Abstracts

Introduction

Food is a basic daily need of human life, permeated by both the biological complexity related to the nutrients necessary for life maintenance and by cultural, regional, social, economic and psychological factors¹1 Maciel ME. Uma cozinha à brasileira. Estud Hist. 2004; 1(33):25-39.^,22 Poulain JP. Sociologias da alimentação: os comedores e o espaço social. 2a ed. Florianópolis: UFSC; 2013.. There is a moment, prior to food intake and nutrient absorption, related to the social and cultural nature of eating, which involves interactions with people that shape individuals’ food systems, and directly influence their food choices³3 Delormier T, Frohlich KL, Potvin L. Food and eating as social practice: understanding eating patterns as social phenomena and implications for public health. Soc Health Illness. 2009; 31(2):215-28. doi:10.1111/j.1467-9566.2008.01128.x.
https://doi.org/10.1111/j.1467-9566.2008... . Although food choices seem superficial and simple, they can involve more than 220 decisions/day⁴4 Wansink B, Sobal J. Mindless eating: the 200 daily food decisions we overlook. Environ Behav. 2007; 39(1):106-23. based on symbolic elements triggered from decisions such as: What? Where? How? How much? With whom? For how long?⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... . Food choices are currently becoming more complex, combining the food abundance resulting from agro-industrial progress, which increases food availability²2 Poulain JP. Sociologias da alimentação: os comedores e o espaço social. 2a ed. Florianópolis: UFSC; 2013., and the widespread dissemination of information related to food and nutrition, with often contradictory information⁶6 Fischler C. Food habits, social change and the nature/culture dilemma. Soc Sci Inf. 1980; 19(6):937-53. doi:10.1177/053901848001900603..

This context brings challenges for health professionals in situations requiring dietary management, such as chronic non-communicable diseases (CNCD), which have a direct relationship with food. Actors involved in the health and eating care of individuals with CNDC – patients, professionals, family, media, state – often tend to manage risk in a rational prescriptive way, considering only the physiological consequences of eating²2 Poulain JP. Sociologias da alimentação: os comedores e o espaço social. 2a ed. Florianópolis: UFSC; 2013..

Individuals give different and several values to food, which vary and are combined, and involve factors such as preferences, habits, sensory aspects, context, and environment⁷7 Connors MM, Bisogni CA, Sobal J, Devine C. Managing values in personal food systems. Appetite. 2001; 36(3):189-200. doi: 10.1006/appe.2001.0400.
https://doi.org/10.1006/appe.2001.0400... . Thus, dealing with diets imposed and disseminated by professionals, family members, and the media, may yield negative values such as loss of pleasure and freedom to eat and indicate challenges in controlling desires⁸8 Péres DS, Franco LJ, Santos MA. Comportamento alimentar em mulheres portadoras de diabetes tipo 2. Rev Saude Publica. 2006; 40(2):310-7. doi: 10.1590/S0034-89102006000200018.
https://doi.org/10.1590/S0034-8910200600... .

Non-adherence to dietary changes can lead to negative consequences in the treatment of heart disease, leading to an increased risk of a new cardiovascular event. The understanding of patients with cardiovascular disease regarding dietary change is understood as opposite to pleasant eating⁹9 Galter C, Rodrigues GC, Galvão ECF. A percepção do paciente cardiopata para a vida ativa após recuperação de cirurgia cardíaca. J Health Sci Inst. 2010; 28(3):255-8. and accompanied by stress and repressed desires¹⁰10 Lima FET, Araújo TL. Prática do autocuidado essencial após a revascularização do miocárdio. Rev Gaucha Enferm. 2007; 28(2):223-32..

Scientific evidence shows that encouraging pleasure eating, as part of a nutritional counseling can be an ally in promoting the development of healthy habits¹¹11 Bedard A, Lamarche PO, Grégoire LM, Trudel-Guy C, Provencher V, Desroches S, et al. Can eating pleasure be a lever for healthy eating? A systematic scoping review of eating pleasure and its links with dietary behaviors and health. PloS One. 2020; 15(12):e0244292. doi: 10.1371/journal.pone.0244292.
https://doi.org/10.1371/journal.pone.024... ^,1212 Cripriano-Crespo C, Rivero-Jiménez B, Conde-Caballero D, Medina FX, Mariano-Juárez L. The Denied pleasure of eating: a qualitative study with functionally diverse people in Spain. Foods. 2021; 10(3):628. doi: 10.3390/foods10030628.
https://doi.org/10.3390/foods10030628... .

Values of pleasure and health attributed by the patients at the time of food choices can be dichotomous and bring challenges in the care of patients with heart disease. These values are part of the personal food system of choice, an important component involved in the food choice process and characterized by individual processes constructed to facilitate it⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... ^,77 Connors MM, Bisogni CA, Sobal J, Devine C. Managing values in personal food systems. Appetite. 2001; 36(3):189-200. doi: 10.1006/appe.2001.0400.
https://doi.org/10.1006/appe.2001.0400... ^,1313 Biltekoff C. Consumer response: the paradoxes of food and health. Ann N Y Acad Sci. 2010; 1190:174-8. doi: 10.1111/j.1749-6632.2009.05268.x.
https://doi.org/10.1111/j.1749-6632.2009... .

