density of retail food stores and fast food restaurants. Two comprehensive microlevel food environment tools were developed and had their inter-rater and test-retest reliability tested: (1) ESAO-s to assess retail food stores and open-air food markets; and (2) ESAO-r to assess all types of restaurants. Food access was measured as the availability, variety, and promotion/signage of healthy and unhealthy foods, and was summarized into two indexes developed for retail food stores and restaurants. Multilevel models were used to examine associations of store type and neighborhood characteristics with food access indexes. Data on food intake of 1842 adults from the same sampled 52 different census tracts were collected. For each participant, the availability, variety, quality, price, and promotion/signage of fruits, vegetables, and SSB were directly assessed in all food stores/restaurants within 1.6 km of their residence. Multilevel logistic regression models were used to examine the associations of consumption of fruits 5 days/week, vegetables 5 days/week, and SSB 5 days/week with stores density and fresh fruits, vegetables, and SSB in-store measures. Results: Tools were reliable and able to discriminate across store types. Kappa coefficients varied from 0.55 to 0.95. Supermarkets and FV specialized stores/markets had a higher availability of healthy foods than corner stores/local grocery stores. Fast-food restaurants, bars and, corner stores were more likely to be located in low socioeconomic level neighborhoods, though supermarkets and FV specialized markets/stores were more likely to be located in neighborhoods in the 2 tertile of education. Multilevel analyses showed that supermarkets and full-service restaurants carried more healthy items adjusted for local and surrounding education levels. Stores with better food access, regardless of the type, were more likely to be found in high socioeconomic status neighborhoods. After adjustment for age, gender, income, and education, a higher price of SSB in low-income neighborhoods was associated with a lower odds of consuming SSB (OR=0.58;95%CI=0.34,0.97), whereas for those living in a high-income neighborhood, an inverse pattern was found (OR=2.33;IC95%=1.12,4.84). A positive association between fruit availability and consumption was consistent and significant using three different measures of neighborhood fruit availability. Living near retail food stores in the upper HFSI quartile increased in 52% the odds of consuming fruits (OR=1.52;95%CI=1.03,2.26). We observed less consistent associations for vegetables. Conclusion: We found differences in the accessibility of healthy foods in Sao Paulo, favoring middle and high socioeconomic status neighborhoods. Our findings suggest that the neighborhood food environment influences fruit, vegetable, and SSB consumption. Policies and interventions aimed at reducing disparities in food access in the city should consider characteristics of the food environment availability, price, variety, and quality of healthy and unhealthy foods

Farmers’ markets are increasingly promoted for their potential to improve access to healthful foods. University campuses are strategic settings for farmers’ markets, because they could improve access to fresh, local produce for large and diverse communities—including college students, who are at risk for poor dietary intake. Universities also offer resources that facilitate farmers’ markets, such as built-in communication channels, common areas, and student volunteers. However, literature describing how to establish campus-based farmers’ markets is limited. We describe the process of developing and operating a student-driven, campus-based farmers’ market at a public university in the Appalachian region of the United States.

