The production process of the food guides for the Brazilian population

In 2014, the Brazilian Ministry of Health released the second edition of the DGBP. This document was conceived in order to constitute one of the strategies to effectuate the National Food and Nutrition Policy (NFNP)^{( 10 )}, the National Food and Nutrition Security Policy (NFNSP)^{( 11 )} and the National Policy on Health Promotion (NPHP)^{( 12 )}. Consequently, the document attempts to encompass a complex promotion interface of the human right to adequate and healthy food, health promotion and disease prevention.

It is recognized that the update of the official food and nutrition guidelines for the Brazilian population over 2 years of age makes up one of the goals of the Multi-Year Plan and the first National Plan for Food Security and Nutrition, both for the period 2012–2015^{( 13 )}. The process for updating the guidelines was initiated in 2011, with coordination of the Ministry of Health in the figure of the General Coordination of Food and Nutrition Policy (CGAN/MS), the material being produced with technical assistance of specialists from the Center for Epidemiological Research in Nutrition and Health, University of São Paulo (NUPENS/USP) and the support of the Pan American Health Organization (PAHO/Brazil)⁽ Reference Monteiro, Cannon and Moubarac ^{6 , 8 )}. The development followed the model proposed by the Institute of Nutrition of Central America and Panama (INCAP) and suggested by the FAO for developing food guidelines in Latin America and the Caribbean^{( 2 )}. The elaboration of the material occurred through face-to-face meetings at the Public Health College of USP, regional meetings held in twenty-six Brazilian states and the Federal District, and by public consultation carried out on the Internet, through which contributions from different institutions from civil society were collected^{( 8 )}. This process was consolidated in 2014 with the publication of Dietary Guidelines for the Brazilian Population, distributed by the Ministry of Health with a circulation of 60 000 copies, in addition to the availability of the online publication in three languages (Portuguese, Spanish and English)⁽ Reference Monteiro, Cannon and Moubarac ^{6 )}.

The development mode of the second DBGP edition was similar to that used in the first edition: the production process also was led by CGAN/MS, with technical assistance of specialists from the Observatory of Food and Nutrition Security Policy at the University of Brasilia (OPSAN/UNB)^{( 7 )}. At that moment, the document represented a collective construction through a gathering of state coordination contributions and collaborating centres and references in food and nutrition, and of an online public consultation in which different collaborations participated^{( 7 )}. This process was consolidated with the publication of Dietary Guidelines for the Brazilian Population: Promoting Healthy Eating in 2006, the distribution of which was carried out by the Ministry of Health with a circulation of 25 000 copies and provision of an online publication in Portuguese^{( 7 )}.

In the DGBP production process, the centrality in the public sector (CGAN/MS), with technical assistance from the academic/scientific sector (OPSAN/UNB and NUPENS/USP), stands out. In the second DGBP, the participation of NUPENS/USP had most importance for assuming the co-authoring of the document, unlike the previous edition of the dietary guide of which, despite relevant participation of academic and scientific institutions, the authorship was by the Ministry of Health on its own. The dietary guidelines development process led by the Ministry of Health comprises a reality similar to that of Chile⁽ Reference Keller and Lang ^{14 )} and ten other Latin American and seven Caribbean countries^{( 2 )}, as well as Iran⁽ Reference Safavi, Omidvar and Djazayery ^{15 )}, Austria⁽ Reference Elmadfa and Freisling ^{16 )}, Taiwan⁽ Reference Sirichakwal and Sranacharoenpong ^{17 )} and New Zealand⁽ Reference Keller and Lang ^{14 )}. Regarding co-authoring, in addition to the Ministry of Health in Latin America and the Caribbean, the authorship of dietary guidelines is shared with institutions such as ministries of education, agriculture, labour and development, universities or nutritionists’ associations^{( 2 )}.

It is also recognized that the second DGBP has the larger range of possible access, not only in terms of the number of initial copies, which was almost three times higher than for the first DGBP, but also the publication in three languages. Yet, the possibility of access by digital media widens with greater access to the Internet when compared for both periods. Currently, half (50 %) of Brazilian households have Internet access^{( 18 )}, while in 2006, these households constituted only 17 %^{( 19 )}. It is noteworthy the engagement of members of NUPENS/USP in the disclosure of the document on social networks, television programmes and non-academic journals, along with a series of materials produced for the Ministry of Health in partnership with the Federal University of Minas Gerais (UFMG) to support health primary care teams promote adequate and healthy diets according to the second DGPB. These materials comprise folders about the ten steps for the adequate and healthy diet, a cook book that contains important hints on using fruits and vegetables, and a book that demystifies doubts about food and nutrition.