The Brazilian Cardioprotective Nutrition Program (Balance) was a multicenter randomized clinical trial conducted in 35 centers in all Brazilian regions investigating a nutritional counseling based on a ludic strategy, aiming to prevent new cardiovascular events in patients with cardiovascular disease¹⁴14 Weber B, Bersch-Ferreira AC, Torreglosa CR, Marcadenti A, Lara ES, Silva JT, et al. Implementation of a brazilian cardioprotective nutritional (BALANCE) program for improvement on quality of diet and secondary prevention of cardiovascular events: a randomized, multicenter trial. Am Heart J. 2019; 215:187-97. doi: 10.1016/j.ahj.2019.06.010.
https://doi.org/10.1016/j.ahj.2019.06.01... . With 2,534 volunteers and more than 300 professionals involved, this clinical trial provided the development of numerous sub-studies (e.g., nutrigenomics¹⁵15 Bersch-Ferreira AC, Sampaio GR, Gehringer MO, Torres EAFS, Ross-Fernandes MB, Silva JT, et al. Association between plasma fatty acids and inflammatory markers in patients with and without insulin resistance and in secondary prevention of cardiovascular disease, a cross-sectional study. Nutr J. 2018; 17(1):26. doi: 10.1186/s12937-018-0342-1.
https://doi.org/10.1186/s12937-018-0342-... and quality of diet¹⁶16 Torreglosa CR, Sarti FM, Bersch-Ferreira AC, Weber B, Santos RHN, Chiavegatto Filho ADP. Qualidade da dieta e despesa diária com alimentação em adultos com doença cardiovascular no Brasil. Cad Saude Publica. 2020; 36(10): e00225019. doi: 10.1590/0102-311X00225019.
https://doi.org/10.1590/0102-311X0022501... ). This paper reports the only study bringing a qualitative perspective, giving voice to the participants about their perceptions about pleasure and healthy eating and allowing us to understand their process of food choices, considering barriers and facilitators, while adhering to the dietary strategy proposed by the Balance Program.

Materials and methods

This project was approved by the Research Ethics Committee of the Federal University of São Paulo (CAAE 61415116.8.0000.5505).

Balance was a multicenter randomized clinical trial to evaluate the effectiveness of the dietary intervention based on nutritional counseling in preventing new cardiovascular events in patients with heart disease¹⁷17 Weber B, Bersch-Ferreira ÂC, Torreglosa CR, Ross-Fernandes MB, Silva JT, Galante AP, et al. The brazilian cardioprotective nutritional program to reduce events and risk factors in secondary prevention for cardiovascular disease: study protocol. Am Heart J. 2016; 171(1):73-81.e1-2. doi: 10.1016/j.ahj.2015.08.010.
https://doi.org/10.1016/j.ahj.2015.08.01... , funded by “Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde” (PROADI-SUS), conducted from 2012 to 2017 in a partnership between Hospital Hcor and the Brazilian Ministry of Health.

The Program included patients aged 45 years or older who had one or more of the following indicators of established cardiovascular disease in the preceding 10 years: (a) coronary disease; (b) previous stroke; (c) peripheral vascular disease¹⁷17 Weber B, Bersch-Ferreira ÂC, Torreglosa CR, Ross-Fernandes MB, Silva JT, Galante AP, et al. The brazilian cardioprotective nutritional program to reduce events and risk factors in secondary prevention for cardiovascular disease: study protocol. Am Heart J. 2016; 171(1):73-81.e1-2. doi: 10.1016/j.ahj.2015.08.010.
https://doi.org/10.1016/j.ahj.2015.08.01... .

A nutritional counseling strategy named Brazilian Cardioprotective Diet¹⁸18 Brasil. Ministério da Saúde. Alimentação cardioprotetora: manual de orientações para os profissionais de saúde da atenção básica. Brasília: Ministério da Saúde; 2018., in line with the Dietary Guidelines for the Brazilian population¹⁹19 Brasil. Ministério da Saúde. Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2014., translated Brazilian nutritional recommendations²⁰20 Sociedade Brasileira de Cardiologia. I diretriz brasileira de prevenção cardiovascular. Rio de Janeiro: SBC - Núcleo Interno de Publicações; 2013. into a ludic nutritional counseling. For that, food was classified according to the colors of the Brazilian flag: green – consume more (i.e., fruits, vegetables, skimmed milk e beans); yellow – consume sparingly (i.e. grains, vegetable oils, tubers and pasta); and blue – consume less (i.e., all kinds of meat - fish, pork, chicken, beef - and confectionery). In addition to the cardioprotective groups, there is also the red group (not represented in the Brazilian flag), composed of ultra-processed foods which consumption should not be stimulated¹⁴14 Weber B, Bersch-Ferreira AC, Torreglosa CR, Marcadenti A, Lara ES, Silva JT, et al. Implementation of a brazilian cardioprotective nutritional (BALANCE) program for improvement on quality of diet and secondary prevention of cardiovascular events: a randomized, multicenter trial. Am Heart J. 2019; 215:187-97. doi: 10.1016/j.ahj.2019.06.010.
https://doi.org/10.1016/j.ahj.2019.06.01... ^,1717 Weber B, Bersch-Ferreira ÂC, Torreglosa CR, Ross-Fernandes MB, Silva JT, Galante AP, et al. The brazilian cardioprotective nutritional program to reduce events and risk factors in secondary prevention for cardiovascular disease: study protocol. Am Heart J. 2016; 171(1):73-81.e1-2. doi: 10.1016/j.ahj.2015.08.010.
https://doi.org/10.1016/j.ahj.2015.08.01... ^,1818 Brasil. Ministério da Saúde. Alimentação cardioprotetora: manual de orientações para os profissionais de saúde da atenção básica. Brasília: Ministério da Saúde; 2018..