Healthy food store availability is by no means equitable, that is supermarkets and supercenters are not located nearby for certain populations. Shopping at healthy food stores is important, as dietary intake is associated with adverse health outcomes, which disproportionally affects racial and ethnic minorities. Yet rural areas and disadvantaged neighborhoods—low income or predominantly racial/ethnic minority compositions—have few healthy food store options available near home. Thus residents must use more resources to access them or make do with what is available close by. However, little is known about the characteristics associated with shopping at healthy food stores or shopping near home. Thus the purpose of this study was to examine predictors of shopping at healthy food stores and shopping within increasing distances from home. This study used data from the USDA’s National Household Food Acquisition and Purchase Survey (FoodAPS) which asked about household food purchasing behaviors. The FoodAPS data set was used to conduct a secondary data analysis of US households (N = 4,826) that was a nationally representative sample. A series of multilevel logistic regression models were conducted to examine the four research questions guiding this study. The four questions examined predictors of: (1) shopping at a healthy food store, (2) shopping at a healthy food store among rural and suburban respondents, (3) shopping within increasing distances from home, and (4) shopping within increasing distances from home among healthy food store shoppers. Results indicated that Hispanic/Latino and other racial/ethnic minority, the distance of travel to the store, and the number of food stores available within 5.0 miles were negatively associated with shopping at a healthy food store. In addition, among rural and urban/suburban respondents had differing predictors of shopping at a healthy food store. Predictors of shopping within increasing distances from home included car to store and living in rural areas. Respondents who used a car as the transportation to the store were less likely to shop within 2.0 miles of home or less. Not surprisingly, rural respondents were also less likely to shop within 5.0 miles of home or less. Several control variables were significant predictors of shopping within increasing distances from home which were unexpected. Results in some instances were surprising and contradictory to findings from past studies. Thus these results are discussed and are compared and contrasted with past studies. The results of this study have practice implications for social workers. Social work practitioners working with individuals can advocate for improving client access in their communities by improving and introducing programming whose goal is to connect people to food resources. Social workers engaged in policy efforts can work at the local, state, and national levels by working in multidisciplinary groups to improve existing programs and prioritize funding that improves issues of equality. While this study examined predictors among a nationally representative sample, it is important for future research to look at differences specifically among age groups, racial and ethnic minorities, and rural residents.

Objectives: This study examined the relation of multiple aspects of the home food environment to dietary intake and body weight among overweight and obese children in southern Appalachia. Methods: The study used baseline data from a cluster-randomized controlled trial, Parent-Led Activity and Nutrition for Healthy Living, evaluating a parent-mediated approach to treating child overweight and obesity in the primary care setting in southern Appalachia. Sixty-seven children ages 5 to 11 years were recruited from four primary care clinics. Multiple linear regression was used to estimate the relation between multiple aspects of the home food environment to dietary intake (fruit and vegetable intake, fat and sweets intake), and standardized body mass index (zBMI), adjusted for baseline family characteristics (education, smoking status during the past month, BMI) and child characteristics (sex, age, Medicaid/TennCare). Results: Findings showed greater parental restriction and pressure in feeding were associated with greater fruit and vegetable intake in children (β = 0.33, β = 0.30, respectively; both P < 0.05). The availability of chips and sweets in a child’s home and parental inappropriate modeling of eating were associated with an increased risk for consumption of fats and sweets by children (β = 0.47, β = 0.54, respectively; both P < 0.01). Parental monitoring of the child’s eating was associated with a reduced risk for fat and sweets intake (β = −0.24; P < 0.01). Finally, parental responsibility for feeding the child was associated with lower zBMI (β = −0.20; P < 0.05). Conclusions: The home food environment, including food availability and parenting behaviors, was associated with overweight and obese children’s dietary intake and weight. This study adds to evidence suggesting that programs aimed at improving overweight and obese children’s eating patterns may target both aspects of the physical home environment and parental behaviors surrounding eating.

The school food environment has the ability to increase the consumption of fruit and vegetables in rural adolescents. This study used a survey to allow adolescents in seven rural counties to self-report their fruit and vegetable intake as well as utilizing the USDA Mathematica tool and the School Nutrition and Meal Cost Study audits to evaluate what food and beverage products were actually available to adolescents. By using these two measures, associations between fruit and vegetable intake and availability of healthy and unhealthy foods were determined. The availability of healthy snacks and beverages was found to be associated with sugar-sweetened beverage intake in adolescents (p < 0.001); the availability of unhealthy snacks and beverages was associated with fruit and vegetable intake in adolescents (p < 0.001); the school marketing of water bottle stations and/or water dispenser availability was associated with sugar- sweetened beverage intake in adolescents (p < 0.001). Increasing the availability and school marketing of healthy foods and beverages in rural schools may be an effective way to improve fruit and vegetable consumption in adolescents.

