ABSTRACT:

Introduction:

Despite the increased consumption of fruits and vegetables in the Brazilian population, a great proportion of people do not meet the recommendations. Purchasing sites associated with fruit and vegetable consumption has not been widely explored.

Objective:

To explore the association between fruit and vegetable purchasing and consumption sites and the consumption of these foods among adults living in the city of São Paulo, Brazil.

Methods:

Cross-sectional study with 2 thousand individuals living in the city of São Paulo, aged between 20 and 59 years, participants of the “Obesogenic Environment Study in São Paulo”. The outcome was fruit and vegetable consumption measured by weekly consumption. Exposure variables included purchasing sites (supermarkets, open-air food markets, fruit and vegetable specialized markets, and corner stores) and consumption sites (full service restaurants and fast food restaurants).

Results:

The sample comprises women (52.3%) aged between 25 and 34 years (30.2%), with at least 8 years of schooling (42.8%) receiving 2 to 5 minimum wages (34.6%). Demographic and socioeconomic variables showed association with regular consumption of fruits and vegetables (p < 0.05). The regular consumption of meals in full service restaurant was associated with vegetables consumption. The regular consumption of meals in fast-food restaurants was not associated with vegetables consumption. Food purchasing sites were not associated with fruit or vegetable consumption.

Conclusion:

The choice of restaurant type was associated with vegetable consumption. In the studied population, food purchasing sites were not associated with fruit or vegetable consumption.

Keywords:
Food consumption; Health promotion; Fruits; Vegetables; Nutritional surveys; Adult

INTRODUCTION

The consumption of fruits and vegetables is considered as a marker of a healthy diet pattern, reducing the risks of death caused by chronic non-communicable diseases due to their composition, rich in vitamins, minerals and fibers, and their low energy density. Fruits and vegetables are also part of the most complete, varied, colorful and attractive meals, with lower presence of ultra-processed foods, according to the Dietary Guide for the Brazilian Population (Guia Alimentar para a População Brasileira)¹1. Brasil. Ministério da Saúde. Guia alimentar para a população brasileira. Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Brasília: Ministério da Saúde; 2014.^,22. Oliveira MS, Lacerda LNL, Santos LC, Lopes ACS, Câmara AMCS, Menzel HJK, et al. Consumo de frutas e hortaliças e as condições de saúde de homens e mulheres atendidos na atenção primaria à saúde. Ciênc Saúde Coletiva 2015; 20(8): 2313-22. DOI: 10.1590/1413-81232015208.18272014
https://doi.org/10.1590/1413-81232015208... ^,33. Pessoa MC, Mendes LL, Caiaffa WT, Malta DC, Velásquez-Meléndez G. Availability of food stores and consumption of fruit, legumes and vegetables in a Brazilian urban area. Nutr Hosp 2014; 31(3): 1438-43. DOI: 10.3305/nh.2015.31.3.8245
https://doi.org/10.3305/nh.2015.31.3.824... ^,44. Figueiredo ICR, Jaime PC, Monteiro CA. Fatores associados ao consumo de frutas, legumes e verduras em adultos na cidade de São Paulo. Rev Saúde Pública 2008; 42(5): 777-85. DOI: 10.1590/S0034-89102008005000049
https://doi.org/10.1590/S0034-8910200800... ^,55. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Departamento de Análise de Situação de Saúde, Ministério da Saúde, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde ; 2011.. The minimum daily intake of these foods to obtain this healthy and protective effect is 400 g per capita, or the equivalent to 5 portions of 80 g⁶6. World Health Organization (WHO). Diet, nutrition and the prevention of chronic diseases. Report of a Joint WHO/FAO Expert Consultation. Geneva: WHO; 2003. 149 p..

This minimum consumption is fulfilled by 24% of the Brazilian population, according to survey Surveillance System of Risk and Protective Factors for Chronic Diseases (VIGITEL), conducted in 2014⁷7. Brasil. Ministério da Saúde. Vigitel Brasil 2014, Saúde Suplementar: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Agência Nacional de Saúde Suplementar, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde ; 2015., and by little less than one third of the Brazilian population, according to the Health National Research (PNS)⁸8. Jaime PC, Stopa SR, Oliveira TP, Vieira ML, Szwarcwald CL, Malta DC. Prevalência e distribuição sociodemográfica de marcadores de alimentação saudável, Pesquisa Nacional de Saúde, Brasil, 2013. Epidemiol Serv Saúde 2015; 24(2): 267-76. DOI: 10.5123/S1679-49742015000200009
https://doi.org/10.5123/S1679-4974201500... .