Participants randomized to Balance group had intensive follow-up through face-to-face visits, group sessions, and phone calls (14-Weber et al 2019). Menus from 1400 kcal to 2400 kcal were calculated, stipulating for each of them the correct amount and combination of portions of the three cardioprotective groups, in accordance with the nutritional recommendations of the Brazilian Cardiology Guidelines²⁰20 Sociedade Brasileira de Cardiologia. I diretriz brasileira de prevenção cardiovascular. Rio de Janeiro: SBC - Núcleo Interno de Publicações; 2013.. Each portion advised to the patient corresponds to a “heart” of the respective colors referring to the group to which the food belongs. Participants follow-up occurred through a six-month frequency of face-to-face individual or group appointments and monthly telephone calls during the first and second years, and during the third and fourth years, every 4 months. After each nutritional appointment, professionals, together with the participant, discussed the different foods grouped by colors, providing an opportunity for patients to think about food choices. For more details of the intervention, the full protocol has been previously published¹⁷17 Weber B, Bersch-Ferreira ÂC, Torreglosa CR, Ross-Fernandes MB, Silva JT, Galante AP, et al. The brazilian cardioprotective nutritional program to reduce events and risk factors in secondary prevention for cardiovascular disease: study protocol. Am Heart J. 2016; 171(1):73-81.e1-2. doi: 10.1016/j.ahj.2015.08.010.
https://doi.org/10.1016/j.ahj.2015.08.01... .

Although the Balance Program trial has finished, some projects promoting the Brazilian Cardioprotective Diet nutritional counseling strategy are still going on via PROADI-SUS²¹21 Brasil. Ministério da Saúde. Manuais de orientação alimentar para o cuidado da pessoa com fatores de risco cardiovasculares no contexto da Atenção Básica [Internet]. Brasília: PROADI-SUS; 2022 [citado 9 Set 2022]. Disponível em: https://hospitais.proadi-sus.org.br/projeto/manuais-alimentacao-cardioprotetora1
https://hospitais.proadi-sus.org.br/proj... . One of those was the development of the “Cardioprotective Diet: a manual for primary health care professionals”, launched in 2018¹⁸18 Brasil. Ministério da Saúde. Alimentação cardioprotetora: manual de orientações para os profissionais de saúde da atenção básica. Brasília: Ministério da Saúde; 2018..

This is an explanatory case study²²22 Yin R. Estudo de caso: planejamento e método. 2a ed. Porto Alegre: Bookman; 2011., conducted with participants of the trial from the Hcor center (n=23), that were between the 27^th and 38^th months of the intervention. Participants’ information (e.g., age, nationality, comorbidity) were obtained from the trial database. All 23 patients who composed the Hcor center intervention group were invited to participate in the interviews; however only 10 individuals accepted.

All semi-structured interviews were conducted and recorded after consent by author M.F.P.F., who had no prior contact with the patients, from March to June 2017. The interviews lasted between 45 and 60 minutes. Figure 1 describes the script’s questions which results are presented in this manuscript.

The interviews were conducted in person in a private room at the hospital (Hcor), located in the city of São Paulo. Volunteers went to the hospital only for the interview and transportation was reimbursed to participants. To guarantee participants’ anonymity and valuing national elements, names were substituted by names of Brazilian trees.

Data were analyzed according to thematic content analysis²³23 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14a ed. São Paulo: Hucitec; 2014. using as theoretical framework the Food Choice Process Model, which describes the factors involved in the process of food choice⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... ^,2424 Sobal J, Bisogni CA, Devine CM, Jastran M. A conceptual model of the food choice process over the life course. In: Shepherd R, Raats M. The psychology of food choice. Cambridge: CABI Publishing; 2006. p. 1-18.. The model was developed based on grounded theory and has three inter-related dimensions to explain food choices processes: life course, influences, and personal food systems. The construction of a personal food system covers the way individuals perceive how foods are classified and eating situations, the establishment and negotiation of values, and the development of strategies, patterns, and routines in food choices, acting together and dynamically during decision making. All this process undergoes changes throughout the course of life and in situations adapted to different contexts⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... .

The themes for the content analysis were defined a priori based on the three inter-related dimensions of the Food Choice Process model. Initially, a free-floating reading of the fully transcribed interviews was carried out for appropriation of the meanings. The next readings allowed the identification of the registry units followed by the context units²³23 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14a ed. São Paulo: Hucitec; 2014..