The favourable political context is also highlighted for the repercussion of the new guide, with the process of consolidation and convergence of public policies in the field of food and nutrition, which, in turn, made possible changes in the approach to food and nutrition. Thus the second DGBP aligns with: the NFNP^{( 10 )} and NPHP^{( 12 )}; the recognition of the human right to adequate and healthy food as a social right and its insertion in the sixth article of the text of the Brazilian Federal Constitution in 2010; the updated NFNSP^{( 11 )}; and the publication of the Reference Framework for Food and Nutrition Education^{( 20 )}, the National Policy of Popular Education in Health^{( 21 )} in the unified health system, and the Reference Framework in Popular Education in Health^{( 22 )}. All this political, legal, technical/scientific apparatus referred to the need for change in the approach to healthy eating practices and the problems related to food and nutrition present in the country, such as the tension of the political confrontation of industrialized foods given their repercussions on health and nutrition.

The graphic strategies of the food guides for the Brazilian population

In the second DGBP, the consolidated document comprises a fully illustrated textbook with pictures of foods, culinary preparations, places of production and distribution of foods and meals (agroecological production system, market places, home cooking practices), and consumption expressed by commensality in different spaces (school meals, home meals, self-service restaurants). This strategy differs from the first DGBP, which features graphics, tables and charts that approach epidemiological data of morbidity/mortality and food consumption, as well as ways of determining recommendations for nutrient consumption and food portions.

The differences in graphic strategies between the two DGBP present, among other factors, the discourses used to promote an adequate and healthy diet. The first DGBP presents the hegemonic nutritional epidemiological discourse, as its images show quantitative information and express technical/scientific terms. This strategy aims to reinforce the scientific arguments that guided the principles and guidelines of the document, in order to convince on the solidity of the recommendations. According to Ratner and Riis, the domain of scientific/nutritional/epidemiological discourses disregards the daily life complexity of human beings in order to encourage individuals to follow guidelines within these bases⁽ Reference Ratner and Riis ^{23 )}.

Moreover, in the second DGBP, the use of photographs denotes more realistic aspects of nourishment, apart from intending to express the recognition of the limits of nutritional sciences assumed in the material⁽ Reference Monteiro, Cannon and Moubarac ^{6 )}. The photographs used demonstrate important sociocultural aspects of feeding, such as subjectivities related to the act of eating, the stories of life, bonding, family relationships, edibility, and local, cultural, regional and global dimensions involved in this dietary pattern. According to Kraemer et al., by employing the human sciences, among which are sociology and anthropology, the approach attempts meet the need to embrace the multidimensional character of food, individuals’ living completeness and their insertion into society – with these aspects being important to promote an adequate and healthy diet⁽ Reference Kraemer, Prado and Ferreira ^{24 )}.

The food classification system of the food guides for the Brazilian population

Regarding the content and organization of material, both DGBP are based on foods^{( 2 , 4 )}. However, the food approach differs between the document editions. In the first DGBP, the food classification system is similar to that used in the Food Pyramid of the USA, adapted to Brazilian reality⁽ Reference Philippi, Latterza and Cruz ^{25 )}, based on food nutrient sources and not on the processing level. In it, the foods are arranged in seven groups organized according to their nutritional equivalence in terms of energy, micro- and macronutrients, as well as their participation in traditional meals and in Brazilian eating habits^{( 7 ,} Reference Philippi, Latterza and Cruz ^{25 )}. These groups are: (i) cereals, roots and tubers; (ii) fruits and vegetables; (iii) milk and its derivates; (iv) meat and eggs; (v) beans and other foods rich in protein; (vi) oils and fats; and (vii) sugars and sweets^{( 7 )}. This food classification seeks to form the basis of dietary and nutritional guidelines aimed at preventing malnutrition, nutrient deficiencies and non-communicable diseases by referring to the appropriate quantitative consumption of each food group.