The dietary behavior is highly complex. The reasons that lead a person to consume a specific food come from the interaction of multiple influences, in different contexts and conditions, being influenced by socioeconomic and demographic characteristics⁹9. Oliveira SP, Theubaud-Mony A. Hábitos e práticas em três localidades da cidade de São Paulo (Brasil). Rev Nutr 1998; 11(1): 37-50. DOI: 10.1590/S1415-52731998000100003
https://doi.org/10.1590/S1415-5273199800... ^,1010. Souza RS, Arbage AP, Neumann PS, Froehlich JM, Diesel V, Silveira PR, et al. Comportamento de compra dos consumidores de frutas, legumes e verduras na região central do Rio Grande do Sul. Cienc Rural 2008; 38(2): 511-17. DOI: 10.1590/S0103-84782008000200034
https://doi.org/10.1590/S0103-8478200800... ^,1111 Almeida LB, Sabbag CC, Jardini V, Santos JTG. O tempo consagrado à alimentação: dimensões da vida moderna e seu impacto sobre os hábitos alimentares. Alimentação Humana. Revista SPCNA 2011; 17(1): 64-8.^,1212. Duran AC, Almeida SL, Latorre MR, Jaime PC. The role of the local retail food environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Public Health Nutrition 2015. [Internet]. Disponível em: Disponível em: http://journals.cambridge.org/download.php?file=%2FPHN%2FS1368980015001524a.pdf&code=6dcaeee54fd5e17915bc15f69c7fae16 (Acessado em 10 de setembro de 2015). DOI: 10.1017/S1368980015001524
http://journals.cambridge.org/download.p... ^,1313. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2008-2009. Ministério do Planejamento, Orçamento e Gestão, Diretoria de Pesquisas Coordenação de Trabalho e Rendimento. Rio de Janeiro: IBGE; 2010.^,1414. Brasil. Ministério da Saúde. Vigitel Brasil 2013: vigilância de fatores de risco e proteção para doenças crônicas po r inquérito telefônico. Ministério da Saúde, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde ; 2014.^,1515. Brasil. Portal da Saúde. Vigitel: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. 2014 [Internet]. Disponível em: Disponível em: http://portalsaude.saude.gov.br/images/pdf/2014/abril/30/Lancamento-Vigitel-28-04-ok.pdf (Acessado em janeiro de 2015).
http://portalsaude.saude.gov.br/images/p... . The choice of locations to purchase food is also influenced by the environment and by individual characteristics¹⁶16. Lytle LA. Measuring the food environment state of the science. Am J Prev Med 2009; 36(4 Suppl): 134-44. DOI: 10.1016/j.amepre.2009.01.018
https://doi.org/10.1016/j.amepre.2009.01... ^,1717. Krukowski RA, Mcsweeney J, Sparks C, West DS. Qualitative study of influences on food store choice. Appetite 2012; 59(2): 510-6. DOI: 10.1016/j.appet.2012.06.019
https://doi.org/10.1016/j.appet.2012.06.... .