As the food choice process is profoundly complex, in this manuscript the authors chose to explore the categories that emerged a posteriori regarding the personal food system dimension of the Food Choice model, as they were particularly relevant in the participants’ reports on their food choices. This dimension of the model is based on contexts and the establishment and negotiation of values⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... , that include pleasure (liked and preferred foods) in opposition to health eating, which generated the following final categories of analysis: 1. Eating for health; 2. Eating for pleasure; and 3. Eating for health versus eating for pleasure: strategies and value trading. The other categories identified were related to the other dimensions of de model (life course and food trajectory and influences) will be discussed in future publications.

Results

Table 1 describes the characteristics of study participants.

From their discourses it was possible to identify how foods were classified and reclassified considering the different dietary contexts and how they established strategies and routines to deal with the complex process of food choices when faced with the need to adhere to a dietary intervention program.

Eating for health

In this category we summarize what patients understand as healthy eating in the context of their cardiovascular disease. The main aspects were the classification of foods into healthy and unhealthy and its relationship with the nutritional counseling and how they apply these concepts to their daily routines.

Given the presence of cardiovascular disease and its relationship with certain dietary practices, patients are expected to be able to identify and adopt the most appropriate foods for their treatment. Classifying food represents one of the first steps in the food choice process, and the healthy/unhealthy classification is an important step in decision making for these patients. They were unanimous to classify fruits and vegetables as both healthy and natural foods, and fatty foods represent unhealthy ones.

This classification is in accordance with the Balance Program, suggesting that patients have incorporated the color groups (green, yellow, and blue) recommendation proposed based on the Brazilian flag and foods.

Discipline, not only regarding what to eat but also to quantity, complements the patients’ conception of healthy eating.

Control in some cases is radical and there is no weighting among other factors that influence food choices – health is the sole focus of decisions.

Thus, the food choice based on health improvement seems to be an important value for respondents to adhere to the Balance guidelines. The classifications involved in eating for health converge with the Program recommendations, which stem from the scientific knowledge that relates the food to cardiovascular disease treatment.

Eating for pleasure

In this category we present the dichotomous perceptions of patients about pleasure and health. Correctly identifying foods which may have adverse health consequences, does not necessarily mean that individuals choose healthier eating options proposed by the Balance program, as the value attributed to food (taste, context) is often the determining factor for food choices.

These reports illustrate the complexity of the participants’ personal food choice system. Despite understanding the Balance guidelines, as they correctly identify healthy or unhealthy foods, the taste of food and the pleasure to eat are important factors for food choices in the case of meat (blue group) and alcohol (red group). Another relevant point is the cultural habit of consuming foods from the countries of origin and/or on a certain day of the week.

For some participants, the information offered by the Program led them to reflect on what is a proper diet to face health and disease situations, however, this knowledge was accompanied by feelings of guilt when not followed.

Respondents frequently associated unhealthy foods with those with a more pleasant taste. However, some individuals have associated the choice of foods classified as healthy with the pleasure of caring for their health.

Although several respondents considered some of the foods that were classified as healthy by the Balance proposal to be pleasurable, reports seem to indicate that eating for pleasure can hinder the adherence to the program guidelines, considering that most foods that participants find tasty are advised to be eaten with some restriction, depending on the group color.

Eating for health versus eating for pleasure: strategies and value negotiation

In this category we report the strategies adopted by the patients to negotiate pleasure and health and adherence to the Balance program. For most patients the frustration of not eating for pleasure is an aspect restraining the adherence to Balance guidelines.

The first type of negotiation observed is when patients eat the advised foods, especially of the green group but balance this choice with some favorite food, as illustrated by the following statement:

The second type of negotiation happened when patients travel and on weekends. The respondents reported the consumption of special favorite food that seems to work like rewards for following the Balance advise on other weekdays.

If on one hand, eating in places other than home (trips, celebrations) can hinder adherence to the program, on the other hand, there is a partial adherence to the guidelines, as individuals consciously choose and maintain periods of healthy eating. For some respondents, the difficulty in choosing between eating for pleasure and eating for health seems to be understood as a disobedience to the guidelines, which make it impossible to fully adhere to the Program guidelines.

Although this interviewee pointed to the possibility of disobeying and not negotiating, other participants mentioned several strategies they use to facilitate and accelerate the process of food choice, given the negotiation process between eating for health and eating for pleasure, such as to restrict the intake of fat (e.g., avoiding fried foods, meats, whole milk and ultra-processed foods); to add or increase the consumption of fruits and vegetables; to limit the consumption of sugary ultra-processed foods; and to modify cooking techniques.

Discussion

Although the food choice process is deeply complex and involves a huge range of influencing factors, in terms of negotiating food choices between health and pleasure, we identified that patients with cardiovascular diseases seek a balance between attending to the nutritional guidance to control their health condition, but also respecting their preferences. The search for health is a dynamic and complex process and begins with the very conception of what the individual understands as healthy²⁶26 Chapman G, Maclean H. “Junk food” and “healthy food”: meanings of food in adolescent women’s culture. J Nutr Educ. 1993; 25(3):108-13. doi: 10.1016/S0022-3182(12)80566-8.
https://doi.org/10.1016/S0022-3182(12)80... ^,2727 Paquette MC. Perceptions of healthy eating: state of knowledge and research gaps. Can J Public Health. 2005; 96 Suppl 3: S15-9, S16-21..

