Estudio ecologico - epidemiologia

Journal of Urban Health: Bulletin of the New York Academy of Medicine doi:10.1007/s11524-010-9537-2 * 2011 The New York Academy of Medicine

Investigating Environmental Determinants of Diet, Physical Activity, and Overweight among Adults in Sao Paulo, Brazil
Patricia Constante Jaime, Ana Clara Duran, Flávia Mori Sarti, and Karen Lock
ABSTRACT There is worldwide recognition that the burden ofnoncommunicable diseases (NCDs) and obesity-related health problems is rapidly increasing in low- and middle-income countries. Environmental determinants of obesity are likely to differ between countries, particularly in those undergoing rapid socioeconomic and nutrition transitions such as Brazil. This study aims to describe some built environment and local food environment variables and toexplore their association with the overweight rate and diet and physical activity area-level aggregated indicators of adults living in the city of Sao Paulo, the largest city in Brazil. This formative study includes an ecological analysis of environmental factors associated with overweight across 31 submunicipalities of the city of Sao Paulo using statistical and spatial analyses. Average prevalence ofoverweight was 41.69% (95% confidence interval 38.74, 44.64), ranging from 27.14% to 60.75% across the submunicipalities. There was a wide geographical variation of both individual diet and physical activity, and indicators of food and built environments, favoring wealthier areas. After controlling for area socioeconomic status, there was a positive correlation between regular fruits andvegetables (FV) intake and density of FV specialized food markets (r=0.497; pG0.001), but no relationship between fastfood restaurant density and overweight prevalence was found. A negative association between overweight prevalence and density of parks and public sport facilities was seen (r=−0.527; pG0.05). Understanding the relationship between local neighborhood environments and increasing rates ofpoor diet, physical activity, and obesity is essential in countries undergoing rapid economic and urban development, such as Brazil, in order to provide insights for policies to reduce increasing rates of NCDs and food access and health inequalities. KEYWORDS Obesity, Diet, Food, Physical activity, Environment

INTRODUCTION The rising prevalence of overweight and obesity is currently one of themajor public health concerns, linked to worsening rates of chronic noncommunicable diseases (NCDs) worldwide. Rates of overweight and obesity have been increasing both in developed and developing countries.1 In Brazil, between 1975 and 2003, the
Jaime is with the Department of Nutrition, School of Public Health, University of Sao Paulo, São Paulo, Brazil; Duran is with the Public Health NutritionProgram, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil; Sarti is with the School of Arts, Sciences and Humanities, University of Sao Paulo, Sao Paulo, Brazil; Lock is with the Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, University of London, London, UK. Correspondence: Patricia Constante Jaime, Department of Nutrition, School ofPublic Health, University of Sao Paulo, São Paulo, Brazil. (E-mail: constant@usp.br)

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prevalence of adult overweight (body mass index≥25 kg/m2) increased from 18% to 41% in men and from 27% to 40% in women. The obesity trends in Brazil also show increasing health inequalities as the highest burden of obesity is shifting towards those adults with the lowest income and the leasteducation.2 From a biological perspective, obesity arises from an imbalance between energy input and output.3 Changes in lifestyles that result in poor diet and lack of physical activity are the main risk factors thought to explain this.4 Until recently, much public health research and policy have concentrated on changing individual-level determinants of obesity-related behaviors. Factors such as...