abstract: Despite the literature suggesting that fruits and vegetables (F&V) can have a protective outcome against overweight, obesity and chronic diseases, consumption is still inadequate. In order to address under consumption of F&V among children, schools have become a platform for a variety of food programs. The Fresh Fruit and Vegetable Program (FFVP), a United States Department of Agriculture (USDA) initiative, aims to increase exposure and consumption of F&V in low-income school children by providing F&V snacks. Participation in FFVP has been associated with higher preference and consumption of F&V and research also suggests that the program has the potential to decrease rates of overweight and obesity. The benefits of this program have been found to extend outside of the school setting, with higher requests for F&V at home and at the grocery store. This study aims to explore how children’s participation in the FFVP influences home food environments and shopping practices through qualitative analysis focus group data. Four focus groups were held with parents (n=25) from three FFVP participating schools. The data was analyzed using an inductive thematic analysis approach to find themes within the discussions. The findings were grouped into three categories: General Perceptions of FFVP, Impact of FFVP on the Home Food Environment, and Impact of FFVP on Shopping Practices. For General Perceptions of FFVP, themes were: Children learn about and enjoy F&V, awareness of farm to school programs, and children make healthier choices. Impact of FFVP on the Home Food Environment included the themes: Choosing heathier foods and snacks, parent F&V behaviors, children request F&V at home, and children talk about or bring F&V home. Finally, Impact of FFVP on Shopping Practices included the themes: children’s involvement in shopping, children request to buy F&V, children request non-produce items, and parents decline or limit unhealthy requests. This qualitative study provides valuable insights about how FFVP participation influences child and family behaviors towards F&V at home and in the grocery store. School food programs, such as the FFVP, have a positive influence on F&V related behaviors among children and should be continued and expanded. / Dissertation/Thesis / Masters Thesis Obesity Prevention and Management 2018

abstract: Childhood obesity has been on the rise for the past decade, and it has been hypothesized that students' food choices may be influenced by easy access to food outlets near their schools that provide unhealthful options. But the results of recent studies on the relationship between the food environment around schools and student weight status are mixed and often contradictory. Most studies have used measures of weight and height that were self-reported by students, or have relied on data from a relatively small sample of students. I examine the association between weight status among school students and the food environment surrounding their schools using professionally-measured, student-level data across the full school-age spectrum. De-identified data were obtained for over 30,000 K-12 students in 79 public schools located in four New Jersey cities. Locations of alternative food-outlets (specifically, supermarkets, convenience stores, small grocery stores, and limited-service restaurants) were obtained from commercial sources and geocoded to develop proximity measures. A simplified social-ecological framework was used to conceptualize the multi-level the association between students' BMI and school proximity to food outlets and multivariate analyses were used to estimate this relationship controlling for student- and school-level factors. Over twenty percent of the students were obese, compared to the national average at 17% (Ogden, Carroll, Kit, & Flegal, 2012). On average, students had 2.6 convenience stores, 2.9 limited-service restaurants, and 0.1 supermarkets within a quarter mile of their school. This study suggests that easy access to small grocery stores (which this study uniquely examines as a separate food outlet category) that offer healthy choices including five types of fresh vegetable, five types of fresh fruits, low-fat dairy, and lean meats is associated with lower BMI z score and lower probability of being obese for middle and high school students. This suggests that improving access to such small food outlets may be a promising area for future investigation in obesity mitigation research. Also, this study separates students of pre-schools, kindergartens and elementary schools (neighborhood schools) from that of the middle and high schools (non-neighborhood) schools because the two groups of schools have different neighborhood characteristics, as well as open-school and bussing policies that result in different levels of exposure that students have to the food outlets around the schools. The result of this study suggests that the relationship between students' weight outcomes and food environment around schools is different in the two groups of schools. / Dissertation/Thesis / M.S. Sustainability 2013