As found in this study, the preference for foods considered as healthy is the most reported factor affecting all patients in their food choices²⁸28 Falk LW, Bisogni CA, Sobal J. Food choice of older adults: a qualitative investigation. J Nutr Educ. 1996; 28(5):257-65. doi: 10.1016/S0022-3182(96)70098-5.
https://doi.org/10.1016/S0022-3182(96)70... . Studies in different contexts show that the healthy category is subcategorized and may include “natural” foods (e.g., fruits and vegetables), as well as having a specific property (e.g., the acidity) or substance⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... , or as those related to weight maintenance, food balance and disease prevention⁷7 Connors MM, Bisogni CA, Sobal J, Devine C. Managing values in personal food systems. Appetite. 2001; 36(3):189-200. doi: 10.1006/appe.2001.0400.
https://doi.org/10.1006/appe.2001.0400... ^,2929 Ross BH, Murphy GL. Food for thought: cross-classification and category organization in a complex real-world domain. Cogn Psychol. 1999; 38(4):495-553. doi: 10.1006/cogp.1998.0712.
https://doi.org/10.1006/cogp.1998.0712... . Among people with different diseases (e.g., diabetes, hypertension) foods classified as unhealthy are usually restricted³⁰30 Barsaglini RA. As representações sociais e a experiência com diabetes: um enfoque socioantropológico. Rio de Janeiro: Editora Fiocruz; 2011. (Coleção Antropologia & Saúde).^,3131 Canesqui AM. “Pressão alta” no cotidiano: representações e experiências. Rio de Janeiro: Editora Fiocruz; 2015..

In this study, the understanding of the food groups according to the Balance Program by the participants, suggests the embodiment of the guidelines, contributing to the adherence to the program. For these patients, healthy eating is associated with the imposition of dietary restrictions (types and/or quantities), and these dietary norms are often opposed to the social norms of individuals and groups³¹31 Canesqui AM. “Pressão alta” no cotidiano: representações e experiências. Rio de Janeiro: Editora Fiocruz; 2015.. The traditional Western medicine discourses such as “make your diet your medication” are common as part of the social construction of a “dietary normality” and contribute to an understanding of the physiological functions of food and diet, emphasizing their biological role over the social aspects of eating and characterizing a medicalization of food³²32 Gracia-Anaiz M. Comer bien, comer mal: la medicalizacíon del comportamiento alimentario. Salud Publica Mexico. 2007; 49(3):236-42..

For the same individual, the notion of healthy can have different meanings according to the stage of life, social context³³33 Blake CE, Bisogni CA, Sobal J, Devine CM, Jastran M. Classifying foods in contexts: how adults categorize foods for different eating settings. Appetite. 2007; 49(2):500-10. doi: 10.1016/j.appet.2007.03.009.
https://doi.org/10.1016/j.appet.2007.03.... , and the disease status. Most of these patients experienced one (or more) acute cardiovascular episode and live with a CNCD that requires scientifically proven dietary care and that guides Balance’s proposition. In this scenario, the difficulty of diet management emerges from a legitimate context of food medicalization, which excludes – or little problematizes – diet as a social and pleasure act.

Still, the concept of ‘healthy’ is dynamic and changeable²⁶26 Chapman G, Maclean H. “Junk food” and “healthy food”: meanings of food in adolescent women’s culture. J Nutr Educ. 1993; 25(3):108-13. doi: 10.1016/S0022-3182(12)80566-8.
https://doi.org/10.1016/S0022-3182(12)80... . The same food can be cross-classified into different categories, and categories can often be antagonistic (e.g., tasty vs. unhealthy), which gives ambiguity to the food choices we perform daily⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... ^,3434 Falk LW, Sobal J, Bisogni CA, Connors M, Devine CM. Managing healthy eating: definitions, classifications, and strategies. Health Educ Behav. 2001; 28(4):425-39. doi: 10.1177/109019810102800405.
https://doi.org/10.1177/1090198101028004... . In addition to health, these classifications are influenced by the individual’s personal experience, taste, cost, routine, preferences, and context in which the choice is made: the convenience of purchase/preparation; the day of the week, the location and the company⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... ^,3434 Falk LW, Sobal J, Bisogni CA, Connors M, Devine CM. Managing healthy eating: definitions, classifications, and strategies. Health Educ Behav. 2001; 28(4):425-39. doi: 10.1177/109019810102800405.
https://doi.org/10.1177/1090198101028004... , as well as the meanings and feelings attributed to each of them.

Taste is often one of the most valued attribute related to food choices⁷7 Connors MM, Bisogni CA, Sobal J, Devine C. Managing values in personal food systems. Appetite. 2001; 36(3):189-200. doi: 10.1006/appe.2001.0400.
https://doi.org/10.1006/appe.2001.0400... ^,3535 Drewnowski A. Taste preferences and food intake. Annu Rev Nutr. 1997; 17:237-53. doi: 10.1146/annurev.nutr.17.1.237.
https://doi.org/10.1146/annurev.nutr.17.... . Several foods mentioned were personal preferences regarding taste and pleasure eating, with wine and meat being the two most frequent foods reported. The preference for meat can be explained by several physiological aspects, such as palatability and texture, as well as the historical and cultural aspects it has in the Brazilian culinary context¹1 Maciel ME. Uma cozinha à brasileira. Estud Hist. 2004; 1(33):25-39.^,1313 Biltekoff C. Consumer response: the paradoxes of food and health. Ann N Y Acad Sci. 2010; 1190:174-8. doi: 10.1111/j.1749-6632.2009.05268.x.
https://doi.org/10.1111/j.1749-6632.2009... .