In the literature, there is no consensus about the influence of the locations of food purchase and its consumption¹⁸18. Taillie LS, Ng SW, Popkin BM. Global growth of “big box” stores and the potential impact on human health and nutrition. Nutr Rev 2016; 74(2): 83-97. DOI: 10.1093/nutrit/nuv062
https://doi.org/10.1093/nutrit/nuv062... . Studies point to possible relations between healthier diets and more access to super and hypermarkets, which offer a greater variety of foods natural at more accessible prices, when compared to convenience stores and corner stores¹²12. Duran AC, Almeida SL, Latorre MR, Jaime PC. The role of the local retail food environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Public Health Nutrition 2015. [Internet]. Disponível em: Disponível em: http://journals.cambridge.org/download.php?file=%2FPHN%2FS1368980015001524a.pdf&code=6dcaeee54fd5e17915bc15f69c7fae16 (Acessado em 10 de setembro de 2015). DOI: 10.1017/S1368980015001524
http://journals.cambridge.org/download.p... ^,1919. Caspi CE, Sorensen G, Subramanian SV, Kawachi I. The local food environment and diet: a systematic review. Health Place 2012; 18(1): 1172-87. DOI: 10.1016/j.healthplace.2012.05.006
https://doi.org/10.1016/j.healthplace.20... . Studies in the United States and in the United Kingdom present diverse results when assessing the presence of purchasing sites for fruits and vegetables, and the effect on the consumption of these foods by the population²⁰20. Pearce J, Hiscock R, Blakely T, Witten K. The contextual effects on neighborhood access to supermarkets and convenience stores on individual fruit and vegetable consumption. J Epidemiol Community Health 2008; 62(3): 198-201. DOI: 10.1136/jech.2006.059196
https://doi.org/10.1136/jech.2006.059196... . Jaime et al.²¹21. Jaime PC, Duran AC, Sarti FM, Lock K. Investigating environmental determinants of diet, physical activity, and overweight among adults in Sao Paulo, Brazil. J Urban Health 2011; 88(3): 567-81. DOI: 10.1007/s11524-010-9537-2
https://doi.org/10.1007/s11524-010-9537-... mention a significant association between the regular intake of fruits and vegetables and the density of fruit stores and fairs; however, according to Carvalho et al.²²22. Carvalho FG, Rezende EG, Rezende ML. Hábitos de compra dos clientes da feira livre de Alfenas-MG. Organizações Rurais e Agroindustriais 2010; 12(1): 131-41., the outdoor fruit fairs have been less visited than markets and fruit markets, and the purchase of fruits and vegetables in these spaces has decreased 19.81%.

Despite the relationships between places of food purchase and the intake of fruits and vegetables, little is assessed about the association of the consumption of these foods with the habit of eating outside the household. In the scientific literature, there are no studies demonstrating this relationship. The studies state that, among the main factors associated with the changes in dietary patterns that the Brazilian population has been undergoing in the past few decades, is the increasing habit of eating meals outside the household²³23. Claro RM, Baraldi LG, Martins APB, Bandoni DH, Levy RB. Evolução das despesas com alimentação fora do domicílio e influência da renda no Brasil, 2002/2003 a 2008/2009. Cad Saúde Pública 2014; 30(7): 1-9. DOI: 10.1590/0102-311X00176113
https://doi.org/10.1590/0102-311X0017611... . This habit, in industrialized countries, is related with cultural, social and environmental factors²⁴24. Jabs J, Devine CM. Time scarcity and food choices: an overview. Appetite 2006; 47(2): 196-204. DOI:10.1016/j.appet.2006.02.014
https://doi.org/10.1016/j.appet.2006.02.... . The increasing consumption of calories, fat and sodium and the low intake of fibers, iron and vitamins is associated to this behavioral change, in some studies²⁵25. Orfanos P, Naska A, Trichopoulou A, Grioni S, Boer JM, van Bakel MM, et al. Eating out of home: energy, macro- and micronutrient intakes in 10 european countries. The european prospective investigation into cancer and nutrition. Eur J Clin Nutr 2009; 63(Suppl 4): 239-62. DOI: 10.1038/ejcn.2009.84
https://doi.org/10.1038/ejcn.2009.84... ^,2626. Bezerra IN, Sichieri R. Eating out of home and obesity: a Brazilian nationwide survey. Public Health Nutr 2009; 12(11): 2037-43. DOI: 10.1017/S1368980009005710
https://doi.org/10.1017/S136898000900571... .

Since most of the responsibility in the development of obesity and chronic diseases is attributed to the diet, it is important to investigate these associations, recognizing the role of the environment in the dietary behavior of the population, considering the lack of publications relating the intake of fruits and vegetables and the behavior of purchase and consumption of foods²⁷27. Larson N, Story M. A review of environmental influences on food choices. Ann Behav Med 2009; 38(Suppl 1): 56-73. DOI: 10.1007/s12160-009-9120-9
https://doi.org/10.1007/s12160-009-9120-... .