Introdução: Estudos realizados em outros contextos mostram que o acesso a alimentos saudáveis e o consumo alimentar variam conforme o local de residência, podendo contribuir com desigualdades em saúde já existentes em áreas urbanas. Objetivos: O estudo apresenta três objetivos: (1) propor e avaliar a confiabilidade de instrumentos de avaliação do microambiente alimentar urbano adaptado ao contexto do Município de São Paulo, (2) investigar se o acesso a alimentos varia de acordo com o nível socioeconômico da vizinhança, após ajustes para o tipo de estabelecimento, e (3) estudar a associação entre o ambiente alimentar local e o consumo de frutas, hortaliças e bebidas açucaradas dentre amostra da população adulta do município de São Paulo. Métodos: Estudo transversal conduzido em 2010-2011 em 52 setores censitários do Município de São Paulo selecionados de acordo com o nível socioeconômico e densidade de equipamentos de comercialização de alimentos. Dois instrumentos de avaliação do microambiente alimentar foram desenvolvidos e tiveram suas confiabilidades inter- e intra-avaliador testadas: (1) ESAO-s instrumento de avaliação de estabelecimentos de comercialização de alimentos para consumo no domicílio; e (2) ESAO-r instrumento de avaliação de estabelecimentos de comercialização de alimentos para consumo imediato. O acesso a alimentos saudáveis foi medido a partir de índices que resumiram as medidas coletadas acerca da disponibilidade, variedade e promoção de alimentos. Associações entre o nível de educação da vizinhança e o acesso a alimentos foram testadas com modelos de regressão multinível. Dados coletados em amostra de 1842 adultos residentes nos mesmos setores censitários acerca do consumo regular ( 5 vezes/semana) de frutas, hortaliças e bebidas açucaradas foram utilizados em modelos multinível de regressão logística com o intuito de estudar as associações entre características do micro- e macro-ambiente alimentar e o consumo de tais alimentos. Para cada participante, disponibilidade, variedade, qualidade, preço e promoção/propaganda de frutas, hortaliças e bebidas açucaradas foram medidos em todos os estabelecimentos de comercialização de alimentos no setor censitário de residência e em todos os estabelecimentos de comercialização de alimentos em um raio de 1,6 km da residência. Resultados: Os instrumentos foram considerados confiáveis, com coeficientes de kappa para as medidas intra e inter-avaliadores variando de 0,55 a 0,95. Eles também foram capazes de discriminar diferentes tipos de estabelecimentos. Supermercados e feiras-livres, mercados municipais e sacolões apresentaram maior disponibilidade de alimentos saudáveis do que pequenos mercados de bairro. Estabelecimentos de comercialização de alimentos localizados em bairros de maior nível socioeconômico apresentaram um maior número de opções saudáveis, quando comparados a estabelecimentos similares, mas localizados em áreas de menor nível de educação. Após ajustes para medidas individuais de sexo, idade, educação e renda, preços altos de bebidas açucaradas em regiões mais pobres da cidade foram associados a uma menor chance de consumi-las (OR=0,58;IC95%=0,34;0,97); enquanto a associação foi inversa nos bairros mais ricos da cidade (OR=2,33;IC95%=1,12;4,84). Associações significativas entre a disponibilidade e consumo de frutas foram mostradas para três diferentes medidas disponibilidade de frutas próximo à residência; presença de pelo menos um estabelecimento que comercializasse frutas, mesmo que com baixa variedade; e residir em uma área no último quartil do índice de acesso a alimentos saudáveis HFSI. Associações entre medidas de acesso e consumo de hortaliças foram menos consistentes. Conclusão: Encontramos diferenças no acesso a alimentos saudáveis em São Paulo, favorecendo as regiões da cidade de níveis socioeconômicos médio e alto. Aspectos do ambiente alimentar foram associados ao consumo de frutas, hortaliças e bebidas açucaradas. Políticas públicas e intervenções com o objetivo de diminuir as desigualdades de acesso da população a alimentos saudáveis devem considerar o impacto de aspectos do ambiente alimentar disponibilidade, preço, variedade e qualidade de alimentos saudáveis e não saudáveis / Introduction: Previous studies carried out in different settings have shown that access to healthy foods and diet patterns vary across neighborhoods, contributing to already present health disparities within urban settings. Objectives: This study comprises three objectives: (1) to develop and examine the reliability of two observational tools to measure the availability, variety, quality, pricing, and signage/promotion of healthy and unhealthy foods in retail food