As found in this study, individuals tend to perceive those foods they consider tasty as not healthy³⁶36 Frich JC, Malterud K, Fugelli P. Experiences of guilt and shame in patients with familial hypercholesterolemia: a qualitative interview study. Patient Educ Couns. 2007; 69 (1-3): 108-13. doi: 10.1016/j.pec.2007.08.001.
https://doi.org/10.1016/j.pec.2007.08.00... . The context of pleasure eating is where the health professional fits in, helping patients to acquire information about an adequate diet while suggesting strategies to help them face the challenges regarding changes that will have to be made. At the same time, professionals can give support to reduce any feeling of guilt³⁷37 Sobal J. Sociability and the meal: facilitation, commensality, and interaction. In: Meiselman H. Dimensions of the meal: the science, culture, business and art of eating. Gaithersburg: Aspen Publishers; 2000. p. 119-33.^,3838 Sobal J, Nelson MK. Commensal eating patterns: a community study. Appetite. 2003; 41(2):181-90. doi: 10.1016/s0195-6663(03)00078-3.
https://doi.org/10.1016/s0195-6663(03)00... and give support to lifelong changes. Professionals must be sensitive to individual needs and understand and collaborate for the negotiation system based on shared choices, interests and meanings³³33 Blake CE, Bisogni CA, Sobal J, Devine CM, Jastran M. Classifying foods in contexts: how adults categorize foods for different eating settings. Appetite. 2007; 49(2):500-10. doi: 10.1016/j.appet.2007.03.009.
https://doi.org/10.1016/j.appet.2007.03.... . The Balance Program’s professional team developed strategies to support patients’ food choices, such as providing a cooking book, telephone monitoring and nutritional education sessions groups. Nevertheless, the professional conduct in Balance Program was based on the calculated menus stipulating the correct amount and combination of portions of the cardioprotective groups, encouraging participants to achieve their dietary goals. This may indicate that the perceptions presented by the participants may be related to the format of prescriptive nutritional guidance.

Food values negotiation can impose dilemmas, such as tradeoffs between taste and health⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... . Rarely all values will be completely satisfied by a specific food or behavior, yet individuals prioritize values (e.g., taste over health) to simplify their choices⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... ^,1313 Biltekoff C. Consumer response: the paradoxes of food and health. Ann N Y Acad Sci. 2010; 1190:174-8. doi: 10.1111/j.1749-6632.2009.05268.x.
https://doi.org/10.1111/j.1749-6632.2009... ^,3939 Smart LR, Bisogni CA. Personal food systems of male college hockey players. Appetite. 2001; 37(1):57-70. doi: 10.1006/appe.2001.0408.
https://doi.org/10.1006/appe.2001.0408... . However, even in a disease situation, food preferences may override health arguments³²32 Gracia-Anaiz M. Comer bien, comer mal: la medicalizacíon del comportamiento alimentario. Salud Publica Mexico. 2007; 49(3):236-42.. Values attributed to food and eating situations varied throughout the interviews, having been mentioned singularly or in combination: health (according to Balance’s recommendations), commensality and pleasure.

While commensality represents pleasurable moments, it can be difficult for patients to adhere to Balance’s recommendation, as family and friends do not share the same eating plan, leading to conflicts at the time of choice. Commensality situations lead to negotiation and food choices must be decided together rather than individually³⁷37 Sobal J. Sociability and the meal: facilitation, commensality, and interaction. In: Meiselman H. Dimensions of the meal: the science, culture, business and art of eating. Gaithersburg: Aspen Publishers; 2000. p. 119-33.^,3838 Sobal J, Nelson MK. Commensal eating patterns: a community study. Appetite. 2003; 41(2):181-90. doi: 10.1016/s0195-6663(03)00078-3.
https://doi.org/10.1016/s0195-6663(03)00... .

Commensality is inserted in the symbolic quality of food²2 Poulain JP. Sociologias da alimentação: os comedores e o espaço social. 2a ed. Florianópolis: UFSC; 2013. and participants described a negotiation process that resulted in different degrees of change, as some chose to maintain some pleasurable practices, even considering the risk of complications or other cardiovascular events.

Thus, value negotiation also considers different contexts, such as the period between meals, workdays versus days off, school/work times versus holidays⁷7 Connors MM, Bisogni CA, Sobal J, Devine C. Managing values in personal food systems. Appetite. 2001; 36(3):189-200. doi: 10.1006/appe.2001.0400.
https://doi.org/10.1006/appe.2001.0400... ^,3939 Smart LR, Bisogni CA. Personal food systems of male college hockey players. Appetite. 2001; 37(1):57-70. doi: 10.1006/appe.2001.0408.
https://doi.org/10.1006/appe.2001.0408... . Santos⁴⁰40 Santos LAS. O corpo, o comer e a comida: um estudo sobre práticas corporais e alimentares no mundo contemporâneo. Salvador: EUDFBA; 2008. identified women who classified weekend eating situations as “unhealthy”, unlike what we found in this study, in which participants identified that “going off the diet” or consuming “prohibited or less healthy foods” on weekends is part of the balance in food consumption between health and pleasure.