The objective of this study was to assess the associations between the locations of meal consumption and the locations of fruit and vegetable purchase with the regular intake of these foods among adults living in São Paulo, controlling the analysis for demographic and socioeconomic variables.

METHODS

This is a cross-sectional study conducted in São Paulo, between April and May, 2011, including 2 thousand individuals of both sexes, aged between 20 and 59 years, living or working in 13 administrative districts previously selected, which were part of the “Obesogenic Environment Study in São Paulo” (ESAO-SP). The studied fields were selected by a purposive sampling methodology, proposed by ESAO-SP, based on the administrative districts and census sectors in which the city of São Paulo is divided, according to geographic and administrative characteristics.

The purposive sample is the sampling method in which the selected areas are chosen with the purpose of representing a specific region, in relation to the criteria established for the study, aiming at ensuring that all main relevant groups for the subject are covered, and also at guaranteeing that, in each one of the criteria, there is any diversity, so that the impact of the diversity of the objects of interest can be explored²⁸28. Ritchie J, Lewis J, Elam G. Designing and selecting samples. In: Ritchie J, Lewis J. Qualitative research practice: a guide for social science students and researchers. London: SAGE Publications; 2003. p. 77-108..

The city of São Paulo is divided in 96 administrative districts, which were classified in socioeconomic level terciles by using the Human Development Index (HID), and in 3 dietary environment indicators according to the density of the equipment of food purchase. After the classifications, two districts were randomly selected in each one of the 6 possible strata, and 1 extra district in case there was much refusal from the commercial businesses of the selected districts, accounting for 13 administrative districts.

In each district, 8 census sectors were randomly selected, totaling 104; of these, 18 were excluded for not containing a location of food sale, leaving 86. Among these, 4 census sectors were randomly selected in each one of the 13 districts, accounting for 52 assessed sectors.

The sample tried to contemplate the socioeconomic and spatial diversities found in the city regarding the food environment. More details on the methodology used in the sampling process can be observed in Duran et al.¹²12. Duran AC, Almeida SL, Latorre MR, Jaime PC. The role of the local retail food environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Public Health Nutrition 2015. [Internet]. Disponível em: Disponível em: http://journals.cambridge.org/download.php?file=%2FPHN%2FS1368980015001524a.pdf&code=6dcaeee54fd5e17915bc15f69c7fae16 (Acessado em 10 de setembro de 2015). DOI: 10.1017/S1368980015001524
http://journals.cambridge.org/download.p... ^,2929. Duran AC, Diez Roux AV, Latorre M do R, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23: 39-47. DOI: 10.1016/j.healthplace.2013.05.001
https://doi.org/10.1016/j.healthplace.20... .

The sample of the individuals was conducted in a non-probability manner, by convenience, and was stratified by sex and age, using the real proportion of each district, according to Census 2000, ensuring the representativeness of the sample for that area³⁰30. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE). Censos Demográficos 2000: agregados por setores censitários dos resultados de universo - 2ª edição. Ministério do Planejamento, Orçamento e Gestão 2002. [Internet]. Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/defaulttab_agregado.shtm (Acessado em 10 de maio de 2010).
http://www.ibge.gov.br/home/estatistica/... . Data collection was conducted face to face, by a trained and supervised team, in places of great circulation of people inside the selected districts, like squares, parks and commercial businesses.

Inclusion criteria were age - between 20 and 59 years - and location of residence or circulation, inside the districts selected in the sampling areas. There were no losses in the questionnaires used. One questionnaire was not fully answered, however, the data available were used.

The dependent variables of the study are the regular consumption of fruits and the regular intake of vegetables - daily intake of any portion -, which were obtained with the questions “On how many days of the week do you usually eat lettuce and tomato, or any other raw vegetable”? and “On how many days of the week do you usually eat cooked vegetables with the food or in the soup, like, for example, cabbage, carrot, chayote, eggplant and zucchini, not to mention potatoes, manioc or yam?”. The answers were given in weekly frequency of consumption. The outcome “regular consumption of fruits and vegetables” was determined by the intake of each type of food (fruits and vegetables) on five or more days of the week¹⁴14. Brasil. Ministério da Saúde. Vigitel Brasil 2013: vigilância de fatores de risco e proteção para doenças crônicas po r inquérito telefônico. Ministério da Saúde, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde ; 2014..

