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Duran ACFL. Ambiente alimentar urbano em São Paulo, Brasil: avaliação, desigualdades e associação com consumo alimentar. / Urban food environments in São Paulo, Brazil: evaluation, disparities, and associations with food consumption. [doctoral dissertation] São Paulo: Faculdade de Saúde Pública da Universidade de São Paulo; 2013 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.