Another important component of the personal food system is the strategies/norms developed to implement their food choices, simplifying dietary choices²⁴24 Sobal J, Bisogni CA, Devine CM, Jastran M. A conceptual model of the food choice process over the life course. In: Shepherd R, Raats M. The psychology of food choice. Cambridge: CABI Publishing; 2006. p. 1-18.. We identified all strategies described by Sobal et al⁵5 Sobal J, Bisogni CA. Constructing food choice decisions. Ann Behav Med. 2009; 38 Suppl 1:S37-46. doi: 10.1007/s12160-009-9124-5.
https://doi.org/10.1007/s12160-009-9124-... : elimination (to avoid or exclude foods or preparations - e.g., fried foods); addition (increase or inclusion of adequate foods and ingredients - e.g., vegetables); limitation (restriction or control of certain foods or ingredients or in portion size - e.g., smaller portions of carbohydrate-rich foods); substitution (trading one food for another - e.g., skimmed milk instead of whole milk); and finally, modification (alteration of adjustment of preparations - e.g., boiling instead of frying).

Health professionals tend to judge an individual’s ability to make choices but must remember their perception has certain patterns shaped by social and cultural norms. The notion that taking risks can be intentional and rational seems unacceptable because we are portrayed as risk-fearing, eager to gain knowledge and not to fall victim. However, voluntary risk taking is present in society and can be attributed to facing fears and showing courage in search of challenges, excitement, emotion and pleasure⁴¹41 Lupton D, Tulloch J. ‘Life would be pretty dull without risk’: voluntary risk-taking and its pleasures. Health Risk Soc. 2002; 4(2):113-24. doi: 10.1080/13698570220137015.
https://doi.org/10.1080/1369857022013701... . Since food is not a risk related to clear and short-term damage, many individuals assume taking this risk or do not perceive diet as such, as observed in this study.

Although in our study participants reported conflict between pleasure and healthy eating, this antagonism is not always present. Studies¹¹11 Bedard A, Lamarche PO, Grégoire LM, Trudel-Guy C, Provencher V, Desroches S, et al. Can eating pleasure be a lever for healthy eating? A systematic scoping review of eating pleasure and its links with dietary behaviors and health. PloS One. 2020; 15(12):e0244292. doi: 10.1371/journal.pone.0244292.
https://doi.org/10.1371/journal.pone.024... ^,4242 Landry M, Lemieux S, Lapointe A, Bédard A, Bélanger-Gravel A, Bégin C, et al. Is eating pleasure compatible with healthy eating? A qualitative study on Quebecers’ perceptions. Appetite. 2018; 125:537-47. doi: 10.1016/j.appet.2018.02.033.
https://doi.org/10.1016/j.appet.2018.02.... ^,4343 Lemos TC, Almo A, Campagnoli RR, Pereira MG, Oliveira L, Volchan E, et al. A red code triggers an unintended approach motivation toward sweet ultra-processed foods: Possible implications for front-of-pack labels. Food Quality Preference. 2020; 79:103784. show that healthy food can be consider tastier and therefore more pleasurable or, at least, that although different, pleasure and health can be compatible.

Furthermore, a recent systematic scoping review brought evidence that strategies focusing on pleasure eating to promote healthy eating may be a lever for positive dietary and health outcomes¹¹11 Bedard A, Lamarche PO, Grégoire LM, Trudel-Guy C, Provencher V, Desroches S, et al. Can eating pleasure be a lever for healthy eating? A systematic scoping review of eating pleasure and its links with dietary behaviors and health. PloS One. 2020; 15(12):e0244292. doi: 10.1371/journal.pone.0244292.
https://doi.org/10.1371/journal.pone.024... . Pleasure eating involved more than 20 dimensions, with sensory (sensory qualities of food from five senses) and social (integration of social aspects with the act of eating) experiences being the most relevant. There were favorable associations between pleasure eating interventions and food choices and portion size outcomes, but only 11 interventions evaluating diet or health outcomes with this approach were identified¹¹11 Bedard A, Lamarche PO, Grégoire LM, Trudel-Guy C, Provencher V, Desroches S, et al. Can eating pleasure be a lever for healthy eating? A systematic scoping review of eating pleasure and its links with dietary behaviors and health. PloS One. 2020; 15(12):e0244292. doi: 10.1371/journal.pone.0244292.
https://doi.org/10.1371/journal.pone.024... . These findings are important as they highlight the importance of the pleasure eating approach and the small scientific production investigating these interventions. In this sense, Balance was reviewed after completion in 2017 and contents of social and sensory experiences were included in the content of the material “Cardioprotective Diet: a manual for primary health care professionals”¹⁸18 Brasil. Ministério da Saúde. Alimentação cardioprotetora: manual de orientações para os profissionais de saúde da atenção básica. Brasília: Ministério da Saúde; 2018..