The variables related with the location of consumption of meals outside the household were: “regular intake of meals in full service restaurants” and “regular intake of meals in fast-food restaurants”. The information was obtained by the questions “On how many days of the week do you usually have lunch or dinner, in this neighborhood, at restaurants (kilo, self-service, barbecue place or a la carte)?”, considered, in this study, full service restaurants - and “On how many days of the week do you usually have lunch or dinner, in this neighborhood, in snack bars, bakeries or bars?” - considered, in this study, fast-food restaurants. The “regular intake of meals at full service restaurants” and the “regular intake of meals at fast-food restaurants” were considered as the consumption on one or more days of the week in these locations.

To obtain data about the locations of purchase of fruits and vegetables, the question was: “Of the locations below, where do you buy fruits and vegetables more often?”; the possible answers were: supermarkets and hypermarkets, fruit stores, outdoor fairs our neighborhood markets.

The demographic and socioeconomic variables were: sex referred by the interviewee; age calculated based on the interviewee’s date of birth; schooling, obtained by the question: “Until what grade did you study?”; and family income, obtained by the question: “What is the total approximate income of your family?”, measured in minimum wages (up to one minimum wage, from one to two minimum wages, from two to five minimum wages, from five to ten minimum wages, and more than ten minimum wages).

The descriptive analysis of the quantitative variables was conducted by using measures of central tendency and dispersion, and the qualitative variables were described according to the absolute and relative frequencies. The associations between the demographic and socioeconomic variables with the regular intake of fruits and vegetables were tested with the Pearson’s χ² test for nominal variables, and with the linear trend test for ordinal variables. The descriptive level of the test was p < 0.05.

To analyze the independent effect of the variables of location of consumption and purchase of foods with the intake of fruits and vegetables, the odds ratio (OR) was calculated for each category related with the location of intake: regular consumption at full service restaurants, regular consumption at fast-food restaurants and non-regular consumption in both locations - and for each category of location for food purchase - supermarket, fruit store, outdoor fairs and neighborhood markets - adjusted by sex, age, schooling and family income, considering a 5% significance level and 95% confidence interval (95%CI). Data was analyzed using the software Statistical Package for the Social Sciences (SPSS), version 17.0.

This study was submitted to and approved by the Research Ethics Committee of the School of Public Health at Universidade de São Paulo (FSP/USP). The participation of the individuals was based on the signature of the Informed Consent Form.

RESULTS

Of the individuals analyzed, 52.3% were female; the prevalent age was 25 to 34 years (30.2%); schooling years, between 8 and 11 (42.8%); and Family income, from 2 to 5 minimum wages (34.6%). Most of the population (67.9%) reported the regular intake of fruits, and 74.9%, of vegetables (Table 1).

The regular consumption (≥ once a week) of main meals at full service restaurants and at fast-food restaurants was reported by 30.4 and 22.5% of the population, respectively. The most frequent location of fruit and vegetable purchase was the fruit store (39.6%), followed by the supermarket (34.3%) (Table 1).

All variables - both demographic and socioeconomic - were associated with the regular consumption of fruits and vegetables (p < 0.05). A higher frequency in the regular intake of fruits was observed among female individuals (71.6%), showing a linear increase with age, schooling and family income (Tabela 2).

There were the same associations for the regular consumption of vegetables, with a difference in the distribution of the age variable, with higher frequency of consumption in the population aged between 45 and 54 years (83.6%) (Table 2).

The regular intake of meals at full service restaurants was not associated with the consumption of fruits, but with the intake of vegetables, after the adjustment for the demographic and socioeconomic characteristics (respectively, OR = 1.51; 95%CI 1.14 - 1.98). The regular intake of meals at fast-food restaurants was not associated with the intake of fruits or vegetables (Table 3).

There was no statistically significant association between the location of fruit and vegetable purchase and the intake of these foods (Table 4).

DISCUSSION

The findings in this study allow to state possible associations between the regular consumption of meals at full service restaurants and the regular consumption of vegetables; however, they do not allow this association with the regular intake of fruits. There is no association between the consumption of fruits and vegetables and the regular intake of meals at fast-food restaurants, according to the data analyzed.