However the second DGBP uses the NOVA food classification, developed by NUPENS/USP. In it, the food groups are conceived by scientific and nutritional logic of the impact of the extent and purpose of industrial processing of foods before being acquired, prepared and consumed⁽ Reference Monteiro, Cannon and Moubarac ^{6 ,} Reference Monteiro, Levy and Claro ^{26 )}. The foods are categorized into four groups: (i) in natura or minimally processed foods; (ii) processed cooking ingredients; (iii) processed foods; and (iv) ultra-processed foods^{( 8 ,} Reference Monteiro, Levy and Claro ^{26 )}.

The change in food classification assumed in the second DGBP is justified by the impact on diets caused by the growing expansion in the consumption of ultra-processed foods, with the offer of these products everywhere and the strong advertising arsenal that encourages their consumption⁽ Reference Monteiro, Levy and Claro ^{26 – 28 )}. According to WHO data, there was a significant worldwide increase in the sales of ultra-processed foods during the period from 2000 to 2013. All over the world this increase corresponded to 43·7 %; in Latin America, the sales increase was 16·3 % and in Brazil was 30·6 %^{( 27 )}. In Brazil, data from the Household Budget Survey (HBS 2008–2009) registered a decrease in the consumption of Brazilian traditional foods, reflected in rice (6 %), beans (18 %) and manioc (18 %); in contrast, it expressed the increased consumption of processed and ultra-processed foods such as biscuits (10 %), cheese (16 %), sausages (25 %), soft drinks (16 %) and ready-made meals/industrialized mixes (40 %)^{( 29 )}.

The increased sales and consumption of ultra-processed foods exhibited a significant impact on the pandemics of obesity and non-communicable diseases⁽ Reference Uauy, Albala and Kain ^{30 ,} Reference Ludwig ^{31 )}. As explained in the second DGBP, and demonstrated by Canella et al., the increase in consumption of ultra-processed foods in Brazil during the period 2008–2009 is associated with an increase in BMI and with the prevalence of overweight and obesity in the Brazilian population, since ready-to-consume foods have lower nutritional quality than in natura or minimally processed foods⁽ Reference Canella, Levy and Martins ^{32 )}.

Concerning the development of obesity, data from the HBS (2008–2009) showed that overweight and obesity are widespread in the Brazilian population, reaching all age groups, and is a major public health problem^{( 29 )}. In children, the National Survey of School Health reported in 2015 that 23·7 % of students, from the ninth year, were overweight, with obesity responsible for 7·8 % of cases^{( 33 )}. The HBS (2008–2009) portrayed overweight in about 30 % of children aged 5–9 years, and in 20 % of the population aged 10–19 years, and among these two groups revealed that obesity corresponded about a quarter of the total excess weight in both sexes^{( 29 )}. Regarding the adult population, according to data from the surveillance of risk and protective factors for chronic diseases by telephone survey (VIGITEL 2013), 51 % of Brazilian adults are overweight, of whom 17·4 % are obese^{( 34 )}.

Ultra-processed foods have higher energy density and higher contents of total fat, saturated fat, sugars and salt, being low in protein and food fibres⁽ Reference Monteiro ^{35 ,} Reference Louzada, Baraldi and Steele ^{36 )}. There are also social and environmental consequences of ultra-processed food production, which uses intensive animal production systems and extensive monoculture to supply inputs such as soyabeans and corn needed to produce these processed foods ready for consumption – producing, in general, degradation and environmental pollution, reduction of biodiversity and jeopardizing water reserves, energy and other natural resources⁽ Reference Moubarac, Martins and Claro ^{37 ,} Reference Popkin ^{38 )}:

Given the above, it is believed that use of the NOVA classification in the second DGBP can contribute to the political confrontation of processed and ultra-processed foods, in order to meet the recommendations set out in NPFN^{( 10 )} and the Strategic Action Plan to Tackle Non-communicable Diseases in Brazil 2011–2022^{( 39 )} for the protection of human health, considering the changes that have occurred in the traditional sociocultural patterns of food, the nutritional risks and seeking to expand the state’s capability to make use of the legal instruments of control necessary to protect the health of the population.

It is noteworthy that international organizations have adopted the NOVA classification in the development of documents concerning the assessment of food consumption profiles in different parts of the planet^{( 27 )}, as well as for analysis and classification of the nutritional profile of processed and ultra-processed foods and beverages in order to determine their content in terms of excessive amounts of free sugars, salt, total fat, saturated fat and trans-fatty acids^{( 28 )}.