From the understanding of the personal system in the food choice process of participants of the Balance, several questions emerged that may support reflections on the strategies used in nutritional counseling and monitoring of patients with heart disease. Based on the reports of the participants, the main facilitator of adherence to Balance is the counselling and embodiment of the food groups classification, defined according to the Brazilian flag, an interesting nutritional education tool, with special focus on some issues: the need to control the consumption of foods such as meat, alcoholic beverages, and sweets, and increase the intake of fruits and vegetables as part of a healthy diet.

The emphasis on the intake of Brazilian foods may also have positively influenced food choices that include, for example, the consumption of fruits, vegetables, rice, and beans. This is an innovative proposal regarding the incorporation of cultural aspects into the dietary guidelines. However, the Balance classification differs from other personal classifications that reflect life trajectories, preferences, aversions, and sociocultural factors. Thus, participants reported maintaining the consumption of pleasurable foods, such as wine and red meat, which are classified as avoidable in the program. This constitutes a barrier to the adherence to Balance and a greater challenge for patients and the professionals to balance consumption between foods considered healthy and unhealthy, but tasty and preferred by patients. Literature indicates that colors are used to communicate specific information such as ‘‘approach’’ or ‘‘avoidance” and, particularly in the case of red, as it is easily detectable, it is frequently used as a warning signal of danger and seems to induce a general avoidance motivation⁴⁴44 Genschow O, Reutner L, Wänke M. The color red reduces snack food and soft drink intake. Appetite. 2012; 58(2):699-702. doi: 10.1016/j.appet.2011.12.023.
https://doi.org/10.1016/j.appet.2011.12.... . However, although red suggests control of intake, it seems to not reduce the appeal of the food/beverage, maintaining the perception of a “tasty” attribute, even if perceived as unhealthy⁴⁴44 Genschow O, Reutner L, Wänke M. The color red reduces snack food and soft drink intake. Appetite. 2012; 58(2):699-702. doi: 10.1016/j.appet.2011.12.023.
https://doi.org/10.1016/j.appet.2011.12.... ^,4545 Huang L, Lu J. Eat with your eyes: package color influences the expectation of food taste and healthiness moderated by external eating. Mark Manag J. 2015; 25(2):71-87.. We suggest this could maintain the desire for foods from the red (“avoidable”) group. Furthermore, the association of these foods with red can accentuate the dichotomy between health and pleasure, which may constitute a limitation of Balance’s proposal. To minimize this possibility, during nutrition counselling with participants of the intervention, in a procedural way, whenever there was an excessive intake of the ultra-processed food groups, possible substitutions were suggested. The ongoing monitoring of patients and constant dialogue about food was assumed as strategies to minimize normative discourse and deepen reflections – and autonomy – on food choices.

Although the nutritional control of these patients is an essential factor in health care, it should be considered in a broader context, considering other values implied in food choices. Defining flexible and built together approaches with patients and families (type of food, eating on special occasions) contribute to patients’ food choices, considering the characteristics and contexts they experience and their expectations, therefore avoiding barriers to adherence to Balance, and providing greater autonomy in food choices and a more dialogic relationships between professionals and patients. This is a complex discussion since decisions about eating in the case of a cardiovascular event may be unique and dependent on factors such as the time of the cardiovascular event (which is related to longer or shorter life expectancy), its severity and prognosis, previous experience and/or presence of comorbidities, life goals/dreams, family, religion, among others.

As limitations, this study reflects the results of only 10 patients of the 2,534 volunteers who participated of the Balance Program. There may be social differences, preferences, and knowledge among participants, highlighting that these results cannot be extrapolated to the whole universe of participants of the Balance Program.

Although the interviews were carried out by an external researcher in an attempt to eliminate possible biases, it is also important to highlight that the 10 participants had a connection with the first author of the study and with the hospital, suggesting that their participation and responses could be inductive about the benefits of the program.

Conclusion

The process of food choices of participants of the Balance Program evidence that the nutritional counseling strategy promoted healthy food choices and changes in habits and behaviors, resulting in the incorporation of some strategies by the patients and adherence to the guidelines: increased consumption of fruits, vegetables and legumes; elimination, restriction or avoidance of some fatty or ultra-processed foods; and modification of the cooking method.

However, choices of pleasurable foods may indicate a non-adherence to Balance, as those foods are normally classified as unhealthy. This led patients to report tensions and conflicts between eating for health and pleasure eating. Thus, we suggest that healthy eating and pleasure – here define as the “pleasure derived from the sensory, symbolic value of food, as well as the experience of social eating and cooking”¹¹11 Bedard A, Lamarche PO, Grégoire LM, Trudel-Guy C, Provencher V, Desroches S, et al. Can eating pleasure be a lever for healthy eating? A systematic scoping review of eating pleasure and its links with dietary behaviors and health. PloS One. 2020; 15(12):e0244292. doi: 10.1371/journal.pone.0244292.
https://doi.org/10.1371/journal.pone.024... (p. 3), should be allies in nutritional counseling for patient with cardiovascular disease as both are equally important aspects of human life.

Although in this article we have chosen to emphasize the negotiations that involve pleasure and health, food choices are a complex, dynamic process that involves numerous other aspects, such as personal trajectories, biological, experiential, sociocultural and environmental determinants influence food choices and should not be forgotten as they can determine conflicts, beyond the health/pleasure dichotomy.

References

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