The data presented reinforce the evidence that points to the influence of demographic and socioeconomic factors regarding the consumption of fruits and vegetables⁸8. Jaime PC, Stopa SR, Oliveira TP, Vieira ML, Szwarcwald CL, Malta DC. Prevalência e distribuição sociodemográfica de marcadores de alimentação saudável, Pesquisa Nacional de Saúde, Brasil, 2013. Epidemiol Serv Saúde 2015; 24(2): 267-76. DOI: 10.5123/S1679-49742015000200009
https://doi.org/10.5123/S1679-4974201500... ^,3131. Jaime PC, Monteiro CA. Fruit and vegetable intake by Brazilian adults, 2003. Cad Saúde Pública 2005; 21(Suppl 1): 19-24. DOI: /S0102-311X2005000700003
https://doi.org//S0102-311X2005000700003... in the studied population. The intake was higher among women, and growing with age, schooling⁸8. Jaime PC, Stopa SR, Oliveira TP, Vieira ML, Szwarcwald CL, Malta DC. Prevalência e distribuição sociodemográfica de marcadores de alimentação saudável, Pesquisa Nacional de Saúde, Brasil, 2013. Epidemiol Serv Saúde 2015; 24(2): 267-76. DOI: 10.5123/S1679-49742015000200009
https://doi.org/10.5123/S1679-4974201500... and family income³3. Pessoa MC, Mendes LL, Caiaffa WT, Malta DC, Velásquez-Meléndez G. Availability of food stores and consumption of fruit, legumes and vegetables in a Brazilian urban area. Nutr Hosp 2014; 31(3): 1438-43. DOI: 10.3305/nh.2015.31.3.8245
https://doi.org/10.3305/nh.2015.31.3.824... .

The population analyzed here presented with regular consumption of fruits and vegetables (55.3%) higher than the usually observed in other Brazilian studies, for example, in Florianópolis (50.1%) and in the city of São Paulo (35.5%)⁷7. Brasil. Ministério da Saúde. Vigitel Brasil 2014, Saúde Suplementar: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Agência Nacional de Saúde Suplementar, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde ; 2015.. This consumption, higher than that observed in the main national studies, can be justified by the fact that the study population represents the areas defined for the study, and not the city of São Paulo in general, so some variations are possible in the characteristics of the population analyzed.

Regarding the meals outside the household, several studies point to worse nutritional quality of the meals in this context²³23. Claro RM, Baraldi LG, Martins APB, Bandoni DH, Levy RB. Evolução das despesas com alimentação fora do domicílio e influência da renda no Brasil, 2002/2003 a 2008/2009. Cad Saúde Pública 2014; 30(7): 1-9. DOI: 10.1590/0102-311X00176113
https://doi.org/10.1590/0102-311X0017611... ^,3232. Bandoni DH, Canella DS, Levy RB, Jaime PC. Eating out or in from home: analyzing the quality of meal according eating locations. Rev Nutr 2013; 26(6): 625-32. DOI: 10.1590/S1415-52732013000600002
https://doi.org/10.1590/S1415-5273201300... , however, this study does not corroborate others mentioned earlier, since it presents a positive relationship between the intake of vegetables and the meals had at full service restaurants. The access to healthy foods varies according to the type of business and the socioeconomic status of the population in the city of São Paulo²⁹29. Duran AC, Diez Roux AV, Latorre M do R, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23: 39-47. DOI: 10.1016/j.healthplace.2013.05.001
https://doi.org/10.1016/j.healthplace.20... . The restaurants that charge per kilo can represent an alternative for a healthy diet outside the household, since the variety of choice is higher³³33. Santos MV, Proença RPC, Fiates GMR, Calvo MCM. Os restaurantes por peso no contexto de alimentação saudável fora de casa. Rev Nutr 2011; 24(4): 641-49. DOI: 10.1590/S1415-52732011000400012
https://doi.org/10.1590/S1415-5273201100... .