stores, specialized fruits and vegetables (FV) markets/stores, open-air food markets, and restaurants; (2) to examine whether food access varies across neighborhoods of different socioeconomic statuses, adjusted by store types; and (3) to examine the relationships between the neighborhood food environment and the consumption of fruits, vegetables, and sugar-sweetened beverages (SSB) among an adult sample from the city of Sao Paulo, Brazil. Methods: Cross-sectional study conducted in 2010-2011 across 52 census tracts in Sao Paulo city. We selected tracts according to socioeconomic characteristics and density of retail food stores and fast food restaurants. Two comprehensive microlevel food environment tools were developed and had their inter-rater and test-retest reliability tested: (1) ESAO-s to assess retail food stores and open-air food markets; and (2) ESAO-r to assess all types of restaurants. Food access was measured as the availability, variety, and promotion/signage of healthy and unhealthy foods, and was summarized into two indexes developed for retail food stores and restaurants. Multilevel models were used to examine associations of store type and neighborhood characteristics with food access indexes. Data on food intake of 1842 adults from the same sampled 52 different census tracts were collected. For each participant, the availability, variety, quality, price, and promotion/signage of fruits, vegetables, and SSB were directly assessed in all food stores/restaurants within 1.6 km of their residence. Multilevel logistic regression models were used to examine the associations of consumption of fruits 5 days/week, vegetables 5 days/week, and SSB 5 days/week with stores density and fresh fruits, vegetables, and SSB in-store measures. Results: Tools were reliable and able to discriminate across store types. Kappa coefficients varied from 0.55 to 0.95. Supermarkets and FV specialized stores/markets had a higher availability of healthy foods than corner stores/local grocery stores. Fast-food restaurants, bars and, corner stores were more likely to be located in low socioeconomic level neighborhoods, though supermarkets and FV specialized markets/stores were more likely to be located in neighborhoods in the 2 tertile of education. Multilevel analyses showed that supermarkets and full-service restaurants carried more healthy items adjusted for local and surrounding education levels. Stores with better food access, regardless of the type, were more likely to be found in high socioeconomic status neighborhoods. After adjustment for age, gender, income, and education, a higher price of SSB in low-income neighborhoods was associated with a lower odds of consuming SSB (OR=0.58;95%CI=0.34,0.97), whereas for those living in a high-income neighborhood, an inverse pattern was found (OR=2.33;IC95%=1.12,4.84). A positive association between fruit availability and consumption was consistent and significant using three different measures of neighborhood fruit availability. Living near retail food stores in the upper HFSI quartile increased in 52% the odds of consuming fruits (OR=1.52;95%CI=1.03,2.26). We observed less consistent associations for vegetables. Conclusion: We found differences in the accessibility of healthy foods in Sao Paulo, favoring middle and high socioeconomic status neighborhoods. Our findings suggest that the neighborhood food environment influences fruit, vegetable, and SSB consumption. Policies and interventions aimed at reducing disparities in food access in the city should consider characteristics of the food environment availability, price, variety, and quality of healthy and unhealthy foods

Introdução: Um ambiente obesogênico pode ser definido como \"a soma de influências, oportunidades ou condições que o ambiente tem na promoção da obesidade\", onde o consumo de alimentos de risco é estimulado em detrimento do consumo de alimentos de proteção. Atualmente, o excesso de peso apresenta-se como um problema de saúde pública, sendo a dieta inadequada um fator modificável para seu desenvolvimento. As frutas e hortaliças desenvolvem um papel fundamental na prevenção do excesso de peso, uma vez que apresentam baixa densidade energética, são fontes de proteínas vegetais e micronutrientes considerados protetores, além de serem ricos em fibras, aumentando a sensação de saciedade. Objetivo: Investigar a associação entre excesso de peso, consumo de frutas e hortaliças por adolescentes e ambiente alimentar local em São Paulo. Métodos: Foram utilizados dados do Inquérito de Saúde de São Paulo 2015, o qual é um estudo transversal de base populacional com amostragem probabilística de residentes em domicílios permanentes no município. Os dados foram coletados por meio de um questionário estruturado e dois recordatórios alimentares de 24 horas. O estado nutricional foi avaliado pelo Índice de Massa Corporal classificado em sem