Use of the NOVA food classification in the second DGBP has provoked reactions from the Brazilian Association of Food Industries (ABIA) and the Institute of Food Technology (ITAL). These institutions promoted an initiative in defence of the country’s food sector: the project ‘Brazil Processed Food 2020: the importance of processed foods for Brazilian society’. This project aims to provide technical and scientific information to oppose the arguments that classify processed foods as harmful to human health; and to build a positive and favourable image of food processing, nutrition and health^{( 40 )}. Both entities have accused the Ministry of Health of encouraging the repulsing of processed foods by publishing documents such as the DGBP and the Regional Brazilian Food Book.

However, the second DGBP recommendations highlight an important distinction between processed foods and ultra-processed foods. The guideline recommends that processed foods may be part of the diet, as ingredients for food preparations or as parts of meals based on in natura or minimally processed foods^{( 8 )}:

This recommendation is confirmed in the presentation of photographs of breakfast and lunch dishes containing processed food (cheese, bread and genipap jam). As for the ultra-processed foods, they are advised to be avoided, including reshaped versions light and diet, in a clear statement:

The growing scientific and academic knowledge about the unbalanced nutritional composition of ultra-processed foods, and their sociocultural and environmental impacts, expresses that there are no longer reasons to recommend ‘moderation’ in consumption of such foods; so they should be avoided/excluded from the diet, in order to make the nourishment more appropriate and healthy.

Principles and guidelines of the food guides for the Brazilian population

As discussed previously, the food processing level is the major concern of the second DGBP, because it has negative impacts on the health profile of the population, environmental sustainability, autonomy and social justice⁽ Reference Monteiro, Cannon and Moubarac ^{6 )}. The central idea of this document is to encourage people to consume natural or minimally processed foods and freshly made dishes and meals instead of ultra-processed foods; therefore it determined five basic principles for the development of food and nutrition guidelines in this edition:

It is recognized that most of these principles change those developed in the first DGBP, which reminded:

In summary, in the first DGBP the principles consolidated nutritional guidelines aimed at preventing diseases, achieved by the quantitative consumption of food groups defined in food portion size/culinary preparations and the appropriate number of these portions to consume.

Comparing the principles of the first and second DGBP, a change is notable in two dimensions of the approach to food: sociocultural and environmental. The sociocultural dimension is common to both materials, and aims to consider the importance of the symbolic and normative aspects of food expressed in culinary practices, in food and traditional meals of the Brazilian people, and the social, emotional and sensory characteristics that interfere with acquiring, preparing and consuming food in both DGBP^{( 7 , 8 )}. However, the second DGBP presents other contours to the sociocultural dimension in its dietary and nutrition guidelines.

The use of the NOVA classification and the emphasis on the following ‘golden rule’: ‘always prefer in natura or minimally processed food and freshly made dishes and meals to ultra-processed food’^{( 8 )}, enabled reconfiguration of the value attributed to culinary practices, traditional eating patterns and meals, and to the act of eating and commensality, while presenting its strategy to promote adequate and healthy diets. From the analysis of the given approaches, new contours to culinary preparations and Brazilian culinary practices of different regions can be exemplified as follows. In the first DGBP, the consumption of a portion of beans in combination with rice is guided in a metric form, at a ratio of 1 to 2 parts. This recommendation values the basic traditional food of Brazilians (rice and beans) as a combination of protein and good for health^{( 7 )}. In the second DGBP, beans hold value beyond their protein content; this food is contextualized within the Brazilian dietary culture and many possibilities of culinary preparations are presented in which beans can be consumed, such as tutu à mineira, ‘tropeiro’ beans, feijoada, bean soup and acarajé, among many others^{( 8 )}. From this perspective, it is emphasized that dietary patterns are different according to geographical areas and socio-economic groups, with the dependent variation in farming practices, climate, ecology, culture and socio-economic factors determining the demand, production and distribution of foods^{( 2 , 4 )}.