However, further studies are necessary to assess the availability and the intake of fruits in this type of business. This study did not mention a relationship between the consumption of fruits and the meals had at full service restaurants, and we did not find studies that tried to demonstrate that specific association for fruits, only for foods natural in general³⁴34. Lassen A, Hansen K, Trolle E. Comparison of buffet and à la carte serving at worksite canteens on nutrient intake and fruit and vegetable consumption. Public Health Nutr 2007; 10(3): 292-7. DOI: 10.1017/S1368980007246610
https://doi.org/10.1017/S136898000724661... ^,3535. Jomori MM, Proenca RPC, Calvo MCM. Food choice factors. Rev Nutr 2008; 21(1): 63-73. DOI: 10.1590/S1415-52732008000100007
https://doi.org/10.1590/S1415-5273200800... .

The consumption of meals at fast-food restaurants was not associated with the consumption of fruits and vegetables. Since the intake of these foods, presented by the studied population, was higher than that found in previous analyses⁷7. Brasil. Ministério da Saúde. Vigitel Brasil 2014, Saúde Suplementar: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Agência Nacional de Saúde Suplementar, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde ; 2015., maybe the intake in this population is not influenced by the consumption or not of meals at fast-food restaurants; that is, the individuals who consume fruits and vegetables are not affected by the regular intake of meals at fast-food restaurants. However, it is still necessary to understand how the presence of this type of restaurant can affect and change the dietary behavior and the health of the population, for the implementation of effective strategies to stimulate healthy diets, even if outside the household¹²12. Duran AC, Almeida SL, Latorre MR, Jaime PC. The role of the local retail food environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Public Health Nutrition 2015. [Internet]. Disponível em: Disponível em: http://journals.cambridge.org/download.php?file=%2FPHN%2FS1368980015001524a.pdf&code=6dcaeee54fd5e17915bc15f69c7fae16 (Acessado em 10 de setembro de 2015). DOI: 10.1017/S1368980015001524
http://journals.cambridge.org/download.p... .

For the evaluation of locations of food purchase, the supermarkets (34.3%) and the fruit stores (39.6%) prevailed in the preference of the population, leaving the neighborhood markets (16.0%) in third in the order of preference for the purchase of fruits and vegetables, and the outdoor fairs (10.0%) in fourth.

The findings in this study are in accordance with the study conducted in Rio Grande do Sul as to the preference of food purchase at supermarkets (59.77%) and fruit stores, and these results were expected by the authors, who observed, in other studies, the “prevalence of super and hypermarkets in the preference of consumers as to the purchase of foods around the world”¹⁰10. Souza RS, Arbage AP, Neumann PS, Froehlich JM, Diesel V, Silveira PR, et al. Comportamento de compra dos consumidores de frutas, legumes e verduras na região central do Rio Grande do Sul. Cienc Rural 2008; 38(2): 511-17. DOI: 10.1590/S0103-84782008000200034
https://doi.org/10.1590/S0103-8478200800... . This fact is also shown in several studies that conclude that fresh food markets, like outdoor fairs, have lost importance and have been replaced by supermarkets³⁶36. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev 2012; 70(1): 3-21. DOI: 10.1111/j.1753-4887.2011.00456.x
https://doi.org/10.1111/j.1753-4887.2011... ^,3737. Reardon T, Timmer CP. The economics of the food system revolution. Annu Rev Resour Economics 2012; 4: 225-64. DOI: 10.1146/annurev.resource.050708.144147
https://doi.org/10.1146/annurev.resource... ^,3838. Hawkes C. Dietary implications of supermarket development: a global perspective. Dev Policy Rev 2008; 26(6): 657-92. DOI: 10.1111/j.1467-7679.2008.00428.x
https://doi.org/10.1111/j.1467-7679.2008... , which are preferred by the Brazilian population for the purchase of foods, according to national studies³⁹39. Costa JC, Claro RM, Martins AP, Levy RB. Food purchasing sites. Repercussions for healthy eating. Appetite 2013; 70: 99-108. DOI: 10.1016/j.appet.2013.06.094
https://doi.org/10.1016/j.appet.2013.06.... .

However, in this study, for the population analyzed, the place of fruit and vegetable purchase did not present a relationship with the frequency of consumption of these foods. This finding can be explained by the hypothesis that, in this population, the regular intake of fruits and vegetables is already consolidated, regardless of the location preferred by people to buy these items.