excesso de peso (percentil <85) e com excesso de peso (percentil >=85) de acordo com a Organização Mundial da Saúde. Os dados de ambiente alimentar foram obtidos do Cadastro Municipal de Vigilância Sanitária e da Secretaria Municipal de Trabalho e Empreendedorismo. Buffers (áreas de influência) de 500, 1000 e 1500 metros foram criados para avaliar a presença dos estabelecimentos ao redor das residências dos adolescentes participantes do estudo. A fim de verificar a associação entre ambiente alimentar, consumo de frutas e hortaliças e excesso de peso foram elaborados modelos de regressão logística multinível, ajustados por potenciais cofundidores. A análise dos dados foi realizada no programa Stata 13.0, considerando nível de significância de 5%. Resultados: Os adolescentes apresentaram baixo consumo de frutas e hortaliças, uma vez que apenas 6,1% consumiram a quantidade recomendada pela Organização Mundial da Saúde. Além disso, 29,6% apresentaram excesso de peso. A maioria dos adolescentes possuía mercados, supermercados e mercearias (85,5%), restaurantes (75,6%) e feiras-livres e sacolões (50,6%) em torno da residência, mas não apresentava restaurantes fast-foods (93,9%), padarias e cafeterias (89,5%), e pizzarias (76,8%). A presença de uma feira-livre na zona mais próxima dos domicílios (500 m) e maior renda familiar foram associadas ao maior consumo de frutas e hortaliças. A presença de restaurantes de fast-foods no buffer de 500 metros em torno da residência foi positivamente associada ao excesso de peso. Conclusão: Esses resultados sugerem que o ambiente alimentar em São Paulo pode ser um fator importante em relação ao consumo alimentar e, consequentemente, ao excesso de peso em adolescentes da cidade. Dessa forma, é necessário intensificar políticas de educação alimentar e nutricional, redução de preços de alimentos protetores e manutenção de ambientes alimentares saudáveis. / Introduction: An obesogenic environment can be defined as \"the sum of influences, opportunities or conditions that the environment has in the promotion of obesity\", where the consumption of risky foods is stimulated to the detriment of protective foods consumption. Currently, overweight presents as a public health problem, and inadequate diet is a modifiable factor for its development. Fruits and vegetables play a key role in the prevention of overweight, since they have low energetic density, are sources of vegetable proteins and micronutrients considered protective, besides being rich in fibers, increasing the feeling of satiety. Objective: To investigate the association between overweight, fruit and vegetable consumption by adolescents and the local food environment in São Paulo. Methods: Data from the 2015 Health Survey of São Paulo were used, which is a cross-sectional population-based study with probabilistic sampling of residents in permanent households in the municipality. Data were collected through a structured questionnaire and two 24h dietary recall. The nutritional status was evaluated by the Body Mass Index classified as non-overweight (percentile <85) and overweight (percentile >=85) according to the World Health Organization. Food environment data were obtained from the Municipal Register Sanitary Surveillance and the Municipal Department of Labor and Entrepreneurship. Buffers (areas of influence) of 500, 1000 and 1500 meters were created to evaluate the presence of establishments around the adolescent\'s residences participating in the study. To verify the association between food environment, consumption of fruits and vegetables and overweight, multilevel logistic regression models were developed, adjusted by potential co-founders. Data analysis was performed in Stata 13.0 program, considering a significance level of 5%. Results: The adolescents presented low consumption of fruits and vegetables, since only 6.1% consumed the amount recommended by the World Health Organization. In addition, 29.6% were overweight. Most of the adolescents had markets, supermarkets and grocery stores (85.5%), restaurants (75.6%), and street markets and fruit and vegetable stands (50.6%) around the residence but did not present fast-food restaurants (93,9%), bakeries and coffee shops (89.5%), and pizzerias (76.8%). The presence of a street market in the area closest to the households (500 m) and higher family income was associated with higher consumption of fruits and vegetables. The presence of fast-food restaurants in the 500 meters buffer around the residence was positively associated with being overweight. Conclusion: These results suggest that the food environment in São Paulo may be an important factor in relation to food consumption and, consequently, to overweight in adolescents in the city. Thus, it is necessary to intensify policies of food and nutritional education, reduction of protective foods prices and maintenance of healthy food environments.