Another aspect of the sociocultural dimension addressed in the dietary guidelines comprises the hedonic and sensory character of foods. The second DGBP guides on the correct use of cooking ingredients, recommending their use in small quantities to season and cook foods and to create culinary preparations based on in natura or minimally processed foods, in order to contribute to diversity and make food tastier without making it nutritionally unbalanced^{( 8 )}:

In these perspectives, the second DGBP seeks to restore the pleasure of foods, evoking sensory stimuli caused by foods and their impact on healthy food choices. This strategy is aimed at facing the consumption of processed foods that have repetitive taste, in a variety of products, resulting from excessive use of sweeteners, flavourings and flavouring agents, salt and artificial spices. This chemical configuration of industrialized foods promotes progressive decrease in taste sensitivity and decreases the pleasure to eat⁽ Reference Martin ^{41 )}.

Noteworthy are also the four chapters of the second DGBP on the act of eating and commensality, emphasizing the circumstances – time and focus, space and company – that influence the use of foods and the pleasure afforded by meals^{( 8 )}. Recovery of eating together and commensality enhances the act of eating as a social activity, opposing the individualizing models powered by the food industry in the promotion of ready-to-consume foods:

Commensality regulates social life and individual behaviour at the social and biological level, since it establishes rules and customs that regulate the eaters, the disposal of the eaters, the distribution and sharing of food, and ‘good manners at the table’. For this reason, the edibility can be considered a protective health practice because eating together provides for spending more time in the act of feeding. People tend to adjust their intake and behave in accordance with the behaviour of other eaters – regulating their food choices, the amount of food and ways to eat⁽ Reference Daly ^{42 ,} Reference Fischler ^{43 )}.

Recommendations on the pleasure of eating and commensality are a reality in some countries that have developed dietary and nutritional guidelines with concern for the social and cultural dimensions of nourishment. Some countries’ guidelines from Europe⁽ Reference Altamirano Martínez, Muñoz and Ojeda ^{44 ,} Reference Montagnese, Santarpia and Buonifacio ^{45 )} and Latin America and the Caribbean^{( 2 )} extend messages addressing the pleasure of food, such as ‘enjoy your meal’, ‘transform meals in social moments’ and ‘enjoy your meals with family members’. These dietary and nutritional guidelines are examples of strategies that incorporate the social and cultural dimensions of nutrition, to the epidemiological and nutritional point of view, forming a perspective of the complexity of nourishment and the determinant elements of healthy food choices. In short, it is understood that the dietary guidelines should not be closed on leading for the control of food intake. The notion of satisfaction is crucial for changing eating habits. Thus it is important to encourage individuals to experience the pleasure of a meal, prepared from in natura or minimally processed foods, which is related to the person’s life story, personal identity and social group, and still feel the satisfaction for that food choice.

Regarding the environmental dimension, the first DGBP seeks to encourage food practices promoting the remodelling of food systems, reducing those systems centred on large-scale monoculture and use of genetically modified organisms, pesticides, hormones and anabolic growth promoters, ionizing radiation and others. On the other hand, it encourages the consumption of local foods and those coming from organic food production systems – as expressed in the principle of environmental sustainability^{( 7 )}.

In the second DGBP, the environmental approach aligns with the NOVA food classification, therefore expressing emphasis on the ‘interdependence between healthy diets and the social and environmental sustainability of the food system’^{( 8 )}, recognizing that ultra-processed foods are derived from inputs arising from intensive animal production and extensive monoculture plant systems, and that – as well as being dense in energy – their sugars, fats and salt content that have favoured the development of obesity and CVD presents an important social impact as gender inequality, racism, acculturation and land concentration, among others⁽ Reference Ludwig ^{31 ,} Reference Lairon ^{46 )}. Also ultra-processed foods are understood as having an impact on social justice, distribution of wealth, autonomy of farmers, the creation of job opportunities and income in the rural environment, and other socio-political issues⁽ Reference Pettit and Wheeler ^{47 )}. The firmament of this positioning is expressed in the ‘golden rule’ and in the assertive: ‘avoid ultra-processed foods’.

Similar to Brazil, some countries around the world have been developing efforts to promote environmental sustainability and fair food trade, like the USA^{( 48 )}, the Netherlands^{( 49 )}, Sweden^{( 50 )} and some countries of the UK^{( 51 )}. In those countries it is aimed to develop, or it was developed, dietary guidelines with messages related to increased consumption of plant foods, reducing consumption of meat and other animal foods, reducing/avoiding the consumption of ultra-processed ready-to-eat foods, preferring buying foods from local producers, or the consumption of fresh foods instead of frozen or canned, in addition to reducing food waste.