A study conducted in Belo Horizonte, based on the data from VIGITEL, observed that the increasing consumption of fruits and vegetables is directly related with the density of the equipment available to sell these items³3. Pessoa MC, Mendes LL, Caiaffa WT, Malta DC, Velásquez-Meléndez G. Availability of food stores and consumption of fruit, legumes and vegetables in a Brazilian urban area. Nutr Hosp 2014; 31(3): 1438-43. DOI: 10.3305/nh.2015.31.3.8245
https://doi.org/10.3305/nh.2015.31.3.824... . In São Paulo, the highest density of supermarkets and fruit stores is associated with the regular intake of fruits and vegetables, especially in the lower income categories¹²12. Duran AC, Almeida SL, Latorre MR, Jaime PC. The role of the local retail food environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Public Health Nutrition 2015. [Internet]. Disponível em: Disponível em: http://journals.cambridge.org/download.php?file=%2FPHN%2FS1368980015001524a.pdf&code=6dcaeee54fd5e17915bc15f69c7fae16 (Acessado em 10 de setembro de 2015). DOI: 10.1017/S1368980015001524
http://journals.cambridge.org/download.p... .

However, these studies do not approach the relationship between the type of equipment used to sell these foods and the frequency of consumption, but the density of equipment in the region.

The dietary environment and the pattern of food purchase are still little explored in Brazil²¹21. Jaime PC, Duran AC, Sarti FM, Lock K. Investigating environmental determinants of diet, physical activity, and overweight among adults in Sao Paulo, Brazil. J Urban Health 2011; 88(3): 567-81. DOI: 10.1007/s11524-010-9537-2
https://doi.org/10.1007/s11524-010-9537-... ^,2929. Duran AC, Diez Roux AV, Latorre M do R, Jaime PC. Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil. Health Place 2013; 23: 39-47. DOI: 10.1016/j.healthplace.2013.05.001
https://doi.org/10.1016/j.healthplace.20... ^,4040. Velásques-Melendez G, Mendes LL, Padez CMP. Built environment and social environment: associations with overweight and obesity in a sample of Brazilian adults. Cad Saúde Pública. 2013; 29(10): 1988-96. DOI: 10.1590/0102-311X00078112
https://doi.org/10.1590/0102-311X0007811... . Therefore, some comparisons cannot be made due to the lack of data referring to the subject. These relationships should be searched in new studies, in order to get to know and design, in a more robust way, the behavior of the purchase in the population, related with the consumption of foods.

A limitation of this study is related with the application of questionnaires for the evaluation of food consumption, which involves possible bias in the measurement of the frequent diet due to errors in the memory of the interviewee, which overcame the underestimation of dietary intake⁴¹41. Medlin C, Skinner JD. Individual dietary intake methodology: a 50-year review of progress. J Am Diet Assoc 1988; 88(10): 1250-7.^,4242. Scagliusi FB, Ferriolli E, Pfrimer K, Laureano C, Cunha CS, Gualano B, et al. Underreporting of energy intake in Brazilian women varies according to dietary assessment: a cross-sectional study using doubly labeled water. J Am Diet Assoc 2008; 108(12): 2031-40. DOI: 10.1016/j.jada.2008.09.012
https://doi.org/10.1016/j.jada.2008.09.0... . The differences of methods to assess the intake of foods and the categorization of data may also have damaged the comparison with other studies, however, the same parameters of evaluation and categorization of the main national surveys were considered for comparison.

CONCLUSION

It is concluded that the regular intake of fruits and vegetables is influenced by sex, age, schooling and Family income. The conduction of meals at full service restaurants has a positive influence on the intake of vegetables, however, it does not affect the consumption of fruits. There were no associations between the choice of locations to purchase fruits and vegetables and the intake of these foods.

Based on the analysis of the data in this study, and on the comparison with others, it is recommended that meals outside the household be conducted, preferably, at full service restaurants, such as those charged by the kilogram, which are a good option in comparison to fast-food restaurants, since they also count on fast service and ensure greater access to healthier meals.

New studies are necessary to investigate about how the dietary environment, specifically locations of food purchase and consumption, may influence the intake of fruits and vegetables. These data are not consolidated in the scientific literature, which has scarce and superficial information to perform comparisons and robust conclusions.

References

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